1. Welcome to the
2009 Pacific Northwest Dental Conference!
PNDC is green! Please visit: www.wsda.org/speakers/defaultpdf.view to download lecture
handouts.
Please turn off all cell phones and pagers.
 There is no photography or recording of any kind allowed during the presentation.
CDE verification forms will be available at the END of the course.
WSDA members may have your ADA card scanned by our room host at the END of the course.
AGD members fill out a CDE verification form and take it down to the AGD counter in the
registration area.
Please fill out the yellow course evaluation form and leave it on the back table or with your host.
Visit the Exhibit Hall & Relaxation Lounge, get free massages and other giveaways. There are
drawings throughout the day, including 2 HD TVs and a Scooter. Please support our exhibitors
who support the PNDC!

2. 2

3. What Will You Do? 3

4. 4

5. Contemporary Prosthodontic
Treatment of the Edentulous
Mandible
Dr Robert Stover, DDS MS
Diplomate, American Board of Prosthodontics
Olympia Family and Cosmetic Dentistry
5

6. Overview
• Treatment options
• Conventional Prosthesis
• Implant overdentures
• Tissue supported
• Implant supported
• Common attachments
• Fixed-detachable denture (‘hybrid’)
• Case Presentation
– Sequencing treatment planning
– Surgical guides & predictability
6

7. Complete denture
Tissue supported Implant supported
implant overdenture Treatment Options implant overdenture
Fixed detachable
(‘hybrid’)
7

8. Prognostic Guidelines
• Prosthetic considerations:
• Stability
• Preservation
• Support
• Esthetics
• Phonetics
• Retention
8

9. Prognostic Guidelines
• Prosthetic considerations:
• Patient confidence
• Hygiene
• Chewing efficiency
• Surgical limitations
• Cost
• Esthetics (again)
9

10. Treatment Sequence
Fabricate Complete Dentures
10

11. Complete Dentures in Atrophic
Patients
Considerations:
• Guide for further treatment
• Establish rapport
• Potentially address chief
complaint
11

12. Complete Dentures in Atrophic
Patients
Considerations:
• Guide for further treatment
• Establish rapport
• Potential to address chief complaint
12

13. Space Analysis
13

14. Conventional Radiographic Guides
14

15. Space Analysis
15
putty matrix for space analysis

16. Conventional Surgical Guides
16

17. 17

18. Complete Dentures
18

19. Complete Dentures in Atrophic
Patients
Limitations:
• Continued resorption
• Individual propensity
• Patient with marked
resorption
• Crestal IAN position
Atwood, D.: Reduction of residual ridge: a major oral disease entitiy. J Prosthet Dent 26: 266-279, 1971.
Tallgren A: The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed-
longitudinal study covering 25 years. J Prothet Dent 27(2):120-132 1972
19

20. Complete denture
Tissue supported Implant supported
implant overdenture Treatment Options implant overdenture
Fixed detachable
(‘hybrid’)
20

21. Overdentures
Benefits:
• Stability
• Retention
• Patient confidence
• Chewing efficiency
• Hygiene access
• Preservation
• Esthetics
• Phonetics
21

22. Overdentures
Limitations:
• Support similar to complete
dentures
• Surgical intervention required
• Potential for implant failure
• Anatomical limitations
• Higher maintenance cost
22

23. Overdentures
Implant supported
• Support similar to hybrid
• Surgical intervention required
• Potential for implant failure
• Biomechanical limitations
• Higher maintenance cost
[implant od pic]
23

24. Common Attachments
Attachments
2.Form
A. Bar and clip
- Dolder, Ackerman, Hader
B. Stud attachments
1. Magnetic
2. Matrix / Patrix
- Locator, Ball and socket, ERA
3.Function
A. Resilient
B. Non-resilient
24

25. Bar Attachments
Bar / clip- Dolder bar
a. Pear shaped (resilient) - allows movement
b. Parallel bar (solid) - no movement
25

26. Bar Attachments
Bar/clip- Ackermann bar
a. Round
b. Egg shaped
26

27. Bar Attachments
Bar/clip- Hader
a. Standard 1.8mm diameter or 13 gauge
b. Compatible with other bar patterns
c. Gold plated machined metal housing
27

28. Bar Attachments

29. Stud Attachments
Advantages
a. Easier hygiene than bars
b. Crown/root ratio enhanced
c. Low profile
2

30. Stud Attachments
3

31. Mini Implants
Small diameter implants
• Victor Sendax
• Titanium alloy (Ti6Al4V)
• 1.8-3.25mm diameter
• 10, 13, 15, 18mm length
• FDA approval*
– Interim & on-going retention
• US intro 1999
• 2008 3M subsidiary
Ulatoqski, TA. Nov 1997. FDA written communication,.Office of Device Evaluation, Center for Devices &
Radiological Health, FDA.
31

32. Mini Implants
Small diameter implants
• Interim overdenture retention
Shatkin TE, et al. Mini dental implants for long-term fixed and removable prosthetics: a retrospective analysis of
2514 implants placed over a five-year period. Compend Contin Educ Dent 2007; 28(2):92-99.
Griffitts TM, et al. Mini dental implants: an adjunct for retention, stability and comfort for the edentulous patient.
Oral Surg,Oral Med Oral Pathol Oral Radiol Endod 2005;100(5):e81-e84.
32

33. Overdentures
Small diameter implants
• Definitive overdenture stabilization
33

34. Overdentures
Small diameter implants
• Definitive overdenture stabilization
34

35. Mini Implants
Contemporary indications:
• Mandibular overdenture
• Cost effective
• Poor surgical candidates
• Compromised medical history
• Adverse to extensive surgery
• Inadequate bone for conventional
implants
Christensen, Gordon J. Feb 2001. Simplified Implant Surgery Techniques. DentalTown Magazine, pg 32.
Christensen, Gordon J. June 2009. The Increased Use of Small-Diameter Implants. JADA, Vol 140, pp
709-712.
Bulard, RA. Dec 2005. Multi-Clinic Evaluation Using Mini-Dental Implants for Long-Term Denture Stabilization:
A Preliminary Biometric Evaluation. Compendium, 26(12):892-897. 35

36. Complete denture
Tissue supported Implant supported
implant overdenture Treatment Options implant overdenture
Fixed detachable
(‘hybrid’)
36

37. Fixed-Detachable Denture
Benefits:
• Extremely stable
• Preservation
• Support
• Retention
• Patient confidence
• Chewing efficiency
• Bypass anatomical structures
37

38. Fixed-Detachable Denture
Limitations:
• Access for hygiene
• Esthetic compromises
• Phonetic compromises
• Costs
• Appropriate lab support
• Anatomical limitations
• Limited cantilever length
38

39. Fixed-Detachable Denture
Limitations:
• Access for hygiene
• Esthetic compromises
• Phonetic compromises
• Costs
• Appropriate lab support
• Anatomical limitations
• Limited cantilever length
39

40. Biomechanics – Force Analysis
Intraforaminal placement
• Historically indicated
• Simple anatomy
• Induces posterior
cantilever
Chewing table
• Limited surface area
• Cantilever length
40

41. Biomechanics – Force Analysis
A-P spread based
• 1½ x (A-P spread)
• 15-20mm / minimum
10mm A-P spread
• maximum implants
maximum spread
McAlarney et al (2000). Theoretical cantilever lengths versus
clinical variables in fifty-five clinical cases. J Prosthet Dent;
83:332-43.
Rangert, B, T Jent, L Jorneus (1989). Forces and moments on Branemark Implants. Int J Oral Maxillofac Implants; 4:241-7.
English CE (1990). The critical A-P spread. Implant Soc J; 1:2-3.
Taylor R and G Bergman (1990). Laboratory techniques for the Branemark System (ed 1). Chicago, IL, Quintessence.
Skalak R (1983). Biomechanical considerations in osseointegrated prostheses. J Prosthet Dent; 49:843-48. 41

42. Biomechanics – Force Analysis
Guidelines for Cantilever
Length
Compressio
• 2-3 premolars n
• <20mm with 5-6 implants
• <15mm with 4 implants
Tension
McAlarney et al (2000). Theoretical cantilever lengths versus
clinical variables in fifty-five clinical cases. J Prosthet Dent;
83:332-43.
Branemark, PI, GA Zarb, T Albrektsson (1985). Tissue Integrated Prostheses. Chicago IL, Quintessence, pp 51-70, 117-128.
Zarb GA and A Schmitt (1990). The longitudinal clinical effectiveness of osseointegrated dental i9mplants: the Toronto study,
part II, the prosthetic results. J Prosthet Dent; 64:53-61. 42

43. Biomechanics – Force
Analysis
Occlusion
• Increased force / area on implants
Richter E (1989). Basic biomechanics of dental implants in prosthetic dentistry. J Prosthet Dent
61:602-9.
• More force on rigid integrated fixtures
Brunski JB, JA Hipp, M El-Wakad (1984). Dental implant design: Biomechanics and interfacial tissues. J
Oral Implantol 12:365-77.
• Cantilevers may increase loading 1½-2x
Skalak R (1983). Biomechanical considerations in osseointegrated prostheses. J Prosthet Dent;
49:843-48.
• Large moments generated by cantilevers
Rangert B, T Jent, L Jorneus (1989). Forces and moments on Branemark Implants. Int J Oral Maxillofac
Implants; 4:241-7.
Rangert B, J Gunne, DY Sullivan (1991). Mechanical aspects of a Branemark implant connected to a
natural tooth: an in vitro study. Int J Oral Maxillof Implants 6:177-85. 43

44. Treatment Sequence
• Diagnostic workup & complete dentures
• Radiographic / surgical guides
• Conventional radiology
• CT scan
• CAD analysis
• Treatment plan
• Surgery
• Definitive prosthesis
44

45. Treatment Sequence
• 42 yo AD Navy PO1
• Edentulous 21 years
• Unsuccessful denture wearer
• Loss of OVD
• Functionally atrophic mandible
45

46. Treatment Sequence
•CC:
“I have a lack of bone on the
bottom and I can’t get my
denture to fit.”
•Expectations:
“I want to be able to wear
bottom dentures comfortably
for the rest of my life.”
•CD prognosis:
max: good
man: extremely guarded/poor
Englemeier, R. and R. Phoenix (1996). Patient Evaluation and Treatment Planning for Complete-Denture Therapy.
DCNA 40:1-18, 1994 46

47. Complete denture
Tissue supported Implant supported
implant overdenture Treatment Options implant overdenture
Fixed detachable
(‘hybrid’)
47

48. Decision Process – Case Presentation
Re-evaluation
– Stability
– Preservation
– Support
– Esthetics
– Phonetics
– Retention
– Patient confidence
– Hygiene
– Chewing efficiency
– Anatomical / surgical limitations
– Cost
48

49. Radiographic / Surgical Guides
49

50. Radiographic / Surgical Guides
50

51. Conventional Radiology
51

52. Conventional Radiographic
Assessment
52

53. Conventional Radiographic
Assessment
16.2mm 7.5mm
7.2mm
13.4mm
13.4mm
• Useful in planning
definitive treatment
53

54. CT-based Assessment
1 1/2 x (A-P)
(A-P)
54

55. Diagnostic Planning
55

56. Diagnostic Planning
2 x (A-P)
(A-P)
56

57. Surgical Guide
57

58. Surgical Guide
58

59. CT / CAD Treatment Planning
CT / CAD design systems
• NobelGuide (NobelBiocare)
• Materialise (Astra)
• StentCAD
• Keystone
59

60. NobelGuide®
1. Fabricate complete dentures
a. Good fit to anatomy
b. Adequate extensions
c. Ideal tooth set-up
2. Radiographic guide
a. Acrylic
b. 6-#4 round burr
reference points
c. Fill with GP
60

61. NobelGuide®
3. CT scan
a. Double scan technique
Radiographic Index First CT Scan Second CT scan
 Secures correct Radiographic Guide only
 Patient
positioning and
seating of the  Radiographic Guide
Radiographic Guide  Radiographic Index
during CT scan
61

62. NobelGuide®
4. Computer planning
62

63. NobelGuide®
Surgical Template Fabricate Stone Model Design Prosthesis
Order sent electronically Use Surgical Template as  Definitive prosthesis
Stereolithograpy the “impression”  Implant Bridge
 Provisional
 short term
63

64. Treatment Plan
• IAN lateralization
• Implant-supported bar overdenture
• 2 posterior bars
• 1 anterior bar
• Supported by 6 implants
64

65. Justification for Treatment
• Inability to tolerate complete denture
• Cost effective
• Oral hygiene access
• Stability
• Retention
• Support
• Esthetics
• Preservation
• Bilateral nerve impingment in premolar area of
edentulous ridge
65

66. Clinical Treatment
• Implant workup / imaging
– Conventional radiology
– CT / Simplant
– Stereolithography
• Surgical guide
• Nerve lateralization
• Phase 1 Implant surgery
• Complete Denture
Maintenance
• Phase 2 Implant surgery
66

67. Nerve Lateralization
• Deglove mandible
• Un-roof nerve
• Lateralization
• Stabilization
• Insulation (bone
graft)
67

68. Implant Placement
68

69. Implant Placement
69

70. Stage 2 Surgery
70

71. Post Healing
• Healing phase
• Re-present for restoration
71

72. Maxillary Overdenture
Locator Attachments
72

73. Refabricate Complete Dentures
73

74. Fabricate Bars
74

75. Refabricate Complete Dentures
75

76. Attachment procedure
76

77. Laboratory Processed Attachments
77

78. Clinical Pick-up
78

79. Final Prostheses
79

80. 80

81. 81

82. Patient preferences
Acceptance
• Denture patients
• Preference evenly split
• Stability (fixed preferred)
• Chewing ability (fixed preferred)
• Ability to clean (removable preferred)
• Esthetics (removable preferred)
Feine, J et al.: Within-subject comparisons of implant-supported mandibular prostheses: Choice of
prosthesis. J Dent Res 73(5): 1105-11, 1994.
82

83. Treatment planning the atrophic mandible
Complete OD OD Fixed
Denture (soft tissue) (implant) Detachable
Stability - ++ + ++ +++
Preservation - +/- + ++ +++
Support +/- +/- ++ +++
Esthetics +++ +++ +++ +
Phonetics ++ +++ +++ -
Retention - +++ +++ +++
Confidence - ++ + ++ +++
Hygiene +++ + ++ ++ +/-
Efficiency - ++ + ++ +++
Fabrication ++ - -- ----
Cost ++ - -- ---- 83

84. Summary
• Treatment options
• Conventional Prosthesis
• Space analysis
• Implant overdenture
• Tissue supported
• Implant supported
• Mini implants
• Attachment types
• Fixed-detachable denture (‘hybrid’)
• Conventional / CAD tx planning
• Case Presentation
84

85. Questions?
Thank You!
OFCD@live.com
85