teeth loss is accelerated in the elderly population engendering large edentulous areas and functional disabilities . masticatory function is dramatically compromised in these cases , affecting the nutritional status by inappropriate food selection . associated esthetic and phonetic dysfunctions can lead to depression and social isolation of the elderly . on average , every patient over 65 years has about five pathological conditions and interdisciplinary collaboration is often necessary to control the clinical evolution . it means that dental therapy in the elderly requires consideration of these co - morbidities . in a clinical evaluation of oral prostheses made by the 6 year students of the faculty of dental medicine , iuliu - hatieganu univ . of medicine and pharmacy , on 49 elderly patients hospitalized in the geriatric department of medical clinic v , iuliu - hatieganu u.m.ph . , we found poor masticatory efficiency of all removable complete and partial dentures due to advance tooth wear and instability in chewing movements . important objectives in the prosthetic treatment are to improve oral function , self - confidence and quality of life . treatment plan decisions in the elderly have to consider , beside oral pathology and general health , other individual aspects regarding : self - care capacity and oral hygiene , psychological factors , communication in the dentist patient relation , social and financial situation , previous denture experience , patient s special demands . adapting abilities recent studies have shown women to have lower acceptance of their new removable partial prostheses . the adequate treatment options have to take into consideration the individual psychological and physical conditions in relation to distinctive categories of elderly patients : 
 healthy , dynamic and independent elderly ; motivated patients with good communication abilities who understand and follow the dentist s recommendations , interested in receiving dental treatmentsindependent persons depressed after retirement , with poor social activity and poor communication abilities , indifferent to their dental problems , untrusting the dentist s recommendationsinstitutionalized elderly with severe systemic pathology , hostile to dental treatments and communication . healthy , dynamic and independent elderly ; motivated patients with good communication abilities who understand and follow the dentist s recommendations , interested in receiving dental treatments independent persons depressed after retirement , with poor social activity and poor communication abilities , indifferent to their dental problems , untrusting the dentist s recommendations institutionalized elderly with severe systemic pathology , hostile to dental treatments and communication . in institutionalized edentulous elderly suffering from severe systemic pathologies , a reserved attitude is recommended in choosing a long and difficult prosthetic treatment when patients are indifferent or hostile . complex prosthetic reconstructions involving many appointments and difficult treatments are indicated in motivated healthy elders , with good communication abilities and realistic expectations . implant supported treatments have to be considered when favorable , general and local , conditions exist , to improve function , better bone maintenance and patient satisfaction . a partially edentulous 74-year - old man came to the dental office because of masticatory and esthetic discomfort due to the existing prosthesis . he was a healthy independent person , demanding a new prosthesis with improved masticatory stability and better esthetics . a fixed partial metal - acrylic prosthesis from 13 to 25 with an intermediary for the missing 24 had esthetic defects due to repeated cementation of the acrylic veneers and incorrect peripheral fitting . the removable maxillary acrylic partial denture restoring posterior edentulous areas had functional instability and extensive wear of the acrylic teeth . two metal - acrylic bridges with incorrect peripheral fitting and esthetic defects were present on the mandibular arch : a cantilever bridge from 33 to 35 with intermediary extension for 36 and another bridge from 43 to 46 ( fig . favorable mandibular bone condition was found on radiographs and clinical examination and implant supported fixed partial prostheses were recommended for mandibular arch rehabilitation . advanced maxillary crests atrophy was unfavorable to implants insertion in this patient unless complementary surgery of sinus lifting was performed . a hybrid treatment was then proposed for the maxillary arch involving a removable partial denture ( rpd ) and a metal - ceramic fixed partial denture ( fpd ) splinting all present teeth 11 , 12 , 13 , 21 , 22 , 23 , 25 . the palatal configuration without tori was favorable to locate the palatal strap of the removable partial denture . two metal - ceramic bridges were proposed for the lateral edentulous mandibular areas , warning the patient on the reduced chewing surfaces because of missing molars . modified saddle crest rapport of the intermediaries and rigid connectors were decided for fixed prosthesis . good compliance regarding oral hygiene and routine maintenance was observed in this patient . after removing the existing fixed prosthesis , resin abutments were realized on the model in order to assess perfect fitting of the framework . metal infrastructure for fixed and articulated removable components were made in the laboratory and then , intraoral fitting was checked ( fig . 2 , 3 ) . teeth color and mold was decided considering antagonist natural teeth and the patient s demands . wax set - up of the rpd was made and checked in the oral cavity for occlusion , aesthetics and phonetic rehabilitation . rpd was stable and the occlusion was convenient with a free gliding movement ( 3 mm ) without cuspal interference during masticatory movements . a proper lip support was observed as well as convenient teeth visibility after prosthetic treatment finalization ( fig . favorable mandibular bone condition was found on radiographs and clinical examination and implant supported fixed partial prostheses were recommended for mandibular arch rehabilitation . advanced maxillary crests atrophy was unfavorable to implants insertion in this patient unless complementary surgery of sinus lifting was performed . a hybrid treatment was then proposed for the maxillary arch involving a removable partial denture ( rpd ) and a metal - ceramic fixed partial denture ( fpd ) splinting all present teeth 11 , 12 , 13 , 21 , 22 , 23 , 25 . the palatal configuration without tori was favorable to locate the palatal strap of the removable partial denture . two metal - ceramic bridges were proposed for the lateral edentulous mandibular areas , warning the patient on the reduced chewing surfaces because of missing molars . modified saddle crest rapport of the intermediaries and rigid connectors were decided for fixed prosthesis . after removing the existing fixed prosthesis , abutment teeth preparation was performed and silicon impressions were made in individual trays . resin abutments were realized on the model in order to assess perfect fitting of the framework . metal infrastructure for fixed and articulated removable components were made in the laboratory and then , intraoral fitting was checked ( fig . 2 , 3 ) . teeth color and mold was decided considering antagonist natural teeth and the patient s demands . wax set - up of the rpd was made and checked in the oral cavity for occlusion , aesthetics and phonetic rehabilitation . rpd was stable and the occlusion was convenient with a free gliding movement ( 3 mm ) without cuspal interference during masticatory movements . approximate symmetrical design of the prosthetic complex is favorable for good acceptance ( fig . 5 ) . a proper lip support was observed as well as convenient teeth visibility after prosthetic treatment finalization ( fig . the patient s satisfaction after full arch restoration was sustained by improved retention , good stability , agreeable esthetic and convenient phonetic pattern . regular controls of articulating system efficiency and prosthesis stability are necessary . proper treatment planning and patient realistic information about all the therapeutic steps is emphasized as an essential role of the dentist . educating the patients for a positive attitude toward treatment and realistic expectations avoids mismatched perceptions . oral hygiene is extremely important in post - therapeutic evolution , especially in the elderly ( with decreased visual acuity and neurologic disease ) . the importance of periodic follow - up has to be explained to the elderly and appointments have to be respected . recommended recall time is 6 months ; periodical check - ups for professional cleaning in patients with serious difficulties in oral hygiene maintenance may be more frequent . a complex prosthetic treatment with many long appointments is hardly supported by the elderly patient , therefore an optimistic attitude of the dentist is beneficial for the patient s psychological wellbeing during the treatments . maxillary posterior extended edentulous areas can be successfully restored by removable dentures articulated to fixed prostheses for improved function , aesthetics , self - confidence and life quality .
complex treatment involving removable articulated to fixed prostheses is indicated in extended edentulous areas , which represent clinical conditions more frequently encountered in elderly patients . 
 a number of aspects must be considered in elderly patients before starting the therapy : physical and mental condition , self - care capacity , time and cost of treatment , predictability . in institutionalized elders , suffering of systemic diseases , 
 the therapy of choice should be the least invasive and able to restore function at an acceptable level . 
 active healthy elders can be beneficiaries of complex prosthetic treatments involving many long sessions and difficult treatments.we present a case of a 74 year - old male with extended maxillary edentulous areas , in whom a complex prosthetic treatment was performed .