Pacific Northwest Dental Conference - Dr. Stover

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!

What Will You Do? 3

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

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

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

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

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

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

Pacific Northwest Dental Conference - Dr. Stover

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