Pacific Northwest Dental Conference - Dr. StoverPresentation 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!
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What Will You Do? 3
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Contemporary ProsthodonticTreatment of the Edentulous Mandible Dr Robert Stover, DDS MSDiplomate, American Board of Prosthodontics Olympia Family and Cosmetic Dentistry 5
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
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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
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
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
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• 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
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