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Pacific Northwest Dental Conference - Dr. Stover
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Pacific Northwest Dental Conference - Dr. Stover

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    Pacific Northwest Dental Conference - Dr. Stover Pacific Northwest Dental Conference - Dr. Stover Presentation Transcript

    • Welcome to the 2009 Pacific Northwest Dental Conference!PNDC is green! Please visit: www.wsda.org/speakers/defaultpdf.view to download lecturehandouts.Please turn off all cell phones and pagers. There is no photography or recording of any kind allowed during the presentation.CDE verification forms will be available at the END of the course.WSDA members may have your ADA card scanned by our room host at the END of the course.AGD members fill out a CDE verification form and take it down to the AGD counter in theregistration area.Please fill out the yellow course evaluation form and leave it on the back table or with your host.Visit the Exhibit Hall & Relaxation Lounge, get free massages and other giveaways. There aredrawings throughout the day, including 2 HD TVs and a Scooter. Please support our exhibitorswho support the PNDC!
    • 2
    • What Will You Do? 3
    • 4
    • Contemporary ProsthodonticTreatment of the Edentulous Mandible Dr Robert Stover, DDS MSDiplomate, American Board of Prosthodontics Olympia Family and Cosmetic Dentistry 5
    • Overview• Treatment options • Conventional Prosthesis • Implant overdentures • Tissue supported • Implant supported • Common attachments • Fixed-detachable denture (‘hybrid’)• Case Presentation – Sequencing treatment planning – Surgical guides & predictability 6
    • Complete denture Tissue supported Implant supportedimplant overdenture Treatment Options implant overdenture Fixed detachable (‘hybrid’) 7
    • Prognostic Guidelines• Prosthetic considerations: • Stability • Preservation • Support • Esthetics • Phonetics • Retention 8
    • Prognostic Guidelines• Prosthetic considerations: • Patient confidence • Hygiene • Chewing efficiency • Surgical limitations • Cost • Esthetics (again) 9
    • Treatment SequenceFabricate Complete Dentures 10
    • Complete Dentures in Atrophic PatientsConsiderations:• Guide for further treatment• Establish rapport• Potentially address chiefcomplaint 11
    • Complete Dentures in Atrophic PatientsConsiderations:• Guide for further treatment• Establish rapport• Potential to address chief complaint 12
    • Space Analysis 13
    • Conventional Radiographic Guides 14
    • Space Analysis 15putty matrix for space analysis
    • Conventional Surgical Guides 16
    • 17
    • Complete Dentures 18
    • Complete Dentures in Atrophic Patients Limitations: • Continued resorption • Individual propensity • Patient with marked resorption • Crestal IAN positionAtwood, D.: Reduction of residual ridge: a major oral disease entitiy. J Prosthet Dent 26: 266-279, 1971.Tallgren A: The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed- longitudinal study covering 25 years. J Prothet Dent 27(2):120-132 1972 19
    • Complete denture Tissue supported Implant supportedimplant overdenture Treatment Options implant overdenture Fixed detachable (‘hybrid’) 20
    • OverdenturesBenefits: • Stability • Retention • Patient confidence • Chewing efficiency • Hygiene access • Preservation • Esthetics • Phonetics 21
    • OverdenturesLimitations:• Support similar to completedentures• Surgical intervention required• Potential for implant failure• Anatomical limitations• Higher maintenance cost 22
    • OverdenturesImplant supported• Support similar to hybrid• Surgical intervention required• Potential for implant failure• Biomechanical limitations• Higher maintenance cost [implant od pic] 23
    • Common AttachmentsAttachments2.Form A. Bar and clip - Dolder, Ackerman, Hader B. Stud attachments 1. Magnetic 2. Matrix / Patrix - Locator, Ball and socket, ERA3.Function A. Resilient B. Non-resilient 24
    • Bar AttachmentsBar / clip- Dolder bar a. Pear shaped (resilient) - allows movement b. Parallel bar (solid) - no movement 25
    • Bar AttachmentsBar/clip- Ackermann bar a. Round b. Egg shaped         26
    • Bar AttachmentsBar/clip- Hader a.  Standard 1.8mm diameter or 13 gauge b.  Compatible with other bar patterns c.  Gold plated machined metal housing 27
    • Bar Attachments
    • Stud AttachmentsAdvantages a. Easier hygiene than bars b. Crown/root ratio enhanced c. Low profile 2
    • Stud Attachments 3
    • Mini Implants Small diameter implants • Victor Sendax • Titanium alloy (Ti6Al4V) • 1.8-3.25mm diameter • 10, 13, 15, 18mm length • FDA approval* – Interim & on-going retention • US intro 1999 • 2008 3M subsidiaryUlatoqski, TA. Nov 1997. FDA written communication,.Office of Device Evaluation, Center for Devices &Radiological Health, FDA. 31
    • Mini Implants Small diameter implants • Interim overdenture retentionShatkin TE, et al. Mini dental implants for long-term fixed and removable prosthetics: a retrospective analysis of2514 implants placed over a five-year period. Compend Contin Educ Dent 2007; 28(2):92-99.Griffitts TM, et al. Mini dental implants: an adjunct for retention, stability and comfort for the edentulous patient.Oral Surg,Oral Med Oral Pathol Oral Radiol Endod 2005;100(5):e81-e84. 32
    • OverdenturesSmall diameter implants• Definitive overdenture stabilization 33
    • OverdenturesSmall diameter implants• Definitive overdenture stabilization 34
    • Mini Implants Contemporary indications: • Mandibular overdenture • Cost effective • Poor surgical candidates • Compromised medical history • Adverse to extensive surgery • Inadequate bone for conventional implantsChristensen, Gordon J. Feb 2001. Simplified Implant Surgery Techniques. DentalTown Magazine, pg 32.Christensen, Gordon J. June 2009. The Increased Use of Small-Diameter Implants. JADA, Vol 140, pp709-712.Bulard, RA. Dec 2005. Multi-Clinic Evaluation Using Mini-Dental Implants for Long-Term Denture Stabilization:A Preliminary Biometric Evaluation. Compendium, 26(12):892-897. 35
    • Complete denture Tissue supported Implant supportedimplant overdenture Treatment Options implant overdenture Fixed detachable (‘hybrid’) 36
    • Fixed-Detachable DentureBenefits:• Extremely stable• Preservation• Support• Retention• Patient confidence• Chewing efficiency• Bypass anatomical structures 37
    • Fixed-Detachable DentureLimitations:• Access for hygiene• Esthetic compromises• Phonetic compromises• Costs• Appropriate lab support• Anatomical limitations• Limited cantilever length 38
    • Fixed-Detachable DentureLimitations:• Access for hygiene• Esthetic compromises• Phonetic compromises• Costs• Appropriate lab support• Anatomical limitations• Limited cantilever length 39
    • Biomechanics – Force AnalysisIntraforaminal placement • Historically indicated • Simple anatomy • Induces posterior cantileverChewing table • Limited surface area • Cantilever length 40
    • Biomechanics – Force Analysis A-P spread based • 1½ x (A-P spread) • 15-20mm / minimum 10mm A-P spread • maximum implants maximum spread McAlarney et al (2000). Theoretical cantilever lengths versus clinical variables in fifty-five clinical cases. J Prosthet Dent; 83:332-43.Rangert, B, T Jent, L Jorneus (1989). Forces and moments on Branemark Implants. Int J Oral Maxillofac Implants; 4:241-7.English CE (1990). The critical A-P spread. Implant Soc J; 1:2-3.Taylor R and G Bergman (1990). Laboratory techniques for the Branemark System (ed 1). Chicago, IL, Quintessence.Skalak R (1983). Biomechanical considerations in osseointegrated prostheses. J Prosthet Dent; 49:843-48. 41
    • Biomechanics – Force Analysis Guidelines for Cantilever Length Compressio • 2-3 premolars n • <20mm with 5-6 implants • <15mm with 4 implants Tension McAlarney et al (2000). Theoretical cantilever lengths versus clinical variables in fifty-five clinical cases. J Prosthet Dent; 83:332-43.Branemark, PI, GA Zarb, T Albrektsson (1985). Tissue Integrated Prostheses. Chicago IL, Quintessence, pp 51-70, 117-128.Zarb GA and A Schmitt (1990). The longitudinal clinical effectiveness of osseointegrated dental i9mplants: the Toronto study,part II, the prosthetic results. J Prosthet Dent; 64:53-61. 42
    • Biomechanics – Force AnalysisOcclusion• Increased force / area on implantsRichter E (1989). Basic biomechanics of dental implants in prosthetic dentistry. J Prosthet Dent 61:602-9.• More force on rigid integrated fixturesBrunski JB, JA Hipp, M El-Wakad (1984). Dental implant design: Biomechanics and interfacial tissues. J Oral Implantol 12:365-77.• Cantilevers may increase loading 1½-2xSkalak R (1983). Biomechanical considerations in osseointegrated prostheses. J Prosthet Dent; 49:843-48.• Large moments generated by cantileversRangert B, T Jent, L Jorneus (1989). Forces and moments on Branemark Implants. Int J Oral Maxillofac Implants; 4:241-7.Rangert B, J Gunne, DY Sullivan (1991). Mechanical aspects of a Branemark implant connected to a natural tooth: an in vitro study. Int J Oral Maxillof Implants 6:177-85. 43
    • Treatment Sequence• Diagnostic workup & complete dentures• Radiographic / surgical guides• Conventional radiology• CT scan• CAD analysis• Treatment plan• Surgery• Definitive prosthesis 44
    • Treatment Sequence• 42 yo AD Navy PO1• Edentulous 21 years• Unsuccessful denture wearer• Loss of OVD• Functionally atrophic mandible 45
    • Treatment Sequence •CC: “I have a lack of bone on the bottom and I can’t get my denture to fit.” •Expectations: “I want to be able to wear bottom dentures comfortably for the rest of my life.” •CD prognosis: max: good man: extremely guarded/poorEnglemeier, R. and R. Phoenix (1996). Patient Evaluation and Treatment Planning for Complete-Denture Therapy.DCNA 40:1-18, 1994 46
    • Complete denture Tissue supported Implant supportedimplant overdenture Treatment Options implant overdenture Fixed detachable (‘hybrid’) 47
    • Decision Process – Case PresentationRe-evaluation – Stability – Preservation – Support – Esthetics – Phonetics – Retention – Patient confidence – Hygiene – Chewing efficiency – Anatomical / surgical limitations – Cost 48
    • Radiographic / Surgical Guides 49
    • Radiographic / Surgical Guides 50
    • Conventional Radiology 51
    • Conventional Radiographic Assessment 52
    • Conventional Radiographic Assessment 16.2mm 7.5mm 7.2mm 13.4mm 13.4mm• Useful in planning definitive treatment 53
    • CT-based Assessment 1 1/2 x (A-P) (A-P) 54
    • Diagnostic Planning 55
    • Diagnostic Planning 2 x (A-P) (A-P) 56
    • Surgical Guide 57
    • Surgical Guide 58
    • CT / CAD Treatment PlanningCT / CAD design systems• NobelGuide (NobelBiocare)• Materialise (Astra)• StentCAD• Keystone 59
    • NobelGuide®1. Fabricate complete dentures a. Good fit to anatomy b. Adequate extensions c. Ideal tooth set-up2. Radiographic guide a. Acrylic b. 6-#4 round burr reference points c. Fill with GP 60
    • NobelGuide® 3. CT scan a. Double scan techniqueRadiographic Index First CT Scan Second CT scan  Secures correct Radiographic Guide only  Patient positioning and seating of the  Radiographic Guide Radiographic Guide  Radiographic Index during CT scan 61
    • NobelGuide®4. Computer planning 62
    • NobelGuide®Surgical Template Fabricate Stone Model Design ProsthesisOrder sent electronically Use Surgical Template as  Definitive prosthesisStereolithograpy the “impression”  Implant Bridge  Provisional  short term 63
    • Treatment Plan• IAN lateralization• Implant-supported bar overdenture• 2 posterior bars• 1 anterior bar• Supported by 6 implants 64
    • Justification for Treatment• Inability to tolerate complete denture• Cost effective• Oral hygiene access• Stability• Retention• Support• Esthetics• Preservation• Bilateral nerve impingment in premolar area of edentulous ridge 65
    • Clinical Treatment• Implant workup / imaging – Conventional radiology – CT / Simplant – Stereolithography• Surgical guide• Nerve lateralization• Phase 1 Implant surgery• Complete Denture Maintenance• Phase 2 Implant surgery 66
    • Nerve Lateralization• Deglove mandible• Un-roof nerve• Lateralization• Stabilization• Insulation (bone graft) 67
    • Implant Placement 68
    • Implant Placement 69
    • Stage 2 Surgery 70
    • Post Healing• Healing phase• Re-present for restoration 71
    • Maxillary Overdenture Locator Attachments 72
    • Refabricate Complete Dentures 73
    • Fabricate Bars 74
    • Refabricate Complete Dentures 75
    • Attachment procedure 76
    • Laboratory Processed Attachments 77
    • Clinical Pick-up 78
    • Final Prostheses 79
    • 80
    • 81
    • Patient preferences Acceptance • Denture patients • Preference evenly split • Stability (fixed preferred) • Chewing ability (fixed preferred) • Ability to clean (removable preferred) • Esthetics (removable preferred)Feine, J et al.: Within-subject comparisons of implant-supported mandibular prostheses: Choice of prosthesis. J Dent Res 73(5): 1105-11, 1994. 82
    • Treatment planning the atrophic mandible Complete OD OD Fixed Denture (soft tissue) (implant) Detachable Stability - ++ + ++ +++ Preservation - +/- + ++ +++ Support +/- +/- ++ +++ Esthetics +++ +++ +++ + Phonetics ++ +++ +++ - Retention - +++ +++ +++ Confidence - ++ + ++ +++ Hygiene +++ + ++ ++ +/- Efficiency - ++ + ++ +++ Fabrication ++ - -- ---- Cost ++ - -- ---- 83
    • Summary• Treatment options • Conventional Prosthesis • Space analysis • Implant overdenture • Tissue supported • Implant supported • Mini implants • Attachment types • Fixed-detachable denture (‘hybrid’)• Conventional / CAD tx planning• Case Presentation 84
    • Questions? Thank You!OFCD@live.com 85