FEBRUARY 26 - MARCH 1, 2009             McCORMICK PLACE, CHICAGO              WWW.CDS.ORG                                 ...
Removable Prosthodontic Classification                                        M. Nader Sharifi, D.D.S., M.S.Use the highes...
M. Nader Sharifi, DDS, MS • 30 North Michigan • Suite 1303 • Chicago, IL 60602 • 312-236-1576Patient Name                 ...
I.        Course Synopsis          A.    What Are Overdentures          B.    Why Offer Overdentures          C.    Three ...
a)    Canned Alginate – As good as anything else                           b)    Syringable Alginate – Initial impressions...
5. If set up is lingualized occlusion, eliminate buccal contacts.                    6. Eccentric Occlusion – Use horsesho...
7.     Existing Teeth – Restorations, Conditions, Treatment     E.   Evaluation of Soft Tissues          1.     Lateral Th...
D.Overdentures Must Allow Movement Parallel to Condyles.            1.     Overdentures which do not allow movement parall...
2. Four Implants – all splinted, but clip in anterior only, cantilever                       ERA attachments off the back ...
1.   Impress Abutments in Final Impression for Denture                    2.   Impress Abutments in Reline Impression     ...
j)Cost is a conventional denture plus implant parts plus a lab                                fabricated framework that va...
b)                               Place Implants, Relieve Denture for Osseointegration                               (1) Do...
(11) Insert Proprietary Abutment Replicas and Block Out                                         Areas Not Being Relined, P...
f)                        Grind flanges away and polish provisional to a ridgelap                              g)         ...
Clinical Procedures to Use the Coble Balancer for Recording Centric Relation                               M. Nader Sharif...
About Your SpeakerM. Nader Sharifi, D.D.S., M.S. holds a certificate in prosthodontics and a mastersdegree in biomaterials...
Journal Articles:1.        Becker CM, Swoope CC, Guckes AD: Lingualized occlusion for removable prosthodontics. J         ...
26.       Petropoulos VC, et al.: Comparison of Retention and Release Periods for Overdentures. Int J          Oral Maxill...
Product List1. Alma Gauge - For fabricating maxillary wax rims. Purchase through: Lantz   Dental Prosthetics, Maumee, OH 8...
CHICAGO DENTAL SOCIETY                                                                   M I D W I N T E R M E E T I N G C...
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FEBRUARY 26 - MARCH 1, 2009 McCORMICK PLACE, CHICAGO

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FEBRUARY 26 - MARCH 1, 2009 McCORMICK PLACE, CHICAGO

  1. 1. FEBRUARY 26 - MARCH 1, 2009 McCORMICK PLACE, CHICAGO WWW.CDS.ORG COURSE F04A DENTURE OR ANYTHING BUT THE DENTURE? M. NADER SHARIFI, DDS, MS THURSDAY, FEBRUARY 26, 2009DISCLAIMER: This work, audio recordings and the accompanying handout, are the intellectual property of the clinician, and permission has beengranted to the Chicago Dental Society, its members, successors and assigns, for the unrestricted, absolute, perpetual, worldwide right to distributesolely as an educational material at the scientific program being presented at the 2009 Midwinter Meeting. Permission has been granted for this workto be shared for non-commercial education purposes only. No other use, including reproduction, retransmission in any form or by any means orediting of the information may be made without the written permission of the author. The Chicago Dental Society does not assume any responsibilityor liability for the content, accuracy, or compliance with applicable laws, and the Chicago Dental Society shall not be sued for any claim involving thedistribution of this work.
  2. 2. Removable Prosthodontic Classification M. Nader Sharifi, D.D.S., M.S.Use the highest class (I through IV) that includes an attribute your patient exhibits.I. Completely Edentulous: McGarry, et al.: J Prosthodontics 1999; 8:27-39. A. Class I 1. Mandibular bone measures 21 mm or more at the smallest measurement on a panorex radiograph. 2. Angle Class I jaw classification. 3. Well shaped arch form (U shaped) 4. High, well rounded ridges. B. Class II 1. Mandibular bone measures 16 - 20 mm at the smallest measurement on a panorex radiograph. 2. Angle Class I jaw classification. 3. Well shaped arch form (U shaped) 4. High or low, well rounded ridges. 5. Muscles that have limited influence on stability. 6. Mild systemic or psychological modifiers. C. Class III 1. Mandibular bone measures 11 - 15 mm at the smallest measurement on a panorex radiograph. 2. Angle Class I, II or III jaw classification. 3. Challenged arch form (V or Square shaped). 4. Low, well rounded ridges or basal bone. 5. Muscles that compromise stability. 6. Moderate systemic or psychological modifiers. 7. TMD, xerostomia, or hyperglossitis. D. Class IV 1. Mandibular bone measures less than 10 mm at the smallest measurement on a panorex radiograph. 2. Angle Class I, II or III jaw classification. 3. Challenged arch form (O shaped). 4. Ridges resorbed to basal bone. 5. Muscles that compromise stability. 6. Moderate systemic or psychological modifiers. 7. Hyperactive gag reflex. 8. Maxillary-mandibular incoordination (Parkinson’s) 9. Refractory patient (unrealistic expectations).© 2008 M. Nader Sharifi, D.D.S., M.S. page 1
  3. 3. M. Nader Sharifi, DDS, MS • 30 North Michigan • Suite 1303 • Chicago, IL 60602 • 312-236-1576Patient Name Social Security Number Date Prosthetic FindingsMaxillary Arch: U Shaped V Shaped O Shaped Square ShapedRidges: High Low Post-extraction Knife-edged Basal boneHard Palate: Deep Shallow Medium Soft Palate ClassTuberosities (R) (L) Torus Attached Mucosa %Frenum: Anterior (R) (L) TeethMandibular Arch: U Shaped V Shaped O Shaped Square ShapedRidges: High Low Post-extraction Knife-edged Basal boneLateral Throat Form Class Torus Attached Mucosa %Buccal Shelf: Large Medium SmallFrenum: Anterior (R) (L) TeethTongue: Position MovementSaliva Consistency AmountJaw Classification: Class I Class II Class IIIExisting Prosthesis: Pt.’s Opinion:Retention: Good Adequate PoorStability: Good Adequate PoorSupport: Good Adequate PoorEsthetics: Good Adequate PoorPhonetics: Good Adequate PoorOcclusion: Good Adequate PoorFacial Shape: Square Square-tapering Ovoid Triangular RoundProfile: Flat Rounded Inverted PersonalityColoring: Hair Eyes Complexion Prosthodontic Privacy?© 2008 M. Nader Sharifi, D.D.S., M.S. page 2
  4. 4. I. Course Synopsis A. What Are Overdentures B. Why Offer Overdentures C. Three Denture Steps D. Treatment Planning E. Clinical Steps for OverdenturesII. Terminology – We realize that Anatomy is very important A. Retention – influenced by Adaptation, Anatomy B. Stability – influenced by Anatomy, Clinical Limitations C. Support – influenced by Anatomy, Clinical LimitationsIII. Definition of an Overdenture A. Overdenture – A patient removable prosthesis that receives retention and limited stability from retained roots [natural or man-made (implants)]. Support should come from the hard and soft tissue of the denture bearing mucosa, not just the roots – or not at all from the roots. B. Patient Removable Fixed Bridge – A prosthesis that is fixed in place with attachments and locks, yet is removable by the patient for hygiene access. The natural or man-made roots provide all retention, stability and support – just like a fixed bridge. The denture bearing mucosa provides no support what so ever. C. Fixed Bridge – Hybrid Prosthesis, Fixed-Detachable, Patti Bridge, Profile Prosthesis, or All-On-Four all the same thing – a dentist removable fixed bridge. The patient cannot remove this option. D. Telescopic Denture – A prosthesis that includes a partial denture framework laser welded to crowns that seat over gold copings that have been final cemented on natural abutments in the mouth. This is most typically a full arch “denture.”IV. Why do we do overdentures? A. Less bone loss B. Improved chewing function: Bars & Balls > Magnets > F/F Dentures C. Improved patient satisfaction D. Intermediate restoration before complete edentulismV. How Do We Make Overdentures? Make Good Dentures A. Three Main Steps: A well extended and well adapted denture with poor occlusion has no chance to succeed, but even a poorly extended denture with ideal centric and good occlusion can be successful. 1. Impression Techniques 2. Records – Centric Record Is Most Important Step 3. Occlusal Design B. Completely Edentulous Patient Impression Techniques 1. Initial Impressions 2. Irreversible Hydrocolloid (Alginate)© 2008 M. Nader Sharifi, D.D.S., M.S. page 3
  5. 5. a) Canned Alginate – As good as anything else b) Syringable Alginate – Initial impressions only C. Final Impressions – three techniques 1. Rubber Base with Green Stick Compound 2. Polyvinyl Siloxanes with Massad/Dentsply Technique 3. Hydrocast Reline Technique (see my journal reference for this) D. Wax Rims and Record Collection 1. Centric Relation – This is the single most important step in denture construction and the use of an intra-oral tracing device significantly increases case success while decreasing the need for occlusal adjustments – and remounts – at delivery. 2. CR Methods: a) Patient closure on own – Fully edentulous repeat. b) Tongue to top, back roof of mouth – Retracts jaw. c) Bilateral Manipulation – Fingers under mandible, thumbs on lower wax rim, rotate closed. d) Intra-oral gothic arch tracing devices – Coble Balancer. Y & M Recorder. Massad Balancer. These are the best, by far. e) See attached supplement to use the Coble Balancer E. Occlusal Design 1. Lingualized Occlusion a) Bilateral Working and Balancing Side Contacts b) Cusp Form Teeth in Maxilla, Flatter Plane in Mandible c) Indications – Esthetics with poor bone remaining or One arch is natural, the other removable partial or complete. d) Controlled in Set-up on the Articulator. (1) Maxillary incisors, cuspids, premolars and first molar mesial cusps all on same plane. (2) Cusps then rise to shallow Curve of Spee. (3) Mandibular posterior teeth have central groove contact to palatal cusps of the maxilla. (4) No posterior contact of maxillary buccal cusps. (5) Anterior open bite. If lowers are 0° – no overbite. 2. Finalize Occlusion at Prosthesis Delivery a) We should have confidence with fit, spend time on bite. b) Lab should have completed selective grind before breakout c) Centric Occlusion 3. Centric Occlusion – Again, this is the difference maker. 4. Use Occlusal Indicator Wax to eliminate prematurities. a) Tap, tap, tap, and squeeze with 80% pressure. b) Adjust Central Groove of Lower Arch c) Prosthesis - equal retention with and without wax© 2008 M. Nader Sharifi, D.D.S., M.S. page 4
  6. 6. 5. If set up is lingualized occlusion, eliminate buccal contacts. 6. Eccentric Occlusion – Use horseshoe red/black articulating paper to develop working and balancing side contacts in group function. 7. Lingualized – can do side-to-side and evaluate both sides working and balancing at the same time. a) Red to Upper, slide side-to-side; adjust upper buccal contacts b) Red to Lower, slide side-to-side; adjust lower buccal contact c) Without Paper: Watch & ask patient where “hitches” occur d) Red to Upper, slide side-to-side; Black to Upper, tap-tap-tap in centric, then adjust the upper denture to eliminate hitches. e) Red to lower, slide side-to-side; Black to Lower, tap-tap-tap in centric, then adjust the lower denture to eliminate hitches. f) In lingualized occlusion, eliminate all buccal contacts.VI. Treatment Planning – Evaluate Overdenture cases just as complete denture cases. Use Completely Edentulous Classification as a guide (see page 2). A. Record Collection begins with a review of history – Medical, Dental, Understand the Patient’s Chief Complaint and their Desires 1. Prosthetic Findings (see page 3) for Anatomic Limitations B. Extra-Oral Exam – First patient contact is outside the mouth 1. Oral Cancer Screening 2. TMD Evaluation C. Radiographic Survey 1. Panoramic, Periapicals as needed 2. Tomograms or other cross-sectional images for implants D. Evaluation of Hard Tissues – Positive is helpful, Negative hurts with regard to Retention, Stability and Support 1. Arch Form – This will influence implant site selection a) Positive – U Shaped, Square b) Negative – Round, V Shaped 2. Ridge Shape a) Positive – High, Low but well rounded b) Negative – Knife Edged, Basal Bone 3. Tuberosities a) Positive – Medium b) Negative – Large, Small 4. Hard Palate a) Positive – Medium b) Negative – Deep, Shallow 5. Buccal Shelf a) Positive – Large, Medium b) Negative – Small 6. Torus – Almost Always a Negative Factor© 2008 M. Nader Sharifi, D.D.S., M.S. page 5
  7. 7. 7. Existing Teeth – Restorations, Conditions, Treatment E. Evaluation of Soft Tissues 1. Lateral Throat Form – Lingual Flange (use Mirror) a) Positive - Class I (all mirror), Class II (most mirror) b) Negative – Class III (see mirror-handle attachment) 2. Soft Palate – Decides depressible tissue at vibrating line a) Positive – Class I (wide & flat), Class II (medium) b) Negative – Class III (narrow drape) 3. Attached Mucosa – Patient Comfort a) Maxilla > 50% b) Mandible > 30% 4. Frenum Interferences 5. Tongue – Note Unusual Circumstances a) Movement and Position – Retruded Position Hurts 6. Saliva – Note Unusual Circumstances a) Flow and Consistency – Mucus or Serus F. Evaluation of Teeth 1. Existing Restorations and their Conditions 2. Necessary Restorations – Simple or Complex 3. Periodontal Screening G. Evaluation of Existing Prosthesis 1. Retention – Swallow water, not thumb on palate 2. Stability – Push and move side-to-side 3. Support – Push and rock forward and back 4. Esthetics – Doctor and Patient Perspective a) May not agree on Prosthodontic Privacy 5. Phonetics – Doctor and Patient Perspective a) Does the patient notice problems? 6. Occlusion – Doctor and Patient Perspective a) How does the patient eat?VII. Bone Preservation – Ensuring time for our prostheses. A. Primary Stress Bearing Areas – Must be taken advantage of B. Secondary Stress Bearing Areas – Must not be over stressed 1. Maxillary: a) Primary – Hard Palate, Tuberosities b) Secondary – Residual Ridge from 1st molar to 1st molar 2. Mandibular: a) Primary – Buccal Shelf (that’s it folks, gotta cover it!) b) Secondary – Residual Ridge from 1st molar to 1st molar C. Overdentures – Retained roots preserve bone. The preserved bone should be used to retain the prostheses. If adequate root length exists then we can incorporate retention as well.© 2008 M. Nader Sharifi, D.D.S., M.S. page 6
  8. 8. D.Overdentures Must Allow Movement Parallel to Condyles. 1. Overdentures which do not allow movement parallel to condyles are “Patient Removable ‘Fixed’ Restorations.”VIII. Overdenture Attachment Selection A. Retention – Bars > Balls, ERA, Locator > Magnets B. Maintenance – Balls, ERA, Locator > Bars C. Bars – Rotational or Non-Rotational 1. Rotational Bars allow forces to be transferred to mucosa 2. Non-Rotational Bars support the occlusal load without sharing 3. Both bars can be made resilient, but it’s not necessary with Non- Rotational bars since they don’t share load with mucosa 4. Clips are 10 mm or more wide, need solder joints on either side so need 12 to 14 mm from implant edge to implant edge (for surgeons: 16 to 18 mm center-to-center), but the total bar length should be less than 26 mm due to strength issues D. Implant and Root Attachments – To be considered a resilient attachment, it must provide vertical movement between 0.3 mm and 0.6 mm 1. ERA – Resilient: Great for implants, not as great with teeth a) To avoid supra-eruption problems, use black male only 2. Locator – Non-Resilient: Great for teeth, not for implants a) actually 0.1 mm of resiliency – very limited 3. Implant Manufacturer Balls – Each are proprietary – ask a) Nobel Biocare Ball (new smaller ball) no vertical resiliency so the implants will be loaded vertically b) Nobel Biocare Ball (old larger ball) had blue spacer to preserve vertical resiliency & get more mucosal support 4. OSO Balls – Non-Resilient 5. Bredent Ball – Resilient, for use over retained roots E. Teeth No Attachment – Occlusal Access Filling Materials 1. Amalgam, Composite, or Glass Ionomer – fulcrum points 2. Gold Copings – fulcrum points 3. Magnets – Intimate contact attachment which requires symmetry and contralateral balance; they aren’t resilient attachments.IX. Overdenture Implant Abutment Position Selection – Canine areas are most common due to favorable anterior fulcrum points (except for “V” shaped arches, then use the lateral incisor spot). Combining canines & first premolars can work – otherwise avoid premolars. Second molars are also very desirable due to favorable posterior fulcrum points. Symmetry helps, unilateral hurts. A. Mandibular Arch 1. Two Implants – can be bar clip or individual balls or ERA – should have posterior ridge height for lateral stability a) Avoid Cantilevers from Two Implants© 2008 M. Nader Sharifi, D.D.S., M.S. page 7
  9. 9. 2. Four Implants – all splinted, but clip in anterior only, cantilever ERA attachments off the back 3. Two Teeth – Locator, Magnet Copings, Non-attachment filling material, ERA with Black attachments only – avoid cantilevers 4. More Than Two Teeth – Careful about fulcrum points B. Maxillary Arch 1. Four Implants – all splinted, but clip in anterior only, cantilever ERA attachments off the back 2. Two Implants is under designed in maxilla due to soft bone 3. Two Teeth – Locator, Magnet Copings, Non-attachment filling material, ERA with Black attachments only, but, hey, upper dentures work great – spend the money and effort in the lower 4. More Than Two Teeth – Careful about fulcrum points – select two canines and/or two second molars and make a telescopic denture! C. Fixed Bridge Requirements – for Patti Bridge, All-On-Four, etc 1. Four implants – Bicortical stabilization in mandible and sinus wall engagement in the maxilla 2. Maximized A-P spread (anterior to posterior implant distance) 3. Minimized Cantilever 4. Longer Implants (Mandible: at least 13 mm; maxilla: 15 mm) D. Overall Conclusions – Resilient and Non-Resilient Attachments 1. Non-Resilient Attachments – Select anterior locations that will minimize anterior cantilevers. Select Posterior locations that will minimize posterior cantilevers. AVOID PREMOLAR LOCATIONS as they are strictly fulcrum points. 2. Resilient Attachments can be placed anywhere, but should still provide rotation - across a fulcrum line - parallel to the condyles E. Fixed Bridge Solutions – Four implants are sufficient for a fixed bridge 1. All-On-Four design with two posterior implants tipped to decrease the cantilever and increase stability of the prosthesis. a) Can be done in conjunction with Nobel Guide Prosthetically driven Pre-Planning software. b) Generate Nobel Guide surgical guide that provides the opportunity to have provisional fabricated in advance. c) Generate Provisional to Deliver same day as implants. d) Select any combination of All-on-Four, Nobel Guide or Immediate load (TIAH) 2. Latest Development: Treating Patients who need to be edentulated a) “Clear Choice” type treatment – Extract remaining teeth, place implants and provisional bridge all in one sitting.X. Clinical Procedures – Overdentures with Implants or Teeth A. Three Different Techniques© 2008 M. Nader Sharifi, D.D.S., M.S. page 8
  10. 10. 1. Impress Abutments in Final Impression for Denture 2. Impress Abutments in Reline Impression 3. Retro-Fit Existing Denture B. Impress Implants In Final Denture – Best for Bar/Clip Dentures 1. Advantages - Essentially Making a Denture, Only One Final Impression, Lab Processes Attachments, No Intra-Oral Pickup 2. Disadvantages – Implants Complicate Difficult Lower Denture Impression, Need To Provisionalize Over Abutments, Can’t Finalize Case Until Abutments Can Be Loaded 3. Clinical Step-By-Step for Bar/Clip Denture a) Make a Denture – Only to Wax Trial (1) Duplicate Wax Up for Surgical Stent b) Place Implants, Relieve Denture for Osseointegration (1) Don’t relieve support area over the buccal shelf c) Expose Implants, Reline Denture Over Abutments d) Final Lower Denture Impression With Implants (1) Add 30 minutes to conventional impression time (2) Order implant replicas from abutment manufacture (3) Make an initial impression with abutments in place (4) Fabricate a custom tray with internal wax spacer (5) Seat impression copings (Nobel Biocare users: select snap-fit closed-tray impression copings) (6) Border mold the custom tray as usual (7) Remove wax spacer, trim border mold, add adhesive (8) Make final wash impression, seat replicas, pour e) Wax Records – Use Intra-Oral Tracing Device for CR (1) Select Teeth and Posterior Occlusal Design f) Wax Trial & Index Abutments - Index adds 30 minutes (1) Can Use Original Upper Wax Trial (2) Make an Index of the abutments for all bar cases. (3) Seat Individual Index Copings using Gold Cylinders (4) Lute Index with GC Pattern Resin (Not Duralay) (5) Remove Index and Connect Abutment Replicas (6) Immediately Pour Index with Mounting Stone g) Detour to Make Framework (1) Lab Makes a Moulage of Wax Up (2) Fabricates Frame to Fit Under Wax Up (3) Cast Framework or Select Balls, ERA, etc. (a) Cast Frames Must Be Tried in (b) Add 30 minutes for trial of framework h) Process Denture Over Bar (Also works for Balls, ERA, etc.) i) Deliver Denture Add 30’ to conventional delivery time© 2008 M. Nader Sharifi, D.D.S., M.S. page 9
  11. 11. j)Cost is a conventional denture plus implant parts plus a lab fabricated framework that varies greatly for two or four implant cases plus two hours extra chairtime k) May be as high as 3 or 4X conventional denture fee C. Impress Implants In Reline Impression – Great for Balls, ERA, Locator 1. Advantages - Essentially Making a Denture, Only One Final Impression, Can Deliver Denture Earlier – Attachments Added at Reline, Lab Processes Attachments, No Intra-Oral Pickup 2. Disadvantages – Really Only for Unsplinted Implants (Balls, ERA, Locator, etc), Sectional Reline Impression is Tricky 3. Clinical Step-By-Step – We’ll do this in the hands-on. a) Make a Denture – Process and Deliver (1) Finalize success with denture and no attachments (2) Duplicate Denture for Surgical Stent b) Place Implants, Relieve Denture for Osseointegration (1) Don’t relieve support area over the buccal shelf c) Expose Implants, Soft Line Denture Over Abutments (1) Use of soft liner appointments can be billed PRN d) Sectional Reline Impression With Implants (1) Order implant replicas from abutment manufacture (2) Use #8 round bur to edge impression borders just distal to the implant location avoiding buccal shelf (3) Ensure Denture Seats Completely with and without attachments in the mouth (4) Complete Reline Impression (rubber base or VPS) (5) Expect 45 minutes total treatment time (6) Does Patient Have a Provisional Denture? e) Lab Processes Reline Over Balls/ERA (1) Insert Proprietary Replicas (2) Block Out Posterior and Pour Processing Cast (3) Process Reline f) Re-Deliver Denture – Extra 15 to 30 minutes g) Cost is a conventional denture plus implant parts plus a lab processed reline (about one hour extra chairtime) h) Easily covered in conventional fee times two (doubled) D. Retro-Fit Existing Denture – Great for Balls, ERAs, Locators 1. Advantages - Essentially Making a Denture, Single Set of Dentures Throughout, Can Retro-Fit Recent Difficult Case 2. Disadvantages – Must Pick Up Attachments Intra-Orally 3. Clinical Step-By-Step – We’ll do this in the hands-on. a) An existing denture has been processed and delivered (1) Duplicate Denture for Surgical Stent© 2008 M. Nader Sharifi, D.D.S., M.S. page 10
  12. 12. b) Place Implants, Relieve Denture for Osseointegration (1) Don’t relieve support area over the buccal shelf c) Expose Implants, Soft Line Denture Over Abutments (1) Use of soft liner appointments can be billed PRN d) Pick Up Attachments – Give Yourself an Hour (1) Relieve Denture Over Attachments (2) Ensure Denture Seats Completely with and without attachments in the mouth (3) Block out with UltraDent Block Out Putty (4) Mix Acrylic (BisGMA resin alternative) (5) Seat Dentures – Allow to FULLY Set (6) Remove Dentures & Add Acrylic to Fill Voids e) Cost is a conventional denture plus implant parts plus a pick up procedure (one hour extra chairtime) f) Easily covered in conventional fee times two (doubled) (1) Since this is an existing denture, the fee will actually be about the conventional denture fee E. Overdentures on Teeth 1. Same protocol as three methods for overdentures on implants 2. Clinical Step-By-Step for Immediates a) Plan to keep cuspids & second molars without furcation involvement. Premolars create fulcrum problems. b) Change Previous Thinking – Extract all anterior teeth and keep posterior teeth that provide vertical stop for maximum intercuspation (near centric) and VDO. We’ll now need a provisional partial, but we gain a lot. (1) Allow Soft Tissue Healing of Initial Extractions (2) Make Final Impressions – System 2 for Immediate Dentures, Wax Records, Wax Trial for Anterior Teeth (3) Model Surgery to Estimate Clinical Result (4) Section Bridgework PRN, Cut Abutment Teeth into Stumps First, Then Extract Remaining Teeth (5) Extrapate Pulp, Irrigate, Medicate, Provisionalize (6) Allow Soft Tissue Maturation – Don’t Cut The Abutment Teeth Down To Healed Soft Tissue – It Can Be Rubber Dam Clamped without Anesthetic (7) Complete RCT on Abutment Teeth (8) Prep and Deliver Copings or Other Attachments (a) ERA & Bredent Balls are Resilient, OSO is not (9) Allow Soft Tissue Maturation (10) Complete Reline Impression© 2008 M. Nader Sharifi, D.D.S., M.S. page 11
  13. 13. (11) Insert Proprietary Abutment Replicas and Block Out Areas Not Being Relined, Pour Cast (12) Reline Denture – Lab Processes Attachments (13) Redeliver Denture F. Fixed Bridge – Fixed Detachable, Hybrid Prosthesis, Patti Bridge, Profile Prosthesis, All-On-Four 1. Advantages – It’s Truly Fixed, Long Term Research History, Highest Patient Satisfaction of Any Dental Procedure 2. Disadvantages – Acrylic Denture Teeth, Expensive Compared to Lesser Alternatives, Intimidating Treatment (but it’s easy) 3. Clinical Step-By-Step – Email for Detailed Handout Supplement 4. First Visit – Master Cast Fabrication a) Make a verification jig with GC Pattern Resin & pour index b) Use verification jig in mouth with guide pins for impression 5. Second Visit – Wax Records like Making a Denture 6. Third Visit – Wax Trial like Making a Denture 7. Fourth Visit – Frame Trial and Pick Up Impression 8. Fifth Visit – Final Wax Trial 9. Deliver then have a post op visit a) First and fourth visit are different from Making a Denture G. Avoiding a Denture Altogether – Treatment Protocol for a dental implant supported temporary denture as an alternative to an immediate denture 1. Very Good Quality Casts – System 2 “final” impressions a) Record incisal edge position at rest and during speech b) Check Occlusal Plane and obtain a Centric Bite Registration 2. Fabricate a Processed Base for ONLY those parts of the arch with- out teeth. This could be limited to the palate for the fully dentate. 3. Complete Wax Records as needed for missing teeth a) Complete model surgery for half the arch (1) this includes tooth removal and ridge reduction b) Lute acrylic denture teeth into position c) Complete the other half of the arch d) This is the “immediate” denture 4. Have the lab duplicate the “immediate” denture a) Working with a duplicate denture provides greater strength 5. Plan the big day a) Remove the remaining teeth and place the planned implants b) Seat final abutments and temporary titanium cylinders c) Cut holes in duplicated denture to accommodate cylinders d) Lute titanium cylinders to the duplicated denture e) Remove cylinders from the mouth and add acrylic to create solid connection between duplicated denture and cylinders© 2008 M. Nader Sharifi, D.D.S., M.S. page 12
  14. 14. f) Grind flanges away and polish provisional to a ridgelap g) Deliver Immediate Fixed Provisional Bridge h) Seal occlusal access holes and finalize occlusion i) Follow Up in One week, one month and at osseointegration j) After the appropriate osseointegration time – fabricate final prosthesis (see above – Section F.)XI. Clinical Steps – All Techniques and Options Require “Making A Denture” A. Three Key Steps to Making Dentures 1. Final Impressions 2. Records – Intra-oral Tracing Device 3. Occlusion – Even Trumps Poor AdaptationXII. Bottom Line A. Overdentures Gotta Have Movement B. Two implant ball overdentures are very cost effective C. If No Movement, Then it’s a Patient Removable Fixed Bridge 1. Nothing Wrong with that – As Long as We’ve Planned for it D. Lower Arch – Two Implants – Multiple Options E. Lower Arch – Four Implants – Great Overdenture 1. Consider All-On-Four Fixed Bridge F. Lower Arch – Two (or more) Teeth – ERA with Black Male or Locators 1. Consider Telescopic Dentures G. Upper Arch – Four Implants – Minimum Necessary 1. Consider All-On-Four Fixed Bridge H. Upper Arch – Two (or more) Teeth – ERA with Black Male or Locators 1. Consider Telescopic Dentures 2. Really, there is nothing much wrong with an upper denture© 2008 M. Nader Sharifi, D.D.S., M.S. page 13
  15. 15. Clinical Procedures to Use the Coble Balancer for Recording Centric Relation M. Nader Sharifi, D.D.S., M.S. A. Centric Relation – the use of an intra-oral tracing device significantly decreases the need for occlusal adjustments – and remounts – at delivery. 1. CR Methods: a) Patient closure on own – Fully edentulous repeat. b) Tongue to top, back roof of mouth – Retracts jaw. c) Bilateral Manipulation – Fingers under mandible, thumbs on lower wax rim, rotate closed. d) Intra-oral gothic arch tracing devices – Coble Balancer. Y & M Recorder. Massad Balancer. These are the best, by far. e) To use the Coble Balancer: 1. Complete upper wax rim to occlusal plane 2. Complete lower wax rim and approximate the posterior occlusal plane to the upper 3. Remove an equal layer wax from the lower wax rim in the posterior area only – this creates a posterior open bite 4. Add the mandibular jig from the Coble Balancer to the lower wax rim in the posterior open bite area – lute with wax 5. Add the “maxillary bearing pin mounting jig” to the mandibular jig 6. Seat the maxillary bearing pin on the mounting jig 7. Add green stick compound to the maxillary bearing pin and the maxillary baseplate 8. Hand articulate the upper and lower wax rims near the expected centric relation and ensure the compound connects the maxillary bearing pin to the baseplate 9. Hold under cool water to hold this position 10. Separate the upper and lower wax rims – remove the maxillary bearing pin mounting jig from the mandibular jig and replace it with a metal striking plate 11. Seat the upper baseplate THEN the lower 12. Have the patient bite together – lengthen the maxillary bearing pin to ensure the patient has a single point of contact when sliding around side-to-side; shorten it if they are open so much that the condyles translate along the condylar eminence 13. Have the patient bite together for about five minutes – this seats the condyles superiorly 14. Have the patient slide side-to-side and forward and back for five minutes 15. Remove the lower baseplate and view the arrowhead tracing of the gothic arch to confirm a sharp point associated with CR 16. Reseat the lower baseplate – have the patient slide forward, back and hold 17. Inject bite registration material between the upper and lower wax rims to record CR then repeat for a second record 18. Make a protrusive record to program the articulator’s condylar inclination© 2008 M. Nader Sharifi, D.D.S., M.S. page 14
  16. 16. About Your SpeakerM. Nader Sharifi, D.D.S., M.S. holds a certificate in prosthodontics and a mastersdegree in biomaterials from Northwestern University. He received his dentaleducation at the University of Illinois. He has received acclaim for the more than 300lectures he has presented on restorative dentistry and patient care from esteemedstudy groups, societies, and associations nationwide.Dr. Sharifi has authored numerous articles and recently provided the chapter onremovable prosthodontics for the textbook, Essential Dental Handbook. He is aformer assistant professor at Northwestern University and former on-call consultantfor Nobel Biocare. In 1996 he was named to the American Dental AssociationsSpeakers Bureau and in 2007 Chicago Dental Society honored him with the GordonChristenson Distinguished Lecturer Award. He maintains a full-time private practiceof adult general dentistry in downtown Chicago. Dr. Sharifi and his wife, Cathy, areparents to eight year-old Alli and five year-old Laini and three year old Gabi.If you would like, you can reach Dr. Sharifi easiest via the internet. Please feel freeto direct any questions or comments at any time to his Email address at MNSDDSMS@ AOL.com.Reference ListTextbooks:1. Branemark PI, Zarb GA, Albrektsson T: Tissue Integrated Prostheses. Quintessence Publishing Co., Inc. Chicago, IL 1985.2. Engleman MJ: Clinical Decision Making and Treatment Planning In Osseointegration. Quintessence Publishing Co., Inc. Chicago, IL 1996.3. Feine JC, Carlsson GE: Implant Overdentures: The Standard of Care for Edentulous Patients. Quintessence Publishing Co., Inc. Chicago, IL 2003.4. Hayakawa I: Principles and Practices of Complete Dentures – Creating the Mental Image of a Denture. Quintessence Publishing Co., Inc. Chicago, IL 2004.5. Jenkins G: Precision Attachments: A Link To Successful Restorative Treatment. Quintessence Publishing Co., Inc. Chicago, IL 1999.6. Levin B: Complete Denture Impressions. Quintessence Publishing Co., Inc. Chicago, IL 1984.7. Renouard F, Rangert B: Risk Factors in Implant Dentistry: Simplified Clinical Analysis for Predictable Treatment. Quintessence Publishing Co., Inc. Chicago, IL 1999.8. Sharifi MN: Essential Dental Handbook: Chapter on Removable Prosthodontics. Edited by Edwab RJ PennWell Publishing, Tulsa, OK 2002. Call 800-752-9764 Request a 10% Discount – Coupon Code: DOAE05© 2008 M. Nader Sharifi, D.D.S., M.S. page 15
  17. 17. Journal Articles:1. Becker CM, Swoope CC, Guckes AD: Lingualized occlusion for removable prosthodontics. J Prosthet Dent 1977; 38:601.2. Beschnidt SM, et al.: Telescopic crown retained removable partial dentures: Review and case report. Comp Cont Ed Dent 2001: 22(11) 927-942.3. Brudvik JS, Howell PG: Evaluation of eccentric occlusal contacts in complete dentures. Int J4. Clough H, Knodle J, Pudwill S, Myron L, Taylor D: A comparison of lingualized occlusion and monoplane occlusion in complete dentures. J Prosthet Dent 1983; 50:176.5. Friedman N, Landesman H, Wexler M: The influences of fear anxiety and Depression on the patient’s responses to complete dentures. Part II. J Prosthet Dent 1988; 59:45.6. Frush JP, Fisher RD: Introduction to dentogenic restorations. J Pros Den 1955; 5:586-595.7. Frush JP, Fisher RD: How dentogenic restorations interpret the sex factor. J Prosthet Dent 1956; 6:160-172.8. Frush JP, Fisher RD: How dentogenic restorations interpret the personality factor. J Prosthet Dent 1956; 6:441-449.9. Frush JP, Fisher RD: The age factor in dentogenics. J Prosthet Dent 1957; 7:5-13.10. Frush JP, Fisher RD: The dynesthetic interpretation of the dentogenic concept. J Prosthet Dent 1958; 8:558-581.11. Frush JP, Fisher RD: Dentogenics: Its practical application. J Pros Dent 1959; 9:914-921.12. Haines R, Barrett S: The structure of the mouth in the mandibular molar region. J Prosthet Dent 1959; 9:962.13. Jacoboson T, Krol A: A contemporary review of the factors involved in complete denture retention, stability and support: Part I: Retention. J Prosthet Dent 1983; 49:5.14. Jacoboson T, Krol A: A contemporary review of the factors involved in complete denture retention, stability and support: Part II: Stability. J Prosthet Dent 1983; 49:165.15. Jacoboson T, Krol A: A contemporary review of the factors involved in complete denture retention, stability and support: Part III: Support. J Prosthet Dent 1983; 49:306.16. Jemt T, et al.: A 5-year prospective multi-center follow-up report on overdentures supported by osseointegrated implants. Int J Oral Maxillo Implants:1996;11(3):291.17. Kimoto K, et al.: Effect of mandibular ridge height on masticatory performance with mandibular conventional and implant-assisted overdentures. Int J Oral Maxillo Implants 2003;18(4):523.18. Lang B, Razzoog M: A practical approach to restoring occlusion for edentulous patients. Part II - Arranging the functional and rational mold combination. J Prosthet Dent 1983; 50:599.19. Lang BR, Razzoog ME: Lingualized integration: tooth molds and an occlusal scheme for edentulous patients. Implant Dentistry 1991; 1:204-211.20. Levin B: A re-evaluation of Hanau’s laws of articulation and the Hanau quint. J Prosthet Dent 1978; 39:254.21. Mazurat RD: Longevity of partial, complete, and fixed prostheses: a literature review. J Can Dent Assoc 1992; 58:500-504.22. Melas F, et al.: Oral health impact on daily performance in patients with implant-stabilized overdentures and patients with conventional complete dentures. Int J Oral Maxillo Implants 2001;16(5):700.23. Millsap C: The posterior palatal seal area for complete dentures. DCNA 1964; 11:663.24. Niedermeier WH, Kramer R: Salivary secretion and denture retention. J Prosthet Dent 1992; 67:211-216.25. Owall B, et al. Removable Partial Denture Production in Western Germany. Quint Int 1995; 26:621-27.© 2008 M. Nader Sharifi, D.D.S., M.S. page 16
  18. 18. 26. Petropoulos VC, et al.: Comparison of Retention and Release Periods for Overdentures. Int J Oral Maxillo Implants 1997;12(2):176.27. Pound E: Accurate protrusive registration for patients edentulous in one or both jaws. J Prosthet Dent 1983; 50:584.28. Pound E: Applying harmony in selecting and arranging teeth. DCNA 1962; 3:242.29. Pound E: Controlling anomalies of vertical dimension and speech. J Prosthet Dent 1976; 36:124.30. Pound E: Let “S” be your guide. J Prosthet Dent 1977; 38:482.31. Pound E: The mandibular movements of speech and their seven related values. J Prosthet Dent 1966; 5:835.32. Raghoebar GH, et al.: A Randomized Prospective Clinical Trial on Effectiveness of Three Treatment Modalities for Patients with Lower Denture Problems: A 10 Year Follow-up Study on Patient Satisfaction. Int J Oral Maxillo Implants 2003; 5:498-503.33. Saito M, et al.: Stress Distribution of Abutments and Base Displacement with Precision Attachment and Telescopic Crown Retained RPDs. J Oral Rehab 2003; 30:482.34. Shannan J: A bilaterally balanced occlusal scheme for patients with arch width and curvature discrepancies. J Prosthet Dent 1980; 44:101.35. Sharifi MN: Functional Impression for the Complete Denture. Quintessence Dental Technology Yearbook 2002.36. Slagter AP, Olthoff LW, Bosman F, Steen WH: Masticatory ability, denture quality, and oral conditions in edentulous subjects. J Prosthet Dent 1992; 68:299-307.37. Tallgren A: The continuing reduction of the residual alveolar ridges in complete denture wearers: A mixed longitudinal study covering 25 years. J Prosthet Dent 1972; 27:120.38. Thayer H, Caputo A: Effects of overdentures upon remaining oral structures. J Prosthet Dent 1977; 37:374.39. Thayer H, Caputo A: Photoelastic stress analysis of overdenture attachments. J Prosthet Dent 1980; 43:611.40. Toolson L, Smith D: A 2-year longitudinal study of overdenture patients. Part I: Incidence and control of caries on overdenture abutments. J Prosthet Dent 1978; 40:486.41. Toolson LB, Taylor TD: A 10-year report of a longitudinal recall of overdenture patients. J Prosthet Dent 1989; 62:179-181.42. van Kampen FM, et al.: An Evaluation of Masticatory Function with Implant Supported Overdentures and Three Different Attachment Systems. J Dent Res: 2004; 9:708-11.43. von Fraunhofer JA, Fazavi R, Khan Z: Wear characteristics of high-strength denture teeth. J Prosthet Dent 1988; 59:173-175.44. Walton JN: A randomized clinical trial comparing two mandibular implant overdenture designs: 3-year prosthetic outcomes using a six-field protocol. Int J Pros 2003;16(3):255.45. Wenz HJ and Lehmann KM: A telescopic crown concept for the restoration of the partially edentulous arch: The Marburg double crown system. Ing J Prothodont 1998: 11:541-550.46. White J: Abutment stress in overdentures. J Prosthet Dent 1978; 40:13.47. Widbom T, et al: Tooth-Supported Telescopic Crown-Retained Dentures: Up to 9-Year Retrospective Clinical Follow-Up Study. Int J Protho 2004; 17: 29.48. Yalisove I: Removable Telescopic Prosthesis for Guarded Prognosis Dentitions Part I. Compen Contin Ed Dent 1984; 5(8): 634-644.49. Yalisove I: Removable Telescopic Prosthesis for Guarded Prognosis Dentitions Part II. Compen Contin Ed Dent 1984; 5(9): 762-772.© 2008 M. Nader Sharifi, D.D.S., M.S. page 17
  19. 19. Product List1. Alma Gauge - For fabricating maxillary wax rims. Purchase through: Lantz Dental Prosthetics, Maumee, OH 800-788-5385.2. Attachments – ERA, Stern G/L and Dalbo attachments. SternGold-Implamed. 800-243-99423. Attachments – VKS - SG vertical Bredent Ball attachment. Bredent USA, Miami, FL; 800-328-3965. Horizontal Ball for RPDs is Non-Resilient.4. Attachments – Ceka, Hader and Dolder Bars. Preat, 800-232-77325. Attachments – Zaag, Locator. Zest Anchors 800-262-23106. Attachments – Attachments International 800-999-30037. Denture Teeth - Antaris/Postaris, Ortholingual and Blue Line. Ivoclar, 800-533-6825.8. Denture Teeth - Physiodens. Vita; 800-828-3839.9. Denture Teeth – Trublend and Portrait Line. Dentsply; 800-877-0020.10.Denture Teeth – Enigma. Leach and Dillon Products; 800-535-2633.11.Denture Teeth - Myerson Lingualized Integration Teeth. Austenol; Chicago, IL; 800-621-0381.12.Denture Tooth Selection Face Shield - Trubyte Tooth Indicator. Dentsply; 800-877-0020.13.Fox Plane - For Leveling Occlusal Plane. Dentsply; 800-877-0020.14.Functional Impression Material - Hydrocast. Kay See Dental, Kansas City, MO; 800-842-8844.15.Functional Impression Material - holds VDO for functional impressions – Microseal. AMCO International; 800-523-074016.Intra-oral device for CR - Coble Balancer or Massad Balancer. Order from Stern/Empire Dental Lab, Houston, TX 713-688-1301 or Lantz Lab (see 1).17.Central Bearing Device - Y & M, Overland Park, KS 913-851-8079.18.Impression Material - System 1 & 2 Alginate. Ivoclar; 800-344-5457.19.Occlude - Marking RPD frameworks. Pascal Co. 800-426-8051.20.Occlusal Indicator Wax - For Occlusal Adjustments and Delivery of Dentures. Kerr, Romulus, MI; 800-537-7123.21.Pressure Indicating Paste - For Post Delivery Adjustments of Denture Sore Spots. Order from your dental supplier.22.Reline Material - New Truliner. Bosworth, Skokie, IL 708-679-340023.Repair Acrylic – XFS Resin. Sultan Chemists, Kay See Dental, Kansas City, MO; 800-842-8844.24.Rubber base impression material (light and medium) - Permlastic. Kerr, Romulus, MI; 800-537-7123.© 2008 M. Nader Sharifi, D.D.S., M.S. page 18
  20. 20. CHICAGO DENTAL SOCIETY M I D W I N T E R M E E T I N G C O U R S E E VA L U AT I O NSPEAKER: DATE:SUBJECT: NUMBER OF ATTENDEES:PLEASE RATE YOUR SPEAKER AS TO: Excellent Good Fair Poor N/ASUBJECT SELECTED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 3 2 1 0TIMELINESS OF SUBJECT . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 3 2 1 0COMPREHENSIVENESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 3 2 1 0MEETING YOUR EXPECTATIONS . . . . . . . . . . . . . . . . . . . . . 4 3 2 1 0CONTENT LEVEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 3 2 1 0DELIVERY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 3 2 1 0VOICE QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 3 2 1 0HOLDING YOUR INTEREST. . . . . . . . . . . . . . . . . . . . . . . . . . 4 3 2 1 0APPROPRIATE AUDIOVISUALS . . . . . . . . . . . . . . . . . . . . . . . 4 3 2 1 0EFFECTIVE AUDIOVISUALS. . . . . . . . . . . . . . . . . . . . . . . . . . 4 3 2 1 0OVERALL EVALUATION OF SPEAKERS . . . . . . . . . . . . . . . . . 4 3 2 1 0OVERALL EVALUATION OF THE PROGRAM . . . . . . . . . . . . . 4 3 2 1 0SHOULD THIS SPEAKER BE INVITED FOR FUTURE MEETINGS? YES NOWHAT TOPICS INTEREST YOU FOR THE FUTURE?COMMENTS (use reverse if you need additional space):NAME (REQUESTED BUT NOT REQUIRED—PLEASE PRINT):Sponsored by the preferred provider DO NOT FOLD CARD. FOR CDS PERMANENT FILES. RETURN EVALUATION CARD TO:of financing for members of the Chicago Dental SocietyChicago Dental Society Aloysius F. Kleszynski, DDS 401 N. Michigan Ave., Suite 200 Chicago, IL 60611-5585

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