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TreatmentplanningV
ImplantSeminarTheodoraKompotiati
4/15/2014
EEdentulous mandibleImplantsupportedoverdenture
Fixedprosthesis
Implantsupportedoverdentures
Implantoverdenture-Advantages
• Minimumanteriorboneloss;preventsbonelossAfterextractionofmandibularteeth,an
averageof4mmverticalbonelossoccursduringthe1st yearaftertreatment.Thisbonelosscontinuesoverthenext25years.Theboneunderanoverdenture mayresorbaslittleas0.6mm over5years.
• Improvedsupporttolipsandsofttissuesofthefacecomparedtoafixedprosthesis.
• Dentureteetheasilyreproducecontoursandestheticscomparedwithtime-consumingandtechniciansensitiveporcelain-metalfixedrestorations.
• Improvedstability- Reducesoreliminatesprosthesismovement.• Improvedocclusion(reproduciblecentricrelationocclusion).• Improvedchewingefficiencyandforce.Chewingefficiencywithan
implantoverdenture isimprovedby20%comparedwithatraditionalcompletedenture.Reducesprosthesissize-amountofsofttissuecoverageandextensionoftheprosthesis.
• Improvedmaxillofacialprostheses.• Improvedspeech.• Reducedcostcomparedtofixedprosthesis.• Easiertorepairthanafixedrestoration
Overdenture- disadvantagesvPsychological(needfornonremovableteeth)vGreaterabutmentcrownheightspacerequiredvLong-termmaintenanceØAttachmentchangeØRelinesØNewprosthesisevery7yearsvContinuedposteriorbonelossvFoodimpactionvMovement
MandibularimplantsiteselectionØ Greatestavailableheightof
boneislocatedintheanteriormandible,betweenmentalforaminae.
Ø Thisregionpresentsoptimaldensityofboneforimplantsupport.
Ø Needforgoodanteriorsupport(pooranteriorsupportandgoodposteriorsupport→rockingbackandforth)
Ø Anteriorforcesshouldberesistedbyimplantsorbars,whereasposteriorforcesmaybedirectedonasofttissuearea
Overdenture treatmentoptions
Overdenture option1
• Costistheprimaryadvantage• Anatomicalconditionsaregood
toexcellent• Posteriorridgeshouldbe
invertedUshapewithhighparallelwallsforconventionaldenturesupport andstability
• Patient’sneedsanddesiresareminimal
• Hygieneisimprovedwithindependent ballattachments
• Taperedarchshape• Additional implantswillbe
insertedwithin3years• Positioning oftheimplantsin
theBandDposition ispreferred-Anteriormovementoftheprosthesisisreduced
Disadvantages• Poorimplantsupportandstability
• Bonelossisnotreducedsignificantlybecauseonlytwoanteriorimplantsareinserted
• Increaseinprostheticmaintenanceappointments
• The2implantsshouldbeparalleltoeachother.The2implantsshouldbepositionedatthesameocclusalheight.
• Implantsshouldbeatequaldistancefromthemidline
Overdenture Option2
• 2implantsinBandDpositions,joinedwithabar• Anatomicalconditionsaregood
toexcellent• Posteriorridgeformsaninverted
Ushape• Patient’sneedsanddesiresare
minimal,primarilyrelatedtolackofretention
• Additionalimplantswillnotbeinsertedformorethan3years
• ImplantsinpositionsAandEshouldnotbesplinted
DisadvantagesofAandEsplinted
• Greaterbarflexibility
• Morescrewloosening
• Increasedforcesonanterioraspectofprosthesis
Overdenture Option3• A,C,Epositions• Barconnectsthe
implants• Lessbarflexure• Lessscrewloosening• Implantforcesare
reduced• Lessprosthesis
movement• Oneimplantfailure
stillprovidesadequateabutmentsupport
Overdenture option4
• 4implantsplacedinA,B,DandEposition
• Implantsprovidesufficientsupportforadistalcantileverupto10mmoneachside.
Indications:
• Moderatetosevereproblemswithtraditionaldentures
• Needsordesiresaredemanding• Desirestoabateposteriorboneloss• Unfavorableanatomyforcompletedentures• Needtodecreasebulkofprosthesis
Overdenture option5• 5implantsareinserted in
A,B,C,D,Epositions.• Limiting thebulkoramountof
prosthesis• Majorconcernsaboutfunction
andstability• Inabilitytoweartraditional
prosthesis• Moredemanding patienttype.• Thelengthofthecantilever
dependsontheanteriorposteriordistanceandforcefactors
• Archshapeaffectsanterior-posteriordistance
Ø Ovoidform:6-8mmØ Squareform:2-5mmØ Taperedform:>8mm
• Thesuprastracture iscantilevereddistallyamaximumof2.5timestheA-Pspreadandaverages15mm(1st molararea)
Completeedentulousmandible:Treatmentplansforfixedrestorations
Fixedvsremovableimplantprosthesis
• Psychological:“feelsliketeeth”• Lessprostheticmaintenanceandprostheticcomplications
• Lessfoodentrapment• Maintenanceofposteriorboneinthemandible
MandibularDynamics• MedialmovementThemandiblebetweenthemandibularforaminae isstablerelativetoflexureandtorsion.Distaltotheforaminae,themandibleexhibitsconsiderablemovementtowardthemidlineonopening.• TorsionMandibletorqueswiththeinferiorborderrotatingoutandupandthecrestal regionrotatinglingually .Thismovementiscausedbythemassetermusclesduringforcefulbitingorparafunction.
• Posteriorrigidfixedimplantssplintedtoeachotherinafull-archrestorationaresubjecttoaconsiderablebuccolingual forceonopeningandduringparafunction.
• Bonelossaroundimplants,lossofimplantfixation,materialfracture(implantorprosthesiscomponents),unretainedrestorations,discomfortuponopening.
• Implantsplacedinfrontoftheforaminaeorimplantinoneposteriorquadrantjoinedtoanteriorimplantshavenotshownthesecomplicationsrelatedtotheflexureortorsionofthemandible.
Treatmentoption1Branemarkapproachü 4-6implantsbetweenmental
foraminaeü Mostcommon#ofimplantis
5ü Archformandpositionof
mentalforaminaeareimportantcriteria
ü Cantilevershouldnotexceed2.5timestheA-Pspread
ü Ifstressfactorsarehighcantileveringoftheprosthesismaybecontraindicated.
Treatmentoption2• 2implantsovertheforaminae,2implantsinthecaninepositions,oneimplantinthemidline
• Secondaryimplantsmaybepositionedinthefirstpremolarsites
• Prerequisiteistheavailableboneovertheforaminae
• Implantstooneposterior regionmaybesplinted toanteriorimplantswithoutcompromise
• Keyimplantpositions arethefirstmolar(oneside),bilateralcaninepositions,bilateralpremolarpositions
• Secondaryimplantpositions include2ndpremolarpositiononthesamesideasthemolarimplantandthecentralincisorposition
• Superior tooption2withbilateralcantileversbecausetheA-Pspreadisincreased,moreimplantsmaybeused,onlyonesidehasacantilever
• Prerequisiteisavailableboneatleastoneposterior regionofthemandible
TreatmentOption3
Treatmentoption4• Bilateralposterior implants-not
splinted together• Indicatedwhenforcefactorsare
greatandpoorbonequalityispresent
• Keyimplantpositions: 2firstmolars,2firstpremolarsand2caninesites
• Secondaryimplantsmaybeaddedinthesecondpremolarsand/ortheincisorposition
• Primaryadvantageiseliminationofcantilevers
• Weakercementscanbeusedtoinstalltheprosthesis
• Ifprosthesis requiresrepairtheaffectedsegmentmayberemovedmoreeasily
• Needforabundantbone isposteriormandiblebothsides
Treatmentoption5• 3independentprostheses• Anteriorregionofthemandible4-5
implants• Keyimplants:2firstmolarsites,2
firstpremolarand2caninesites• Secondarypositionsarethe2
secondpremolarandcentralincisorsites
• Smallersegmentsincaseonefracturesorbecomesuncemented
• Independentrestorationsallowthemostflexibilityandtorsionofthemandible
• Greater#ofimplantsisrequired• Availableboneneedsaregreatest
Balaguer etal.,2013
ØMonitoredoveranaverageof95±23monthsImplantsurvivalinthemaxilla was91.9% andinthemandible 98.6%.ØSmokerspresentedalowersurvivalrateØ Inmaxilla#ofimplantshadasignificantinfluenceonsurvival.100%forsix,85.7%forfour.
Ø3-implantmandibularoverdentures hadanequivalentsurvivalrateto4.
Roccuzzo etal.,2012• Systematicreview• Optimal#ofimplantsforremovablereconstructions• Noarticleswerefoundprovidinginformationregardingthemaxilla
• 11studiesonthemandiblewereincluded• Noconclusionthatboneloss,patientsatisfaction,or#ofcomplicationsissignificantlyrelatedto#ofimplantssupportingtheoverdenture
• Poormethological qualityofpublishedarticles• Largerwelldesignedlong-termtrialsareneeded.
ImplantTooth-SupportedRemovablePartialDenturewithatLeast15-YearLong-TermFollow-
Up.Mijiritsky etal.,2012
• 42implantsin20patients• 15yearsfollowup• Noimplantfailurenoted,implantsurvival100%• Marginalbonelossaroundimplantsranged0-2mm• Minorprostheticcomplications-restrupture• Patientsreportedgoodchewingabilityandstabilityoftheprosthesis
Dhima etal.2013,
• 29yearfollow-upofimplantprosthesis• Overallprosthesissurvivalat20yearswas86%.• Prostheticeventsoccursignificantlylaterandmorefrequentlythanbiologicevents
• Mostcommonprostheticeventwasfracturedgoldscrewsandmostcommonbiologiceventwassofttissuehyperplasia
DeFreitas etal.,2012
• Removableimplant-supportedpartialdenturesinKennedyClassIandIIarches(freeend)
• 5studies• Follow-up12-96months• Implantsurvivalrate98-99%• Prosthesissurvivalrate:needforrelining,pittingofthehealingabutment,
replacementofattachmentcomponent,damageinframework,screwloosening,damageinacrylicdenturebase.
v Payneetal,58.3%ofthepatientsneededfurtherprostheticrepair.• Patientsatisfactiononascale1-5:4.12-5.0
Tiltedimplants• Presenceofmaxillarysinususuallyprecludes theinsertionoflong implantsinto
thedistalareasofresorbedmaxillae• Short implants(<10mm)havebeenproposed (Degidi etal.2007,Telleman et
al.,2011,Annibali etal.,2012)• Bonegraftingprocedurestoincreasebonevolumeareaviableprocedure.
However,associatedwithcomplications,morbidity andhighcosts.• Tiltingoftheimplantsparalleltotheanteriormaxillarywallmayrepresenta
feasibletreatmentoption (Krekmanov,2000,Aparicio etal.,2001,Fortinetal.,2002,Koutouzis andWennstrom, 2007)
• Implantsplacedinthepterygoid region, thetuberorthezygoma (Bahat 1992,Balshi etal.,1999,Branemark etal.,2004)- Considerablesurgicalrisksandsinuscomplications
Menini etal.,2012
TiltedImplantsintheImmediateLoadingRehabilitationoftheMaxilla:ASystematicReview
• Meta-analysis• Full- archfixedprosthesesforedentulousmaxilla
• Atleast1yearoffunction• NSDinfailureratebetweentiltedanduprightimplants
• NSDwithregardstoboneloss• Randomizedlong-termtrialsareneeded
Monje etal.,2012• Systematicreview• Implantsupportedfixedprosthesis• 8studiesincluded• 12monthsorlongerfollow-up• NSSDinmeanmarginalbonelossbetweentiltedandstraightimplants
• 3articlesreportedbiomechanicalcomplications.Abutmentscrewlooseningwasthemostcommon.NoSDbetweentiltedandstraightimplants
• Long-termresultsarerequired
Pre-operativeconditionsthatcouldleadtocomplications1) Inadequateverticalrestorativespace2) Inadequatehorizontalrestorativespace3) Limitedjawopening4) Inadeaquate alveolarwidthforoptimal
buccolingual positioning5) Maxillaryandmandibulartori
Verticalspacerequirementforfixedrestorations
Single-unitfixedrestoration:Theminimumverticalspaceneededforacement-retainedcrownis9mmfromcrestofthebonetotheocclusalplaneoftheopposingdentitionor6mm fromthesofttissuetotheocclusalplane.Multi-unitfixedprosthesis:Variesbymaterial.Iftheverticalspace<15mm,porcelainisthematerialofchoice.Ifspaceis≥15mmahybridprosthesisshouldbeconsidered.
Verticalspacerequirementforremovableprosthesis
• Barretainedoverdenture:minimumof17mmofverticalspace(softtissue+bar+thicknessforacrylicresin)
• Ballorlocator- retainedoverdenture:Minimumof14mmverticalspace(softtissue+abutmentheight+acrylic resin)
Solutionsfordeficientverticalspace
• Removalofhardtissue(Alveoloplasty)• Surgicalremovalofsofttissue• Useofdifferentabutmenttype- gainof1mmormoreofavailableverticaldimension
• Selectionofdifferenttypeofprosthesis-gain1mmormoreofavailableverticaldimension(screwretainedratherthancementretained,fixedinsteadofremovableprosthesis)
Inadequatehorizontalrestorativespace
• Interimplant distanceminimum3mm
• Implant–toothdistance:1.5-2mm
• Orthodontictreatment• Enameloplasty• Smaller-diameterimplants
Limitedjawopening
• Normalopeningis40mmfrommaxillaryandmandibularincisal edge
• <40mm,difficultyinimplantplacementinposteriorregionofmandible
• Excessivelyangulatedimplants
Inadequatealveolarwidthforoptimalimplantposition
• Guidedboneregeneration• Alveolarridgeexpansion• Blockgrafting
Maxillary/Mandibulartori
Indicationsforremoval:ØInterferencewithaconventionalorimplantsupporteddenture
ØSpeechimpedimentØRepeatedtraumatooverlyingmucosaduetomastication
ØMalignancyphobiaofthepatient
• Misch.Treatmentplansrelatedtokeyimplantpositionsandimplantnumber(CH8).Pp147-159.ContemporaryImplantDentistry,Misch,C.E.,3rdEdition,2008,MosbyYearBook. (portionsconcerningfixedcompleteprosthesis• PartIIdentifyingPreoperativeConditions thatcouldleadtoComplications.(complications1-5).pp2-16.Surgicalcomplicationsinoralimplantology:etiology,prevention,andmanagementLouieAl-Faraje.QuintessencePub.,c2011.• Francetti L,RomeoD,Agliardi E,delFabbroM.TherapeuticAlternativesfortheImmediateRehabilitationofAtrophicJawsUsingTiltedImplants.(CH8)pp295-333.ImmediateLoading:ANewErainOralImplantology.Testori,Galli,delFabbro.2011.Quintessence.• Biscardo L,Beccattelli A,PoggioP.ComplexRehabilitationsinCompletelyEdentulousPatients.(CH9)pp335-359.ImmediateLoading:ANewErainOralImplantology.Testori,Galli,delFabbro.2011.Quintessence.• deFreitas RF,deCarvalho DiasK,etal.Mandibularimplant-supportedremovablepartialdenturewithdistalextension:asystematicreview.JOralRehabil.2012Oct;39(10):791-8.• Mijiritsky E,Lorean A,etal.ImplantTooth-SupportedRemovablePartialDenturewithatLeast15-YearLong-TermFollow-Up.Clin ImplantDentRelat Res.2013Dec27.doi:10.1111/cid.12190. [Epub aheadofprint]• Hertel implantplacementmand overdenture• Roccuzzo,M.,Bonino,F.,Gaudioso,L.&Meijer,H. (2012)Whatistheoptimalnumberofimplantsforremovablereconstructions?Asystematicreviewonimplant-supportedoverdentures ClinicalOralImplantResearch23(Suppl.6):229–237.• Dhima M,Paulusova V,etal.Practice-BasedEvidencefrom29-YearOutcomeAnalysisofManagementoftheEdentulousJawUsingOsseointegratedDentalImplants.JProsthodont.2013 Jul26.[Epub aheadofprint]• Monje A,ChanHL,etal.Marginalbonelossaroundtiltedimplantsincomparisontostraightimplants:ameta-analysis.Int JOralMaxillofac Implants.2012Nov-Dec;27(6):1576-83.Review.
• Grandi T,Guazzi P,Samarani R,Grandi G.Immediateloadingoffour(all-on-4)post-extractiveimplantssupportingmandibularcross-archfixedprostheses:18-monthfollow-upfromamulticentre prospectivecohort study.Eur JOralImplantol.2012Autumn;5(3):277-85.• Balaguer J,Ata-AliJ,Peñarrocha-Oltra D,GarciaB,Peñarrocha M.LONG-TERMSURVIVALRATESOFIMPLANTSSUPPORTINGOVERDENTURES.JOralImplantol.2013Jun10.[Epub aheadofprint]
References
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