Pacific Northwest Dental Conference - Dr. Stover

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Pacific Northwest Dental Conference - Dr. Stover

  1. 1. 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. 2. 2
  3. 3. What Will You Do? 3
  4. 4. 4
  5. 5. Contemporary ProsthodonticTreatment of the Edentulous Mandible Dr Robert Stover, DDS MSDiplomate, American Board of Prosthodontics Olympia Family and Cosmetic Dentistry 5
  6. 6. 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
  7. 7. Complete denture Tissue supported Implant supportedimplant overdenture Treatment Options implant overdenture Fixed detachable (‘hybrid’) 7
  8. 8. Prognostic Guidelines• Prosthetic considerations: • Stability • Preservation • Support • Esthetics • Phonetics • Retention 8
  9. 9. Prognostic Guidelines• Prosthetic considerations: • Patient confidence • Hygiene • Chewing efficiency • Surgical limitations • Cost • Esthetics (again) 9
  10. 10. Treatment SequenceFabricate Complete Dentures 10
  11. 11. Complete Dentures in Atrophic PatientsConsiderations:• Guide for further treatment• Establish rapport• Potentially address chiefcomplaint 11
  12. 12. Complete Dentures in Atrophic PatientsConsiderations:• Guide for further treatment• Establish rapport• Potential to address chief complaint 12
  13. 13. Space Analysis 13
  14. 14. Conventional Radiographic Guides 14
  15. 15. Space Analysis 15putty matrix for space analysis
  16. 16. Conventional Surgical Guides 16
  17. 17. 17
  18. 18. Complete Dentures 18
  19. 19. 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
  20. 20. Complete denture Tissue supported Implant supportedimplant overdenture Treatment Options implant overdenture Fixed detachable (‘hybrid’) 20
  21. 21. OverdenturesBenefits: • Stability • Retention • Patient confidence • Chewing efficiency • Hygiene access • Preservation • Esthetics • Phonetics 21
  22. 22. OverdenturesLimitations:• Support similar to completedentures• Surgical intervention required• Potential for implant failure• Anatomical limitations• Higher maintenance cost 22
  23. 23. OverdenturesImplant supported• Support similar to hybrid• Surgical intervention required• Potential for implant failure• Biomechanical limitations• Higher maintenance cost [implant od pic] 23
  24. 24. 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
  25. 25. Bar AttachmentsBar / clip- Dolder bar a. Pear shaped (resilient) - allows movement b. Parallel bar (solid) - no movement 25
  26. 26. Bar AttachmentsBar/clip- Ackermann bar a. Round b. Egg shaped         26
  27. 27. 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
  28. 28. Bar Attachments
  29. 29. Stud AttachmentsAdvantages a. Easier hygiene than bars b. Crown/root ratio enhanced c. Low profile 2
  30. 30. Stud Attachments 3
  31. 31. 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
  32. 32. 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
  33. 33. OverdenturesSmall diameter implants• Definitive overdenture stabilization 33
  34. 34. OverdenturesSmall diameter implants• Definitive overdenture stabilization 34
  35. 35. 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
  36. 36. Complete denture Tissue supported Implant supportedimplant overdenture Treatment Options implant overdenture Fixed detachable (‘hybrid’) 36
  37. 37. Fixed-Detachable DentureBenefits:• Extremely stable• Preservation• Support• Retention• Patient confidence• Chewing efficiency• Bypass anatomical structures 37
  38. 38. Fixed-Detachable DentureLimitations:• Access for hygiene• Esthetic compromises• Phonetic compromises• Costs• Appropriate lab support• Anatomical limitations• Limited cantilever length 38
  39. 39. Fixed-Detachable DentureLimitations:• Access for hygiene• Esthetic compromises• Phonetic compromises• Costs• Appropriate lab support• Anatomical limitations• Limited cantilever length 39
  40. 40. Biomechanics – Force AnalysisIntraforaminal placement • Historically indicated • Simple anatomy • Induces posterior cantileverChewing table • Limited surface area • Cantilever length 40
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. Treatment Sequence• Diagnostic workup & complete dentures• Radiographic / surgical guides• Conventional radiology• CT scan• CAD analysis• Treatment plan• Surgery• Definitive prosthesis 44
  45. 45. Treatment Sequence• 42 yo AD Navy PO1• Edentulous 21 years• Unsuccessful denture wearer• Loss of OVD• Functionally atrophic mandible 45
  46. 46. 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
  47. 47. Complete denture Tissue supported Implant supportedimplant overdenture Treatment Options implant overdenture Fixed detachable (‘hybrid’) 47
  48. 48. Decision Process – Case PresentationRe-evaluation – Stability – Preservation – Support – Esthetics – Phonetics – Retention – Patient confidence – Hygiene – Chewing efficiency – Anatomical / surgical limitations – Cost 48
  49. 49. Radiographic / Surgical Guides 49
  50. 50. Radiographic / Surgical Guides 50
  51. 51. Conventional Radiology 51
  52. 52. Conventional Radiographic Assessment 52
  53. 53. Conventional Radiographic Assessment 16.2mm 7.5mm 7.2mm 13.4mm 13.4mm• Useful in planning definitive treatment 53
  54. 54. CT-based Assessment 1 1/2 x (A-P) (A-P) 54
  55. 55. Diagnostic Planning 55
  56. 56. Diagnostic Planning 2 x (A-P) (A-P) 56
  57. 57. Surgical Guide 57
  58. 58. Surgical Guide 58
  59. 59. CT / CAD Treatment PlanningCT / CAD design systems• NobelGuide (NobelBiocare)• Materialise (Astra)• StentCAD• Keystone 59
  60. 60. 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
  61. 61. 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
  62. 62. NobelGuide®4. Computer planning 62
  63. 63. NobelGuide®Surgical Template Fabricate Stone Model Design ProsthesisOrder sent electronically Use Surgical Template as  Definitive prosthesisStereolithograpy the “impression”  Implant Bridge  Provisional  short term 63
  64. 64. Treatment Plan• IAN lateralization• Implant-supported bar overdenture• 2 posterior bars• 1 anterior bar• Supported by 6 implants 64
  65. 65. 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
  66. 66. 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
  67. 67. Nerve Lateralization• Deglove mandible• Un-roof nerve• Lateralization• Stabilization• Insulation (bone graft) 67
  68. 68. Implant Placement 68
  69. 69. Implant Placement 69
  70. 70. Stage 2 Surgery 70
  71. 71. Post Healing• Healing phase• Re-present for restoration 71
  72. 72. Maxillary Overdenture Locator Attachments 72
  73. 73. Refabricate Complete Dentures 73
  74. 74. Fabricate Bars 74
  75. 75. Refabricate Complete Dentures 75
  76. 76. Attachment procedure 76
  77. 77. Laboratory Processed Attachments 77
  78. 78. Clinical Pick-up 78
  79. 79. Final Prostheses 79
  80. 80. 80
  81. 81. 81
  82. 82. 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
  83. 83. 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
  84. 84. 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
  85. 85. Questions? Thank You!OFCD@live.com 85

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