Overdentures/ orthodontic straight wire technique

TREATMENT OPTIONS FOR MANDIBULAR OVERDENTURES

&& TREATMENT PLANNING FORTREATMENT PLANNING FOR EDENTULOUS POSTERIOR MAXILLAEDENTULOUS POSTERIOR MAXILLA

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.com

MANDIBULAR IMPLANT OVERDENTURES-INTRODUCTION

• DENTAL PROFESSION AND PUBLIC ARE DENTAL PROFESSION AND PUBLIC ARE MORE AWARE OF THE PROBLEMS MORE AWARE OF THE PROBLEMS ASSOCIATED WITH A COMPLETE ASSOCIATED WITH A COMPLETE MANDIBULAR DENTURE THAN ANY MANDIBULAR DENTURE THAN ANY OTHER DENTAL PROSTHESISOTHER DENTAL PROSTHESIS

• INSERTION OF IMPLANTS FOR INSERTION OF IMPLANTS FOR SUPPORT,RETENTION AND STABILITY OF SUPPORT,RETENTION AND STABILITY OF AN OVERDENTURE CONTRIBUTES A MORE AN OVERDENTURE CONTRIBUTES A MORE FAVORABLE ENVIRONMENT FOR THE FAVORABLE ENVIRONMENT FOR THE RESTORATIONRESTORATION


ADVANTAGES OF IMPLANT SUPPORTED OVERDENTURES

• PREVENT BONE LOSSPREVENT BONE LOSS• MAINTAIN FACIAL MAINTAIN FACIAL ESTHETICSESTHETICS• REDUCE OR REDUCE OR ELIMINATE PROSTHESIS ELIMINATE PROSTHESIS

MOVEMENTMOVEMENT• CREATE CREATE REPRODUCIBEREPRODUCIBE CENTRIC CENTRIC

RELATION RELATION OCCULUSIONOCCULUSION• ELIMINATE SOFT TISSUE ABRASIONELIMINATE SOFT TISSUE ABRASION• IMPROVE IMPROVE CHEWING EFFICIENCYCHEWING EFFICIENCY



http://www.indiandentalacademy.com/

• INCREASE INCREASE OCCLUSAL FORCE• IMPROVE IMPROVE PROSTHESIS STABILITY• IMPROVE PROSTHESIS IMPROVE PROSTHESIS RETENTION• IMPROVE IMPROVE SPEECH • REDUCE OR ELIMINATE DENTURE REDUCE OR ELIMINATE DENTURE

SIZE (FLANGESSIZE (FLANGES))• REQUIRE FEWER IMPLANTS REQUIRE FEWER IMPLANTS

COMPARED WITH FIXED COMPARED WITH FIXED PROSTHESESPROSTHESES


• IMPROVEIMPROVE HYGIENE HYGIENE • REMOVE EASILYREMOVE EASILY AT NIGHT TO AT NIGHT TO • CONTROL NOCTURNAL CONTROL NOCTURNAL

PARAFUNCTIONPARAFUNCTION• REPAIR EASILYREPAIR EASILY COMPARED WITH COMPARED WITH

FIXED PROSTHESIS FIXED PROSTHESIS • REQUIRE SHORTER PROSTHETIC REQUIRE SHORTER PROSTHETIC

APPTS, REDUCED LABORATORY APPTS, REDUCED LABORATORY FEES AND FEWER IMPLANTS WHICHFEES AND FEWER IMPLANTS WHICH REDUCE OVERALL COSTREDUCE OVERALL COST..


DISADVANTAGES

• PRIMARY DISADVANTAGE-RELATED TO PATIENTS DESIRE (OVERDENTURE WOULD NOT SATISFY THE PSYCHOLOGIC NEED OF PATIENT TO FEEL THE PROSTHESIS AS A PART OF THEIR BODY

• LACK OF SUFFICIENT ARCH SPACE MAKES AN OVERDENTURE DENTURE SYSTEM MORE DIFFICULT


MANDIBULAR IMPLANT SITE SELECTION

• 1.GREATEST AVAILABLE HEIGHT OF BONE IS AVAILABLE IN THE ANTERIOR MANDIBLE BETWEEN THE MENTAL FORAMINA OR ANTERIOR LOOPS OF THE MANDIBULAR CANAL

• DENSITY OF BONE IN THIS AREA IS ALSO OPTIMAL FOR IMPLANT SUPPORT


IMPLANT SITE SELECTION (CONTD…)

• AVAILABLE BONE IN THE ANTERIOR MANDIBLE IS DIVIDED INTO 5 EQUAL COLUMNS OF BONE SERVING AS POTENTIAL IMPLANT SITES LABELLED AS A,B,C,D AND E STARTING FROM PATIENTS RIGHT


CLASSIFICATION OF OVERDENTURE MOVEMENT

• IMPLANT OVERDENTURE MOVEMENTS HAVE BEEN SORTED IN SIX DIRECTIONS OR RANGE OF MOVEMENTS

• PROSTHESIS MOVEMENT IS EVALUATED WHILE RESTORATION IS IN THE MOUTH


OVER DENTURE MOVEMENT (CONTD….)

• PM-0 :THE PROSTHESIS DOES NOT HAVE MOVEMENT DURING FUNCTION

• PM-2 :PROSTHESIS WITH A HINGE MOTION

• PM-3 :PROSTHESIS WITH AN APICAL AND HINGE MOTION

• PM-4 :ALLOWS MOVEMENT IN FOUR DIRECTIONS

• PM-6 :HAS ALL RANGES OF PROSTHESIS MOVEMENT


OVERDENTURE ATTACHMENTS

• OVERDENTURE ATTACHMENT PERMITS MOVEMENT DURING FUNCTION AND OR REMOVAL FROM THE MOUTH.

• FEMALE PORTION OF THE ATTACHEMENT IN THE PROSTHESIS SHOULD BE DESIGNED TO WEAR AND BE REPLACED NOT THE MALE PORTION (PATRIX) CONNECTED TO THE SUPERSTRUCTURE OR IMPLANT

• IDEALLY THE ATTACHMENT SHOULD OFFER THE POSSIBILITY TO CONTROL THE DEGREE OF RETENTIONwww.indiandentalacademy.com

O RING ATTACHMENTS (BALL ATTACHMENTS)

• O RINGS ARE DOUGH NUT SHAPED, SYNTHETIC POLYMER OBJECTS THAT POSSESS THE ABILITY TO BEND WITH RESISTANCE AND THEN RETURN TO THEIR APPROXIMATE ORIGINAL SHAPE

• O RING IS COMPRESSED RADIALLY BETWEEN TWO MATING SURFACES COMPRISING A POST AND A METAL ENCAPSULATOR INTO WHICH THE O RING IS INSTALLED


O RING ATTACHMENTS (CONTD..)

• THE DYNAMIC MOVEMENT OF O RING IS ONE OF THE MOST RESILIENT OR MOBILE TYPE OF ATTACHMENTS

• O RINGS MAY HAVE A RANGE OF MOTION OF SIX DIFFERENT DIRECTIONS


METAL ENCAPSULATOR

• A METAL ENCAPSULATOR PERMITS THE EASY REPLACEMENT OF THE O RING AFTER WEARING OR DAMAGE

• THE ENCAPSULATOR HAS AN UNDERCUT REGION THAT HOUSES THE O RING CALLED THE INTERNAL CAVITY


HADER BAR AND CLIP

• HADER BAR AND RIDER SYSTEM WAS MODIFIED TO HADER EDS SYSTEM

• EDS BAR SYSTEM IS ONLY 3mm HIGH,CLIPS HAVE THREE DIFFERENT RETENTION STRENGTHS AND A 20 DEGREE CLIP ROTATION(WHICH INCREASES THE FLEXIBILTY OF THE SYSTEM

• HADER BAR AND CLIP IS A TYPE 2 ATTACHMENT AND MAY BE USED FOR PM-0 OR PM-2 TREATMENT PLANS


MANDIBULAR OVERDENTURE TREATMENT OPTIONS

IMPLANTS IN THE B AND D POSITION, INDEPENDENT OF EACH OTHER

IDEAL ANTERIOR AND POSTERIOR RIDGE FORM IDEAL DENTURE COST IS A MAJOR

FACTOR RETENTION ONLY

OPTION 1


OPTION 1• INDICATED PRIMARILY WHEN COST IS

THE MOST SIGNIFICANT FACTOR• OTHER INDICATIONS ARE WHEN THE

SPAN BETWEEN THE IMPLANTS IS TOO LONG AND INSUFICIENT SPACE EXISTS TO ACCOMDATE ATTACHMENTS ON A BAR AND IN ARCHES TEAR SHAPED ANTERIORLY

• POSTERIOR RIDGE FORM SHOLD BE INVERTED U SHAPE WITH HIGH PARALLEL WALLS FOR GOOD TO EXCELLENT ANATOMIC CONDITIONS FOR DENTURE RETENTION,SUPPORT AND STABILITY.www.indiandentalacademy.com

OPTION 1 (CONTD…)

• MOST COMMON ATTACHMENT USED HERE IS THE O RING DESIGN AND PROSTHESIS MOVEMENT MUST BE AS PRACTICAL(PM-6)

• TWO IMPLANTS ARE INSERTED IN B AND D POSITION AND THEY ARE INDEPENDENT AND NOT CONNECTED WITH A SUPERSTRUCTURE

• IT IS BETTER TO HAVE IMPLANTS IN THE B AND D POSITION RATHER THAN IN THE A AND E REGIONS


OPTION 1 (CONTD….)

• INDEPENDENT IMPLANTS IN THE AND E POSITIONS PERMIT MORE ROCKING OF THE RESTORATION COMPARED WITH B AND D REGIONS

• PLACED IN B AND D POSITIONS-ANTERIOR MOVEMENT OF THE PROSTHESIS IS REDUCED AND PROSTHESIS ALSO ACTS AS A SPLINT TO THE TEETH,DECREASING SOME OF THE STRESS TO EACH IMPLANT


OPTION 2

IMPLANTS IN THE B AND D POSITION JOINED RIGIDLY BY A BAR

IDEAL POSTERIOR RIDGE FORM

IDEAL DENTURE

COST IS A MAJOR FACTOR

RETENTION AND MINOR STABILITY


OPTION 2

• SELECTED ONLY ON RARE OCCASIONS• IMPLANTS USUALLY PLACED IN B AND D

POSITIONS SPLINTED TOGETHER WITH A SUPERSTRUCTURE WITHOUT ANY DISTAL CANTILEVER

• RETENTIVE ELEMENT MAY BE O – RING OR CLIP DESIGN BASED ON THE INTERARCH DISTANCE AVAILABLE

• BAR , SIMILAR TO THOSE DESIGNED BY DOLDER OR HADER


IMPLANTS IN ‘B’ AND ‘D’ POSITIONS

• IMPLANTS PLACED IN ‘B’ AND ‘D’ POSITION SATISFIES IDEAL DISTANCE BETWEEN IMPLANTS ( 20 TO 22MM RANGE)

• IMPLANTS SPLINTED IN ‘B’ AND ‘D’ POSITIONS REDUCES IMPLANT REACTION FORCES – PROVIDES LESS STRESS TO IMPLANT AT CREST OF THE BONE


DISADVANTAGES OF SPLINTED ‘A’ AND ‘E’ IMPLANTS

• IMPLANTS JOINED WITH STRAIGHT BAR ARE LINGUAL TO THE RIDGE

B.ANTERIOR TIPPING OF OVERDENTURE C.FIVE TIMES MORE BAR FLEXURE THAN ‘B’ AND ‘D’ POSITIONS


• 2) IMPLANTS JOINED WITH ANTERIOR CURVED BAR

A.GREATER BAR FLEXIBILTY

(9 TIMES THE B AND D POSITIONS)

B.INCREASED SCREW LOOSENING

C.INCREASED MOMENT FORCES

ON ANTERIOR OF PROSTHESIS

D.ATTACHMENT OR CURVED BAR MAY

PREVENT PROSTHESIS MOVEMENT

DISADVANTAGES OF SPLINTED

‘A’ AND ‘E’ IMPLANTS (CONTD….)


DISADVANTAGES OF SPLINTED‘A’ AND ‘E’ IMPLANTS (CONTD…..)

• 3)HIGHER BITE FORCE THAN ‘B’ AND ‘D’ POSITIONS

• 4) MORE LATERAL LOAD FROM PROSTHESIS TO IMPLANTS THAN ‘B’ AND ‘D’ POSITION


OPTION 3(A)

IMPLANTS IN THE B,C AND D POSITION JOINED BY A RIGID BAR WHEN THE POSTERIOR RIDGE FORM IS POOR

• DIVISION C-h ANTERIOR BONE VOLUME

• POOR POSTERIOR RIDGE FORM• RETENTION AND MINOR

STABILITY• PM3 TO PM6www.indiandentalacademy.com

OPTION 3 ( CONTD….)

• USUAL TREATMENT FOR A PATIENT WITH MINIMAL COMPLAINTS

• CONCERN - PRIMARILY RETENTION AND ANTERIOR STABILITY

• POSTERIOR RIDGE FORM DETERMINES THE LINGUAL FLANGE EXTENSION OF THE DENTURE

• IF POSTERIOR RIDGE FORM IS GOOD,IMPLANTS ARE PLACED IN ‘A’, ‘C’ AND ‘E’ AREAS AND PM-2 TO PM –6 RANGE OF MOTION IS REASONABLE.www.indiandentalacademy.com

OPTION 3 ( CONTD…..)

• IF ANTERIOR OR POSTERIOR RIDGE FORM IS POOR THE IMPLANTS ARE PLACED IN THE ‘B’, ‘C’ AND ‘D’ REGIONS

• THIS INCREASES THE POSTERIOR MOVEMENT OF THE RESTORATION BUT DECREASES THE AMOUNT OF STRESS ON THE IMPLANTS AND THE SCREW RETAINED BAR

• PM FOR THREE IMPLANTS IN ‘B’, ‘C’ AND ‘D’ AREAS SHOULD HAVE PM-3 TO PM-6 RANGES OF MOTIONwww.indiandentalacademy.com

OPTION 3(B)

IMPLANTS IN THE ‘A’, ‘C’ AND ‘E’ POSITION RIGIDLY JOINED BY A BAR IF POSTERIOR RIDGE FORM IS GOOD

• IDEAL POSTERIOR RIDGE FORM

• IDEAL DENTURE• RETENTION AND MODERATE

STABILITY• PM2 TO PM6www.indiandentalacademy.com

ADVANTAGES OF SPLINTED ‘A’, ‘C’ AND ‘E’ IMPLANTS

• SIX TIMES LESS BAR FLEXURE COMPARED WITH ‘A’ AND ‘E’ POSITIONS

• LESS SCREW LOSENING A. LESS FLEXURE B. THREE IMPLANT ABUTMENTS• LESS STRESS TO EACH IMPLANT

COMPARED WITH ‘A’ AND ‘E’ IMPLANTS A. GREATER SURFACE AREA B. MORE IMPLANTS C. GREATER ‘A’ TO ‘D’ DISTANCE


• ONE HALF MOMENT FORCE COMPARED WITH ‘A’ AND ‘E’ IMPLANTS

• LESS PROSTHESIS MOVEMENT• ONE IMPLANT FAILURE STILL

PROVIDES ADEQUATE IMPLANT SUPPORT


OPTION 4

IMPLANTS IN THE ‘A’, ‘B’, ‘D’ AND ‘E’ POSITIONS RIGIDLY JOINED BY A BAR CANTILEVERED DISTALLY ABOUT 10mm

• PATIENT DESIRES GREATER RETENTION, MAJOR STABILITY AND SUPPORT

• PM2 TO PM6 www.indiandentalacademy.com

OPTION 4 (CONTD…)

• IN OD-4 FOUR IMPLANTS ARE PLACED IN ‘A’, ‘B’, ‘D’ AND ‘E’ POSITIONS

• CANTILEVERED SUPERSTRUCTURE IS A FEATURE OF FOUR OR MORE IMPLANTS FOR

1) INCREASE IN IMPLANT SUPPORT COMPARED WITH OD-1 TO OD-3

2) ADDITIONAL RETENTION OF SUPERSTRUCTURE LIMITS THE RISK OF SCREW LOSSENING AND RELATED COMPLICATIONS www.indiandentalacademy.com

OPTION 4 ( CONTD….)

• PATIENTS INDICATION FOR OD-4 INCLUDE POOR POSTERIOR ANATOMY WITH THE POSTERIOR MANDIBLE BEING MORE RESORBED THAN ANTERIOR

• A PM-2 RANGE OF MOTION IS MOST COMMON

• ATTACHEMENTS ARE OFTEN PLACED IN DISTAL CANTILEVERS AND IN MIDLINE


OPTION 4 ( CONTD…)

• THE PATIENT BENEFITS FROM THE 4 IMPLANTS BECAUSE THERE IS GREAT VERTICAL SUPPORT AND LATERAL STABILITY


OPTION 5

IMPLANTS IN THE ‘A’, ‘B’, ‘C’, ‘D’ AND ‘E’ POSITIONS RIGIDLY JOINED BY A BAR CANTILEVERED DISTALLY ABOUT 15mm

• PATIENT HAS HIGH DEMANDS OR DESIRES RETENTION,STABILITY AND SUPPORT

• PM0www.indiandentalacademy.com

OPTION 5 (CONTD….)

• DESIGNED FOR PATIENTS WITH MODERATE TO SEVERE PROBLEMS RELATED TO A TRADITIONAL RESTORATION

• FIVE IMPALANTS ARE INSERTED IN THE ‘A’, ‘B’, ‘C’, ‘D’ AND ‘E’ POSITIONS.

• SUPERSTRUCTURE IS CANTILEVERED DISTALLY A MAXIMUM OF 2.5 TIMES THE A-P DISTANCE OR APPROXIMATELY 15mm,WHICH PLACES IT UNDER THE FIRST MOLAR AREA.www.indiandentalacademy.com


• IF STRESS FACTORS ARE NOT FAVORABLE CANTILEVER SHOULD BE REDUCED

• TEETH OF FINAL RESTORATION USUALLY DO NOT EXTEND BEYOND THE FIRST MOLAR AND THIS HELPS PREVENT A HIDDEN CANTILEVER,WHICH MAY EXTEND BEYOND THIS POSITION

• RESTORATION OFTEN RP-4, COMPLETELY IMPLANT SUPPORTED www.indiandentalacademy.com


• FOUR TO SIX RETENTIVE ELEMENTS ARE INCLUDED IN THE BAR DESIGN (TYPICALLY O-RINGS AND HADER CLIPS) AND THEY PROVIDE RETENTION AND OPPOSE PROSTHESIS MOVEMENT


CONCLUSION

• FIVE MENTIONED OPTIONS PROVIDE ORGANIZED APPROACH TO SOLVING A PATIENTS COMPLAINTS OR ANATOMIC LIMITATIONS

• PROSTHESIS SUPPORT AND RANGE OF MOTION SHOULD BE A PART OF INITIAL DIAGNOSIS


• OD 2 AND OD 3 ARE COMPARED TO A TWO LEGGED CHAIR(PROVIDES SOME VERTICAL SUPPORT,BUT CAN ROCK BACK AND FORTH

• OD 4 IS COMPARED TO A THREE LEGGED CHAIR(PROVIDES FURTHER SUPPORT BUT CAN BE ROCKED ONE WAY OR OTHER BY LATERAL FORCES

• OD 5 COMPARED TO A FOUR LEGGED CHAIR PROVIDES GREATEST SUPPORT AND IS A STABLE AND RETENTIVE PROSTHESIS


• ADVANTAGES OF IMPLANT OVERDENTURES RELATE TO

• 1)ABILITY TO PLACE RIGID HEALTHY ABUTMENTS IN ANTERIOR POSITIONS OF CHOICE

• 2)THE NUMBER,LOCATION, SUPERSTRUCTURE DESIGN AND PROSTHETIC RANGE OF MOTION CAN BE DETERMINED BASED ON PATIENTS EXPRESSED NEEDS AND DESIRES


• IMPLANTS PLACED IN ‘B’, ‘C’ AND ‘D’ POSITIONS ALLOWS MORE MOVEMENT IN THE PROSTHESIS SO IMPLANTS WILL NOT BE OVERLOADED

• PROSTHESES MOVEMENT SHOULD BE PM3 OR GREATER TO REDUCE THE STRESS ON THE B, C AND D IMPLANTS


TREATMENT PLANNING FOR EDENTULOUS POSTERIOR MAXILLA

• MAXILLARY POSTERIOR EDENTULOUS REGION PRESENTS WITH MANY UNIQUE AND CHALLENGING CONDITIONS

• BONE QUALITY,BONE DENSITY AND INCREASED FORCES IN THIS REGION HAVE TO BE CONSIDERED IN THE TREATMENT PLAN OF THIS REGION OF THE MOUTH


ANATOMIC CONSIDERATIONS

• EVOLUTION OF POSTERIOR MAXILLA WITH LOSS OF TEETH

1.AVAILABLE BONE HEIGHT IS LOST IN THE POSTERIOR MAXILLA

2.DECREASE IN BONE WIDTH AT THE EXPENSE OF LABIAL BONY PLATE

3.WIDTH IN THIS REGION-DECREASES AT A RAPID RATE HERE THAN ANY OTHER REGION IN THE JAW.

4.ABUNDANT DIVISION A BONE RIDGE IS RESORBED INTO A MEDIALLY POSITIONED DIVISION B BONE


ANATOMIC CONSIDERATIONS (CONTD….)

• DENSITY IS DECREASED IN LONG TERM MORE THAN ANY OTHER REGION

• ABSENCE OF CORTICAL PLATE ON THE CREST OF THE RIDGE - COMPROMISES INITIAL IMPLANT STABILITY

• LABIAL CORTICAL PLATE IS THIN AND RIDGE IS OFTEN WIDE

• DIMENSION IN HEIGHT OF POST.MAXILLA IS GREATLY REDUCED - DUE TO DUAL ABSORPTION FROM

1.CREST OF RIDGE AND 2.PNEUMATIZATION OF THE SINUS

AFTER TEETH LOSSwww.indiandentalacademy.com

SPECIAL CONSIDERATIONS (CONTD…)

• OCCLUSAL FORCES IN THE POSTERIOR REGION ARE GREATER THAN IN THE ANTERIOR REGION

• POSTERIOR MAXILLA ALWAYS OPPOSES NATURAL TEETH OR IMPLANT SUPPORTED RESTORATIONS-THIS FUIRTHER INCREASES FORCES COMPARED WITH SOFT TISSUE BORNE RESTRATIONS


EXPANSION OF MAXILLARY SINUS

• A EXPANSION PHENOMENON OF THE MAXILLARY SINUS OCCURS AFTER LOSS OF THE POSTERIOR TEETH

• ANTRUM EXPANDS IN INFERIOR , LATERAL ASPECT AND MAY EVEN PROCEED TO LATERAL PIRIFORM OF THE NOSE AND INVADES CANINE EMINENCE REGION

• HENCE,AMOUNT OF BONE IN POSTERIOR MAXILLA IS GREATLY DECREASES IN HEIGHT


EXPANSION OF MAXILLARY SINUS (CONTD….)

• FOLLOWING PERIODONTAL DISEASE TOOTH LOSS AND SINUS EXPANSION,LESS THAN 10MM REMAINS BETWEEN ALVEOLAR RIDGE CREST AND FLOOR OF THE MAXILLARY SINUS


SPECIAL CONSIDERATIONS FOR THE POSTERIOR MAXILLA

• INTERARCH DISTANCE SHOULD BE EVALUATED BEFORE IMPLANT PLACEMENT-

SHOULD BE > THAN 6mm. IF LESS SPACE IS PRESENT THEN

FOLLOWING CAN BE DONE TO RESTORE CORRECT RIDGE ORIENTATION

1. GINGIVECTOMY 2.OSTEOPLASTY AND / OR VERTICAL

OSTEOTOMYwww.indiandentalacademy.com

SUB ANTRAL OPTION 1(CONTD….)

• STRESSES OCCUR PRIMARILY AT THE CRESTAL REGION

• 1.BIOMECHANICAL DESIGNS OF IMPLANTS TO MINIMIZE THEIR NOXIOUS EFFECT ARE IMPLEMENTED

• 2.IMPLANT DIAMETER IS AN EFFECTIVE METHOD TO INCREASE SURFACE AREA AT THE CRESTAL REGION

• 3.IMPLANT NUMBER – A GOOD METHOD TO DECREASE CRESTAL STRESSES


RADIOGRAPHIC EVALUATION

• TECHNIQUES COMMONLY USED:TECHNIQUES COMMONLY USED:

1.WATERS PROJECTION1.WATERS PROJECTION

2.PANORAMIC XRAY2.PANORAMIC XRAY

• OTHER TECHNIQUES OTHER TECHNIQUES

1.COMPUTERIZED TOMOGRAPHY1.COMPUTERIZED TOMOGRAPHY

2.MAGNETIC RESONANCE IMAGING2.MAGNETIC RESONANCE IMAGING


WATERS VIEW

• TRADITIONALLY EMPLOYED FOR THE STUDY OF THE MAXILLARY SINUS

• BETTER VIEW TO ILLUSTRATE CLOUDINESS AND SCLEROTIC CHANGES OF THE MAXILLARY SINUS


PANORAMIC XRAY (BENEFITS)

PROVIDES BETTER ILLUSTRATION OF:

• CONTOUR OF SINUS• PRESENCE OF CYST LIKE DENSITIES• FLOOR OF THE ANTRUM AND THE AMOUT OF

AVAILABLE BONE BETWEEN CREST OF THE RIDGE AND THE SINUS FLOOR

• DISTANCE BETWEEN THE PALATAL LINES AND THE FLOOR OF THE ANTRUM –GOOD INDICATION OF THE FACIAL HEIGHT OF THE BONE BELOW THE ZYGOMA FOR DIRECT SURGICAL ACCESS FOR THE SINUS GRAFT


USES OF COMPUTED TOMOGRAPHY

PROVIDES CLEAR VIEW OF:

1. IMAGES OF MAX SINUS IN ALL DIRECTIONS2. ALL WALLS OF MAXILLARY SINUS3. POTENTIAL ASSOCIATED PATHOLOGIES4. DETAILED REGIONAL ANATOMY5. EXTENT OF MUCOPERIOSTEAL THICKENING

(MIDDLE MEATUS AND INFUNDIBULAR REGION)

6. HIGHLY DIAGNOSTIC VIEW OF POSTEROLATERAL WALLS TOGETHER WITH THE SOFT TISSUE STRUCTURE OF INFRATEMPORAL & PTERYGOPALATINE FOSSA


SUBANTRAL OPTION 1

DONE WHEN SUFFICIENT AVAILABLE BONE HEIGHT TO PERMIT THE PLACEMENT OF ENDOSTEAL IMPLANTS


SUB ANTRAL OPTION 1(CONTD…)

• IN ABUNDANT BONE VOLUME DIVISION A ROOT FORM IMPLANTS ARE USED

• MINIMUM BONE HEIGHT IS RELATED TO IMPLANT DESIGN AND BONE DENSITY

D2 BONE-ATLEAST 11mm D3 BONE-ATLEAST 12mm D4 BONE-ATLEAST 13mm (FOR A 4mm DIAMETER SCREW

IMPLANT)www.indiandentalacademy.com


• SURGICAL APPROACH DECIDED BY BONE DENSITY

IF NARROWER BONE VOLUME IS THERE

OSTEOPLASTY OR

AUGMENTATION TO INCREASE THE WIDTH (WITH BONE SPREADING AND INTRAPOSITIONAL& GRAFTS)

• IF LESS THAN 2.5mm WIDTH IS ONLY AVAILABLE THEN ONLAY AUTOGENOUS BONE GRAFTS IS DONE



• AFTER HEALING,AREA IS REEVALUATED TO DETERMINE PROPER TREATMENT PLAN

• ENDOSTEAL IMPLANTS ARE LEFT TO HEAL IN A NONFUNCTIONAL ENVIRONMENT FOR APPROXIMATELY 4 TO 8 MONTHS BEFORE THE ABUTMENT POSTS ARE ADDED FOR PROSTHODONTIC RECONSTRUCTION

• AFTER INITIAL HEALING PHASE ,PROGRESSIVE LOADING PHASE TREATMENT IS CARRIED OUT


SUBANTRAL OPTION 2: SINUS LIFT

• 1.SELECTED WHEN 10-12MM VERTICAL BONE PRESENT

• 2.IMPLANTS SCREW TYPE DESIGN ROOT FORM IMPLANTSwww.indiandentalacademy.com

SUB ANTRAL OPTION 2 (CONTD….)

• 3.TO OBTAIN 12-14MM OF VERTICAL BONE NECESSARY FOR IMPROVED IMPLANT SURVIVAL-ANTRAL FLOOR IS ELEVATED FROM BELOW BY SURGERY

• FINAL IMPLANT MAY THEN BE INSERTED INTO THE IMPLANT OSTEOTOMY AND 0 TO 2mm OF NEW BONE FORMATION IS ALLOWED TO OCCUR



• 4.NATURAL ELEVATION OF SINUS MEMBRANE WILL OCCUR AROUND TEETH WITH PERIAPICAL DISEASE-THIS ELEVATION RESULTS IN NEW BONE FORMATION

• 4.6 TO 8 MONTHS AFTER SURGERY IS USED TO INDICATE THE SUCCES OF 0 TO 2MM OF INCREASED VERTICAL HEIGHT



IF SINUS PERFORATION OCCURSIF SINUS PERFORATION OCCURS DURING DURING SURGERY:SURGERY:

• EXTRA 2 MONTHS IS ADDED TO USUAL HEALING TIME FOR INTEGRATION OF BONE WITH IMPLANT AND FOR 1 TO 2 mm

• AN ADDITIONAL IMPLANT OR WIDER IMPLANT IS INCLUDED IN CASE IF BONE DOES NOT FORM B’COZ OF PERFORATION



• IF NO BONE FORMATION IS OBTAINED

AROUND APICAL PORTION OF IMPLANT:

• STILL CORTICAL LINING OF SINUS ENGAGES THE IMPLANT IN APICAL THIRD REGION AND IMPROVES RIGIDITY AND STREE RANSFER

• 10-12mm IMPLANT PORTION IN BONE IS MANAGED WITH PROGRESSIVE LOADING


SUBANTRAL OPTION 3 :SINUS GRAFT AND INITIAL DELAYED ENDOSTEAL IMPLANT PLACEMENT

INDICATED WHEN

• ATLEAST 5mm OF VERTICAL BONE PRESENT

• SUFFICIENT WIDTH PRESENT BETWEEN ANTRAL FLOOR AND CREST OF RESIDUAL RIDGE


SUB ANTRAL OPTION 3 (CONTD…)

• TREATMENT PROCEDURE

• 1.TATUM LATERAL MAXILLARY WALL APPROACH IS PERFORMED JUST SUPERIOR TO RESIDUAL ALVEOLAR BONE

• 2. LATERAL ACCESS WINDOW AND MEMBRANE ARE ROTATED IN AND UPWARD TO A SUPERIOR POSITION

• 3.A MIXTURE OF AUTOGENOUS BONE,ALLOPLAST AND ALLOGRAFT MATERIAL IS PLACED IN SPACE PREVIOUSLY OCCUPIED BY THE SINUSwww.indiandentalacademy.com


• AFTER 2 TO 4 MONTHS WHEN THE AREA HEALS THE IMPLANTS ARE INSERTED(THIS SHORT DELAY ENSURES GRAFT IS STABLE AND HEALS WITHOUT COMPROMISE

• IT IS PRUDENT TO DELAY IMPLANT PLACEMENT UNTIL THE GRAFT INITIALLY MATURES AND THE RISK OF INFECTION IS ELIMINATED


SUB ANTRAL OPTION 3 (CONTD…..)

• DELAYED IMPLANT INSERTION ALSO ALLOWS THE SURGEON TO ASSESS THE BONE AUGMENTATION FORMATION AND DENSITY BEFORE IMPLANT PLACEMENT

• IMPLANT (B’COZ OF THE DELAYED PLACEMENT )IS MORE RIGIDLY FIXED SINCE SURROUNDED BY A MATURE BONE GRAFT



• IMPLANT DESIGN AND SURGICAL APPROACH ARE SIMILAR TO OTHER REGIONS OF MOUTH-VOLUME,DENSITY OF BONE,STRESS FACTORS AND PROSTHETIC OPTION DETERMINE HOW MANY ROOT FORMS ARE INDICATED

• OSTEOPLASTY CAN BE DONE IF WIDER ROOT FORM IMPLANTS ARE TO BE PLACED



• IF NO OSTEOPLASTY AND ONLY ONLAY GRAFTING IS DONE,ADDITIONAL 6 MONTH HEALING TIME IS NEEDED

• ADDITIONAL 4 TO 8 MONTH HEALING IS INDICATED BEFORE STAGE II UNCOVERY AND PERMUCOSAL ABUTMENT PLCEMENT


SUBANTRAL OPTION 4

• SERVES TO AUGMENT REGION FOR FUTURE IMPLANT PLACEMENT

• THIS IS INDICATED WHEN LESS THAN 5 mm IS PRESENT BETWEEN THE RESIDUAL CREST OF BONE AND FLOOR OF THE SINUS


SUB ANTRAL OPTION 4 ( CONTD…..)

• THERE IS INSUFFICIENT HOST BONE IN HEIGHT AND QUALITY IN THE REGION TO PERMIT PREDICTABLE IMPLANT PLACEMENT

• THESE CONDITIONS ALSO NEED GREATER GRAFT VOLUME

• COMPROMISED OSSEOUS BED,EXTENSIVE PNEUMATIZATION AND INSUFFICIENT BONE STRUCTURE FOR PRIMARY IMPLANT STABILIZATION REQUIRE MORE TIME FOR BONE TO REPLACE GRAFT


SUB ANTRAL OPTION 4 ( CONTD….)

• TATUM LATERAL WALL APPROACH IS DONE SAME AS IN SA 3

• MEMBRANE IS ELEVATED TO ALLOW PLACEMENT OF AUTOGENOUS BONE,ALLOPLASTS AND ALLOGRAFTS

• USUALLY ADDITIONAL GRAFT SITE FOR AUTOGENOUS BONE IS USED APART FROM TUBEROSITY

• AUGMENTED REGION ALLOWED TO HEAL FOR 6 TO 10 MONTHS BEFORE REENTRY FOR ENDOSTEAL IMPLANTS



• IMPLANT DESIGN AS IN OTHER REGIONS DEPENDS ON AVAILABLE BONE AND INTENDED PROSTHESIS

• LESS THAN 5mm BONE IS SUFFICIENT FOR ROOT FORM IMPLANTS AFTER SINUS GRAFT HAS MATURED

• IMPLANT IS OFTEN PLACED IN THE REGION OF LINGUAL CUSP OF NATURAL TOOTH


SUB ANTRAL OPTION 4 (CONTD…..)

• BONE GRAFT IS EVALUATED AT IMPLANT PLACEMENT TO DETERMINE HEALING TIME FOR ENDOSTEAL IMPLANT

• 4 TO 10 ADDITIONAL MONTHS ELAPSE BEFORE PROSTHODONTIC RECONSTRUCTION


SUMMARY

• POSTERIOR MAXILLA IS THE LEAST PREDICTABLE AREA FOR IMPLANT SURVIVAL DUE TO INADEQUATE BONE HEIGHT,POOR BONE DENSITY AND HIGH OCCLUSAL FORCES

• INITIALLY PAST IMPLANT MODALITIES ATTEMPTED TO AVOID THIS AREA


• LATER TECHNIQUES FOR MAXILLARY SINUS ELEVATION AND SUBANTRAL BONE REGENERATION TO IMPROVE IMPLANT HEIGHT WERE DEVELOPED

• OPTIONS WERE THEN MODIFIED TO REFLECT WIDTH OF THE AVAILABLE BONE

• AFTER THE NECESSARY PROCEDURES FOR HEIGHT AND WIDTH ,ROOT FORM IMPLANTS WERE INDICATEDwww.indiandentalacademy.com

• UNFAVORABLE RIDGE ANATOMY (NARROW WIDTH )NECESSITATES THE USAGE OF AUTOGENOUS BONE GRAFTS OR OSTEOPLASTY TECHNIQUES



http://www.indiandentalacademy.com/

Overdentures/ orthodontic straight wire technique

Education

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complete mandibular

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bone loss

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