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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