/ dental implant courses by Indian dental academy

TREATMENT OPTIONS FOR
MANDIBULAR OVERDENTURES
&&
TREATMENT PLANNING FORTREATMENT PLANNING FOR
EDENTULOUS POSTERIOR MAXILLAEDENTULOUS POSTERIOR MAXILLA
INDIAN DENTAL ACADEMYINDIAN DENTAL ACADEMY
Leader in continuing Dental EducationLeader in continuing Dental Education
www.indiandentalacademy.com

MANDIBULAR IMPLANT
OVERDENTURES-INTRODUCTION
• DENTAL PROFESSION AND PUBLIC AREDENTAL PROFESSION AND PUBLIC ARE
MORE AWARE OF THE PROBLEMSMORE AWARE OF THE PROBLEMS
ASSOCIATED WITH A COMPLETEASSOCIATED WITH A COMPLETE
MANDIBULAR DENTURE THAN ANYMANDIBULAR DENTURE THAN ANY
OTHER DENTAL PROSTHESISOTHER DENTAL PROSTHESIS
• INSERTION OF IMPLANTS FORINSERTION OF IMPLANTS FOR
SUPPORT,RETENTION AND STABILITY OFSUPPORT,RETENTION AND STABILITY OF
AN OVERDENTURE CONTRIBUTES A MOREAN OVERDENTURE CONTRIBUTES A MORE
FAVORABLE ENVIRONMENT FOR THEFAVORABLE ENVIRONMENT FOR THE
RESTORATIONRESTORATION

ADVANTAGES OF IMPLANT
SUPPORTED OVERDENTURES
• PREVENT BONE LOSSPREVENT BONE LOSS
• MAINTAIN FACIALMAINTAIN FACIAL ESTHETICSESTHETICS
• REDUCE ORREDUCE OR ELIMINATE PROSTHESISELIMINATE PROSTHESIS
MOVEMENTMOVEMENT
• CREATECREATE REPRODUCIBEREPRODUCIBE CENTRICCENTRIC
RELATIONRELATION OCCULUSIONOCCULUSION
• ELIMINATE SOFT TISSUE ABRASIONELIMINATE SOFT TISSUE ABRASION
• IMPROVEIMPROVE CHEWING EFFICIENCYCHEWING EFFICIENCY

• INCREASEINCREASE OCCLUSAL FORCE
• IMPROVEIMPROVE PROSTHESIS STABILITY
• IMPROVE PROSTHESISIMPROVE PROSTHESIS RETENTION
• IMPROVEIMPROVE SPEECH
• REDUCE OR ELIMINATE DENTUREREDUCE OR ELIMINATE DENTURE
SIZE (FLANGESSIZE (FLANGES))
• REQUIRE FEWER IMPLANTSREQUIRE FEWER IMPLANTS
COMPARED WITH FIXEDCOMPARED WITH FIXED
PROSTHESESPROSTHESES

• IMPROVEIMPROVE HYGIENEHYGIENE
• REMOVE EASILYREMOVE EASILY AT NIGHT TOAT NIGHT TO
• CONTROL NOCTURNALCONTROL NOCTURNAL
PARAFUNCTIONPARAFUNCTION
• REPAIR EASILYREPAIR EASILY COMPARED WITHCOMPARED WITH
FIXED PROSTHESISFIXED PROSTHESIS
• REQUIRE SHORTER PROSTHETICREQUIRE SHORTER PROSTHETIC
APPTS, REDUCED LABORATORYAPPTS, 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

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

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
COMPLICATIONSwww.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 SUPPORTEDwww.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
PROSTHESISwww.indiandentalacademy.com

• 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 LOSS

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
OSTEOTOMY

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 www.indiandentalacademy.com

RADIOGRAPHIC EVALUATION
• TECHNIQUES COMMONLY USED:TECHNIQUES COMMONLY USED:
1.WATERS PROJECTION1.WATERS PROJECTION
2.PANORAMIC XRAY2.PANORAMIC XRAY
• OTHER TECHNIQUESOTHER 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 DIRECTIONS
2. ALL WALLS OF MAXILLARY SINUS
3. POTENTIAL ASSOCIATED PATHOLOGIES
4. DETAILED REGIONAL ANATOMY
5. 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 www.indiandentalacademy.com

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
(FOR A 4mm DIAMETER SCREW
IMPLANT)

• 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 DURINGDURING
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

THANK YOU

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