what is our role as the dentist? - prosites,...
TRANSCRIPT
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Samantha W. Chou, D.M.D.2325 N. Southport Ave. Chicago, Illinois 60614
Phone: 312-608-6881Fax: 773-296-0601
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What is our role as the dentist?
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"We live in a culture in which people are often judged by their facial expression, especially the smile as an indication of intelligence, competence, inner reflections, thoughts and emotions."
Harold Slavkin, D.D.S. Director, National Institute of Dental and Craniofacial Research.
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What do our patients ask of us? People want to look good- more so now than ever
People want to be able to chew
Improved oral health
Improved overall health and well being
People have active lifestyles during their treatment
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Our Role as the Dentist Exam and diagnose
Be attentive to patient’s needs and desires
Be aware of the current treatment philosophies
Be able to compare and contrast advantages vs. disadvantages of various treatment options
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PROSTHETIC OPTIONS Denture
Over-denture
Implant retained, tissue supported
Implant retained/supported, tissue supported
Implant retained/supported
Fixed-Removable Prosthesis “All on 4” Hybrid prosthesis
Fixed Prosthesis
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The patient’s
1. Complaints,
2. Anatomy,
3. Desires, and
4. Financial commitment
determine the amount of implant support, retention, and stability required.
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ANATOMY OF THE EDENTULOUS MAXILLA
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Supporting Structures
• Bone (residual ridge)
• Incisive foramen
• Maxillary tuberosity
• Sharp spiny processes
• Torus Palatinus
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ANATOMY OF THE EDENTULOUS MANDIBLE
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• Crest of residual ridge
• Buccal shelf
• Retro-molar pad
• Mylohyoid ridge
• Mental foramen
• Genial Tubercles
• Torus Mandibularis
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The needs, concerns, and expectations of patients often
exceed
the mere restoration of oral function.
It is therefore essential to have a clear understanding
of smile zone and functional and skeletal anatomy
for more effective treatment planning.
Myron Nevins and James Mellonig
Implant Therapy: Clinical Approaches and Evidence of Success
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MAXILLARY/ MANDIBULAR PROSTHETICS Mandibular Prosthetic options are governed by
availability of bone and function.
Maxillary Prosthetic options are dictated by function and esthetics.
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PROSTHETIC OPTIONS Denture
Over-denture
Implant retained, tissue supported
Implant retained/supported, tissue supported
Implant retained/supported
Fixed-Removable Prosthesis
“All on 4” Hybrid prosthesis Fixed Prosthesis
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Maxillary Denture Examine the maxillary ridge morphology
- Ridge height
- Vestibular depth (anterior and buccal)
- Frenum attachments
- Palate morphology
- Maxillary tuberosity definition
- Pterygomaxillary notch definition
- Palatal throat form (does the soft palate drop)
- Vibrating line position
- Sufficient space between coronoid process and tuberosity?
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Mandibular Denture Examine the mandibular ridge morphology
- Ridge height
- Vestibular depth (anterior and buccal)
- Frenum attachments
- Muscle attachment
- Arch form
- Buccal shelf
- Lateral throat form
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Diagnostic/ Final impression
Make sure the anatomical landmarks are captured
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PATIENT PROSTHETIC COMPLAINTS Dentures are loose
Dentures do not fit adequately
Cannot feel or taste food appropriately
Dislike removable appliances
Dentures are more high maintenance
Psychological effects of dentures
TeethFallOut.mpg
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If residual ridge morphology is severely resorbed, unable to fabricate complete dentures that are retentive or stable…….
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PROSTHETIC OPTIONS Denture
Over-denture
Implant retained, tissue supported
Implant retained/supported, tissue supported
Implant retained/supported
Fixed-Removable Prosthesis
“All on 4” Hybrid prosthesis Fixed Prosthesis
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Advantages of Implant Overdentures
Prevent bone loss
Maintain facial esthetics
Reduce or eliminate prosthesis movement
Create reproducible CO
Eliminate soft tissue abrasions
Improve chewing efficiency
Increase occlusal forces
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Advantages of Implant Overdentures
Increase prosthesis Retention, Stability and Support
Improve speech
Reduce or eliminate denture size
Remove easily at night to control nocturnal parafunction
Repair easier than fixed prosthesis
Shorter prosthetic appointments
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BIOMECHANICS AND PROSTHODONTICS
RETENTION
Quality inherent in the prosthesis acting to resist the forces of dislodgement along the path of placement.
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RETENTION
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BIOMECHANICS AND PROSTHODONTICS
RETENTION
Quality inherent in the prosthesis acting to resist the forces of dislodgement along the path of placement.
SUPPORT
Resistance to occlusal function; the foundation on which a prosthesis rests. Resistance to occlusal load.
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SUPPORT
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BIOMECHANICS AND PROSTHODONTICS
RETENTION Quality inherent in the prosthesis acting to resist the
forces of dislodgement along the path of placement.
SUPPORT Resistance to occlusal function; the foundation on
which a prosthesis rests. Resistance to occlusal load.
STABILITY The quality of a prosthesis to be firm, steady, or
constant, to resist displacement by functional horizontal or rotational stresses.
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STABILITY
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PROSTHETIC OPTIONS Denture
Over-denture
Implant retained, tissue supported
Implant retained/supported, tissue supported
Implant retained/supported
Fixed-Removable Prosthesis
“All on 4” Hybrid prosthesis Fixed Prosthesis
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Maxillary Overdenture
IMPLANT RETAINED TISSUE SUPPORTED
Anatomical conditions are good to excellent
Patient’s needs and desires are minimal: primarily
related to lack of retention
Cost is a primary factor
Prosthesis all tissue supported, retained by implants
Common type of attachment used for this prosthesis
is a locater, O-ring (“ball and socket”) or an ERA
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Mandibular Overdenture IMPLANT RETAINED TISSUE SUPPORTED
Implants in position of canines, independent of each
other in final prosthesis,
Allows prosthesis saggittal rotation, no horizontal
rotation
Posterior ridge must have good anatomy, stability
and denture retention
Prosthesis all tissue supported, retained by implants.
Common type of attachment used for this prosthesis is an Locater, O-ring (“ball and socket”) or an ERA
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EQUAL DISTANCE OFF THE MIDLINE
Implants should be parallel to eachOther and perpendicular to the Occlusal plane, at the same horizontal height
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Implant retained/ Tissue supported Overdenture Advantage: Cost
Disadvantage:
Poor implant support and stability
Increase in prosthetic maintenance
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Mandibular Overdenture IMPLANT RETAINED TISSUE SUPPORTED
Implants in the same position as the locater/ O-ring prostheses, but
implants are splinted together by a bar without any distal
cantilever.
Reduced loading forces than individual implants
Anatomical conditions are good to excellent
Posterior ridge must have good anatomy, stability and denture
retention
Patient’s needs and desires are minimal
Patient can afford new prosthesis and connecting bar
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BAR ALLOWS THE ANTERIOR CURVE OF THE ARCH RESULTS IN AN IMPROVED LINGUAL CONTOUR OF THE RESTORATION
BAR SHOULD NOT HAVE CANTILEVERTO THE DISTAL SIDE OF THE IMPLANTS
HADER BAR ATTACHEMENT WILL ALLOWMOVEMENT OF THE PROSTHESIS TO REDUCEFORCE ON THE BAR
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Greatest failure of implants is due to occlusal overload
The metal connecting bar needs passive fit
Take PA x- rays to verify seating
Cut and solder if necessary
Denture is tissue supported, implant retained
Bar design must allow for saggital rotation, if not posterior region will be a cantilever
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PROSTHETIC OPTIONS Denture
Over-denture
Implant retained, tissue supported
Implant retained/supported, tissue supported
Implant retained/supported
Fixed-Removable Prosthesis
“All on 4” Hybrid prosthesis Fixed Prosthesis
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Maxillary Overdenture IMPLANT RETAINED-SUPPORTED, TISSUE
SUPPORTED
4 implants are placed, joined by a rigid bar
Implant positions allow for a cantilever
Denture has less rotation, only that permitted by the bar attachments
Palate of the overdenture is maintained for tissue support
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PALATE IS REINFORCED TO PREVENT PROSTHESIS FRACTURE AND ALSO TO PREVENT DISTAL CANTILEVER FROMPLACING TOO MUCH OCCLUSAL LOADON THE BAR.
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Maxillary Overdenture IMPLANT RETAINED-SUPPORTED, TISSUE
SUPPORTED
Excellent retention and stability
Opposing occlusion must be stable
Design of this denture is according to implants A-P spread, opposing occlusion and patient’s previous dental history
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Mandibular Overdenture IMPLANT RETAINED-SUPPORTED, TISSUE
SUPPORTED
Moderate to poor posterior anatomy
Lack of retention and stability in the traditional denture
Soft tissue abrasion from the traditional denture
Speech difficulties from the traditional denture
More demanding patient type
4-5 implants are placed, joined by a rigid bar
Denture has less rotation, only that permitted by the bar attachments
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PROSTHETIC OPTIONS Denture
Over-denture
Implant retained, tissue supported
Implant retained/supported, tissue supported
Implant retained/supported
Fixed-Removable Prosthesis
“All on 4” Hybrid prosthesis Fixed Prosthesis
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Maxillary Overdenture IMPLANT RETAINED-SUPPORTED
Moderate- severe problems with traditional dentures
Needs or desires are demanding
Need to increase bulk of prosthesis
Inability to wear traditional prosthesis
Desire to abate bone loss
Unfavorable anatomy for complete dentures
Problems with function and stability
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MESO BAR OF THE MARIUS BRIDGE
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SECONDARY STRUCTURE OF THE MARIUS BRIDGE IS EMBEDDED IN THE REMOVABLE PORTIONOF THE PROSTHESIS.
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O- RINGS ON CAST PALLADIUM BAR
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Maxillary Overdenture IMPLANT RETAINED-SUPPORTED PALATLESS
OVERDENTURE
The palate can be removed only if the A-P spread is
adequate
If not enough support and stability a partial palate will
be maintained
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LOCATOR ABUTMENTS ON CAD/CAM MILLED TITANIUM BAR
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IF PATIENT DOES NOT WANT CO-CR METAL REINFORCEMENT, CAN EMBED TITANIUM MESH WITHIN THE ACRYLIC TO REINFORCE OVERDENTURE
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Mandibular Overdenture IMPLANT RETAINED-SUPPORTED
4-6 Implants joined rigidly by a bar
Cantilever is used
Posterior bearing areas are not adequate
Implants give enough support to avoid tissue contact
Movement is minimum, only that permitted by attachments.
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Mandibular Overdenture• IMPLANT RETAINED-SUPPORTED
Excellent retention and stability
Opposing occlusion must be stable
Design denture according to A-P spread and opposing occlusion
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Disadvantages of Implant Overdenture Psychological (need for non-removable teeth)
Prosthetic space required
Long-term maintenance
Attachment
Relines
New prosthesis every 7 years
Food impaction
Movement, permitted by the attachments
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Advantages of Implant Overdenture over Fixed Prosthesis Esthetics is easier to control providing more soft tissue
support with labial flanges and denture teeth than with metal and porcelain in the fixed prosthesis.
When parafunction is present, the prosthesis may be removed at night helping in the treatment.
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PROSTHETIC OPTIONS Denture
Over-denture
Implant retained, tissue supported
Implant retained/supported, tissue supported
Implant retained/supported
Fixed-Removable Prosthesis
“All on 4” Hybrid prosthesis Fixed Prosthesis
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FIXED-REMOVABLE PROSTHESIS Fixed-Removable Prosthesis
4 or more implants
Cannot be removed by patient, only by dentist
Prosthesis is completely implant retained/supported
CAD/CAM milled bar or casted bar that has a processed
denture over it
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A-P spread
THE GREATER THE AP DISTANCE, THE MOREFAVORABLE THE SITUATION FOR A POSTERIOR CANTILEVER
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FIXED-REMOVABLE PROSTHESIS
Opposing dentition stable
Prosthesis does not allow any type of rotation
A-P spread must be adequate for posterior cantilever
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What is an “All-on-4”?
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Introduction to All-on-4™PrincipleFour implants (two straight implants in the anterior and
two angled implants in the posterior) supporting a
provisional, fixed and immediately loaded full-arch
prosthesis
IndicationsEdentulous mandible or maxilla, terminal dentition
Surgical Access• Open flap
Available Implant Systems• All Nobel Biocare implant systems with Multi-Unit
Abutments
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Principles of All-on-4™When speaking of the “All-on-4” history, research and application, it should really be divided up into the following pieces:
•immediate loading of the fully edentulous mandible•immediate loading of the fully edentulous maxilla•support for a full arch fixed restoration on 4 implants instead of the more common 6-8 for the maxilla and 5-6 for the mandible•use of tilted implants in the posterior to avoid bone grafting
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All-on-4™ BenefitsBenefits of Angled posterior
implants:• Help avoid relevant anatomical structures and can
be anchored in better quality anterior bone
• Offer improved support of the prosthesis by
reducing cantilevers
• Reduce the need for bone grafting by increasing
bone-to-implant contact
Final restoration:• Full-arch restoration with only 4 implants
• Fixed and removable final prosthetic solutions
• Flexible solutions
Efficient Treatment Flow:• Immediately loaded for shorter treatment times
and improved patient satisfaction
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Dr. Paolo Malo is credited with developing the All-on-4 technique using Nobel implants that were
specifically designed by him to provide torque.
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2 weeks post op
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PROSTHETIC OPTIONS Denture
Over-denture
Implant retained, tissue supported
Implant retained/supported, tissue supported
Implant retained/supported (Marius Bridge)
Fixed-Removable Prosthesis
“All on 4” Hybrid prosthesis Fixed Prosthesis
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FIXED PROSTHESIS FIXED PROSTHESIS
The patient wants to have non removable restorations
Bone quantity and quality have to be optimal, if not, augmentation procedures will be necessary
Lip support is close to adequate (no need of acrylic)
Patient is committed to a long, complicated and expensive treatment
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FIXED PROSTHESIS
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Fixed Prosthesis
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FIXED PROSTHESIS
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FIXED PROSTHESIS The case is approached in a different manner
Provisionals
Bone grafting
Sinus Augmentation
Vertical and Horizontal Ridge Augmentations
Implant placements
Soft Tissue Management
Final Prosthesis
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FIXED PROSTHESIS During treatment planning, if all remaining teeth in
an arch needs to be extracted and patient would like to have fixed provisionals.
Extractions and implant placements can be done in stages to allow fixed provisionals during treatment period.
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FIXED PROSTHESIS Treatment plan for the Edentulous Maxilla
Arch Form Number of Implants
Implantposition in the premaxilla
Square 6 2 implants in Canines
Ovoid 7 2 canines and 1 incisor
Tapering 8 2 canines and 2 incisors
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Maxillary arch formSquare Ovoid Tapering
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Advantages of Fixed Prosthesis Psychological: “feels like teeth”
Less prosthetic maintenance
- Attachments
- Relines
- New Overdenture
Less food entrapment
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Mandiblular Dynamics The mandible flexes towards the midline on opening
or during protrusive movements as a result of the internal pterygoid muscle attachments on the ramus.
The mandible also torques when the inferior border rotating out and up and the crestal region rotating lingually- the movements is caused by the massetermuscles during forceful biting or parafunction.
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Mandibular Dynamics The flexure of the mandible during opening and
protrusive movements occurs distal to the mental foramens.
The amount of flexure depends on the bone volume and sites in question.
From the first molar to the first molar region, the medial movement maybe 800 microns.
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IMPLANTS THAT ARE PLACED BEHIND MENTAL FORAMENS CANNOT BE SPLINTEDTOGETHER
FABRICATE THREE INDEPENDENT PROSTHESIS OR MORE WHEN GREATER MANDIBULAR BODY MOVEMENT IS EXPECTED DUE TO PARAFUNCTION