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THE EDENTULOUS MANDIBLE and MAXILLA: FIXED VERSUS REMOVABLE TREATMENT PLANNING Increasing Demand for Dental Implants

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THE EDENTULOUS MANDIBLE and MAXILLA: FIXED VERSUS REMOVABLE TREATMENT PLANNING Increasing Demand for Dental Implants THE EDENTULOUS MANDIBLE AND MAXILLA: FIXED VERSUS REMOVABLE TREATMENT PLANNING Increasing Demand for Dental Implants (1) patients living longer (2) age-related tooth loss (3) patients are more socially active and esthetic conscious (4) conventional prosthesis complications (5) the inherent advantages of implant-supported restoration Anatomic Consequences Of Edentulism ■ Bone requires stimulation to maintain its form and density ■ Teeth transmit compressive and tensile forces to the surrounding bone. ■ When a tooth is lost, the lack of stimulation to the residual bone causes a decrease in trabeculae and bone density in the area, with loss in external width, then height, of the bone volume ■ There is a 25% decrease in the width of bone during the first year after tooth loss and an overall 4 mm decrease in height during the first year after extractions for an immediate denture Advantages of Implant-Supported Prostheses ■ Maintenance of Bone ■ Occlusion Stability ■ Occlusal Awareness ■ Masticatory Efficiency ■ General Health ■ Higher Success in Comparison To Other Treatments ■ Increased Biting Force ■ Nutrition ■ Psychological Health Mandibular Treatment Planning Principles Anteroposterior Spread ■ The distance from the center of the most anterior implant to a line joining the distal aspect of the two most distal implants on each side ■ the greater the A-P spread, the farther the distal cantilever may be extended to replace the missing posterior teeth ■ when five to six anterior implants are placed in the anterior mandible between the foramina to support a fixed prosthesis, the cantilever should not exceed two times the A- P spread, with all other stress factors being low ■ The A-P distance is affected by the arch form. The types of arch forms may be separated into 1. Square 0 to 6 mm 2. Ovoid 7 to 9 mm 3. Tapering greater than 9 mm Hence whereas a tapering arch form may support a 20-mm cantilever, a square arch form requires the cantilever to be reduced to 12 mm or less, however is directly dependent upon force factors. ■ The position of the mental foramen can affect the A-P spread The farther forward the foramen, the shorter the cantilever length because the A-P spread is reduced ■ If the stress factors are high (e.g., parafunction, crown height, masticatory musculature dynamics, opposing arch), the cantilever length of a prosthesis should be reduced and may even be contraindicated. ■ The density of bone is also an important criterion. The softest bone types (D3 and D4) should not have as great of a cantilever than the denser types (D1 and D2( Mandibular Flexure ■ Many reports have addressed the dimensional changes of the mandible during jaw activity as a result of masticatory muscle action. ■ Medial convergence is the one most commonly addressed ■ The mandible between the mental foramina is stable relative to flexure and torsion. However, distal to the foramina, the mandible exhibits considerable movement toward the midline on opening. ■ This movement is caused primarily by the attachment of internal pterygoid muscles on the medial ramus of the mandible The distortion of the mandible occurs early in the opening cycle, and the maximum changes may occur with as little as 28% opening (or about 12 mm). This flexure has also been observed during protrusive jaw movements Torsion ■ the mandible twisted on the working side and bent in the parasagittal plane on the balancing side during the power stroke of mastication and unilateral molar biting ■ The torsion during parafunction is caused primarily by forceful contraction of the masseter muscle attachments ■ Therefore parafunctional bruxism and clenching may cause torsion-related problems in the implant support system and prosthesis when the mandibular teeth are splinted from the molar-to-molar regions Mandibular Overdenture Treatment Planning (RP-4 and RP-5) Anatomy of the Mandible ■ In treatment planning the mandible for a fixed or removable prosthesis, the mandible is divided into three regions: (1) anterior mandible (2) posterior right (3) posterior left ■ The available bone in the anterior mandible is divided into five equal columns of bone serving as potential implant sites, labeled A, B, C, D, and E, starting from the patient’s right side Overdenture Option 1 ■ The first treatment option for mandibular overdentures (OD-1) is indicated primarily when cost is the most significant patient factor and minimal retention is required ■ Bone volume should be abundant (Division A or B) in the anterior, and the posterior ridge form should be an inverted U shape, with high parallel walls for good-to-excellent anatomic conditions for conventional denture, support, and stability The buccal shelf (primary stress bearing area) should be prominent to withstand the forces Under these conditions, two implants may be inserted in the B and D positions. The implants usually remain independent of each other and are not connected with a superstructure ■ Positioning of the implants in the B and D positions is a much better prosthetic option in OD-1 than positioning in the A and E regions ■ Independent implants in the A and E positions allow a greater amplitude of rocking of the prosthesis compared with implants in the B and D regions ■ When using B and D implants, the anterior movement of the prosthesis is reduced, and the prosthesis even may act as a splint for the two implants during anterior biting forces, thereby decreasing the stress to each implant ■ Hygiene procedures also are facilitated with independent attachments. ■ The disadvantages of the OD-1 relate to its relatively poor implant support and stability, compared with the other options, because of the independent nature of the two implants. The other disadvantages of OD-1 relate to an increase in prosthetic maintenance appointments. ■ For the prosthesis to be inserted and function ideally, the two implants should be parallel to each other, perpendicular to the occlusal plane, at the same horizontal height (parallel to the occlusal plane), and equal distance off the midline If one implant is not parallel to the other, the prosthesis will wear one attachment faster because of the greater displacement during insertion and removal than the other. is severe, the prosthesis at all. ■ The two independent implants should be positioned at the same occlusal height, parallel to the occlusal plane. If one implant is higher than the other, the prosthesis will disengage from the lower implant during function and rotate primarily on the higher implant. ■ This situation will accelerate the wear of the attachment on the lower implant. In addition, because the higher implant receives the majority of the occlusal load, an increased risk for complications may occur, including abutment screw loosening, crestal bone loss, and implant failure ■ The implants should be equal distance off the midline. If one implant is more distal (farther from the midline) , it will serve as the primary rotation point or fulcrum when the patient occludes in the posterior segments. As such, the more medial implant attachment will wear faster, and the more distal implant will receive a greater occlusal load Overdenture Option 2 ■ Three root form implants are placed in the A, C, and E positions for the second overdenture treatment option ■ The additional implant provides a six fold reduction in superstructure flexure (i.e. if splinted bar is used) and limits the consequences previously discussed. screw loosening occurs less frequently The greater surface area of implant to bone allows better distribution of forces. ■ The risk for abutment or coping screw loosening is reduced further because force factors are decreased. ■ distribute stresses more efficiently and minimize crestal bone loss ■ Ideally, the implants in the A, C, and E positions should not form a straight line ■ The C implant is anterior to the more distal A and E implants and directly under the cingulum position of the denture teeth The greater the A-P spread of the A, C, and E implants, the greater the biomechanical advantage to reduce stress on the implant and the better the lateral stability of the implant bar and overdenture system Rotation of the prosthesis may also be more limited compared with OD-1 ■ This is usually the first treatment option for a patient with minimal complaints who is concerned primarily with retention and anterior stability when cost is a moderate factor. ■ If the anterior and posterior ridge form is favorable (Divisions A or B), the implants are placed in the A, C, and E areas, and a wide range of attachments is available ■ If the posterior ridge form is poor (Division C−h), the lack of lateral stability places additional forces on the anterior implants. Implants then are best placed in the B-C-D position to allow greater freedom of movement of the prosthesis ■ The prosthesis movement for three implants with C−h posterior bone should be greater to minimize forces on the implants and bar or individual attachment system. Overdenture Option 3 ■ In the third mandibular overdenture option (OD-3), four implants are placed in the A, B, D, and E positions ■ These implants usually provide sufficient support to include a distal cantilever up to 10 mm on each side if the stress factors are low ■ The patient’s indications for this OD-3 include moderate-to-poor posterior anatomy that causes a lack of retention and stability, soft tissue abrasions, and difficulty with speech ■ The edentulous posterior mandible resorbs four times faster than the anterior mandible. ■ In the C−h posterior mandible the external oblique and mylohyoid ridges are high and often correspond to the crest of the residual ridge. The muscle attachments therefore are at the crest of the ridge. The OD-3 prosthesis is indicated to obtain greater stability and a more limited range of prosthesis motion. The overdenture attachments often are placed in the distal cantilevers.
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