TOPICS OFINTERESTTOPICS OFINTEREST

Classification System for Partial Edentulism

Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS, Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical

mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2

Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that

through the inward positioning of the

implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The

treatment concept of PS has been

developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants

with PS suggested a reduction of the

loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants

4 years after restoration either with

PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.

2009, Vigolo & Givani 2009).

Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant

design, implant microstructure and

the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308

and CES/0156) and performed in

accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local

exclusion criteria included history of

local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted

timely according to the group. The

mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.

Pre-treatment and surgical procedures

A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was

planned to be taken at least 6 weeks

post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were

cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser

et al. 2002). A crown was deemed

successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective

significance level of 0.05 was used.

Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in

Fig. 3. Between May 2009 and

November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants

placed were 11 mm in length, 36 in

the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.

In both groups the majority of

implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two

implants were lost (pre-loading fail-ures) in the PS group, and none in

the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68

Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the

implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5

13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40

0.46 mm (95% CI:0.51,0.29) and

0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available

implants with identical outer geome-try and internal implant-abutment

connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily

reflecting the real situation. Our

study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM

p-value N Mean SD (mm) N Mean SD (mm)

Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence

marginal bone resorption, this was

not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,

our flat-to-flat abutment connection

model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and

PM. Radiographical bone gain or no

changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,

Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year

ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527

matching abutments of the same

implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and

same internal implant-abutment con-nection allowing comparable results.

Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal
bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in

the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2

, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their

specific role in marginal bone level

alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the

surface area to which the soft tissue

can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in

the jaw of dogs by Jung et al. (2008)

and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological

human data displayed minimal bone

loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a

trend towards better bone level

maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant

characteristics of the selected articles.

Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in

bone changes between PS and PM

between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took

medication interfering with bone

metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each

patient corresponding to either PS or

PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the

randomization and fitted immediately

after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with

further evaluations planned at 24,

36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at

1 year post-loading, performance of

the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and

minimum difference of 0.2 mm.

PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both

randomization and centre effect at a

significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in

the PS and 49.97 14.77 in the PM

group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at

1 year post-loading (g).

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.

No statistically significant difference

was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and

12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72

Platform switching group

Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)

Class IV 4 (5.4) 1 (1.4)

Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a

negative a bone loss) from surgery to

12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;

95% CI: 0.04, 0.56). The other two

centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference

(p=0.004). Our findings are compa-rable with those of Canullo et al.

(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)

Loading 68 0.05 0.12 69 0.01 0.06

6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible

could not find a statistical difference

between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and

0.29 0.34 mm for the PM group

(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading

suggesting that changes could hap-pen in a time-dependent manner.

Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between

loading and 12 months. Therefore we

were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a

positive impact in maintenance or

even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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Goldstein, M., Arnhart, C., Barlattani, A.,
Jackowski, J., Knauf, M., Lorenzoni, M.,
Maiorana, C., Mericske-Stern, R., Rompen,
E. & Sanz, M. (2009) Randomized controlled
trial comparing a variable-thread novel
tapered and a standard tapered implant:

interim one year results. Journal of Prosthetic

Dentistry101, 293305.
Lazzara, R. J. & Porter, S. S. (2006) Platform
switching: a new concept in implant dentistry
for controlling postrestorative crestal bone lev-els.The International Journal of
Periodontics &
Restorative Dentistry26,917.
Lekholm, U. & Zarb, G. A. (1985) Patient selec-tion and preparation. In: Branemark,
P. I.,
Zarb, G. A. & Albrektsson, T. (eds).Tissue
Integrated Prostheses: Osseointegration in Clini-cal Dentistry, pp. 199209, Chicago,
IL: Quin-tessence.
Luongo, R., Traini, T., Guidone, P. C., Bianco,
G., Cocchetto, R. & Celletti, R. (2008) Hard
and soft tissue responses to the platform-switch-ing technique. The International
Journal of
Periodontics & Restorative Dentistry 28,
551557.
Maeda, Y., Miura, J., Taki, I. & Sogo, M. (2007)
Biomechanical analysis on platform switching:
is there any biomechanical rationale? Clinical
Oral Implants Research18, 581584.
Nicolau, P., Korostoff, J., Ganeles, J., Jackowski,
J., Krafft, T., Neves, M., Divi, J., Rasse, M.,
Guerra, F. & Fischer, K. (2013) Immediate and
early loading of chemically modified implants
in posterior jaws: 3-year results from a prospec-tive randomized multicenter study.
Clinical

Implant Dentistry and Related Research 15,

600612.
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(2002) The causes of early implant bone loss:
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Prosper, L., Redaelli, S., Pasi, M., Zarone, F.,
Radaelli, G. & Gherlone, E. F. (2009) A ran-domized prospective multicenter trial
evaluat-ing the platform-switching technique for the
prevention of postrestorative crestal bone loss.
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(2005) Early wound healing around endisseous
implants: a review of literature. The Interna-tional Journal of Oral & Maxillofacial
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Wang, H. L. (2009) Effect of platform
switching on implant crest bone stress: a
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Manzanera-Pastor, E., Lorrio-Castro, C.,
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(2011) The influence of platform switching in
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688697.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de

Medicina da Universidade de Coimbra

Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal
bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible

1-year results of a multicentre

randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.

Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein

University Hospital, University of Kiel, Kiel,

Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no

conflict of interests related to this study.

This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with

PS also contributed to the growing

clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to

the cancellous bone (Maeda et al.

2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and

the collagen content, the authors

speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM

implants. No such difference could

be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more

or less influence the outcomes.

The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion

criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed

extraction sites, keratinized gingiva

less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and

0.35 mm for the implants with a

5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene

instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic

antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of

prosthesis placement was the baseline

for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523

(Fig. 2). Two centres used digital

radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.

Plaque index (PLI: 03), sulcus

bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were

included. Thirty-five patients were

randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were

9 mm in length and 27 were placed in

the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to

Lekholm & Zarb (1985) (Table 1a).

All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to

implant success rates of 97.3% and

100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34

Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)

Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.

No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).

From loading to 12 months the

total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute

to a more accurate and better under-standing of how PS can influence

marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since

the diameter of the implant was

selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns

Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*

ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a

platform healing abutment seemed

to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression

posts) could have an influence in

early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform

switching implants, meaning 47 out

of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if

the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two

different techniques at 12 months

post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.

Principal findings: Platform switching

group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal
bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal

implant site were enrolled. Randomization followed implant placement. Definitive

restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore

Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level

alteration is still subject of current

research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue

can attach and establish a biological

width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)

and on histological preparations by

Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone

loss and a reduced dimension of the

inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level

maintenance for the PM implants,

without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.

Despite the demonstrated difference

between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM

between loading and yearly follow-ups.

Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone

metabolism or presenting abuse of

drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or

PM group. Patients who met inclu-sion criteria after implant placement

were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately

after surgery. Healing was transgingi-val. Radiographs and photographs

were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,

36, 48 and 60 months post-loading

(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of

the restorative components, nature

and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.

PASS 2008 version 0.8.0.4 (NCSS,

LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a

significance level of 0.05. When no

centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM

group (Table 1a). A total of 146

implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons

Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference

was observed between the two

groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.

Radiographical changes in crestal bone

levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group

Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)

Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to

12 months was 0.54 0.59 mm

(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two

centers showed no significant differ-ences. Radiographical bone gain from

loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.

(2010a) who reported a higher bone

loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06

6-months 67 0.22 0.28 67 0.20 0.32

12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference

between groups. Baseline was at sur-gery, however, implants healed in a

submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group

(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.

Some systematic reviews and

meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we

were unable to reject the hypothesis.

In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or

even enhancement of crestal bone

levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC

3030 075 Coimbra

Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal
bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.

Platform switch versus platform match in the posterior mandible1-year results of

a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner

2
,
J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;

implant success; platform matching; platform

switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons

Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of

implants either with horizontal flat,

outward inclined or inward oblique
mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of

bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different

and responsible for the diminished

bone loss around PS implants
(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,

2010a, Crespi et al. 2009, Kielbassa

et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in

bone level changes between PS and

PM restorations using same implants
in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth

mesial to the most proximal implant

site, adequate bone quality and
quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were

lack of implant primary stability or

inappropriate implant position
according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.

Randomization
The study was planned to include at
least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm

supracrestally. (Fig. 1b) The most

proximal implant was placed 1.5
2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can

be predictably maintained in relation

to the implant shoulder when the
implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to

the implant shoulder was measured to

the nearest 0.1 mm and the mean of
the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,

6-month and 1-year post loading.

Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard

deviations (SD) and 95% confidence

intervals (CI) were calculated for each
treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American

Society of Anesthesiologists physical

status classification system (ASA).
Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in

the PS and 10 in the PM group

(Table 1b). The position of implants
by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was

optional and thus measured for 73

implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading

visit and required new impression

and prosthesis delivery.
Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72

Exclusion after surgery

- Not meeting inclusion criteria:
Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14

Implants per quadrant

2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd

Platform switch versus platform matcha RCT 525

142 implants from surgery to
12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically

significant interaction between the

centre and the treatment group on
BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after

surgery regarding to avoid any ten-dency to change surgical protocol.

This aspect is important to exclude
any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization

(platform switching =74, platform matching=72).

Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.

No significant differences between study groups were observed.

*Difference between study groups is statistically significant (independent studentsttest).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.

From prosthetic placement to

1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place

before prosthetic restoration and not

only after as suggested by some
authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2

were lost due to pre-loading failure

in the PS group, yielding implant
success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results

are related mostly to the ongoing

status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank

Franc oise Peters, Alex Schar and

Peter Thommen from the Camlog
Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared

to the platform matching group.

Practical implications: Platform
switching preserves the marginal
bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were

determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1

1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.

Radiographs of the restored implants

exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was

reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in

related animal studies conducted by

Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these

implants (Degidi et al. 2008, Luongo

et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler

et al. 2007, Crespi et al. 2009,

Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)

claimed that additional clinical trials

are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in

three centres located in Germany

(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.

equivalent to more than 10 ciga-rettes/day or presenting handicaps

that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)

and length (9, 11, and 13 mm) were

selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:

quadrant where the higher number of

implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were

removed (Fig. 1c).

Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)

Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were

recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.

This RCT had 5 years of follow-up

including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed

using Bonferroni correction.

Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in

diameter, 62 (42.5%) were 4.3 mm

and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites

(88.6%) received two and four

(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the

PS and 85.1% for the PM group and

18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for

Assessed for eligibility (surgery performed)

Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)

Platform matching group

Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35

(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction

between the centre and the treatment

group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of

the PM implants. The results are sum-marized in Table 2b and Fig. 5.

Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included

several dimensions of mismatch from

0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm

Loading 64 1.78 0.79 61 1.69 0.51

6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by

different healing abutments as

occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before

loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least

0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.

2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were

lower for the PS group. We could

demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform

Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal

E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal
bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.

doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,

J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial

Accepted for publication 15 February 2014

Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521

This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,

outward inclined or inward oblique

mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo

et al. 2010a and Cocchetto et al.

2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished

bone loss around PS implants

(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa

et al. 2009, Prosper et al. 2009,

Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and

PM restorations using same implants

in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant

site, adequate bone quality and

quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or

inappropriate implant position

according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization

The study was planned to include at

least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most

proximal implant was placed 1.5

2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation

to the implant shoulder when the

implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to

the nearest 0.1 mm and the mean of

the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.

Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence

intervals (CI) were calculated for each

treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical

status classification system (ASA).

Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group

(Table 1b). The position of implants

by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73

implants (37 in the PS and 36 in the

PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression

and prosthesis delivery.

Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery

- Not meeting inclusion criteria:

Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant

2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 525

142 implants from surgery to

12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the

centre and the treatment group on

BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.

This aspect is important to exclude

any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).

Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.

*Difference between study groups is statistically significant (independent studentsttest).

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to

1 year post-loading, one centre pre-sented a significant difference

(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not

only after as suggested by some

authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure

in the PS group, yielding implant

success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing

status of the study but the relevant

results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and

Peter Thommen from the Camlog

Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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P. I.,
Zarb, G. A. & Albrektsson, T. (eds).Tissue
Integrated Prostheses: Osseointegration in Clini-cal Dentistry, pp. 199209, Chicago,
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Luongo, R., Traini, T., Guidone, P. C., Bianco,
G., Cocchetto, R. & Celletti, R. (2008) Hard
and soft tissue responses to the platform-switch-ing technique. The International
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Periodontics & Restorative Dentistry 28,
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Biomechanical analysis on platform switching:

is there any biomechanical rationale? Clinical
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Nicolau, P., Korostoff, J., Ganeles, J., Jackowski,
J., Krafft, T., Neves, M., Divi, J., Rasse, M.,
Guerra, F. & Fischer, K. (2013) Immediate and
early loading of chemically modified implants
in posterior jaws: 3-year results from a prospec-tive randomized multicenter study.
Clinical
Implant Dentistry and Related Research 15,
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(2002) The causes of early implant bone loss:
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Prosper, L., Redaelli, S., Pasi, M., Zarone, F.,
Radaelli, G. & Gherlone, E. F. (2009) A ran-domized prospective multicenter trial
evaluat-ing the platform-switching technique for the
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(2005) Early wound healing around endisseous
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switching on implant crest bone stress: a

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Manzanera-Pastor, E., Lorrio-Castro, C.,
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(2011) The influence of platform switching in
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Telleman, G., Raghoebar, G. M., Vissink, A. &
Meijer, H. J. (2012) Impact of platform
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688697.
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Vigolo, P. & Givani, A. (2009) Platform-switched

restorations on wide diameter implants: a
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24, 103109.
Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform

switching preserves the marginal

bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group

and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,

Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal

bone remodeling (Lazzara & Porter

2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this

characteristic implant/abutment inter-face mismatch as a valuable treatment

option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).

Biomechanical simulations using

finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological

characterization of peri-implant soft

tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.

2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm

the advantageous effect of PS. Espe-cially because various factors such as

implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study

was approved by the competent

Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability

to perform adequate oral hygiene, or

prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.

Healing abutments, impression

posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the

same number of implants priority was

given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement

For implants inserted in bone type I

III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization

and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an

assessment of implant mobility, peri-implant radiolucency, peri-implant

recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power

analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants

The current status of the study after

1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups

by randomization was almost even.

Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites

(81.8%) with two and six (18.2%)

with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.

Implant success and complications

During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171

Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72

Fig. 3.Flow chart of the study design.

Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0

9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=

0.533). From surgery the mean BLC

in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors

knowledge, this is the first RCT

where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done

by increasing the diameter of the

implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51

(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized

next to each other on the same side

of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to

device installation as reported by

Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of

0.3 mm and 0.35 mm we could

observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are

in accordance with previous clinical

studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons

Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:

Platform switching aims to pre-serve crestal bone height and soft

tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal
bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract

Objective:The purpose of this ongoing randomized study was to assess differ-ences

in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3

, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental

implants has been attributed to se-veral factors. Stress-concentration

after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,

which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific

data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the

bacterial composition of the biofilm

since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).

A systematic review with meta-analysis (Atieh et al. 2010) where PS

and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &

Givani 2009) were already part of

the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both

groups. Implants supporting single

crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit

the insertion of a dental implant and

with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.

Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding

approximately to 24 patients per cen-tre. A block-randomization list with

block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural

tooth and a minimal distance of

3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with

PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.

The radiographical measurements

were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for

equivalence of crestal bone levels of

the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and

percentages were calculated for cate-gorical variables. Bone level changes

(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as

ASA 1 (89.7%) and seven patients as

ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.

(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to

45 Ncm. After a mean healing period

of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and

probing depth over time

Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2

Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6

Implants (n)7472 Centre 1 12 12

Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and

for 131 implants from loading to

12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in

the PS group was 0.08 0.41 mm

(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation

depth, which revealed to be of influ-ence on marginal bone levels

(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)

PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons

Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between

groups, however, the overall results

did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).

Emphasizing the biological aspect it

seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and

100% in PM. Within the secondary

outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,

in our opinion, to decide in a more

accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational

support and also to Ana Messias for

her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal

bone level more predictably than

the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from

surgery to 12 months was significant between groups (p<0.004). Radiographical

mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;

2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter

2006). The authors assumed that

through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment

option (Luongo et al. 2008). The

treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using

finite element analyses at implants

with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft

tissue biopsies taken from implants

4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo

et al. 2009, 2010a, Prosper et al.

2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as

implant insertion depth, implant

design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent

Ethics Committees (FECI 09/1308

and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or

prevent completion of the study par-ticipation were excluded. Local

exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression

posts, and abutments were inserted

timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was

given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I

III, impression (PS or PM) was

planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization

and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an

assessment of implant mobility, peri-implant radiolucency, peri-implant

recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power

analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants

The current status of the study after

1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups

by randomization was almost even.

Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites

(81.8%) with two and six (18.2%)

with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.

Implant success and complications

During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171

Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72

Fig. 3.Flow chart of the study design.

Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0

9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=

0.533). From surgery the mean BLC

in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors

knowledge, this is the first RCT

where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done

by increasing the diameter of the

implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51

(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized

next to each other on the same side

of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to

device installation as reported by

Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of

0.3 mm and 0.35 mm we could

observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are

in accordance with previous clinical

studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons

Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:

Platform switching aims to pre-serve crestal bone height and soft

tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal
bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract

Objective:The purpose of this ongoing randomized study was to assess differ-ences

in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3

, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental

implants has been attributed to se-veral factors. Stress-concentration

after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,

which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific

data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the

bacterial composition of the biofilm

since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).

A systematic review with meta-analysis (Atieh et al. 2010) where PS

and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &

Givani 2009) were already part of

the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both

groups. Implants supporting single

crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit

the insertion of a dental implant and

with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.

Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding

approximately to 24 patients per cen-tre. A block-randomization list with

block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural

tooth and a minimal distance of

3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with

PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.

The radiographical measurements

were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for

equivalence of crestal bone levels of

the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and

percentages were calculated for cate-gorical variables. Bone level changes

(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as

ASA 1 (89.7%) and seven patients as

ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.

(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to

45 Ncm. After a mean healing period

of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and

probing depth over time

Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2

Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6

Implants (n)7472 Centre 1 12 12

Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and

for 131 implants from loading to

12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in

the PS group was 0.08 0.41 mm

(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation

depth, which revealed to be of influ-ence on marginal bone levels

(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)

PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons

Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between

groups, however, the overall results

did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).

Emphasizing the biological aspect it

seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and

100% in PM. Within the secondary

outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,

in our opinion, to decide in a more

accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational

support and also to Ana Messias for

her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal

bone level more predictably than

the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from

surgery to 12 months was significant between groups (p<0.004). Radiographical

mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;

2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter

2006). The authors assumed that

through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment

option (Luongo et al. 2008). The

treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using

finite element analyses at implants

with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft

tissue biopsies taken from implants

4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo

et al. 2009, 2010a, Prosper et al.

2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as

implant insertion depth, implant

design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent

Ethics Committees (FECI 09/1308

and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or

prevent completion of the study par-ticipation were excluded. Local

exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression

posts, and abutments were inserted

timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was

given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I

III, impression (PS or PM) was

planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization

and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an

assessment of implant mobility, peri-implant radiolucency, peri-implant

recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power

analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants

The current status of the study after

1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups

by randomization was almost even.

Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites

(81.8%) with two and six (18.2%)

with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.

Implant success and complications

During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171

Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72

Fig. 3.Flow chart of the study design.

Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0

9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=

0.533). From surgery the mean BLC

in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors

knowledge, this is the first RCT

where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done

by increasing the diameter of the

implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51

(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized

next to each other on the same side

of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to

device installation as reported by

Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of

0.3 mm and 0.35 mm we could

observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are

in accordance with previous clinical

studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons

Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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and soft tissue responses to the platform-switch-ing technique. The International
Journal of
Periodontics & Restorative Dentistry 28,
551557.
Maeda, Y., Miura, J., Taki, I. & Sogo, M. (2007)
Biomechanical analysis on platform switching:
is there any biomechanical rationale? Clinical
Oral Implants Research18, 581584.
Nicolau, P., Korostoff, J., Ganeles, J., Jackowski,
J., Krafft, T., Neves, M., Divi, J., Rasse, M.,
Guerra, F. & Fischer, K. (2013) Immediate and
early loading of chemically modified implants
in posterior jaws: 3-year results from a prospec-tive randomized multicenter study.
Clinical
Implant Dentistry and Related Research 15,
600612.
Oh, T. J., Yoon, J., Misch, C. E. & Wang, H. L.
(2002) The causes of early implant bone loss:
Myth or science?Journal of Periodontology73,
322333.
Prosper, L., Redaelli, S., Pasi, M., Zarone, F.,

Radaelli, G. & Gherlone, E. F. (2009) A ran-domized prospective multicenter trial

evaluat-ing the platform-switching technique for the
prevention of postrestorative crestal bone loss.
The International Journal of Oral & Maxillofa-cial Implants24, 299308.
Raghavendra, S., Wood, M. C. & Taylor, T. D.
(2005) Early wound healing around endisseous
implants: a review of literature. The Interna-tional Journal of Oral & Maxillofacial
Implants
20, 425431.
Schrotenboer, J., Tsao, Y. P., Kinariwala, V. &
Wang, H. L. (2009) Effect of platform
switching on implant crest bone stress: a
finite element analysis. Implant Dentistry 18,
260269.
Serrano-Sanchez, P., Calvo-Guirado, J. L.,
Manzanera-Pastor, E., Lorrio-Castro, C.,
Bretones-L opez, P. & Perez-Llanes, J. A.
(2011) The influence of platform switching in
dental implants. A literature review.Medicina
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e400e405.
Telleman, G., Raghoebar, G. M., Vissink, A. &
Meijer, H. J. (2012) Impact of platform
switching on inter-proximal bone levels

around short implants in the posterior region;

1-year results from a randomized clinical
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688697.
Trammell, K., Geurs, N. C., ONeal, S. J., Liu,
P. G., Kenealy, J. N. & Reddy, M. S. (2009)
A prospective, randomized, controlled com-parison of platform-switched and
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599605.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:

Platform switching aims to pre-serve crestal bone height and soft

tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal
bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract

Objective:The purpose of this ongoing randomized study was to assess differ-ences

in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3

, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental

implants has been attributed to se-veral factors. Stress-concentration

after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,

which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific

data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the

bacterial composition of the biofilm

since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).

A systematic review with meta-analysis (Atieh et al. 2010) where PS

and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &

Givani 2009) were already part of

the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both

groups. Implants supporting single

crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit

the insertion of a dental implant and

with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.

Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding

approximately to 24 patients per cen-tre. A block-randomization list with

block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural

tooth and a minimal distance of

3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with

PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.

The radiographical measurements

were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for

equivalence of crestal bone levels of

the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and

percentages were calculated for cate-gorical variables. Bone level changes

(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as

ASA 1 (89.7%) and seven patients as

ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.

(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to

45 Ncm. After a mean healing period

of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and

probing depth over time

Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2

Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6

Implants (n)7472 Centre 1 12 12

Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and

for 131 implants from loading to

12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in

the PS group was 0.08 0.41 mm

(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation

depth, which revealed to be of influ-ence on marginal bone levels

(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)

PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons

Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between

groups, however, the overall results

did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).

Emphasizing the biological aspect it

seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and

100% in PM. Within the secondary

outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,

in our opinion, to decide in a more

accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational

support and also to Ana Messias for

her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal

bone level more predictably than

the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract
Objective:The purpose of this ongoing randomized study was to assess differ-ences
in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from

surgery to 12 months was significant between groups (p<0.004). Radiographical

mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3
, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;

2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental
implants has been attributed to se-veral factors. Stress-concentration
after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter

2006). The authors assumed that

through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment

option (Luongo et al. 2008). The

treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific
data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using

finite element analyses at implants

with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the
bacterial composition of the biofilm
since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft

tissue biopsies taken from implants

4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).
A systematic review with meta-analysis (Atieh et al. 2010) where PS
and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo

et al. 2009, 2010a, Prosper et al.

2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &
Givani 2009) were already part of
the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as

implant insertion depth, implant

design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both
groups. Implants supporting single
crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent

Ethics Committees (FECI 09/1308

and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit
the insertion of a dental implant and
with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or

prevent completion of the study par-ticipation were excluded. Local

exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.
Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression

posts, and abutments were inserted

timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding
approximately to 24 patients per cen-tre. A block-randomization list with
block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was

given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural
tooth and a minimal distance of
3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I

III, impression (PS or PM) was

planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with
PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization

and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.
The radiographical measurements
were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an

assessment of implant mobility, peri-implant radiolucency, peri-implant

recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for
equivalence of crestal bone levels of
the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power

analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and
percentages were calculated for cate-gorical variables. Bone level changes
(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants

The current status of the study after

1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as
ASA 1 (89.7%) and seven patients as
ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups

by randomization was almost even.

Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.
(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites

(81.8%) with two and six (18.2%)

with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to
45 Ncm. After a mean healing period
of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.

Implant success and complications

During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and
probing depth over time
Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171

Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2
Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72

Fig. 3.Flow chart of the study design.

Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6
Implants (n)7472 Centre 1 12 12
Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0

9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
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Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and
for 131 implants from loading to
12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=

0.533). From surgery the mean BLC

in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in
the PS group was 0.08 0.41 mm
(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors

knowledge, this is the first RCT

where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation
depth, which revealed to be of influ-ence on marginal bone levels
(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done

by increasing the diameter of the

implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)
PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51

(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized

next to each other on the same side

of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between
groups, however, the overall results
did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to

device installation as reported by

Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).
Emphasizing the biological aspect it
seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of

0.3 mm and 0.35 mm we could

observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and
100% in PM. Within the secondary
outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are

in accordance with previous clinical

studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,
in our opinion, to decide in a more
accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons

Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational
support and also to Ana Messias for
her contribution in the statistical
analysis.
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C. (2007) Peri-implant bone level around
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Kielbassa, A. M., Martinez-de Fuentes, R.,
Goldstein, M., Arnhart, C., Barlattani, A.,
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Radaelli, G. & Gherlone, E. F. (2009) A ran-domized prospective multicenter trial

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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:

Platform switching aims to pre-serve crestal bone height and soft

tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal
bone level more predictably than
the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529Platform switch versus platform
match in the posterior mandible
1-year results of a multicentre
randomized clinical trial
Guerra F, Wagner W, Wiltfang J, Rocha S, Moergel M, Behrens E, Nicolau P.
Platform switch versus platform match in the posterior mandible1-year results of
a multicenter randomized clinical trial. J Clin Periodontol 2014; 41: 521529.
doi: 10.1111/jcpe.12244.
Abstract

Objective:The purpose of this ongoing randomized study was to assess differ-ences

in bone level changes and success rates using implants supporting single
crowns in the posterior mandible either with platform matched or platform
switched abutments.
Material and Methods:Patients aged 18 and above, missing at least two teeth in
the posterior mandible and with a natural tooth mesial to the most proximal
implant site were enrolled. Randomization followed implant placement. Definitive
restorations were placed after a minimum transgingival healing period of 8 weeks.
Changes in crestal bone level from surgery and loading (baseline) to 12-month
post-loading were radiographically measured. Implant survival and success were
determined.
Results:Sixty-eight patients received 74 implants in the platform switching group
and 72 in the other one. The difference of mean marginal bone level change from
surgery to 12 months was significant between groups (p<0.004). Radiographical
mean bone gain or no bone loss from loading was noted for 67.1% of the plat-form
switching and 49.2% of the platform matching implants. Implant success
rates were 97.3% and 100%, respectively.
Conclusions:Within the same implant system the platform switching concept
showed a positive effect on marginal bone levels when compared with restorations
with platform matching.
Fernando Guerra
1
, Wilfried Wagner
2
,
J org Wiltfang
3

, Salom~ ao Rocha
1
,
Maximilian Moergel
2
, Eleonore
Behrens
3
and Pedro Nicolau
1
1
Faculty of Medicine, University of Coimbra,
Coimbra, Portugal;
2
Medical Center of
Johannes Gutenberg University of Mainz,
Mainz, Germany;
3
Schleswig-Holstein
University Hospital, University of Kiel, Kiel,
Germany
Key words: crestal bone preservation;
implant success; platform matching; platform
switching; randomized clinical trial
Accepted for publication 15 February 2014
Crestal bone loss around dental

implants has been attributed to se-veral factors. Stress-concentration

after implant loading, the counter-sinking during implant placement
procedures and localized soft-tissue
inflammation are certain factors
among others (Oh et al. 2002). Their
specific role in marginal bone level
alteration is still subject of current
research. The potential benefit of
platform switching (PS) was dis-covered casually due to a production
delay of prosthetic components.
Radiographs of the restored implants
exhibited minimal alveolar crestal
bone remodeling (Lazzara & Porter
2006). The authors assumed that
through the inward positioning of the
implant/abutment junction: (i) the
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests related to this study.
This study was funded by an unre-stricted grant of the Camlog Founda-tion, Basel,
Switzerland. Prof. F.
Guerra and Prof. W. Wagner are mem-bers of the Camlog Foundation Board.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd 521
This is an open access article under the terms of the Creative Commons AttributionNonCommercial-NoDerivs License,

which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and
no modifications or adaptations are made.
J Clin Periodontol 2014; 41: 521529 doi: 10.1111/jcpe.12244
distance of the junction in relation to
the adjacent crestal bone and (ii) the
surface area to which the soft tissue
can attach and establish a biological
width was increased and therefore
bone resorption at the implant-abut-ment junction associated with the
inflammatory cell infiltrate was
reduced.
Other authors introduced this
characteristic implant/abutment inter-face mismatch as a valuable treatment
option (Luongo et al. 2008). The
treatment concept of PS has been
developed. The biological processes
(Lazzara & Porter 2006) and bio-mechanics (Maeda et al. 2007, Schro-tenboer et al.
2009, Chang et al.
2010) proposed to be associated with
PS also contributed to the growing
clinical application of this concept.
The market responded to the putative
success of PS with the release of
implants either with horizontal flat,
outward inclined or inward oblique
mismatch supported by few scientific

data.
Further animal and human stu-dies have predominantly measured
changes in crestal bone levels not
always demonstrating a positive
effect of PS. Whereas PS with mini-mal bone loss could be observed on
radiographs of implants inserted in
the jaw of dogs by Jung et al. (2008)
and on histological preparations by
Cochran et al. (2009), no statistically
significant differences could be verified
between the two treatment concepts in
related animal studies conducted by
Becker et al. (2007, 2009).
Biomechanical simulations using
finite element analyses at implants
with PS suggested a reduction of the
loading stress at the bone-implant
interface and therefore in the crestal
region of the cortical bone via trans-ferring it along the implant axis to
the cancellous bone (Maeda et al.
2007, Schrotenboer et al. 2009,
Chang et al. 2010).
Furthermore, the reduced size of
bone loss seems to be inversely cor-related to the extent of the horizon-tal platform
mismatch (Canullo
et al. 2010a and Cocchetto et al.
2010) and to be independent of the

bacterial composition of the biofilm

since the peri-implant microbiota at
implants with and without PS was
almost indistinguishable (Canullo
et al. 2010b). In accordance with the
beneficial concept of PS, histological
human data displayed minimal bone
loss and a reduced dimension of the
inflammatory cell infiltrate indicated
by its limited apical extension
beyond the platform in these
implants (Degidi et al. 2008, Luongo
et al. 2008). Although histological
characterization of peri-implant soft
tissue biopsies taken from implants
4 years after restoration either with
PS or platform matching (PM) abut-ments was not different in terms of
the extent of inflamed connective
tissue, the microvascular density and
the collagen content, the authors
speculated that early soft tissue
events such as the formation of the
biological width may be different
and responsible for the diminished
bone loss around PS implants
(Canullo et al. 2011).

A systematic review with meta-analysis (Atieh et al. 2010) where PS

and PM were reported included 10
controlled clinical trials. Radio-graphical marginal bone level
changes and failure rates after a fol-low-up period of 1260 months were
evaluated. Only one (Kielbassa et al.
2009) of the 10 studies showed a
trend towards better bone level
maintenance for the PM implants,
without significance. The remaining
studies reported favourable results
for PS, four as a trend (H urzeler
et al. 2007, Crespi et al. 2009,
Trammell et al. 2009, Enkling et al.
2011) and five with statistical signifi-cance (Cappiello et al. 2008, Canullo
et al. 2009, 2010a, Prosper et al.
2009, Vigolo & Givani 2009).
Accordingly, the authors concluded
that marginal bone loss for PS was
significantly less than around PM
implants. No such difference could
be found between PS and PM
regarding failure rates. Another sys-tematic review included nine articles
(Al-Nsour et al. 2012), eight (Cappi-ello et al. 2008, Canullo et al. 2009,
2010a, Crespi et al. 2009, Kielbassa
et al. 2009, Prosper et al. 2009,
Trammell et al. 2009, Vigolo &

Givani 2009) were already part of

the meta-analysis conducted by
Atieh et al. (2010) and one article
was added (Fickl et al. 2010). In this
systematic review no meta-analysis
was performed because of the hetero-geneous study designs and implant
characteristics of the selected articles.
Despite the demonstrated difference
between PS and PM, the authors of
both systematic reviews as well as
others (Serrano-Sanchez et al. 2011)
claimed that additional clinical trials
are needed to substantially confirm
the advantageous effect of PS. Espe-cially because various factors such as
implant insertion depth, implant
design, implant microstructure and
the size of the implant platform were
often heterogeneous within the same
PS study and might therefore more
or less influence the outcomes.
The purpose of this prospective
randomized multicenter clinical study
(RCT) was to assess the differences in
bone level changes between PS and
PM restorations using same implants
in the same implant indication in both

groups. Implants supporting single

crowns were inserted in the posterior
mandible with fixed dentition in the
opposite and restored either with PM
or PS abutments. The null hypothesis
(H0) was that there is no difference in
bone changes between PS and PM
between loading and yearly follow-ups.
Materials and Methods
Study design
The prospective multicenter random-ized clinical study was performed in
three centres located in Germany
(two) and Portugal (one). The study
was approved by the competent
Ethics Committees (FECI 09/1308
and CES/0156) and performed in
accordance with the Declaration of
Helsinki (2008).
Study population, inclusion and exclusion
criteria
Patients aged 18 and above with two
or more adjacent missing teeth in the
posterior mandible, a natural tooth
mesial to the most proximal implant
site, adequate bone quality and
quantity at the implant site to permit

the insertion of a dental implant and

with natural teeth or implant-sup-ported fixed restoration as opposing
dentition were included. Free end sit-uations were allowed. All patients
signed the detailed informed consent
form before surgery.
Individuals who presented uncon-trolled systemic diseases or took
medication interfering with bone
metabolism or presenting abuse of
drugs or alcohol, use of tobacco
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
522 Guerra et al.
equivalent to more than 10 ciga-rettes/day or presenting handicaps
that would interfere with the ability
to perform adequate oral hygiene, or
prevent completion of the study par-ticipation were excluded. Local
exclusion criteria included history of
local inflammation, untreated peri-odontitis, mucosal diseases, local
irradiation therapy, history of
implant failure as well as unhealed
extraction sites, keratinized gingiva
less than 4 mm or patient presenting
a thin phenotype or parafunctions.
Exclusion criteria at surgery were
lack of implant primary stability or
inappropriate implant position
according to prosthetic requirements.

Material
Per randomized site, 24 adjacent
CAMLOG

SCREW-LINE Implants
with a Promote

plus surface (CAM-LOG Biotechnologies AG, Basel,

Switzerland) were placed. The most
coronal part of the implant neck pre-sented a machined part of 0.4 mm.
Implant diameter (3.8, 4.3 or 5.0 mm)
and length (9, 11, and 13 mm) were
selected according to available bone.
Healing abutments, impression
posts, and abutments were inserted
timely according to the group. The
mismatch of the PS group was
0.3 mm for the implants with a
diameter of 3.8 and 4.3 mm and
0.35 mm for the implants with a
5.0 mm diameter. All products used
were registered products, commer-cially available and used within their
cleared indications.
Randomization
The study was planned to include at
least 160 implants, corresponding

approximately to 24 patients per cen-tre. A block-randomization list with

block sizes of 4 and 6 was generated
by an independent person. This
allowed a competitive recruitment of
patients. Investigators received a
sealed treatment envelop for each
patient corresponding to either PS or
PM group. Patients who met inclu-sion criteria after implant placement
were randomized. If a patient could
be randomized for both quadrants, it
respected the following priorities:
quadrant where the higher number of
implants was required was first ran-domized; if both quadrants had the
same number of implants priority was
given to quadrant 4.
Pre-treatment and surgical procedures
A calibration meeting preceded the
study initiation. After eligibility the
patients received oral hygiene
instructions and intra-oral photo-graphs were obtained. (Fig. 1a) Pro-phylactic
antibiotics were allowed
according to the procedures of each
centre. Surgery was performed in an
outpatient facility under local anaes-thesia. Implants were placed 0.4 mm
supracrestally. (Fig. 1b) The most
proximal implant was placed 1.5
2.0 mm from the adjacent natural

tooth and a minimal distance of

3.0 mm between two implants was
left depending on the required space
of the prosthetic crown. Primary sta-bility was assessed using direct hand
testing. The healing abutment (PS or
PM) was selected according to the
randomization and fitted immediately
after surgery. Healing was transgingi-val. Radiographs and photographs
were taken immediately post-surgery.
Patients were instructed to use a sur-gical brush in the site and to rinse
three times per day with chlorhexi-dine (0.12%) until sutures were
removed (Fig. 1c).
Prosthesis placement
For implants inserted in bone type I
III, impression (PS or PM) was
planned to be taken at least 6 weeks
post-surgery and in bone type IV at
12 weeks. Final abutments were tor-qued to 20 Ncm and crowns were
cemented 23 weeks later. The day of
prosthesis placement was the baseline
for further measurements (Fig. 1d,e).
Primary and secondary objectives
Theprimary objective was to deter-mine the level at which the bone can
be predictably maintained in relation
to the implant shoulder when the
implants were restored either with

PS or PM abutments.
Bone level changes were evalu-ated on standardized peri-apical
radiographs, which were taken using
a customized holder at pre-surgery,
immediately post-surgery with heal-ing abutment, at loading and at
12 months following baseline with
further evaluations planned at 24,
36, 48 and 60 months post-loading
(a)
(d) (e)
(b) (c)
Fig. 1.(a) Pre-operative view of the edentulous area. (b) The implants placed 0.4 mm
supracrestal. (c) The healing abutments were inserted according to the
randomization
and the flap was sutured. (d) Impression copings. (e) Single ceramo-metal crowns
were
cemented.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 523
(Fig. 2). Two centres used digital
radiography and one centre digitized
their analogue radiographs by scan-ning. The distance from the mesial
and distal first visible bone contact to
the implant shoulder was measured to
the nearest 0.1 mm and the mean of
the two measurements was calculated.

The radiographical measurements

were validated and analysed by an
independent person using ImageJ
1.44p (http://imagej.nih.gov/ij/).
Thesecondary objectives included
implant success and survival rate at
1 year post-loading, performance of
the restorative components, nature
and frequency of the adverse events.
At each control visit the perfor-mance of the restoration and any
occurrence of adverse events were
recorded.
A particular implant was deemed
a success or failure based on an
assessment of implant mobility, peri-implant radiolucency, peri-implant
recurrent infection and pain (Buser
et al. 2002). A crown was deemed
successful if it continued to be sta-ble, functional, and if there was no
associated patient discomfort.
Plaque index (PLI: 03), sulcus
bleeding index (SBI: 03) and probing
pocket depth (PPD) were measured at
four sites per implant at loading,
6-month and 1-year post loading.
Statistical methods
The study was designed to test for

equivalence of crestal bone levels of

the groups receiving PM or PS reha-bilitations. In order to achieve 80%
power at a significance level of 0.01,
sample size was computed consider-ing similar distributions with 0.3 mm
standard deviation (SD; Fischer &
Stenberg 2004) in each group and
minimum difference of 0.2 mm.
PASS 2008 version 0.8.0.4 (NCSS,
LCC, Kaysville, UT, USA) deter-mined that 64 implants were required
per treatment arm, corresponding to
24 (1632) patients per group for ran-domization according to protocol.
This RCT had 5 years of follow-up
including multiple analysis thus the
level of significance of the power
analysis was adjusted to 0.01. Consid-ering that the present paper reported
only the 1-year results, an effective
significance level of 0.05 was used.
Statistical analysis was performed
with the SPSS

Statistics 20 (SPSS
Inc., Chicago, IL, USA). Demo-graphics and baseline characteristics
were descriptively reported. For con-tinuous variables, means, standard
deviations (SD) and 95% confidence
intervals (CI) were calculated for each
treatment group, and numbers and

percentages were calculated for cate-gorical variables. Bone level changes

(BLC) were measured at mesial and
distal implant site and averaged to
represent the BLC over time per
implant. The BLC were compared
with two-wayANOVAconsidering both
randomization and centre effect at a
significance level of 0.05. When no
centre effect was determined, a two-sidedt-test was used. Survival analy-sis was
applied to calculate implant
success and survival rate. Post-hoc
multiple comparisons were performed
using Bonferroni correction.
Results
Subjects and implants
The current status of the study after
1 year of follow-up is illustrated in
Fig. 3. Between May 2009 and
November 2011, a total of 68
patients, 37 male and 31 female were
included. Thirty-five patients were
randomized in the PS and 33 in the
PM group. General health condition
was assessed with the American
Society of Anesthesiologists physical
status classification system (ASA).
Sixty one patients were classified as

ASA 1 (89.7%) and seven patients as

ASA 2 (10.3%). Oral hygiene at sur-gery was considered excellent (1.5%),
good (80.9%) and fair (17.6%) and
was homogeneously distributed
between the two groups. The mean
age of patients was 52.84 10.38 in
the PS and 49.97 14.77 in the PM
group (Table 1a). A total of 146
implants were placed, 74 in the PS
and 72 in the PM group. Sixty-one
implants (41.8%) were 3.8 mm in
diameter, 62 (42.5%) were 4.3 mm
and 23 (15.8%) were 5.0 mm wide.
Their distribution in the two groups
by randomization was almost even.
Seventy-six (52.1%) of the implants
placed were 11 mm in length, 36 in
the PS and 40 in the PM group.
Forty-nine implants (33.6%) were
9 mm in length and 27 were placed in
the PS and 22 in the PM group. Of
the remaining 21 implants (14.4%)
with 13 mm length 11 were placed in
the PS and 10 in the PM group
(Table 1b). The position of implants
by randomization is shown in Fig. 4.

(a) (b)
(c) (d) (e)
(f) (g)
Fig. 2.(a, b) Peri-apical radiographs were standardized using a customized holder (c)
Standardized peri-apical radiographs were taken before implant placement (c),
imme-diately post-surgery (d), before (e) and after abutment/crown placement (f)
and at
1 year post-loading (g).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
524 Guerra et al.
Within the PS group 31 sites
(88.6%) received two and four
(11.4%) received three implants. The
PM group represented 27 sites
(81.8%) with two and six (18.2%)
with three implants.
In both groups the majority of
implants were placed in type II or
type III bone classified according to
Lekholm & Zarb (1985) (Table 1a).
All implants were firmly anchored
and free of mobility at insertion.
Measurement of the torque value was
optional and thus measured for 73
implants (37 in the PS and 36 in the
PM group). Values ranged from 25 to

45 Ncm. After a mean healing period

of 8.56 4.21 weeks in the PS and
8.11 5.21 weeks in the PM group,
impression was taken. Implants were
restored with single crowns 12.33
5.27 weeks post-surgery in the PS and
12.14 6.02 weeks in the PM group.
No statistically significant difference
was observed between the two
groups. The type of cemented crowns
was 81.9% of metal-ceramic for the
PS and 85.1% for the PM group and
18.1% and 14.9% ceramo-ceramic,
respectively.
Implant success and complications
During the healing period two
implants were lost (pre-loading fail-ures) in the PS group, and none in
the PM group, thereafter no compli-cations according to Buser et al.
(2002) were observed yielding to
implant success rates of 97.3% and
100%, respectively. One patient
experienced an extensive ceramic
chipping at 12 months post-loading
visit and required new impression
and prosthesis delivery.
Plaque index, sulcus bleeding index and

probing depth over time

Plaque and sulcus bleeding index
were determined in mean values.
Probing pocket depth (PPD) was
measured in mm and reported in
mean values (Table 2a). No statisti-cal significance was noticed between
the two groups at loading, 6 and
12 months post-loading.
Radiographical changes in crestal bone
levels
Out of the 144 study implants, stan-dard radiographs were available for
Assessed for eligibility (surgery performed)
Patients N= 70
Implants N= 171
Randomized patients/implants
Patients N= 68
Implants N= 146
12-month post-loading (analysed)
Patients N= 34
Implants N= 72
Loading/Prosthesis delivery
Patients N= 34
Implants N= 72
Exclusion after surgery
- Not meeting inclusion criteria:
Patients N= 2

Implants N= 25
Loading/Prosthesis delivery
Patients N= 33
Implants N= 72
12-month post-loading (analysed)
Patients N= 33
Implants N= 72
Platform switching group
Patients N= 35
Implants N= 74
Early failures: 2 implants in one patient lost (PS)
Platform matching group
Patients N = 33
Implants N= 72
Fig. 3.Flow chart of the study design.
Table 1. (a) Demographical and clinical parameter of the study population and the
implanted sites. (b) Implant distribution for PS and PM according to length and
diameter
in mm. 41.8% of the implants were of 3.8 mm, 42.5% of 4.3 mm
(a)
Treatment group PS PM
Characteristics (patients) 35 33
Mean age SD (years) 52.84 10.38 49.97 14.77
Gender male/female 18/17 19/14
Implants per quadrant
2 adjacent implants 31 27
3 adjacent implants 4 6

Implants (n)7472 Centre 1 12 12

Centre 2 25 22
Centre 3 37 38
Bone quality;nimplants (%)
Class I 4 (5.4) 4 (5.6)
Class II 40 (54.1) 45 (62.5)
Class III 26 (35.1) 22 (30.6)
Class IV 4 (5.4) 1 (1.4)
Torque at insertion;nimplants 37 36
Mean SD (Ncm) 31.95 4.39 31.25 3.02
Min/Max 25/45 25/35
(b)
Diameter /Length PS PM
3.8 4.3 5.0 3.8 4.3 5.0
9mm 11889103
11 mm 15 17 4 16 19 5
13mm 452631
Total 30 30 14 31 32 9
PM, platform matching; PS, platform switching.
No significant differences between study groups were observed (Mann Whitney rank
test,
Chi square test).
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 525
142 implants from surgery to
12 months (72 PS and 70 PM) and

for 131 implants from loading to

12 months (70 PS and 61 PM). For
13 implants radiographs were not
taken either at loading (11 implants)
or at 12 months (two implants).
The total mean BLC (a positive
value represents a bone gain, and a
negative a bone loss) from surgery to
12 months was 0.54 0.59 mm
(95% CI: 0.64, 0.44). Two-way
ANOVA determined no interaction
between the centre and the treatment
group on BLC (p=0.762) and no
centre effect was determined (p=
0.533). From surgery the mean BLC
in the PS group was 0.40
0.46 mm (95% CI:0.51,0.29) and
0.69 0.68 mm (95% CI: 0.85,
0.53) in the PM group with signifi-cance (p=0.004).
From loading to 12 months the
total mean BLC was 0.01 0.45 mm
(95% CI: 0.06, 0.09). The analysis
from loading revealed a statistically
significant interaction between the
centre and the treatment group on
BLC (p=0.018). The mean BLC in

the PS group was 0.08 0.41 mm

(95% CI: 0.02, 0.18) and0.06
0.49 mm (95% CI:0.18, 0.07) in the
PM group. Pairwise comparisons for
each centre determined a significant
mean difference of 0.30 between PS
and PM in one centre (p=0.003;
95% CI: 0.04, 0.56). The other two
centers showed no significant differ-ences. Radiographical bone gain from
loading to 12 months was observable
in 67.1% of the PS and in 49.2% of
the PM implants. The results are sum-marized in Table 2b and Fig. 5.
Discussion
In this RCT some study design fac-tors must be taken into consider-ation: to the best
of the authors
knowledge, this is the first RCT
where commercially available
implants with identical outer geome-try and internal implant-abutment
connection for both groups were
used allowing comparable condi-tions. These factors may contribute
to a more accurate and better under-standing of how PS can influence
marginal bone levels around
implants with the same features.
Randomization was done after
surgery regarding to avoid any ten-dency to change surgical protocol.
This aspect is important to exclude
any bias regarding implantation

depth, which revealed to be of influ-ence on marginal bone levels

(Nicolau et al. 2013).
The present study yields a mean
marginal bone level value change
from surgery to 12 months post-loading of 0.40 0.46 mm for PS
and 0.69 0.58 mm for PM,
showing a significant difference
(p=0.004). Our findings are compa-rable with those of Canullo et al.
(2010a) who reported a higher bone
loss in the PM group than in the PS
one. However, their design included
several dimensions of mismatch from
0.25 mm to 0.85 mm. They postu-lated that the BLC could be biased
by the fact the mismatch was done
by increasing the diameter of the
implants and then not necessarily
reflecting the real situation. Our
study reflected a patient-oriented
approach of the real situation since
the diameter of the implant was
selected according to the available
buccal-lingual bone width and the
Fig. 4.Distribution of implants in posterior mandible according to randomization
(platform switching =74, platform matching=72).
Table 2. (a) Soft-tissue health: PI, SBI, PPD. (b) Mean crestal bone level changes in
mm
(a)

PS PM
N Mean SD N Mean SD
Plaque index (Score 03)
Loading 68 0.25 0.46 69 0.06 0.18
6-months 67 0.13 0.22 67 0.06 0.14
12-months 72 0.10 0.21 70 0.09 0.18
Sulcus bleeding index (Score 03)
Loading 68 0.05 0.12 69 0.01 0.06
6-months 67 0.22 0.28 67 0.20 0.32
12-months 72 0.21 0.28 70 0.20 0.29
Probing pocket depth in mm
Loading 64 1.78 0.79 61 1.69 0.51
6-months 62 2.18 0.51 62 2.48 0.59
12-months 72 2.21 0.47 70 2.46 0.51
(b)
PS PM
p-value N Mean SD (mm) N Mean SD (mm)
Surgery to loading 70 0.50 0.42 63 0.66 0.70 Ns
Loading to 12-month 70 0.08 0.41 61 0.06 0.49 Ns
Surgery to 12-month 72 0.40 0.46 70 0.69 0.68 0.004*
ns, non-significant; PM, platform matching; PS, platform switching; PI, plaque index;
PPD,
probing pocket depth; SBI, sulcus bleeding index.
No significant differences between study groups were observed.
*Difference between study groups is statistically significant (independent studentsttest).

2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons

Ltd
526 Guerra et al.
maximum mismatch was 0.35 mm
for the 5.0 mm implants.
Enkling et al. (2011) using
implants with a similar mismatch
(0.35 mm) in the posterior mandible
could not find a statistical difference
between groups. Baseline was at sur-gery, however, implants healed in a
submerged position. This means that
the first 3 months of bone remodel-ing could not be influenced by
different healing abutments as
occurred in our study. Also the fact
that both implants were randomized
next to each other on the same side
of the mandible could influence
marginal bone resorption, this was
not the case in our observations. In
fact, in our study the influence of a
platform healing abutment seemed
to benefit bone preservation in
favour of the platform switching
group.
From prosthetic placement to
1 year post-loading, one centre pre-sented a significant difference
(p=0.003) in mean BLC between

groups, however, the overall results

did not confirm this finding. One of
the explanations to this centre effect
could be the result of patient distri-bution among centres (Table 1a).
H urzeler et al. (2007) in a single cen-tre study reported a significant mean
BLC from final prosthetic recon-struction to 1-year follow-up of
0.12 0.40 mm for PS group and
0.29 0.34 mm for the PM group
(p=0.0132).
Changes were noticed in crestal
bone levels after surgery and before
loading between groups but not sig-nificant and the limited amount of
crestal bone loss is according to a
theoretical biological response to
device installation as reported by
Raghavendra et al. (2005). Indeed,
our flat-to-flat abutment connection
model using platform switching con-cept from the day of surgery (PS
healing abutments, PS impression
posts) could have an influence in
early crestal bone remodeling. This
could be an additional factor in the
biological process taking place
before prosthetic restoration and not
only after as suggested by some
authors (Hermann et al. 2007).

Emphasizing the biological aspect it

seems that bone resorption may be
related to the re-establishment of
biological width that takes place fol-lowing bacterial invasion of the
implant/abutment interface (Canullo
et al. 2012). Indeed, in our study sig-nificant differences were found from
surgery to 12-month post-loading
suggesting that changes could hap-pen in a time-dependent manner.
Some systematic reviews and
meta-analysis suggested an implant/
abutment mismatch of at least
0.4 mm is more beneficial for pre-serving marginal bone (Atieh et al.
2010, and Annibali et al. 2012). In
our study, even with mismatches of
0.3 mm and 0.35 mm we could
observe a difference between PS and
PM. Radiographical bone gain or no
changes at 12 months post-loading
was noted in 67.1% for the platform
switching implants, meaning 47 out
of 70 implants, and 49.2% for the
standard group, meaning 30 impl-ants out of 61.
Of the 146 implants placed, 2
were lost due to pre-loading failure
in the PS group, yielding implant
success rates of 97.3% in PS and

100% in PM. Within the secondary

outcome (PI, SBI, PD) we could not
identify statistical differences bet-ween the two groups.
We hypothesized that there is no
difference at PS and PM 1-year post-loading. We found a statistically sig-nificant
difference in terms of BLC
between the two groups between sur-gery and 12 months post-loading and
no significant difference between
loading and 12 months. Therefore we
were unable to reject the hypothesis.
In spite of that, for each time interval
the mean bone loss and variance were
lower for the PS group. We could
demonstrate that PS reduced peri-implant crestal bone resorption at
1-year post-loading. These results are
in accordance with previous clinical
studies (Cappiello et al. 2008,
Fernandez-Formoso et al. 2012, Tell-eman et al. 2012). This is a 5-year
ongoing clinical study and further
results are necessary to determine if
the concept of PS will show superior-ity in terms of BLC over time, as sug-gested by
other authors (Astrand
et al. 2004, Vigolo & Givani 2009).
Limitations of the present results
are related mostly to the ongoing
status of the study but the relevant
results up to this moment justify dis-semination and may help clinicians,

in our opinion, to decide in a more

accurate perspective and a better
understanding on procedures and
choices between PS and PM abut-ments within the same implant
system.
Conclusions
Within the limitations of the present
study platform switching showed a
positive impact in maintenance or
even enhancement of crestal bone
levels when compared with platform
Fig. 5.Mean bone level changes at 1-year post-loading. Number of implants subdivided in 0.2 mm intervals. In 67.1% of the implants in platform switching group and
49.2% in platform matching group bone gain was observed.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 527
matching abutments of the same
implant system, allowing clinicians
to a better understanding of two
different techniques at 12 months
post-loading.
Acknowledgements
The authors would like to thank
Franc oise Peters, Alex Schar and
Peter Thommen from the Camlog
Foundation for their organizational

support and also to Ana Messias for

her contribution in the statistical
analysis.
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Address:
Fernando Guerra
Area de Medicina Dent aria da Faculdade de
Medicina da Universidade de Coimbra
Avenida Bissaia Barreto
Blocos de CelasHUC
3030 075 Coimbra
Portugal
E-mail: fguerra@ci.uc.pt
Clinical Relevance
Scientific rationale for the study:
Platform switching aims to pre-serve crestal bone height and soft
tissue levels increasing quality out-comes. However, theres a lack of
prospective randomized clinical tri-als evaluating platform switching
versus platform matching with iden-tical implant outer geometry and
same internal implant-abutment con-nection allowing comparable results.
Principal findings: Platform switching
group showed significant interproxi-mal bone preservation or even bone
gain between the time of surgery and
12-month post-loading compared
to the platform matching group.
Practical implications: Platform
switching preserves the marginal

bone level more predictably than

the implants restored with match-ing abutments in the posterior
mandible after 1 year post-loading.
2014 The Authors.Journal of Clinical PeriodontologyPublished by John Wiley & Sons
Ltd
Platform switch versus platform matcha RCT 529
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by

specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.

2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6

Clinical Associate Professor, Department of Restorative Dentistry,

University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.

Location of muscle attachments conducive to denture base stability and retention;

type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla

Location of muscle attachments with moderate influence on denture base stability

and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships

Residual ridge offering no resistance to horizontal or vertical movement; type D

maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment

for triaging the patient upon entry into an institu-tional setting.

Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment

and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.

Criteria 1: Location and Extent of the

Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.

183 September 2002, Volume 11, Number 3

D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.

Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,

periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and

the anterior sextant extends from tooth 6 to tooth 11. In

the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial

edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)

This class is characterized by moderately compro-mised location and extent of

edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4

incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.

Edentulous areas compromise the physiologic

support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.

189 September 2002, Volume 11, Number 3

Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:

Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or

support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:

1.Consideration of future treatment procedures

must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to

achieve and maintain periodontal health so that

appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised

Moderately compromised1-2 sextants

Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.

4. If there is an esthetic concern/challenge, the classification is increased in

complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
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2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
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3. Reynolds JM: Abutment selection for fixed prosthodontics. J
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4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
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option. Dent Clin North Am 1969;13:263-279

6. Kelly E: Changes caused by a mandibular removable partial

denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
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8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
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7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health

1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
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20. Sabri R: Management of missing maxillary lateral incisors.
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193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3

Robert H. Ahlstrom, DDS, MS,

4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.

J Prosthodont 2002;11:181-193. Copyright2002 by The American College of

Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in

a simplified, sequential progression designed to fa-cilitate consistent and

predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.

This project was funded by the American College of Prosthodontists.

Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.

Residual bone height of 16 to 20 mm measured at the least vertical height of the

mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required

Multiple extractions leading to complete edentulism for immediate denture

placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required

Hard tissue augmentation required

Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.

The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical

outcomes will be evaluated in terms of evi-dence-based criteria.

When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that

does not exceed 4 incisors

Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition

Abutments in 1 or 2 sextants* have insufficient

tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.

Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.

(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum

intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:

The edentulous area is confined to a single arch.

The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.

187 September 2002, Volume 11, Number 3

Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized

adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth

structure to retain or support intracoronal or

extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,

maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive

relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.

4.Residual ridge morphology conforms to the class

IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.

191 September 2002, Volume 11, Number 3

4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those

patients most likely to require treatment by a spe-cialist or by a practitioner with

additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD

Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by

practitioners, educators, and researchers, this sys-tem will be modified as needed.

Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
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with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7

The American College of Prosthodontists (ACP) has developed a classification

system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic

criteria for partial edentulism has been a long-standing impediment to effective

recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2

Professor and Chairman, Department of Prosthodontics, University of

Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094

181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193

TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations

Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV

This class represents the most debilitated edentulous condition. Surgical

reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology

Hyperactive gag reflex managed with medication

Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).

The classification system is intended to offer the

following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria

This section describes four broad diagnostic catego-ries relevant to classification of

partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors

Any anterior mandibular edentulous area that

does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered

type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics

Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.

Class II division 2 and Class III molar and jaw

relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.

2.The abutment condition is ideal or minimally

compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical

dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the

Class II complete edentulism description.

Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal

scheme without an accompanying change in the

occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas

results in severe occlusal compromise:

Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of

Classification System for

Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism

classification system, and the mandible is classi-fied according to the partial

edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,

will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia

Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
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The biologic price of prosthodontic intervention. Aust Dent

J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39

22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont

1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical

situation and class IV representing a complex clinical situation. Each class is

differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification

system for complete edentulism.

2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.

6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.

Location of muscle attachments conducive to denture base stability and retention;

type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla

Location of muscle attachments with moderate influence on denture base stability

and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships

Residual ridge offering no resistance to horizontal or vertical movement; type D

maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment

for triaging the patient upon entry into an institu-tional setting.

Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment

and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.

Criteria 1: Location and Extent of the

Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.

183 September 2002, Volume 11, Number 3

D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.

Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,

periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and

the anterior sextant extends from tooth 6 to tooth 11. In

the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial

edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)

This class is characterized by moderately compro-mised location and extent of

edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4

incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.

Edentulous areas compromise the physiologic

support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.

189 September 2002, Volume 11, Number 3

Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:

Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or

support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:

1.Consideration of future treatment procedures

must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to

achieve and maintain periodontal health so that

appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised

Moderately compromised1-2 sextants

Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.

4. If there is an esthetic concern/challenge, the classification is increased in

complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
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6. Kelly E: Changes caused by a mandibular removable partial

denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
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8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
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North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health

1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
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distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
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with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3

Robert H. Ahlstrom, DDS, MS,

4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.

J Prosthodont 2002;11:181-193. Copyright2002 by The American College of

Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in

a simplified, sequential progression designed to fa-cilitate consistent and

predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.

This project was funded by the American College of Prosthodontists.

Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.

Residual bone height of 16 to 20 mm measured at the least vertical height of the

mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required

Multiple extractions leading to complete edentulism for immediate denture

placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required

Hard tissue augmentation required

Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.

The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical

outcomes will be evaluated in terms of evi-dence-based criteria.

When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that

does not exceed 4 incisors

Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition

Abutments in 1 or 2 sextants* have insufficient

tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.

Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.

(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum

intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:

The edentulous area is confined to a single arch.

The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.

187 September 2002, Volume 11, Number 3

Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized

adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth

structure to retain or support intracoronal or

extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,

maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive

relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.

4.Residual ridge morphology conforms to the class

IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.

191 September 2002, Volume 11, Number 3

4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those

patients most likely to require treatment by a spe-cialist or by a practitioner with

additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD

Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by

practitioners, educators, and researchers, this sys-tem will be modified as needed.

Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34

9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin

North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the

Kennedy classification. J Oral Rehabil 1999;26:165-169

19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7

The American College of Prosthodontists (ACP) has developed a classification

system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic

criteria for partial edentulism has been a long-standing impediment to effective

recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2

Professor and Chairman, Department of Prosthodontics, University of

Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094

181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193

TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations

Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV

This class represents the most debilitated edentulous condition. Surgical

reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology

Hyperactive gag reflex managed with medication

Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).

The classification system is intended to offer the

following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria

This section describes four broad diagnostic catego-ries relevant to classification of

partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors

Any anterior mandibular edentulous area that

does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered

type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics

Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.

Class II division 2 and Class III molar and jaw

relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.

2.The abutment condition is ideal or minimally

compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical

dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the

Class II complete edentulism description.

Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal

scheme without an accompanying change in the

occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas

results in severe occlusal compromise:

Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of

Classification System for

Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism

classification system, and the mandible is classi-fied according to the partial

edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,

will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia

Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:

Suggestions for its preservation. J Prosthet Dent 1951;2:210-218

2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent

J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39

22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont

1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical

situation and class IV representing a complex clinical situation. Each class is

differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification

system for complete edentulism.

2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.

6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.

Location of muscle attachments conducive to denture base stability and retention;

type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla

Location of muscle attachments with moderate influence on denture base stability

and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships

Residual ridge offering no resistance to horizontal or vertical movement; type D

maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment

for triaging the patient upon entry into an institu-tional setting.

Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment

and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.

Criteria 1: Location and Extent of the

Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.

183 September 2002, Volume 11, Number 3

D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.

Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,

periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and

the anterior sextant extends from tooth 6 to tooth 11. In

the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial

edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)

This class is characterized by moderately compro-mised location and extent of

edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4

incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.

Edentulous areas compromise the physiologic

support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.

189 September 2002, Volume 11, Number 3

Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:

Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or

support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:

1.Consideration of future treatment procedures

must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to

achieve and maintain periodontal health so that

appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised

Moderately compromised1-2 sextants

Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.

4. If there is an esthetic concern/challenge, the classification is increased in

complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279

6. Kelly E: Changes caused by a mandibular removable partial

denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health

1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3

Robert H. Ahlstrom, DDS, MS,

4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.

J Prosthodont 2002;11:181-193. Copyright2002 by The American College of

Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in

a simplified, sequential progression designed to fa-cilitate consistent and

predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.

This project was funded by the American College of Prosthodontists.

Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.

Residual bone height of 16 to 20 mm measured at the least vertical height of the

mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required

Multiple extractions leading to complete edentulism for immediate denture

placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required

Hard tissue augmentation required

Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.

The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical

outcomes will be evaluated in terms of evi-dence-based criteria.

When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that

does not exceed 4 incisors

Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition

Abutments in 1 or 2 sextants* have insufficient

tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.

Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.

(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum

intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:

The edentulous area is confined to a single arch.

The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.

187 September 2002, Volume 11, Number 3

Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized

adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth

structure to retain or support intracoronal or

extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,

maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive

relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.

4.Residual ridge morphology conforms to the class

IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.

191 September 2002, Volume 11, Number 3

4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those

patients most likely to require treatment by a spe-cialist or by a practitioner with

additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD

Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by

practitioners, educators, and researchers, this sys-tem will be modified as needed.

Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34

9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin

North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the

Kennedy classification. J Oral Rehabil 1999;26:165-169

19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7

The American College of Prosthodontists (ACP) has developed a classification

system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic

criteria for partial edentulism has been a long-standing impediment to effective

recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2

Professor and Chairman, Department of Prosthodontics, University of

Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094

181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193

TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations

Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV

This class represents the most debilitated edentulous condition. Surgical

reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology

Hyperactive gag reflex managed with medication

Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).

The classification system is intended to offer the

following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria

This section describes four broad diagnostic catego-ries relevant to classification of

partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors

Any anterior mandibular edentulous area that

does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered

type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics

Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.

Class II division 2 and Class III molar and jaw

relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.

2.The abutment condition is ideal or minimally

compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical

dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the

Class II complete edentulism description.

Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal

scheme without an accompanying change in the

occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas

results in severe occlusal compromise:

Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of

Classification System for

Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism

classification system, and the mandible is classi-fied according to the partial

edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,

will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia

Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:

Suggestions for its preservation. J Prosthet Dent 1951;2:210-218

2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent

J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39

22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont

1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical

situation and class IV representing a complex clinical situation. Each class is

differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification

system for complete edentulism.

2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.

6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.

Location of muscle attachments conducive to denture base stability and retention;

type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla

Location of muscle attachments with moderate influence on denture base stability

and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships

Residual ridge offering no resistance to horizontal or vertical movement; type D

maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment

for triaging the patient upon entry into an institu-tional setting.

Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment

and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.

Criteria 1: Location and Extent of the

Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.

183 September 2002, Volume 11, Number 3

D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.

Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,

periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and

the anterior sextant extends from tooth 6 to tooth 11. In

the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial

edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)

This class is characterized by moderately compro-mised location and extent of

edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4

incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.

Edentulous areas compromise the physiologic

support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.

189 September 2002, Volume 11, Number 3

Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:

Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or

support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:

1.Consideration of future treatment procedures

must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to

achieve and maintain periodontal health so that

appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised

Moderately compromised1-2 sextants

Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.

4. If there is an esthetic concern/challenge, the classification is increased in

complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279

6. Kelly E: Changes caused by a mandibular removable partial

denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health

1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3

Robert H. Ahlstrom, DDS, MS,

4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.

J Prosthodont 2002;11:181-193. Copyright2002 by The American College of

Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in

a simplified, sequential progression designed to fa-cilitate consistent and

predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.

This project was funded by the American College of Prosthodontists.

Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.

Residual bone height of 16 to 20 mm measured at the least vertical height of the

mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required

Multiple extractions leading to complete edentulism for immediate denture

placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required

Hard tissue augmentation required

Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.

The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical

outcomes will be evaluated in terms of evi-dence-based criteria.

When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that

does not exceed 4 incisors

Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition

Abutments in 1 or 2 sextants* have insufficient

tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.

Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.

(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum

intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:

The edentulous area is confined to a single arch.

The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.

187 September 2002, Volume 11, Number 3

Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized

adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth

structure to retain or support intracoronal or

extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,

maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive

relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.

4.Residual ridge morphology conforms to the class

IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.

191 September 2002, Volume 11, Number 3

4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those

patients most likely to require treatment by a spe-cialist or by a practitioner with

additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD

Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by

practitioners, educators, and researchers, this sys-tem will be modified as needed.

Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34

9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin

North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the

Kennedy classification. J Oral Rehabil 1999;26:165-169

19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7

The American College of Prosthodontists (ACP) has developed a classification

system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic

criteria for partial edentulism has been a long-standing impediment to effective

recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2

Professor and Chairman, Department of Prosthodontics, University of

Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094

181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193

TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations

Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV

This class represents the most debilitated edentulous condition. Surgical

reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology

Hyperactive gag reflex managed with medication

Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).

The classification system is intended to offer the

following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria

This section describes four broad diagnostic catego-ries relevant to classification of

partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors

Any anterior mandibular edentulous area that

does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered

type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics

Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.

Class II division 2 and Class III molar and jaw

relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.

2.The abutment condition is ideal or minimally

compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical

dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the

Class II complete edentulism description.

Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal

scheme without an accompanying change in the

occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas

results in severe occlusal compromise:

Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of

Classification System for

Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism

classification system, and the mandible is classi-fied according to the partial

edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,

will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia

Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:

Suggestions for its preservation. J Prosthet Dent 1951;2:210-218

2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent

J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39

22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont

1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical

situation and class IV representing a complex clinical situation. Each class is

differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification

system for complete edentulism.

2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.

6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.

Location of muscle attachments conducive to denture base stability and retention;

type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla

Location of muscle attachments with moderate influence on denture base stability

and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships

Residual ridge offering no resistance to horizontal or vertical movement; type D

maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment

for triaging the patient upon entry into an institu-tional setting.

Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment

and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.

Criteria 1: Location and Extent of the

Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.

183 September 2002, Volume 11, Number 3

D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.

Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,

periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and

the anterior sextant extends from tooth 6 to tooth 11. In

the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial

edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)

This class is characterized by moderately compro-mised location and extent of

edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4

incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.

Edentulous areas compromise the physiologic

support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.

189 September 2002, Volume 11, Number 3

Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:

Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or

support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:

1.Consideration of future treatment procedures

must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to

achieve and maintain periodontal health so that

appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised

Moderately compromised1-2 sextants

Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.

4. If there is an esthetic concern/challenge, the classification is increased in

complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279

6. Kelly E: Changes caused by a mandibular removable partial

denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health

1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3

Robert H. Ahlstrom, DDS, MS,

4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.

J Prosthodont 2002;11:181-193. Copyright2002 by The American College of

Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in

a simplified, sequential progression designed to fa-cilitate consistent and

predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.

This project was funded by the American College of Prosthodontists.

Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.

Residual bone height of 16 to 20 mm measured at the least vertical height of the

mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required

Multiple extractions leading to complete edentulism for immediate denture

placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required

Hard tissue augmentation required

Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.

The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical

outcomes will be evaluated in terms of evi-dence-based criteria.

When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that

does not exceed 4 incisors

Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition

Abutments in 1 or 2 sextants* have insufficient

tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.

Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.

(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum

intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:

The edentulous area is confined to a single arch.

The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.

187 September 2002, Volume 11, Number 3

Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized

adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth

structure to retain or support intracoronal or

extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,

maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive

relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.

4.Residual ridge morphology conforms to the class

IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.

191 September 2002, Volume 11, Number 3

4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those

patients most likely to require treatment by a spe-cialist or by a practitioner with

additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD

Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by

practitioners, educators, and researchers, this sys-tem will be modified as needed.

Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34

9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin

North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the

Kennedy classification. J Oral Rehabil 1999;26:165-169

19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7

The American College of Prosthodontists (ACP) has developed a classification

system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic

criteria for partial edentulism has been a long-standing impediment to effective

recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2

Professor and Chairman, Department of Prosthodontics, University of

Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094

181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193

TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations

Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV

This class represents the most debilitated edentulous condition. Surgical

reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology

Hyperactive gag reflex managed with medication

Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).

The classification system is intended to offer the

following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria

This section describes four broad diagnostic catego-ries relevant to classification of

partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors

Any anterior mandibular edentulous area that

does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered

type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics

Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.

Class II division 2 and Class III molar and jaw

relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.

2.The abutment condition is ideal or minimally

compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical

dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the

Class II complete edentulism description.

Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal

scheme without an accompanying change in the

occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas

results in severe occlusal compromise:

Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of

Classification System for

Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism

classification system, and the mandible is classi-fied according to the partial

edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,

will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia

Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:

Suggestions for its preservation. J Prosthet Dent 1951;2:210-218

2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent

J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39

22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont

1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical

situation and class IV representing a complex clinical situation. Each class is

differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification

system for complete edentulism.

2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.

6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.

Location of muscle attachments conducive to denture base stability and retention;

type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla

Location of muscle attachments with moderate influence on denture base stability

and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships

Residual ridge offering no resistance to horizontal or vertical movement; type D

maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment

for triaging the patient upon entry into an institu-tional setting.

Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment

and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.

Criteria 1: Location and Extent of the

Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.

183 September 2002, Volume 11, Number 3

D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.

Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,

periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and

the anterior sextant extends from tooth 6 to tooth 11. In

the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial

edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)

This class is characterized by moderately compro-mised location and extent of

edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4

incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.

Edentulous areas compromise the physiologic

support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.

189 September 2002, Volume 11, Number 3

Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:

Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or

support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:

1.Consideration of future treatment procedures

must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to

achieve and maintain periodontal health so that

appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised

Moderately compromised1-2 sextants

Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.

4. If there is an esthetic concern/challenge, the classification is increased in

complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279

6. Kelly E: Changes caused by a mandibular removable partial

denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health

1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3

Robert H. Ahlstrom, DDS, MS,

4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.

J Prosthodont 2002;11:181-193. Copyright2002 by The American College of

Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in

a simplified, sequential progression designed to fa-cilitate consistent and

predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.

This project was funded by the American College of Prosthodontists.

Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.

Residual bone height of 16 to 20 mm measured at the least vertical height of the

mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required

Multiple extractions leading to complete edentulism for immediate denture

placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required

Hard tissue augmentation required

Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.

The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical

outcomes will be evaluated in terms of evi-dence-based criteria.

When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that

does not exceed 4 incisors

Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition

Abutments in 1 or 2 sextants* have insufficient

tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.

Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.

(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum

intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:

The edentulous area is confined to a single arch.

The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.

187 September 2002, Volume 11, Number 3

Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized

adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth

structure to retain or support intracoronal or

extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,

maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive

relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.

4.Residual ridge morphology conforms to the class

IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.

191 September 2002, Volume 11, Number 3

4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those

patients most likely to require treatment by a spe-cialist or by a practitioner with

additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD

Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by

practitioners, educators, and researchers, this sys-tem will be modified as needed.

Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34

9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin

North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the

Kennedy classification. J Oral Rehabil 1999;26:165-169

19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7

The American College of Prosthodontists (ACP) has developed a classification

system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic

criteria for partial edentulism has been a long-standing impediment to effective

recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2

Professor and Chairman, Department of Prosthodontics, University of

Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094

181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193

TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations

Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV

This class represents the most debilitated edentulous condition. Surgical

reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology

Hyperactive gag reflex managed with medication

Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).

The classification system is intended to offer the

following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria

This section describes four broad diagnostic catego-ries relevant to classification of

partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors

Any anterior mandibular edentulous area that

does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered

type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics

Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.

Class II division 2 and Class III molar and jaw

relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.

2.The abutment condition is ideal or minimally

compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical

dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the

Class II complete edentulism description.

Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal

scheme without an accompanying change in the

occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas

results in severe occlusal compromise:

Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of

Classification System for

Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism

classification system, and the mandible is classi-fied according to the partial

edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,

will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia

Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:

Suggestions for its preservation. J Prosthet Dent 1951;2:210-218

2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent

J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39

22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont

1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical

situation and class IV representing a complex clinical situation. Each class is

differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification

system for complete edentulism.

2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.

6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.

Location of muscle attachments conducive to denture base stability and retention;

type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla

Location of muscle attachments with moderate influence on denture base stability

and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships

Residual ridge offering no resistance to horizontal or vertical movement; type D

maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment

for triaging the patient upon entry into an institu-tional setting.

Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment

and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.

Criteria 1: Location and Extent of the

Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.

183 September 2002, Volume 11, Number 3

D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.

Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,

periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and

the anterior sextant extends from tooth 6 to tooth 11. In

the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial

edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)

This class is characterized by moderately compro-mised location and extent of

edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4

incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.

Edentulous areas compromise the physiologic

support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.

189 September 2002, Volume 11, Number 3

Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:

Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or

support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:

1.Consideration of future treatment procedures

must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to

achieve and maintain periodontal health so that

appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised

Moderately compromised1-2 sextants

Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.

4. If there is an esthetic concern/challenge, the classification is increased in

complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279

6. Kelly E: Changes caused by a mandibular removable partial

denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health

1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3

Robert H. Ahlstrom, DDS, MS,

4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.

J Prosthodont 2002;11:181-193. Copyright2002 by The American College of

Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in

a simplified, sequential progression designed to fa-cilitate consistent and

predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.

This project was funded by the American College of Prosthodontists.

Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.

Residual bone height of 16 to 20 mm measured at the least vertical height of the

mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required

Multiple extractions leading to complete edentulism for immediate denture

placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required

Hard tissue augmentation required

Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.

The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical

outcomes will be evaluated in terms of evi-dence-based criteria.

When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that

does not exceed 4 incisors

Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition

Abutments in 1 or 2 sextants* have insufficient

tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.

Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.

(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum

intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:

The edentulous area is confined to a single arch.

The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.

187 September 2002, Volume 11, Number 3

Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized

adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth

structure to retain or support intracoronal or

extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,

maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive

relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.

4.Residual ridge morphology conforms to the class

IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.

191 September 2002, Volume 11, Number 3

4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those

patients most likely to require treatment by a spe-cialist or by a practitioner with

additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD

Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by

practitioners, educators, and researchers, this sys-tem will be modified as needed.

Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34

9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin

North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the

Kennedy classification. J Oral Rehabil 1999;26:165-169

19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7

The American College of Prosthodontists (ACP) has developed a classification

system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic

criteria for partial edentulism has been a long-standing impediment to effective

recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2

Professor and Chairman, Department of Prosthodontics, University of

Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094

181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193

TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations

Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV

This class represents the most debilitated edentulous condition. Surgical

reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology

Hyperactive gag reflex managed with medication

Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).

The classification system is intended to offer the

following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria

This section describes four broad diagnostic catego-ries relevant to classification of

partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors

Any anterior mandibular edentulous area that

does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered

type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics

Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.

Class II division 2 and Class III molar and jaw

relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.

2.The abutment condition is ideal or minimally

compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical

dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the

Class II complete edentulism description.

Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal

scheme without an accompanying change in the

occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas

results in severe occlusal compromise:

Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of

Classification System for

Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism

classification system, and the mandible is classi-fied according to the partial

edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,

will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia

Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:

Suggestions for its preservation. J Prosthet Dent 1951;2:210-218

2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent

J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39

22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont

1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical

situation and class IV representing a complex clinical situation. Each class is

differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification

system for complete edentulism.

2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.

6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.

Location of muscle attachments conducive to denture base stability and retention;

type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla

Location of muscle attachments with moderate influence on denture base stability

and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships

Residual ridge offering no resistance to horizontal or vertical movement; type D

maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment

for triaging the patient upon entry into an institu-tional setting.

Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment

and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.

Criteria 1: Location and Extent of the

Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.

183 September 2002, Volume 11, Number 3

D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.

Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,

periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and

the anterior sextant extends from tooth 6 to tooth 11. In

the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial

edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)

This class is characterized by moderately compro-mised location and extent of

edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4

incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.

Edentulous areas compromise the physiologic

support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.

189 September 2002, Volume 11, Number 3

Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:

Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or

support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:

1.Consideration of future treatment procedures

must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to

achieve and maintain periodontal health so that

appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised

Moderately compromised1-2 sextants

Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.

4. If there is an esthetic concern/challenge, the classification is increased in

complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279

6. Kelly E: Changes caused by a mandibular removable partial

denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health

1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3

Robert H. Ahlstrom, DDS, MS,

4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.

J Prosthodont 2002;11:181-193. Copyright2002 by The American College of

Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in

a simplified, sequential progression designed to fa-cilitate consistent and

predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.

This project was funded by the American College of Prosthodontists.

Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.

Residual bone height of 16 to 20 mm measured at the least vertical height of the

mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required

Multiple extractions leading to complete edentulism for immediate denture

placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required

Hard tissue augmentation required

Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.

The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical

outcomes will be evaluated in terms of evi-dence-based criteria.

When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that

does not exceed 4 incisors

Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition

Abutments in 1 or 2 sextants* have insufficient

tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.

Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.

(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum

intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:

The edentulous area is confined to a single arch.

The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.

187 September 2002, Volume 11, Number 3

Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized

adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth

structure to retain or support intracoronal or

extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,

maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive

relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.

4.Residual ridge morphology conforms to the class

IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.

191 September 2002, Volume 11, Number 3

4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those

patients most likely to require treatment by a spe-cialist or by a practitioner with

additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD

Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by

practitioners, educators, and researchers, this sys-tem will be modified as needed.

Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34

9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin

North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the

Kennedy classification. J Oral Rehabil 1999;26:165-169

19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jTOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical

situation and class IV representing a complex clinical situation. Each class is

differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification

system for complete edentulism.

2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.

6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.

Location of muscle attachments conducive to denture base stability and retention;

type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla

Location of muscle attachments with moderate influence on denture base stability

and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships

Residual ridge offering no resistance to horizontal or vertical movement; type D

maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment

for triaging the patient upon entry into an institu-tional setting.

Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment

and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.

Criteria 1: Location and Extent of the

Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.

183 September 2002, Volume 11, Number 3

D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.

Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,

periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and

the anterior sextant extends from tooth 6 to tooth 11. In

the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial

edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)

This class is characterized by moderately compro-mised location and extent of

edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4

incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.

Edentulous areas compromise the physiologic

support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.

189 September 2002, Volume 11, Number 3

Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:

Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or

support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:

1.Consideration of future treatment procedures

must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to

achieve and maintain periodontal health so that

appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised

Moderately compromised1-2 sextants

Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.

4. If there is an esthetic concern/challenge, the classification is increased in

complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
Suggestions for its preservation. J Prosthet Dent 1951;2:210-218
2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279

6. Kelly E: Changes caused by a mandibular removable partial

denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34
9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin
North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health

1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
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193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3

Robert H. Ahlstrom, DDS, MS,

4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.

J Prosthodont 2002;11:181-193. Copyright2002 by The American College of

Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in

a simplified, sequential progression designed to fa-cilitate consistent and

predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.

This project was funded by the American College of Prosthodontists.

Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.

Residual bone height of 16 to 20 mm measured at the least vertical height of the

mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required

Multiple extractions leading to complete edentulism for immediate denture

placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required

Hard tissue augmentation required

Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.

The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical

outcomes will be evaluated in terms of evi-dence-based criteria.

When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that

does not exceed 4 incisors

Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition

Abutments in 1 or 2 sextants* have insufficient

tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.

Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.

(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum

intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:

The edentulous area is confined to a single arch.

The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.

187 September 2002, Volume 11, Number 3

Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized

adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth

structure to retain or support intracoronal or

extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,

maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive

relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.

4.Residual ridge morphology conforms to the class

IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.

191 September 2002, Volume 11, Number 3

4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those

patients most likely to require treatment by a spe-cialist or by a practitioner with

additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD

Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by

practitioners, educators, and researchers, this sys-tem will be modified as needed.

Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
1. DeVan MM: The nature of the partial denture foundation:
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2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
Prosthet Dent 1960;10:112
3. Reynolds JM: Abutment selection for fixed prosthodontics. J
Prosthet Dent 1968;19:483-488
4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
for the periodontal patient. The current statusan
option. Dent Clin North Am 1969;13:263-279
6. Kelly E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J Prosthet
Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
edentulous patient. Dent Clin North Am 1973;17:611-630
8. Turner CH, Ritchie GM: The problems of maxillary com-plete dentures opposed by
retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34

9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin

North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the

Kennedy classification. J Oral Rehabil 1999;26:165-169

19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
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193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7

The American College of Prosthodontists (ACP) has developed a classification

system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic

criteria for partial edentulism has been a long-standing impediment to effective

recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2

Professor and Chairman, Department of Prosthodontics, University of

Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094

181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193

TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations

Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV

This class represents the most debilitated edentulous condition. Surgical

reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology

Hyperactive gag reflex managed with medication

Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).

The classification system is intended to offer the

following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria

This section describes four broad diagnostic catego-ries relevant to classification of

partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors

Any anterior mandibular edentulous area that

does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered

type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics

Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.

Class II division 2 and Class III molar and jaw

relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.

2.The abutment condition is ideal or minimally

compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical

dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the

Class II complete edentulism description.

Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal

scheme without an accompanying change in the

occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas

results in severe occlusal compromise:

Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of

Classification System for

Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism

classification system, and the mandible is classi-fied according to the partial

edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,

will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia

Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
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193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical

situation and class IV representing a complex clinical situation. Each class is

differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification

system for complete edentulism.

2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.

6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.

Location of muscle attachments conducive to denture base stability and retention;

type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla

Location of muscle attachments with moderate influence on denture base stability

and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships

Residual ridge offering no resistance to horizontal or vertical movement; type D

maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment

for triaging the patient upon entry into an institu-tional setting.

Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment

and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.

Criteria 1: Location and Extent of the

Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.

183 September 2002, Volume 11, Number 3

D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.

Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,

periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and

the anterior sextant extends from tooth 6 to tooth 11. In

the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial

edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)

This class is characterized by moderately compro-mised location and extent of

edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4

incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.

Edentulous areas compromise the physiologic

support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.

189 September 2002, Volume 11, Number 3

Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:

Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or

support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:

1.Consideration of future treatment procedures

must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to

achieve and maintain periodontal health so that

appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised

Moderately compromised1-2 sextants

Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.

4. If there is an esthetic concern/challenge, the classification is increased in

complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
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1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the
Kennedy classification. J Oral Rehabil 1999;26:165-169
19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3

Robert H. Ahlstrom, DDS, MS,

4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7
The American College of Prosthodontists (ACP) has developed a classification
system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.

J Prosthodont 2002;11:181-193. Copyright2002 by The American College of

Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic
criteria for partial edentulism has been a long-standing impediment to effective
recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in

a simplified, sequential progression designed to fa-cilitate consistent and

predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2
Professor and Chairman, Department of Prosthodontics, University of
Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.

This project was funded by the American College of Prosthodontists.

Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094
181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193
TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.

Residual bone height of 16 to 20 mm measured at the least vertical height of the

mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations
Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required

Multiple extractions leading to complete edentulism for immediate denture

placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV
This class represents the most debilitated edentulous condition. Surgical
reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required

Hard tissue augmentation required

Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology
Hyperactive gag reflex managed with medication
Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.

The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).
The classification system is intended to offer the
following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical

outcomes will be evaluated in terms of evi-dence-based criteria.

When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria
This section describes four broad diagnostic catego-ries relevant to classification of
partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that

does not exceed 4 incisors

Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition

Abutments in 1 or 2 sextants* have insufficient

tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered
type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.

Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics
Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.

(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum

intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.
Class II division 2 and Class III molar and jaw
relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:

The edentulous area is confined to a single arch.

The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.
2.The abutment condition is ideal or minimally
compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.

187 September 2002, Volume 11, Number 3

Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical
dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum
intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized

adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class II complete edentulism description.
Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth

structure to retain or support intracoronal or

extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal
scheme without an accompanying change in the
occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,

maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive

relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas
results in severe occlusal compromise:
Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.

4.Residual ridge morphology conforms to the class

IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of
Classification System for
Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.

191 September 2002, Volume 11, Number 3

4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism
classification system, and the mandible is classi-fied according to the partial
edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those

patients most likely to require treatment by a spe-cialist or by a practitioner with

additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,
will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD

Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by

practitioners, educators, and researchers, this sys-tem will be modified as needed.

Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
References
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2. Applegate OC: An evaluation of the support for the remov-able partial denture. J
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3. Reynolds JM: Abutment selection for fixed prosthodontics. J
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4. Mehta JD, Joglekar AP: Vertical jaw relations as a factor in
partial dentures. J Prosthet Dent 1969;21:618-625
5. Willarson KL: Removable partial denture prosthesis
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6. Kelly E: Changes caused by a mandibular removable partial
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Dent 1972;27:140-150
7. Laney WR, Desjardins RP: Surgical preparation of the partially
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retained mandibular incisor and
canine teeth (I). Quintessence Int 1978;9:29-34

9. Culpepper WD, Moulton PS: Considerations in fixed prosth-odontics. Dent Clin

North Am 1979;23:21-35
10. Saunders TR, Gillis RE Jr, Desjardins RP: The maxillary
complete denture opposing the mandibular bilateral distal-extension partial
denture: Treatment considerations. J Pros-thet Dent 1979;41:124-128
11. Dibai N, Mechanic E: Prosthodontic treatment for the com-plex mandibular Class
I partially edentulous patient. J Dent
Que 1980;17:63-65
12. Zarb GA, MacKay HF: The partially edentulous patient. I.
The biologic price of prosthodontic intervention. Aust Dent
J 1980;25:63-68
13. Pekkarinen V, Yli-Urpo A: Dysfunction of the masticatory
system and the mutilated dental arch: Anamnestic index,
dysfunction index and occlusal index before restorative and
prosthetic treatment. Proc Finn Dent Soc 1984;80:73-79
14. Misch CE, Judy KW: Classification of partially edentulous
arches for implant dentistry. Int J Oral Implantol 1987;4:
7-13
15. Arlin ML: Dental implants and the partially edentulous
patient. Diagnosis and treatment planning. Oral Health
1989;79:19-21
16. Devlin H: Replacement of missing molar teethA prosth-odontic dilemma. Br
Dent J 1994;176:31-33
17. Goldberg PV: Retention of teeth and placement of implan-tsin the partially
edentulous maxilla: the decision-making
process. Dent Implantol Update 1995;6:9-13
18. Ben-Ur Z, Shifman BZ, Aviv I: Further aspects of design for
distal extension removable partial dentures based on the

Kennedy classification. J Oral Rehabil 1999;26:165-169

19. Ihde SK: Fixed prosthodontics in skeletal Class III patients
with partially edentulous jaws and age-related prognathism:
The basal osseointegration procedure. Implant Dent 1999;
8:241-246
20. Sabri R: Management of missing maxillary lateral incisors.
J Am Dent Assoc 1999;130:80-84
21. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system
for complete edentulism. J Prosthodont 1999;8:27-39
22. Parameters of Care for the American College of Prosth-odontists. J Prosthodont
1996;5:3-71
193 September 2002, Volume 11, Number 3TOPICS OFINTEREST
Classification System for Partial Edentulism
Thomas J. McGarry, DDS,
1
Arthur Nimmo, DDS,
2
James F. Skiba, DDS,
3
Robert H. Ahlstrom, DDS, MS,
4
Christopher R. Smith, DDS,
5
Jack H. Koumjian, DDS, MSD,
6
and Nancy S. Arbree, DDS, MS
7

The American College of Prosthodontists (ACP) has developed a classification

system for partial
edentulism based on diagnostic findings. This classification system is similar to the
classification
system for complete edentulism previously developed by the ACP. These guidelines
are intended to
help practitioners determine appropriate treatments for their patients. Four
categories of partial
edentulism are defined, Class I to Class IV, with Class I representing an
uncomplicated clinical
situation and class IV representing a complex clinical situation. Each class is
differentiated by
specific diagnostic criteria. This system is designed for use by dental professionals
involved in the
diagnosis and treatment of partially edentulous patients. Potential benefits of the
system include (1)
improved intraoperator consistency, (2) improved professional communication, (3)
insurance reim-bursement commensurate with complexity of care, (4) improved
screening tool for dental school
admission clinics, (5) standardized criteria for outcomes assessment and research,
(6) enhanced
diagnostic consistency, and (7) simplified aid in the decision to refer a patient.
J Prosthodont 2002;11:181-193. Copyright2002 by The American College of
Prosthodontists.
INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education,
outcomes
assessment, quality assurance, treatment outcomes, patient risk profiles
P
ARTIALLY EDENTULOUSpatients exhibit a wide
range of physical variations and health con-ditions. The absence of organized
diagnostic

criteria for partial edentulism has been a long-standing impediment to effective

recognition
of risk factors that may affect treatment out-comes. Although described thoroughly
in the
dental literature,1-0
the diverse nature of par-tial edentulism has not been organized in such
a way to guide dental professionals in the treat-ment planning process. To address
this prob-lem, the American College of Prosthodontists
(ACP) Subcommittee on Prosthodontic Classi-fication was formed and charged with
develop-ing a classification system for partial edentu-lism consistent with the
existing classification
system for complete edentulism.
2
A summary
of the ACP edentulous classification system is
given in Table 1.
The purpose of this classification system is to
provide a framework for the organization of clinical
observations. Clinical variables that establish dif-ferent levels of partial edentulism
are organized in
a simplified, sequential progression designed to fa-cilitate consistent and
predictable treatment plan-ning decisions. This framework is designed to indi-cate
increasing levels of diagnostic and treatment
complexity presented by patients with varying de-grees of partial edentulism. This
may suggest
points at which referral to other specialists is ap-propriate. The framework is
structured to support
1
Private Practice, Oklahoma City, OK.
2

Professor and Chairman, Department of Prosthodontics, University of

Florida College of Dentistry, Gainsville, FL.
3
Private Practice, Montclair, NJ.
4
Private Practice, Reno, NV, and Associate Clinical Professor, Depart-ment of
Restorative Dentistry, University of the Pacific, Stockton, CA.
5
Associate Professor, Department of Clinical Surgery, University of
Chicago, Chicago, IL.
6
Clinical Associate Professor, Department of Restorative Dentistry,
University of California-San Francisco School of Dentistry, San
Francsico, CA, and Private Practice, Palo Alto, CA.
7
Professor and Associate Dean of Academic Affairs, Tufts University
School of Dental Medicine and Private Practice, Boston, MA.
Accepted April 8, 2002.
This project was funded by the American College of Prosthodontists.
Presented at the Annual Sessions of the American Dental Education
Association, Washington, DC, April 2, 2000, and the American College of
Prosthodontists, Hawaii, November 15, 2000.
Correspondence to: Thomas J. McGarry, DDS, 4320 McAuley Blvd.,
Oklahoma City, OK 73120.
Copyright 2002 by The American College of Prosthodontists
1059-941X/02/1103-0006$35.00/0
doi:10.1053/jpro.2002.126094

181 Journal of Prosthodontics, Vol 11, No 3 (September), 2002: pp 181-193

TABLE 1.ACP Classification System of Complete Edentulism
Class I
This class characterizes the stage of edentulism that is most apt to be successfully
treated with complete dentures
using conventional prosthodontic techniques. All 4 of the diagnostic criteria are
favorable.
Residual bone height of 21 mm measured at the least vertical height of the
mandible on a panoramic radiograph.
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A maxilla.
Location of muscle attachments conducive to denture base stability and retention;
type A or B mandible
Class I maxillomandibular relationship
Class II
This class is distinguished by the continued physical degradation of the denturesupporting anatomy. It is also
characterized by the early onset of systemic disease interactions and by specific
patient management and lifestyle
considerations.
Residual bone height of 16 to 20 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Residual ridge morphology resistant to horizontal and vertical movement of the
denture base; type A or B maxilla
Location of muscle attachments with limited influence on denture base stability
and retention; type A or B
mandible
Class I maxillomandibular relationship
Minor modifiers, psychosocial considerations, mild systemic disease with oral
manifestations

Class III
This class is characterized by the need for surgical revision of supporting structures
to allow for adequate
prosthodontic function. Additional factors now play a significant role in treatment
outcomes.
Residual alveolar bone height of 11 to 15 mm measured at the least vertical
height of the mandible on a
panoramic radiograph
Residual ridge morphology with minimum influence to resist horizontal or vertical
movement of the denture
base; type C maxilla
Location of muscle attachments with moderate influence on denture base stability
and retention; type C mandible
Class I, II, or III maxillomandibular relationship
Conditions requiring preprosthetic surgery
Minor soft tissue procedures
Minor hard tissue procedures including alveoloplasty
Simple implant placement; no augmentation required
Multiple extractions leading to complete edentulism for immediate denture
placement
Limited interarch space (18 to 20 mm)
Moderate psychosocial considerations and/or moderate oral manifestations of
systemic diseases or conditions
such as xerostomia
TMD symptoms
Large tongue (occludes interdental space) with or without hyperactivity
Hyperactive gag reflex
Class IV

This class represents the most debilitated edentulous condition. Surgical

reconstruction is almost always indicated
but cannot always be accomplished because of the patients health, preferences,
past dental history, and financial
considerations. When surgical revision is not an option, prosthodontic techniques of
a specialized nature must be
used to achieve an adequate outcome.
Residual vertical bone height of10 mm measured at the least vertical height of the
mandible on a panoramic
radiograph
Class I, II, or III maxillomandibular relationships
Residual ridge offering no resistance to horizontal or vertical movement; type D
maxilla
Muscle attachment location that can be expected to have significant influence on
denture base stability and
retention; type D or E mandible
Major conditions requiring preprosthetic surgery
Complex implant placement, augmentation required
Surgical correction of dentofacial deformities required
Hard tissue augmentation required
Major soft tissue revision required, that is, vestibular extensions with or without
soft tissue grafting
History of paresthesia or dysesthesia
Insufficient interarch space necessitating surgical correction
Acquired or congenital maxillofacial defects
Severe oral manifestation of systemic disease or conditions such as sequelae from
oncologic treatment
Maxillomandibular ataxia (incoordination)
Hyperactivity of tongue possibly associated with a retracted tongue position
and/or its associated morphology

Hyperactive gag reflex managed with medication

Refractory patient (a patient who presents with chronic complaints following
appropriate therapy), who may
continue to have difficulty achieving their treatment expectations despite the
thoroughness or frequency of the
treatments provided.
Psychosocial conditions warranting professional intervention
182 Classification System for Partial Edentulism McGarry et al
diagnostically driven treatment plan options and
will also be useful in an educational environment
for triaging the patient upon entry into an institu-tional setting.
Partial edentulism is defined as the absence
of some but not all of the natural teeth in a
dental arch. In a partially edentulous patient,
the loss and continuing degradation of the al-veolar bone, adjacent teeth, and
supporting
structures influence the level of difficulty in
achieving adequate prosthetic restoration.
The quality of the supporting structures con-tributes to the overall condition and is
consid-ered in the diagnostic levels of the classification
system.
Only the most significant diagnostic criteria
have been identified. Selection of appropriate treat-ment will be developed
subsequently in a Parame-ters of Care document.
3
It is anticipated that both
the edentulous and partially edentulous classifica-tion systems will be incorporated
into existing elec-tronic diagnostic and procedural databases (SNO-DENT, ICD, CPT,
and CDT).

The classification system is intended to offer the

following benefits:
1.Improved intraoperator consistency
2.Improved professional communication
3.Insurance reimbursement commensurate with
complexity of care
4.An objective method for patient screening in
dental education
5.Standardized criteria for outcomes assessment
and research
6.Improved diagnostic consistency
7.A simplified, organized aid in the decision-mak-ing process relating to referral.
Applications
Diagnosis must be determined before treat-ment recommendations can be made.
While
this classification system is not a predictor of
success of the prosthodontic treatment, clinical
outcomes will be evaluated in terms of evi-dence-based criteria.
When combined with the Parameters of Care
document, this classification system will provide a
basis for diagnosis and treatment procedures. The
experiences gained will enable updating of the Pa-rameters of Care. The
classification system will be
subject to revision based upon input from clinicians,
as well as when new diagnostic and treatment in-formation becomes available.
Review of the Diagnostic Criteria

This section describes four broad diagnostic catego-ries relevant to classification of

partially edentulous
patients:
1.Location and extent of the edentulous area(s)
2.Condition of abutments
3.Occlusion
4.Residual ridge characteristics.
The criteria descriptions begin with the least
complicated and progress to the most complicated.
The diagnostic criteria are as follows.
Criteria 1: Location and Extent of the
Edentulous Area(s)
A.Ideal or minimally compromised edentulous area
The edentulous span is confined to a single arch
and 1 of the following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors
Any anterior mandibular edentulous area that
does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar.
B.Moderately compromised edentulous area
Edentulous areas in both arches and in 1 of the
following:
Any anterior maxillary edentulous area that does
not exceed 2 incisors

Any anterior mandibular edentulous area that

does not exceed 4 incisors
Any posterior maxillary or mandibular edentu-lous area that does not exceed 2
premolars, or 1
premolar and 1 molar
A missing maxillary or mandibular canine.
C.Substantially compromised edentulous area
Any posterior maxillary or mandibular edentu-lous area greater than 3 teeth or 2
molars
Any edentulous areas including anterior and pos-terior areas of 3 or more teeth.
183 September 2002, Volume 11, Number 3
D.Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance.
Criteria 2: Abutment Conditions
A.Ideal or minimally compromised abutment conditions
No preprosthetic therapy is indicated.
B.Moderately compromised abutment condition
Abutments in 1 or 2 sextants* have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy (ie, periodontal, endodontic,
or orthodontic procedures).
Figure 1.Class I patient. This patient 1 is categorized in Class I due to an ideal or
minimally compromised edentulous
area, abutment condition, and occlusion. There is a single edentulous area in 1
sextant. The residual ridge is considered

type A.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.
184 Classification System for Partial Edentulism McGarry et al
C.Substantially compromised abutment condition
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic, or orthodontic procedures).
D.Severely compromised abutment condition
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive adjunctive therapy (ie,
periodontal, end-odontic, or orthodontic procedures).
Abutments have guarded prognoses.
Criteria 3: Occlusion
A.Ideal or minimally compromised occlusal characteristics
No preprosthetic therapy is required
Class I molar and jaw relationships are seen.
B.Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(eg, enameloplasty on premature occlusal con-tacts).
Class I molar and jaw relationships are seen.
C.Substantially compromised occlusal characteristics

Entire occlusion must be reestablished, but with-out any change in the occlusal
vertical dimen-sion.
Class II molar and jaw relationships are seen.
Figure 1. (Contd) (G) Right lateral view, right working movement.(H) Left lateral
view, left working movement.(I)
Full mouth radiographic series.
*A sextant is a subdivision of the dental arch. The
maxillary and mandibular dental arches may be sub-divided into 6 areas or
sextants. In the maxilla, the right
posterior sextant extends from tooth 1 to tooth 5, the left
posterior sextant extends from tooth 12 to tooth 16, and
the anterior sextant extends from tooth 6 to tooth 11. In
the mandible, the right posterior sextant extends from
tooth 28 to tooth 32, the left posterior sextant extends
from tooth 17 to tooth 21, and the anterior sextant
extends from tooth 22 to tooth 27.
185 September 2002, Volume 11, Number 3
Figure 2.Class II patient. This patient is Class II because he has edentulous areas in
2 sextants in different arches.
(A) Frontal view, maximum intercuspation.(B) Right lateral view, maximum
intercuspation.(C) Left lateral view,
maximum intercuspation.(D) Occlusal view, maxillary arch.(E) Occlusal view,
mandibular arch.(F) Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
186 Classification System for Partial Edentulism McGarry et al
D.Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension.

Class II division 2 and Class III molar and jaw

relationships are seen.
Criteria 4: Residual Ridge Characteristics
The criteria published for the Classification System
for Complete Edentulism are used to categorize
any edentulous span present in the partially eden-tulous patient (see Table 1).
Classification System for Partial
Edentulism
The 4 criteria and their subclassifications are orga-nized into an overall classification
system for partial
edentulism.
Class I (Fig 1AI)
This class is characterized by ideal or minimal
compromise in the location and extent of edentu-lous area (which is confined to a
single arch), abut-ment conditions, occlusal characteristics, and resid-ual ridge
conditions. All 4 of the diagnostic criteria
are favorable.
1.The location and extent of the edentulous area
are ideal or minimally compromised:
The edentulous area is confined to a single arch.
The edentulous area does not compromise the
physiologic support of the abutments.
The edentulous area may include any anterior
maxillary span that does not exceed 2 incisors,
any anterior mandibular span that does not ex-ceed 4 missing incisors, or any
posterior span
that does not exceed 2 premolars or 1 premolar
and 1 molar.

2.The abutment condition is ideal or minimally

compromised, with no need for preprosthetic
therapy.
3.The occlusion is ideal or minimally compro-mised, with no need for preprosthetic
therapy;
maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class I complete edentulism description.
Class II (Fig 2)
This class is characterized by moderately compro-mised location and extent of
edentulous areas in
both arches, abutment conditions requiring local-ized adjunctive therapy, occlusal
characteristics re-quiring localized adjunctive therapy, and residual
ridge conditions.
1.The location and extent of the edentulous area
are moderately compromised:
Edentulous areas may exist in 1 or both arches.
Figure 2. (Contd)(I) Full mouth radiographic series.
187 September 2002, Volume 11, Number 3
Figure 3.Class III patient. This patient is Class III because the edentulous area(s) are
located in both arches and
multiple locations within each arch. The abutment condition is substantially
compromised due to the need for
extracoronal restorations. There are teeth that are extruded and malpositioned. The
occlusion is substantially
compromised because reestablishment of the occlusal scheme is required without a
change in the occlusal vertical

dimension.(A)Frontal view, maximum intercuspation.(B)Right lateral view, maximum

intercuspation.(C)Left lateral
view, maximum intercuspation.(D)Occlusal view, maxillary arch.(E)Occlusal view,
mandibular arch.(F)Frontal view,
protrusive relationship.(G) Right lateral view, right working movement.(H) Left
lateral view, left working movement.
188 Classification System for Partial Edentulism McGarry et al
The edentulous areas do not compromise the
physiologic support of the abutments.
Edentulous areas may include any anterior max-illary span that does not exceed 2
incisors, any
anterior mandibular span that does not exceed 4
incisors, any posterior span (maxillary or man-dibular) that does not exceed 2
premolars, or 1
premolar and 1 molar or any missing canine
(maxillary or mandibular).
2.Condition of the abutments is moderately com-promised:
Abutments in 1 or 2 sextants have insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
Abutments in 1 or 2 sextants require localized
adjunctive therapy.
3.Occlusion is moderately compromised:
Occlusal correction requires localized adjunctive
therapy.
Maxillomandibular relationship: Class I molar
and jaw relationships.
4.Residual ridge morphology conforms to the

Class II complete edentulism description.

Class III (Fig 3)
This class is characterized by substantially compro-mised location and extent of
edentulous areas in
both arches, abutment condition requiring substan-tial localized adjunctive therapy,
occlusal character-istics requiring reestablishment of the entire occlu-sion without a
change in the occlusal vertical
dimension, and residual ridge condition.
1.The location and extent of the edentulous areas
are substantially compromised:
Edentulous areas may be present in 1 or both
arches.
Edentulous areas compromise the physiologic
support of the abutments.
Edentulous areas may include any posterior max-illary or mandibular edentulous
area greater
than 3 teeth or 2 molars, or anterior and poste-rior edentulous areas of 3 or more
teeth.
2.The condition of the abutments is moderately
compromised:
Abutments in 3 sextants have insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
Abutments in 3 sextants require more substan-tial localized adjunctive therapy (ie,
periodontal,
endodontic or orthodontic procedures).
Abutments have a fair prognosis.
3.Occlusion is substantially compromised:
Requires reestablishment of the entire occlusal

scheme without an accompanying change in the

occlusal vertical dimension.
Maxillomandibular relationship: Class II molar
and jaw relationships.
4.Residual ridge morphology conforms to the
Class III complete edentulism description.
Class IV (Fig 4)
This class is characterized by severely compromised
location and extent of edentulous areas with
Figure 3. (Contd)(I) Full mouth radiographic series.
189 September 2002, Volume 11, Number 3
Figure 4.Class IV patient. Edentulous areas are found in both arches, and the
physiologic abutment support is
compromised. Abutment condition is severely compromised due to advanced
attrition and failing restorations,
necessitating extracoronal restorations and adjunctive therapy. The occlusion is
severely compromised, necessitating
reestablishment of occlusal vertical dimension and a proper occlusal scheme.
(A)Frontal view, maximum intercuspation.
(B) Right lateral view, maximum intercuspation.(C) Left lateral view, maximum
intercuspation.(D) Occlusal view,
maxillary arch.(E)Occlusal view, mandibular arch.(F)Frontal view, protrusive
relationship.(G)Right lateral view, right
working movement.(H) Left lateral view, left working movement.
guarded prognosis, abutments requiring extensive
therapy, occlusion characteristics requiring rees-tablishment of the occlusion with a
change in the
occlusal vertical dimension, and residual ridge con-ditions.
1.The location and extent of the edentulous areas

results in severe occlusal compromise:

Edentulous areas may be extensive and may
occur in both arches.
Edentulous areas compromise the physiologic
support of the abutment teeth to create a
guarded prognosis.
Edentulous areas include acquired or congenital
maxillofacial defects.
At least 1 edentulous area has a guarded prog-nosis.
2.Abutments are severely compromised:
Abutments in 4 or more sextants have insuffi-cient tooth structure to retain or
support intra-coronal or extracoronal restorations.
Abutments in 4 or more sextants require exten-sive localized adjunctive therapy.
Abutments have a guarded prognosis.
3.Occlusion is severely compromised:
Reestablishment of the entire occlusal scheme,
including changes in the occlusal vertical dimen-sion, is necessary.
Maxillomandibular relationship: class II division
2 or Class III molar and jaw relationships.
4.Residual ridge morphology conforms to the class
IV complete edentulism description.
Other characteristics include severe manifesta-tions of local or systemic disease,
including sequelae
from oncologic treatment, maxillomandibular dys-kinesia and/or ataxia, and
refractory patient (a
patient who presents with chronic complaints fol-lowing appropriate therapy).
Guidelines for the Use of

Classification System for

Partial Edentulism
The analysis of diagnostic factors is facilitated with
the use of a worksheet (Table 2). Each criterion is
evaluated and a checkmark placed in the appropri-ate box. In those instances in
which a patients
diagnostic criteria overlap 2 or more classes, the
patient is placed in the more complex class.
The following additional guidelines should be
followed to ensure consistent application of the
classification system:
1.Consideration of future treatment procedures
must not influence the choice of diagnostic level.
2.Initial preprosthetic treatment and/or adjunc-tive therapy can change the initial
classification
level. Classification may need to be reassessed
after existing prostheses are removed.
3.Esthetic concerns or challenges raise the classi-fication by 1 level in Class I and II
patients.
Figure 4. (Contd) (I) Full mouth radiographic series.
191 September 2002, Volume 11, Number 3
4.The presence of TMD symptoms raises the clas-sification by 1 or more levels in
Class I and II
patients.
5.In a patient presenting with an edentulous max-illa opposing a partially
edentulous mandible,
each arch is diagnosed according to the appro-priate classification system; that is,
the maxilla is
classified according to the complete edentulism

classification system, and the mandible is classi-fied according to the partial

edentulism classifi-cation system. The sole exception to this rule
occurs when the patient presents with an eden-tulous mandible opposed by a
partially edentu-lous or dentate maxilla. This clinical situation
presents significant complexity and potential
long-term morbidity and as such, should be di-agnosed as a Class IV in either
system.
6.Periodontal health is intimately related to the
diagnosis and prognosis for partially edentulous
patients. For the purpose of this system, it is
assumed that patients will receive therapy to
achieve and maintain periodontal health so that
appropriate prosthodontic care can be accom-plished.
Closing Statement
The classification system for partial edentulism is
based on the most objective criteria available to
facilitate uniform use of the system. Such standard-ization may lead to improved
communications
among dental professionals and third parties. This
classification system will serve to identify those
patients most likely to require treatment by a spe-cialist or by a practitioner with
additional training
and experience in advanced techniques. This sys-tem should also be valuable to
research protocols as
different treatment procedures are evaluated. With
the increasing complexity of patient treatment, this
partial edentulism classification system, coupled
with the complete edentulism classification system,

will help dental school faculty assess entering pa-TABLE 2.Worksheet Used to
Determine Classification
Class I Class II Class III Class IV
Location & Extent of Edentulous Areas
Ideal or minimally compromisedsingle arch
Moderately compromisedboth arches
Substantially compromised 3 teeth
Severely compromisedguarded prognosis
Congenital or acquired maxillofacial defect
Abutment Condition
Ideal or minimally compromised
Moderately compromised1-2 sextants
Substantially compromised3 sextants
Severely compromised4 or more sextants
Occlusion
Ideal or minimally compromised
Moderately compromisedlocal adjunctive tx
Substantially compromisedocclusal scheme
Severely compromisedchange in OVD
Residual Ridge
Class I Edentulous
Class II Edentulous
Class III Edentulous
Class IV Edentulous
Conditions Creating a Guarded Prognosis
Severe oral manifestations of systemic disease
Maxillomandibular dyskinesia and/or ataxia

Refractory patient
NOTE. Individual diagnostic criteria are evaluated and the appropriate box is
checked. The most advanced finding determines the final
classification.
Guidelines for use of the worksheet
1. Any single criterion of a more complex class places the patient into the more
complex class.
2. Consideration of future treatment procedures must not influence the diagnostic
level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in
complexity by one level in Class I and II patients.
5. In the presence of TMD symptoms, the classification is increased in complexity by
one or more levels in Class I and II patients.
6. In the situation where the patient presents with an edentulous mandible opposing
a partially endentulous or dentate maxilla,
classification IV.
192 Classification System for Partial Edentulism McGarry et al
tients for the most appropriate patient assignment
for better care. Based on use and observations by
practitioners, educators, and researchers, this sys-tem will be modified as needed.
Acknowledgement
The authors thank Dr. David Cagna and Dr. Rodney D.
Phoenix, Department of Prosthodontics, University of
Texas Health Science Center, San Antonio for their
assistance in providing the classification illustrations.
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