TAGD
O f f i c ial P u b li c ation o f t h e T e x as A c adem y o f G eneral D entistr y
TEXASGP
WWW.TAGD.ORG
SPRING 2012, VOLUME 38, ISSUE 2
Doesn't Matter What You Wear, but How You Get There
Also in this issue:
TAGD Advocacy • Our Profession at risk New Dentist Conference Preview
Shoulder to Shoulder
SPOTLIGHT ON THE COMPONENTS South Texas AGD
I
graduated from the University of Texas Dental Branch at Houston in 1985. I have been an active member of the AGD since 1996. I never realized, until recently, how important it is to have an organization as relevant as the AGD advocate on my behalf. Dempsey Speer, DDS
With so many changes occurring in our economy and in the health profession, I am secure in knowing the AGD is truly protecting the interests of the general dentist and the profession of Dentistry, as well as the needs of our patient's oral care. Unbelievably, we have not had a TAGD component in the Corpus Christi area since the 1980s. Seeing the need for our own VOICE, a few fellow dentists and I decided it was time to join the AGD movement once again. With the generous help of the TAGD leadership and staff, we were able to revitalize the old Corpus Christi AGD into the new South Texas AGD with a strong enthusiasm for growth and leadership in our area. It is amazing to see how much has been done in such a small amount of time. Thanks to our newly formed ST AGD Board of Directors, we are now laying the foundation for an AGD chapter that is solid. We look forward to many exciting years of serving with the TAGD, not only for advocacy reasons, but to uphold the tenets of the AGD Dentist. I am immensely proud of the fact that South Texas is back on the TAGD MAP!
Dental Philosophies
G
etting through our vigorous dental curriculum is hard enough, but trying to think about the future is even harder! As dental students, our focus centers on meeting our requirements and passing every course. It is purely considered a bonus to have faculty help guide us clinically, mentally, academically, and additionally to share their dental philosophies. Because of my remarkable mentors, I have begun to develop my own personal dental philosophies. Though certainly not a requirement in order to graduate, I credit my faculty for this individual growth because they have taught me to “aim high” and become A Great Dentist (AGD). Providing consistent quality care that comes from the heart is what I think makes our profession reputable and trustworthy, built on a foundation of compassion for patients, sound integrity, evidence-based and ethical decision-making. By embracing the counsel of my faculty and the unique2
Dallas AGD
I
received my BS in Biology and Biochemistry from West Texas A&M University and my Doctor of Dental Surgery degree from the University of Texas Health Science Center in San Antonio. As a student at UTHSCSA I was first exposed Shane Ricci, DDS, FAGD to the Academy of General Dentistry through my involvement in the FellowTrack Program. Shortly after I entered private practice in Plano in 2007. I was asked by a former faculty member in my residency to participate in the formation of the TAGD New Dentist Committee. Since this first position on the committee I have become even more involved with the AGD serving on the Dallas AGD board for several years, most currently as President, and I am also the current Chair of the TAGD New Dentist Committee and New Dentist Conference, and I have served as Texas Delegate for the national AGD Governance meeting. TAGD has been a great organization for me and has served as a stepping stone in many ways. Not only has it provided me with numerous ways to become involved in organized dentistry on the local and state level but I have met so many great people along the way. I encourage everyone to get involved in some way, you won't be disappointed.
ness of the dental profession, I have created a Top 10 Fundamentals list as I begin to develop my own dental philosophy: 1. What is right is right, what is wrong is wrong. If it’s in between, then it’s wrong! 2. Quality, not quantity. Quantity is acceptable ONLY when there’s quality! 3. Treat your patients with the kindness and respect that they deserve, and then they’ll be your best patients and practice builders. (If you’re lucky, they might bring you some baked goods!) 4. Treatment planning is the most important aspect of care. Always have a plan and a back up! 5. We will be “practicing” dentistry, so we are going to make mistakes! It is how you handle it that makes you a good dentist. Learn from each mistake. 6. Preventive and preservative dentistry should be our first consideration. 7. Continue to grow as a dentist and
never think your days of learning are over. Surprise yourself with knowledge you can obtain during the journey of life-long learning.
Nina Trinh
8. Be involved in den- 4th year, UTHSCSA tistry outside the walls of your office. With advocacy, we can provide more and better care if we work to ensure our profession’s resources are utilized to the max. 9. Smile, because it’s contagious. If the dentist is happy, everyone is happy. 10. Lastly, enjoy what you do because only you have the ability to control your own attitude. In conclusion, my transition from dental school into private practice is greatly anticipated knowing that the philosophies I gained here will serve as a solid foundation for the rest of my dental career. JOURNAL OF THE TEXAS ACADEMY OF GENERAL DENTISTRY
2011 - 2012 OFFICERS President Joey Cazares, DDS, FAGD McAllen President-Elect Mark Peppard, DDS, MAGD Austin Immediate Past-President Craig Armstrong, DDS, MAGD Houston Secretary/Treasurer Jamie Bone, DDS, MAGD Kerrville
J O U R N A L
T A B L E
O F
O F
T H E
T E X A S
A C A D E M Y
Director Jennifer Bone, DDS, MAGD Kerrville Director Christopher Perry, DMD, FAGD San Antonio Director Marc Worob, DDS, FAGD Austin AGD Regional Director David Tillman, DDS, MAGD Fort Worth AGD National Trustee Douglas Bogan, DDS, FAGD Houston Executive Director Connie Sonnier, CAE Round Rock TAGD Staff Sandy Frizzell • Member Services Director Laura Ceglio • Communications Coordinator Lindsey Robbins • PACE Assistant
Fall 2011
D E N T I S T R Y
SPRING 2012
Dentistry - Our Profession at Risk
6 Implant Overdenture Therapy
Director Marko Alanis, DDS Edinburg
Director Kevin Gureckis, DMD, MAGD, ABGD San Antonio
G E N E R A L
C O N T E N T S
Editor Andrew Lazaris, DDS, FAGD Plano
Director Paige Sohn, DDS, MAGD Frisco
O F
8 New Dentist Conference Thank You
12 15
Component Update ............................................................................2 A Dental Student's Perspective............................................................2 Dental Fillins.......................................................................................4 President's Message............................................................................5 Cover Photo credit to Sophie Lazaris
NEXT ISSUE:
Texas dentist of the year nominees Information change request: Send your new address, phone, fax and e-mail to Laura@TAGD.org Disclaimer: The TAGD does not necessarily endorse opinions or statements contained in articles or editorials published in the TexasGP. The publication of advertisements in the TexasGP does not indicate endorsement for products and services. Texas GP is published quarterly by the Texas Academy of General Dentistry, 409 West Main Street, Round Rock, TX 78664. Address changes should be sent to the TAGD. TexasGP is provided as a member service to members of the TAGD. Nonmember subscription rates are $25.00 individual and $40.00 institutional. Canadian orders add $5.00; outside the U.S. or Canada, add $10.00. Single copy rates are $3.00 to individuals and $4.50 to institutions (orders outside the U.S. add $1.00 postage). All orders must be prepaid in U.S. dollars. Printed in U.S.A. Copyright 2011, Texas Academy of General Dentistry, Round Rock, TX. No portion of TexasGP may be reproduced in any form without prior written permission from the TAGD. The opinions expressed by TexasGP are not necessarily endorsed by the TAGD. The publication of an advertisement in TexasGP does not indicate endorsement for products and services. TAGD/AGD approval for continuing education courses or course sponsors will be clearly stated.
Important Contacts TAGD
512-244-0577 877-464-8243 (Toll-free) 512-244-0476 (Fax) www.tagd.org
AGD
888-243-3368 www.agd.org
ADA
800-621-8099 www.ada.org
TDA
800-832-1145 www.tda.org
TSBDE 512-463-6400 www.tsbde.state.tx.us 3
DENTAL FILLINS • Perspective
L
ike some of you reading this, I am now on the other side of the big 4-0. As I’ve been managing my mild symptoms of OLD for some time now, I’m always happy to pass on my sage advice to others. Just the other day, my youthful dental assistant was telling me how she tweaked a muscle from playing sports and it was still noticeable to her the next day. After a short review of symptoms, I concluded that she was experiencing the first stages of OLD as well. This was not entirely surprising since she just turned 25. The diagnosis was further supported by reports of chronic EEN (early evening narcolepsy).
good tips on how to improve your denture making techniques. I hope to see you all there… in black socks and tennis shoes of course. I was reading the other day that research shows almost half of us make New Year’s resolutions. And of those people, almost 50 percent maintain their resolutions after 6 months. What is encouraging is that people that explicitly make resolutions are 10 times more likely to attain their goals.
ready involved in leadership? Think about attending the Leadership Conference in Chicago in November. Come sit in on a TAGD Board meeting or Andrew Lazaris, DDS, FAGD join a committee.
Is this your year to become involved in advocacy? Subscribe to The Gatekeeper, TAGD’s online newsletter to What did you want to accomplish prokeep current with legislative issues. fessionally this year? There is still time Contact TAGD for information on and plenty of opportunities through how you can be involved in advoTAGD. So, where was I again? Living with OLD cacy issues. Attend one of the TAGD has given me some insight into previousTown Hall meetings for updates and Is this your year to set new educational ly unexplainable phenomena. Namely, opportunities to ask questions to your goals? This is the perfect time to work on black dress socks and tennis shoes. UnTAGD advocacy leaders. Did you your Fellowship Award or pursue Mastil a couple of months ago, I wouldn’t know that TAGD has a Legislative tership. You will find that the journey have been caught dead like that. Consultant, David Mintz? In adWho in their right mind thought dition to advising on advocacy isthat looked acceptable? But one "Not I – Not anyone can travel that road with sues, Mr. Mintz was welcomed to morning, I was getting ready to you. You must travel it for yourself – With Dallas recently to discuss current walk my daughter to school issues with Baylor Fellowtrack and I made a fateful deci- comfy socks of course." students. How do you feel about sion. Get up and walk 10 feet issues that affect how you will - Walt Whitman to get a pair of tube practice? Do you want to be insocks or put on the black volved? It can be as simple and is its own reward. Pin up your calendar dress socks in my hand? Easy painless as making an online donation issue of TexasGP or go to TAGD.org to decision. Besides, no one would see my on www.tagd.org. search educational opportunities. Make shameful combination anyway. this the year to try a new conference you Is this your year to become involved The walk was a revelation. It was great! have not attended before. Attend the New more socially? Get out there and reconAlmost on par with the first time I used Dentist Conference, Lone Star Dental nect with your old classmates, instructors an Isolite. And to think that I thought I Conference, and/or the AGD Annual and mentors. There are many amazing knew all there was to know about sock Meeting in Philadelphia. people in TAGD doing extraordinary fashion. Now, I’m all about rockin’ the things. black socks. Is this your year to volunteer? Has it been a while since you’ve volunteered? Have This issue’s student editorial is by Nina My favorite new conference I attended you ever volunteered? The Jack T. Clark Dinh, a fourth year dental student in last year was definitely the New Dentist Foundation is your ticket to quality CE San Antonio. So much wisdom packed Conference. What a great job the New and volunteer opportunities. into 10 simple statements. It doesn’t matDentist Committee did putting it on! ter if you are just starting dentistry or are a Dr. Bill Robbins kicked off the inaugural Is this your year to become involved in bit seasoned. I know some of you will see event and will be followed this year by leadership? Your local component would this on the “right” day and it will make Dr. Joseph Massad and Dr. Scott Leune. love to have you. This issue we spotlight a positive difference. If you haven’t had a chance to hear Dr. Corpus AGD and Dallas AGD and Massad speak, do yourself a favor and sign One more thing; black socks and santheir presidents share with us how they up now. You will definitely pick up some dals? Really? Those dudes are weird. became involved in leadership roles. Al4
JOURNAL OF THE TEXAS ACADEMY OF GENERAL DENTISTRY
MESSAGE FROM THE PRESIDENT M
embership in organized dentistry is an integral part of being a dental professional. Having graduated over 25 years ago from dental school, I have seen a proliferation of dental groups/associations offering membership to dentists. Why does a dentist look for membership into a professional association? Could it be for credibility to show their patients, professional satisfaction or a positive image that membership can possibly exhibit?
As a member of the TAGD, I have experienced a different twist to membership. Just like the old song from the sitcom, Cheers that says “where everybody knows your name,” this is what TAGD is all about – a place where we feel we belong, surrounded by friends. If you know of someone who seems lost in the profession or feels burned out, I will venture to say they are not members. Invite them to become one. As we all go through the cycle of life, we all have our life’s occurrences. My fatherin-law recently passed. Several dentistfriends of mine have recently lost loved ones. Not just as TAGD members, but as true friends, we feel their loss as well. We all have close friends that we see going through these and other life-altering events. I have seen nothing but support for each other as we navigate ourselves through these tough “curve balls” that life throws us. When confronting these difficult times, what is better than to have the support of family and friends. This is what I have experienced as a member of TAGD. None of us are immune to these difficult situations. After all is said and done, what is most important to all is family and friends. I have personally become close to many of my TAGD friends, their wives and their families. If it were not for TAGD, I would have missed out on the happiness that each and every friend/colleague has brought me. These are people that will stand with you when you need them most. I am certain of that. People often ask me if I get tired of going out of town to go to TAGD meetings. I politely respond that I am going out of town for two things – to help preserve and Spring 2012
protect my profession, helping to make it the best it can be, and to visit my TAGD friends who are on the same mission that I am. Although I may refer to them as my TAGD friends for the purpose of this President’s message, these are people I consider true friends, that I will have as lifelong friends. People that I will cherish, respect and support in any way possible. I recently attended a Lone Star Dental Conference Committee meeting. I was so impressed with the energy in the room – all working to improve the Lone Star Conference. To see so many current and past TAGD leaders taking time out of their busy schedules to come and be part of the process was so inspiring. It is easy to see why TAGD is so respected nationally and has become THE group to be a member of if you are a general dentist in Texas. Texas Dentistry is currently undergoing many changes. Medicaid is now under the direction of three managed care organizations, starting March 1, 2012. There are still many questions to be answered as Medicaid dental providers participate in this new process. Here at TAGD, we strive to be at the forefront of information, and to be able to best represent our members and their concerns. A new committee on Barriers to Care, chaired by Dr. Craig Armstrong, has been formed to help TAGD learn how to best deal with existing problems that seem to prevent patients from receiving dental care. I expect this committee to be able to provide TAGD with pertinent information as we prepare to break down the barriers that are preventing us from treating those who are requesting our services.
Donating to the TAGD Advocacy Fund is imperative for all members. As we progress into the future, it is apparent that more regulations are lurking in our path that can affect the way we practice. It is important that TAGD be at the forefront of representation of general dentists so that our members are able to continue providing the best care and maintaining the high ethics that TAGD adheres to. Keeping our legislators informed is an ongoing process.
The media often portrays dentists in a negative light with their sensationalism. We shall continue, with your help, to show that dentistry is a model profession; it is “health care that works.”
Joey Cazares, DDS, FAGD
We need to celebrate what our members do on a daily basis to help our fellow man. Although the list is endless, I want to acknowledge the work that some specific TAGD members are involved in. Drs. Kevin Seidler and T. Bob Davis continue their dental missions; what an unselfish feat they do on a continuing basis. Dr. Z Helmer, another great role model, also donates his services abroad. He was awarded AGD’s Humanitarian Award for his unselfish care to those in need. Dr. David Tillman is another dentist that I admire for his continued work for TAGD and his representation of Texas at the national level. Dr. Tillman – you are truly admired by so many and I pray for your quick recovery. These are but a few of the members that are doing great things for the profession. Come and attend the Lone Star Dental Conference and the Dentist of the Year Gala and you will meet even more. You will not believe the commitment of our Texas dentists as they do great things in their communities, not because they want the limelight, but because they are just good people. It is inspiring to watch. My brother, sister and family members attended the last gala; they left impressed with the profession and its members. It was a proud moment for me to be a member of the dental profession and Texas AGD. Be a part of the TAGD team. Get involved at the component level. Be a protector of the dental profession. Voice your opinions so that all can hear. Together, we can keep dentistry as great as it is today and maintain the high standards for generations to come. 5
Dentistry – Our Profession at Risk
GUILTY?
as insignificant as a mere allegation. These monies are being held – in some instances for over six months now with no hearing scheduled. Doctors are being treated as guilty on the basis of allegations. None of the accused doctors have been adjudicated guilty of anything.
UNINTENDED CONSEQUENCES
T
he Patient Protection and Affordable Health Care Act (Obamacare) is taking a heavy toll on dentistry in ways we never suspected. Large numbers of orthodontists, pediatric dentists and general dentists are involved in the current Medicaid pre-authorization dispute and the many controversies regarding the transition of the management of the Texas Medicaid programs from TMHP to the MCOs. These doctors have been and are providing care for tens of thousands of underserved children in the programs. Many of these doctors are under investigation due to allegations of Medicaid irregularities involving billing and the pre-authorization process. The following is an update involving current real live cases.
HISTORY
Following mandates resulting from findings from the Frew v Hawkins case, Texas dentists including orthodontists, pediatric dentists and general dentists were encouraged to provide more orthodontic services to Medicaid beneficiaries. Reimbursements were increased resulting in more orthodontic care and more providers participating in the program. Some requirements such as submitting models for preauthorization were reduced or eliminated. An audit was performed regarding the Texas Health & Human Services Commission (HHSC) and Texas Medicaid Healthcare Partners (TMHP} management of the program in 2008. Findings from the audit included many discrepancies on the part of HHSC and TMHP in the program requiring response from those agencies. 6
The responses resulted in some changes in the programs and findings that mistakes were made and procedures were not followed particularly in the pre-authorization process, i.e., cases were being approved for treatment without required examination by qualified examiners – all confirmed by officials of the Texas Health & Human Services Commission, at the Texas House Public Health Committee hearing last February. Following a series of “investigative” TV reports regarding Texas Medicaid orthodontics last year the Office of the Inspector General (OIG) began wide spread investigations looking for irregularities in Medicaid pre-authorizations and billings. As a result of these investigations some of these orthodontists have now been placed on “recoupment hold” by the OIG meaning that their Medicaid reimbursements are being held pending results of a series of hearings to determine the validity of allegations of fraud – primarily during the pre-authorization process. The OIG claims authority and the obligation to impose the hold based on the Patient Protection and Affordable Care Act (Obamacare) that requires the State to withhold Medicaid reimbursements if there is an “indicia” of “credible evidence” of fraud and a doctor or entity is under investigation. According to the Federal Statute, Federal funds will be withheld from the State unless the State cuts off the funds of the doctor being investigated. It is important to note that OIG refuses to define indicia and that credible evidence can be
There are other vital interests at stake here – Medicaid beneficiaries. These offices have currently in treatment well over 100,000 Medicaid children. In the transition of the Medicaid programs from TMHP to DentaQuest, Delta Dental and MCNA many of these doctors began receiving letters notifying them that the MCOs have been ordered by OIG to deny their provider status in the Medicaid programs because they are merely under investigation. Without provider status and their reimbursements withheld, some of the affected offices will have to close or at least terminate their Medicaid patients. I have inquired on several occasions of OIG staff if any consideration had been given to the issue of what will happen to the children in treatment and how are they to be taken care of if these doctors are forced to cease treatment for the children. The answer was essentially “NO”. The answer I received from a federal prosecutor in a similar case was, “We’re not concerned about the children in treatment – the market will take care of that!!” If you are the only orthodontist within a hundred and sixty mile radius, there is no market!! In spite of assurances from OIG that there was absolutely no intent to put anyone out of business, just last week two of these doctors were forced out of taking care of these children because they could no longer afford to provide the care for lack of funds and another doctor who had been promised payment had over 100 claims denied.
TRANSITION FROM TMHP TO MCOs
To make matters worse, on March 1, 2012, on schedule, the Medicaid programs were transferred to a managed care program with three managed care organizations. Beneficiaries were required prior to that time to register with one of the MCOs and name their “home dentist”. This process has resulted in mass confusion with beneficiaries being assigned to dental homes at random without regard to their current treating dentist and children in the same JOURNAL OF THE TEXAS ACADEMY OF GENERAL DENTISTRY
family being assigned to different dentists. Worse yet, are at least two provisions in the new rules allowing an MCO to re-evaluate a pre-authorization made prior to March 1, 2012. If it is determined that there is no medical necessity, the MCO can order that the case be “debanded” – clearly a retroactive punitive action. There are thousands of these cases. How are they to be handled? Who’s going to tell the parent that it was medically necessary to place braces on their child’s teeth, but now there is no medical necessity and the braces are coming off? The other is a requirement that according to new guidelines, only board certified or board eligible orthodontists can treat Level III and Level IV orthodontic cases. This rule is clearly in violation of American Dental Association Policy and does not take into account the thousands of cases currently in treatment by qualified general and pediatric dentists.
CONCLUSION
In conclusion – all of these doctors, whether they have been accused or not and whether they are under investigation or not along with the children they treat, all entered in the program as providers and beneficiaries in good faith. They had every assurance from HHSC and TMHP that the cases they submitted would be evaluated by competent evaluators; that medical necessity would be determined not by the doctors themselves, but by a qualified evaluator; that if they were pre-authorized, they had submitted everything that was required and they could initiate the treatment and continue with confidence that they would be appropriately compensated. In short the doctors have done what The State of Texas asked them
to do – provide more orthodontic care for more children at an agreed to fee. The Texas Medicaid program has evolved into an unsustainable nightmare. As noted doctors are being forced out of business and beneficiaries are forced out of treatment or into doctors’ offices they did not choose. Many doctors who are current providers in the program and have been providers in the program since inception are being denied provider status because they are under investigation or because they have an existing disciplinary action from the Texas State Board of Dental Examiners.
RECOMMENDATIONS
Recognizing that there are no quick answers, consideration should be given to some possible immediate action: 1. A moratorium could be placed on these recoupment holds. The doctors are forced by these holds without adequate compensation to continue treatment to avoid abandonment issues. Those who now can no longer afford to continue treatment in this manner are forced to dismiss the patients and there is nowhere for these patients to go; 2. Doctors who have been providers in the program even though they are under investigation or serving an Agreed Board Order should be allowed to continue as providers in the program. The MCOs are not consistent in the approval process. Some approve the doctor while one or more will not approve. Many of these doctors are major providers in their area which is often a highly underserved area. 3. The rule of re-examining cases that have been pre-authorized prior to March 1, 2012, should be abolished as unacceptable and retroactive.
4. The new criteria for determining preauthorization for orthodontic treatment should be re-evaluated. As currently stated, very few if any cases will qualify. The requirement that only board certified or board eligible orthodontists are approved to treat Level III and Level IV cases is in violation of American Dental Association Policy and is discriminatory against general dentists and pediatric dentists who are well qualified and have been successfully treating these cases for many years. Heretofore there has been no discrimination of provider. If allowed to become a precedent, eventually only oral surgeons could perform extractions, only endodontists could perform endodontic therapy and only periodontists could perform perio. Is this where we as a profession want to go? 5. Finally, the transition from TMHP to a Managed Care Program is severely, if not fatally flawed. The process should be postponed for an additional six months until the programs can be revisited and re-evaluated, this time with provider representation at the table. If no action is taken this situation will surely escalate. The investigations began with orthodontics, but have now extended to general dentists and pediatric dentists as well. Whether we participate in Medicaid or not - all dentistry is affected. Our profession is at risk!! Robert M. Anderton, DDS, JD
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INTERDISCIPLINARY MANAGEMENT OF IMPLANT OVERDENTURE THERAPY INTRODUCTION
• moderate, left-side, maxillary gingival display • asymmetrical, reverse occlusal plane orientation • mandibular dentoalveolar extrusion • excessive mandibular tooth display in repose and smile • excessively narrow buccal corridors • flat to reverse anterior-posterior occlusal plane • thin, diminished maxillary vermillion lip dimensions • adequate mandibular vermillion lip dimensions for patient’s age.
The management of complicated dental problems often requires an interdisciplinary approach to diagnosis, treatment planning, and therapy. Staging interactions among multiple providers and processes is critical to an optimal therapeutic outcome. The dental patient presented here required thorough diagnosis and treatment planning, as well as carefully orchestrated interdisciplinary management to arrive at a successful treatment result.
PATIENT PRESENTATION AND EVALUATION
A 61-year-old female presented for dental evaluation and treatment of her failing natural dentition (Figure 1). The patient indicated having seen 5 dentists in the last several years, suggesting that none were able to satisfy her treatment requests or stay within her economic means. She also expressed displeasure with her smile aesthetics, indicating that her teeth had drifted over the past few years. The patient desired to improve her oral function and appearance. Following review of medical and dental histories, thorough intra- and extraoral examinations were accomplished. A radiographic survey was completed, including a full mouth series of periapical and bitewing radiographs and a panoramic radiograph (Figure 2). In general, the patient possessed a rapidly failing maxillary and mandibular dentition, generalized periodontal bone loss, and recurrent cervical caries, with functional and aesthetic compromise. The maxillary occlusal plane was canted. Excessive maxillary gingival display, consistent with vertical maxillary excess, and overabundant mandibular anterior tooth display, consistent with dentoalveolar extrusion, adversely affected smile aesthetics. Radiographs indicated bilateral pneumatized maxillary sinuses. Pretreatment photographs were made depicting repose, average animation, full animation, intraoral maximum intercuspal (Figure 3) and eccentric positions, and occlusal views of the maxilla (Figure 4) and mandible (Figure 5). Thermoplastic stock impression trays (Strong-Massad Denplant Tray [Global Dental Impression Trays]) were gently heated and carefully adapted to the maxillary and mandibular dental arches and vestibular areas. Vinyl polysiloxane (VPS) (Aquasil Ultra [DENTSPLY 8
Figure 1. Pretreatment facial appearance: profile repose, frontal repose, and frontal full smile views.
Using a periodontal probe, linear distances between the maxillary vermillion border and the maxillary free gingival margins during full smile were recorded. These measurements were transferred to the maxillary cast using digital calipers. Individual measurements between mandibular incisal edges and the margin of the mandibular vermillion border in repose were recorded (Figures 7a and 7b). These dimensions were then transferred to the mandibular cast.
THE TREATMENT PLAN
Figure 2. Pretreatment panoramic radiograph
Caulk]) impressions were made using a layering technique to accurately capture both tooth positions and functional vestibular borders. Completed impressions were cast in dental stone (Figure 6). Resultant dental casts were mounted in a semi-adjustable articulator using a face-bow transfer registration and an interocclusal record made in the centric relation position. In order to address aesthetic concerns ex pressed by the patient, a smile analysis was undertaken. Specific attention was given to: • facial and tooth arrangement symmetry • dentogingival display • buccal corridor visibility • anterior-posterior occlusal plane orientation • medial-lateral occlusal plane orientation • maxillary and mandibular lip dimensions. This analysis revealed the following: • asymmetrical smile display • vertical maxillary excess • excessive, right-side, maxillary gingival display
The patient’s residual dentition was determined to be affected by substantial periodontal, aesthetic, and restorative compromised. Any attempt to adequately restore existing teeth would result in guarded short-term and very poor long-term prognoses. In order to satisfy the patient’s desire for improved oral function and appearance, and to provide durable dental restorations, it was decided to extract the remaining teeth, accomplish carefully planned osteoplasty/ostecomy of the residual edentulous ridges, surgically place dental implants, and provide maxillary and mandibular immediate dentures (Figure 8). Upon adequate postoperative healing and osseointegration, fabrication of maxillary and mandibular implant-supported overdentures was planned.
PREOPERATIVE THERAPY
Paraocclusal record bases were fabricated on the patient’s dental casts. A central bearing device (Jaw Recorder [Global Dental Impression Trays]) was then attached to the record bases in preparation for interocclusal registration procedures (Figure 9). Next, clinical evaluations of the planned vertical and horizontal maxillomandibular relationships were accomplished. JOURNAL OF THE TEXAS ACADEMY OF GENERAL DENTISTRY
An indelible marking stick was used to place a dot on the tip of the patient’s nose and anterior prominence of the chin. Sitting upright in the dental chair, the patient was instructed to deeply inhale and exhale several times, open the mouth wide, and then slowly close the mouth until lip contact is first perceived. This mandibular posture approximated the rest vertical dimension (RVD). This sequence of breathing and mandibular posture was practiced several times. A measuring divider was used to record the distance between reference marks on the nose and chin. When a consistent and repeatable distance was established and recorded (RVD), approximately 3 mm was subtracted to arrive at the proposed occlusal vertical dimension (OVD) to be use during subsequent prosthodontic procedures.1 The 3-mm difference between RVD and OVD represents a clinically acceptable interocclusal distance or freeway space. Interocclusal distance varies and may be affected by many factors, including age, physical/emotional conditions, fatigue, medications, and typical interpersonal variability.2 Having recorded the proposed OVD of the planned prosthesis, the record bases with attached central bearing device were placed in the patient’s mouth. The central bearing pin was adjusted to contact the central bearing plate at the desired OVD. The patient was instructed to make repeated mandibular movements between protrusion and centric relation while keeping the central bearing pin in contact with the plate. Additionally, the patient was instructed to make mandibular movements from centric relation to right and left lateral excursions. As the patient accomplished the protrusive and lateral mandibular movement while maintaining contact between the central bearing pin Spring 2012
Figure 3. Pretreatment intraoral frontal view in maximal intercuspal position
Figure 4. Pretreatment intraoral maxillary occlusal view.
Figure 5. Pretreatment intraoral mandibular occlusal view.
Figure 6. Maxiallary immediate denture impression (a). and working cast (b). Mandibular immediate denture impression (c) and working cast (d).
Figure 7. Linear measurements during full smile used to calculate excessive maxillary gingival display and mandibular anterior dentoalveolar extrusion (a). Measured dimensions were then transferred to workings casts (b).
lar position was performed. The central bearing plate attached to the maxillary record base was painted with ink and replaced in the patient’s mouth. The patient was again instructed to perform protrusive, left lateral and right lateral mandibular movement, always returning to the centric relation position at the completion of each prescribed movement. After repeating each movement several times, the maxillary record base and bearing plate were removed and the resultant Gothic arch was evaluated (Figure 12). The apex of the tracing—i.e., the junction between left lateral, right lateral, and protrusive paths—represents a mandibular posture that corresponds to centric relation. For patients with healthy temporomandibular joints (TMJs) and unencumbered mandibular motion, the Gothic arch created by a central bearing device is a crisp, clean tracing. However, for patients possessing TMJ inflammation, TMJ derangement, or a limited range of mandibular movement, the tracing produced on the bearing plate may be erroneous and/ or difficult to read. Appropriate therapeutic intervention may be required in order to assure resolution of TMJ problems prior to the confident registration of a treatment position and predictable prosthodontic restoration.3,4
Figure 8. Based on calculated mandibular anterior dentoalveolar extrusion, 10 mm of alveolar vertical reducation is necessary to accommodate the planned overdenture and implant attachment system
Figure 9. Maxillary paraocclusal record base with central bearing plate. Mandibular paraocclusal record base with central bearing pin.
and plate, it was noted clinically that occlusal interferences obstructing full range mandibular movements occurred involving anterior teeth and second molars (Figure 10). With the patient’s permission, the elimination of these occlusal interferences was planned.
tooth reduction matrix to the patient’s mouth, occlusal adjustment of the offending teeth through the reduction matrix was accomplished (Figure 11). This process assured that the full range of mandibular motion was possible. The tooth reduction matrix was then transferred back to the mandibular cast in order to guide similar modification of the teeth on the cast.
Upon identification of an acceptable Gothic arch tracing with a discernible centric relation point, a clear centering disk was adhered to the bearing plate using sticky wax (Figure 13). The small perforation in the centering disk was positioned directly over the apex of the Gothic arch. This perforation, or indentation, assisted the patient in returning to the centric relation position during interarch registration procedures.
Next, registration of the patient’s centric relation mandibu-
The maxillary record base and bearing plate were returned to
On the mandibular cast, a pressure formed tooth reduction matrix was fabricated (Essix A+ [DENTSPLY Essix Raintree Glenroe]). Transferring the
9
the patient’s mouth, and the patient’s mandible was carefully manipulated to the centric relation position. Upon closure, the patient felt the central bearing pin enter the perforation in the clear centering disk on the bearing plate. While maintaining this centric relation position, a VPS interocclusal registration material (Regisil Rigid [DENTSPLY Caulk]) was injected between the maxillary and mandibular teeth (Figure 13). Upon polymerization of the registration material, the record was removed, inspected for completeness/accuracy, and trimmed in preparation for cast mounting. A face-bow transfer record was also made. The maxillary cast was mounted in a semi-adjustable articulator using the face-bow transfer registration Next, the carefully trimmed interocclusal record was used to mount the mandibular cast against the maxillary cast in the articulator. In order to account for the dentoalveolar extrusion and gummy smile associated with the patient’s chief complaint and affecting her dental appearance, diagnostic calculation of optimal tooth position with in the patient’s smile was made. This consideration, in turn, impacted planned surgical intervention and space management in the mandibular arch. Locating the proposed mandibular incisal edges at the superior margin of the resting mandibular vermillion border, and using the average vertical height of mandibular incisors, the vertical position of the planned anterior prosthetic free gingival margins were identified on the cast. Previous professional literature describes the oral space necessary to accommodate implant overdentures.5 Most popular attachment systems may be used if vertical space between the crest of the soft-tissue edentu10
Figure 10. With the central bearing device posturing the mandible at the planned occlusal vertical dimension, note anterior tooth interferences restricting eccentric movements
Figure 11. Tooth reduction matrix off and on the mandibular cast. Note tooth structure extending beyond the matrix, which was to be eliminated from the cast.
Figure 12. Gothic arch tracing produced on the central bearing plate by the patient.
Figure 14. Functional maxillary vestibular impression on the maxillary working cast (a). Contours of the vestibular impression captured with facial matrix (b) to aid in denture tooth set-up (c).
Figure 15. Postoperative panoramic radiograph illustrating implant placement
Figure 2. Clear plastic disk (a) overlying the centric relation portion of the Gothic arch. The central bearing pin engages the hole in the clear disk (b) to assure the interocclusal record (c) is made in centric relation.
lous ridge and the occlusal plane is 10 to 15 mm. Less restorative space re quires more strategic management of attachment system selection and incorporation, excessive denture tooth adjustment during the set-up process, incorporation of metal frameworks for prosthesis struc-
tural reinforcement, and possible displacement denture teeth away from aesthetically and functionally optimal positions. In order to establish favorable spatial conditions for the pre sent patient, approximately 10 mm of anterior vertical mandibular alveolar ridge reduction was required following tooth extraction and prior to implant placement. The relative approximation of the maxillary teeth to the maxillary lip during full smile was recorded. Measurements from the apex of the free gingival margins to the inferior margin of the maxillary vermillion border during full animation were transferred to the mounted maxillary cast. The resultant line represented the proposed location for the cervical aspects of the anterior denture teeth for
Figure 16. Maxillary implant closed-tray impression posts (a) and clear stock impression tray. Impression material placed in a tray (c) to form tray stops (d) prior to definitive impression
the planned prosthesis (Figures 7a and 7b).
Additionally, it was observed that the existing buccal corridors presented excessive negative space. In order to negate this aesthetic detractor, setting the maxillary denture premolar and molar denture teeth to a more facial position than existing natural teeth was considered. To accomplish this reorientation of posterior denture teeth, encroachment on the normal physiologic function of the checks and tongue muscles needed to be avoided.6 A functional vestibular impression was made by injecting a rigid VPS (Aquasil Ultra Heavy [DENTSPLY Caulk]) into the maxillary buccal and labial vestibules. The patient was instructed purse her lips outward and forcibly smile, open wide JOURNAL OF THE TEXAS ACADEMY OF GENERAL DENTISTRY
and close. This sequence of oral movements was repeated several times until the VPS registration polymerized. The functional vestibular impression was removed and inspected (Figure 14). Using the same process, a second functional impression was made of the mandibular buccal and labial vestibules. The physiologic influence of tongue movements on mandibular denture tooth position was recorded using a functional lingual vestibular impression. Rigid VPS was injected bilaterally into the lingual vestibules. The patient was instructed to place the tip of the tongue forward out of the mouth and then move the tongue side to side. Next, the patient retracted the tip of the tongue to touch the posterior palate. These tongue movements were repeated several times. Upon polymerization, the functional lingual vestibular impression was removed and inspected. Evaluation of the vestibular registrations revealed that posterior denture teeth could be set facial to the natural posterior tooth predecessors. In doing so, an improvement in buccal corridor aesthetics would result from improved denture tooth positions, reduced negative space display, and reduced denture base display. The registered absence of lingual vestibular space provided additional supported to the value of facial movement of posterior denture teeth. In order to guide denture fabrication, vestibular registrations were adapted to fit on their respective casts and laboratory putty matrices were created to guide denture tooth set-up (Figure 14). Immediate denture construction was carried out using conventional techniques.7 Denture tooth set-up matrices were used to guide optimal facial-lingual posterior tooth placement. Metal castings were incorporated into definitive denture bases to reinforce prostheses that would require multiple reline procedures during the postextraction phase of therapy. Immediate dentures were waxed, flasked, processed, finished, and polished. The final prostheses were duplicated in clear acrylic resin to facilitate preimplant radiographic treatment planning procedures.
SURGICAL THERAPY
The patient completed a 30 second pre operative oral chlorhexidine (CHX) rinse. After obtaining satisfactory intravenous general anesthesia, the oral cavity was sucSpring 2012
tioned free of all secretions and a gauze throat pack placed. Left and right maxillary and mandibular block local anesthesia was administered (8 cc of 0.5% Marcaine with 1:200,000 epinephrine). The maxillary and mandibular teeth were atraumatically removed using elevator and forceps technique. A crestal gingival incision was then made extending from the right tuberosity circumferentially to the left tuberosity. A full-arch, full-thickness muco - periosteal flap was reflected. The hypertrophic anterior maxillary alveolus was vertically reduced by approximately 7 to 8 mm. Six evenly spaced root form implants (Replace Tapered Groovy [Nobel Biocare]) were then placed in selected extraction sites. All implants demonstrated good primary stability and were seated with 35 to 40 Ncm of rotational torque. Cover screws were then placed on each implant. Osseous voids adjacent to implants and all un-utilized extraction sockets were grafted with solventdehydrated, mineralized cortical bone allograft (Puros Cortical Particulate Allograft [Zimmer Dental]). After excising redundant gingival tissue, the full-thickness flap was closed using 4-0 interrupted chromic sutures. Attention was then turned to the mandibular arch. Using an identical surgical technique, the remaining mandibular teeth were removed. The hypertrophic anterior mandibular alveolus was vertically reduced and 4 anterior root form implants (Replace Tapered Groovy) were placed achieving a rotational seating torque of 45 Ncm. Implant socket voids and areas of thin labial cortex were grafted in the same manner as previously described and cover screws were placed on the implants. The full-thickness mucoperiosteal flap was then closed using 4-0 interrupted chromic sutures. The gauze throat pack was removed and the procedure terminated. Postoperative narcotic analgesics, systemic antibiotics, corticosteroids, and oral CHX rinse were prescribed. Following dental extractions and implant placements, the maxillary and mandibular immediate dentures were adjusted, adapted using a provisional soft liner, and placed. The patient returned for 48-hour postplacement evaluation and management (Figure 15). At this appointment, all surgical sites were closely evaluated for healing progress and denture irritations. The existing provisional liner was replaced with a plasticized acrylic resin liner (PermaSoft
[DENTSPLY Prosthetics]). Proper occlusion was evaluated and adjusted. The patient was scheduled for monthly reevaluations (Figure 16). Five months following implant placement, the patient returned for surgical uncovering of the previously placed maxillary and mandibular implants to the oral cavity. After completing a 30-second preoperative CHX rinse, and then obtaining satisfactory intravenous general anesthesia, the oral cavity was suctioned free of all secretions, and a gauze throat pack was placed. Block local anesthesia was administered (8 cc of 0.5% Marcaine with 1:200,000 epinephrine). A gingival crest incision was made over each of the previously placed maxillary and mandibular implants. Limited split thickness mucoperiosteal flap were elevated to exposing each of the previously placed dental implants. Cover screws were removed and replaced with healing abutments of the appropriate diameter and 3 mm in height. Gingival tissues were then advanced and adapted around the healing abutments using 5-0 chromic suture. The gauze throat pack was removed and the procedure terminated. Post operative anti-inflammatory analgesics were prescribed.
DEFINITIVE PROSTHODONTIC THERAPY
Four weeks following the patient’s second surgical intervention, new impressions were made to begin fabrication of the definitive maxillary and mandibular implant-supported overdentures. Healing abutments were removed from all maxillary implants and closed tray impression posts were placed (Figure 17a). After carefully estimating the dimensions of the maxillary arch, an appropriate stock impression tray was selected (Strong-Massad Denplant Tray). These clear plastic trays allow one to see through them to help in selecting and fitting the tray as well as to ensure that sufficient room is available between the tray and of the all impression components (Figure 17b). The polystyrene-based polymer trays used are thermoplastic. Subtle alterations to flange trajectory were made by passing the appropriate portion of the tray quickly through a microflame until the resin softened. Careful manipulation the softened tray was made and the tray was cooled in water. Tray flanges identified to be overextended were subtractively adjusted by grinding with conventional acrylic resin ro11
tary instrumentation. The definitive impression procedure required multiple placements of the impression tray in the patient’s mouth. In order to achieve consistently repeatable tray placements, tray stops were developed. Using high viscosity VPS (Aquasil Ultra Heavy), three-quarter size circles of material were placed in the tuberosity and midpalate areas. Additional material was dispensed into the anterior tray (Figure 17c). The tray was seated on the edentulous maxilla and centered over the ridge and implant impression components. The objective was to develop an adequate and consistent space between the tray and impression surfaces. Upon material polymerization, the tray was removed and the stops inspected for even thickness. Stops were trimmed with a sharp knife to minimize the area of tissue contact. A rope of high viscosity VPS (Aquasil Ultra Heavy) was dispensed along the peripheral tray borders to begin the border molding process (Figures 18a to 18c). The tray was placed and centered on the maxilla. The following tissue manipulations were used to define peripheral borders: • To define the labial notch, the philtrum was grasped close to the vermilion border and pulled downward. • To form the labial vestibular borders, the patient was instructed to purse her lips forcefully using a sucking action and then smile widely. • To define the buccal notches and buccal vestibular borders, the cheek was grasped at the corner of the mouth with forefinger and thumb and pulled downward and forward. This process was then repeated on the contralateral side. • To define the coronomaxillary vestibular border and hamular frenum area, the 12
Figure 17. A bead of rigid impression material placed along the tray borders (a). Rotary instrumentation can be used to make adjustments (b) following border molding manipulations, tray show-through (c).
Figure 18. Definitive maxillary impression with replaced impression posts and implant analogs (a). Resultant maxillary master cast (b) and mandibular case (c).
Figure 19. ERA Micro Angulated Female Abutments (Sterngold) rotated to parallelism on the master case
Figure 20. ERA Micro Anuglated Female Abutments rotated to parallelism in the patients mouth prior to cementation
Figure 21. Maxillary record base with central being plate (a) and mandibular record base with central bearing pin (b).
Figure 22. Neutral zone impression illustrating compound rim (a), record base (b), completed registration with designated occlusal plane (c) facial view, and completed registration (d) occlusal view.
Figure 23. Definitive maxillary and mandibular implant overdentures.
patient was instructed to open her mouth wide. This caused the coronoid processes to translate through the coronomaxillary spaces, bringing associated muscles to their terminal positions. • To functionally form the posterior border of the tray, the patient was instructed in the Valsalva maneuver.8-10 The patient’s nostrils were manually occluded while the she forcibly exhaled through her nose. This caused the soft palate to valve downward, forming the VPS along the postpalatal seal aspect of the impression tray.
tray was removed and inspected to assure that appropriate anatomic and functional detail was represented. Finally, all borders were relieved approximately one to 2 mm using a scalpel blade and/or rotary instrumentation in preparation for the definitive impression (Figures 18a to 18c).
Following polymerization of the VPS, the maxillary impression
Prior to making the definitive impressions, soft-tissue conditions across the denture bearing tissues of the maxilla were closely examined. The viscosity of VPS impression material was selected based on relative tissue conditions, ie, the more mobile/ unattached the denture bearing tissues, the lower the viscosity of the impression material used. For the patient described here, a
low viscosity material (Aquasil Ultra LV [DENTSPLY Caulk]) was selected to make the definitive impression. The low viscosity impression material was intraorally injected around the maxillary impression posts and loaded into the tray. The impression tray was then seated and centered on the maxilla using the tray stops as guides. All border molding manipulations were repeated. Upon polymerization of the impression material, the definitive impression was removed and inspected for appropriate anatomic, functional, and surface details. Impression posts were then removed from the mouth, one at a time, attached to implant analogs, and placed JOURNAL OF THE TEXAS ACADEMY OF GENERAL DENTISTRY
into the impression in proper position (Figure 19). The impression was then beaded, boxed, and cast in a suitable vacuum mixed dental stone. This impression procedure was essentially repeated to make the mandibular definitive impression. Border molding manipulations used in order to customize the mandibular stock tray included: • To functionally form the lingual and retromylohyoid flange borders, the patient was instructed to place the tip of the tongue forward out of the mouth and then move the tongue side to side. Next the patient was instructed to retract the tip of the tongue to touch the posterior palate. • To form the labial notch, the lower lip was grasped at the vermilion and pull outward and upward. • To functionally form the labial and buccal borders, the tray was stabilized with the index and middle fingers on the finger rests with the thumb beneath the chin. The patient was asked to purse the lips using a sucking action and then smile widely. • To form a buccal notch, a cheek was grasped with the forefinger and thumb at the corner of the mouth and pulled upward and forward. This process was repeated on the opposite side. Following completion of the mandibular definitive impression, the impression posts were removed from the mouth, one at a time, and implant analogs were attached and placed into the impression in proper position. The mandibular impression was then beaded, boxed, and cast in a suitable vacuum mixed dental stone (Figure 19).
mentarium provided by the manufacturer, it was determined that the facial trajectory of the 4 maxillary anterior implants required use of 17° ERA Micro Abutments, and the buccal trajectory of the 2 most posterior maxillary implants required incorporation of 11° EAR Micro Abutments (Figure 20). Because the mandibular implants demonstrated relative parallelism, zero-degree ERA Micro Abutments were selected for the mandibular restoration. Healing abutments were removed from the maxillary implants and abutment bases were screw fastened to each of the implants. The abutment bases were tightened to 20 Ncm of torque. Angle correction ERA Micro Female Attachments, as described previously, were placed in the abutment bases using alignment handles. Using the alignment handles to assess parallelism, each attachment was rotated until relative parallelism was achieved. A permanent, fine-tipped ink pen was used to mark a line from each abutment base onto its angle correction attachment to record appropriate rotational orientation. One by one, each attachment was removed from its respective base, cement was applied to the base and attachment (ERA Lock Cement [Sterngold], and the attachment was reinserted into the base, being careful to realign the pen marks (Figure 21). Upon polymerization, excess cement was removed. Healing abutments were removed from the mandibular implants. Four zero-degree ERA Micro Abutments were screw fastened to the implants. Each abutment was tightened to 20 Ncm of torque.
In determining the attachment mechanisms to be used for the planned implant overdentures, consideration was given to relative trajectory of the implants in each arch and available restorative space. Despite aggressive efforts to reduce alveolar projection and improve restorative space conditions, there was not enough restorative space to accommodate a bar attachment system. Additionally, the lack of absolute maxillary implant parallelism required use of a studtype mechanical attachment system capable of angle correction. For these reasons, the ERA Micro Angled Attachment System (Sterngold) was selected.
Maxillary and mandibular record bases were fabricated and a central bearing device was attached (Figure 22). As previously described, the central bearing device was used to make and interarch centric relation record at the patient’s proposed OVD. A second mandibular record base was constructed to carry a compound rim in order to accomplish a neutral zone registration (Figure 23). Detailed description of the neutral zone registration technique is provided elsewhere.6 A second maxillary record base with wax rim was adjusted to appropriate contour and used to record repose and high smile maxillary lip positions, record dental midline, and to aid in the face-bow transfer record.
Using angle correction diagnostic arma-
The maxillary definitive cast was mounted
Spring 2012
in a semi-adjustable articulator using the face-bow registration. The mandibular cast was mounted against the maxillary cast in the articulator using the centric relation interarch record. Using the adjusted wax rim, maxillary anterior denture teeth were set to the aesthetic dictates indicated on the wax rim. The mandibular denture teeth were set using facial and lingual matrices fabricated from the neutral zone registration. Posterior maxillary denture teeth were set into a balanced lingualized occlusal scheme. The wax trial denture was placed in the patient’s mouth and she approved the aesthetic and phonetic results. An external impression was then made to define the precise denture cameo surface contours that resulted in optimal denture stability. A detailed discussion of the external impression procedure is available in the professional literature.11 The definitive implantsupported overdentures were then flasked, processed, finished, and polished (Lucitone 199 [DENTSPLY Prosthetics]). Metal reinforcing frameworks were fabricated and incorporated in the overdentures during the processing sequence (Figure 24). The definitive prostheses were taken to the patient’s mouth and adjusted for fit, form, and function. ERA retentive elements were placed on each of the implant abutments in preparation for intraoral pick-up procedures. Rubber dam material was used as a means of block-out (Figure 25). The prostheses were seated over the attachments in order to determine if adequate clearance between the denture base and attachment housings was available. This was accomplished by assuring that the patient’s prescribed OVD was maintained and any inadvertent contact was disclosed using VPS and appropriately adjusted. Chemically-activated composite resin material (ERA PickUp Resin [Sterngold]) was used to pick-up the attachments into each of the overdentures (Figure 25). Care was taken to assure that the patient achieved the prescribed centric relation posture at the planned OVD during the attachment pick-up procedure. Following the clinical attachment pick-up procedure, the overdentures were removed and inspected to completeness. Excess material was eliminated. The definitive attachment female components were placed into the overdentures in accordance with the desired level of prosthesis retention (Figures 25a to 25c). Removal and placement of 13
the overdentures was discussed with and demonstrated to the patient. The patient was then made to demonstrate mastery of the removal and placement of her new dentures. The following figures will show the patient after the new prosthesis has been placed. Further procedures at the patient’s request were then initialized to enhance the maxillary lip and other areas on the face, which had deprived tissue and severe wrinkling. With the use of several different enhancement materials in the both the upper lip, lower lip, cheeks, nose, earlobes, and infraorbital areas were injected as a filler into the areas bringing the face upward and enhancing both the maxillary and mandibular vermilion borders and decreased the sunken-in appearance.
Figure 25. Full-facial views of patient in repose before treatment (a), after immediate denture placement (b), and 14 months following facial cosmetic injection therapy (c).
Figure 26. Full-facial views of patient smiling before treatment (a), after immediate denture placement (b), and 14 months following facial cosmetic injection therapy (c).
therapy. All facial cosmetic treatment was performed over a 6-month period of time. Results are demonstrated in Figures 25a to 25c and 26a to 26c.
FACIAL COSMETIC THERAPY
Following placement of the definitive, implant-supported maxillary and mandibular overdentures, the patient expressed interest in learning more about procedures available to improve the cosmetic appearance of her lips, face, and associated structures. The patient was referred to an aesthetic nurse specialist for evaluation and treatment of upper lip vermilion border volume loss compounded by generalized advanced facial volume deficiency and deep rhytids. The diagnostic findings of generalized adipose facial crevicing contributed to the thread-like upper lip vermilion dimension and deep rhytids requiring volumization of peripheral areas of the face to improve the lip dimension. It was emphasized to the patient that therapy limited to the lips in the presence of a substantially depleted facial canvas would accentuate the lips creating a significant aesthetic deficiency. Four treatment sessions were accomplished attempting to 14
Figure 24. Attachment pick-up procedure illustrating block-out (a) and application of pick-up resin (b). Intaglio surface views of prostheses with attachments (c and d)
volumize the entire facial area, including the forehead, below and under the eyebrows, temples, crow’s feet, tear troughs, zygomatic and malar areas of the midface, cheek hollows, lip vermilion borders, white shoulder and body of the lips, oral commissures, mandible, preauricular areas, procerus, chin philtrum, and earlobes. The injectable products used included: Artefill (Suneva Medical); Sculptra Aesthetic (Dermik Laboratories); Radiesse (Merz Aesthetic); Juvederm Ultra XC, Juvederm Ultra Plus XC, and Botox Cosmetic (Allergan); Perlane-L, Restylane-L, and Dysport (Medicus). The patient also received full face and neck fractional laser treatment during injection
Reprinted by permission of Dentistry Today, c2011 Dentistry Today. Acknowledgement Dr. Massad would like to acknowledge his prosthetic technician Zarko Danilov of Carmichael, Calif, for his detailed work involving this case. References 1.
2.
3.
4. 5.
6.
7.
Landa JS. The free-way space and its significance in the rehabilitation of the masticatory apparatus. J Prosthet Dent. 1952;2:756-779. Atwood DA. A cephalometric study of the clinical rest position of the mandible: Part III: Clinical factors related to variability of the clinical rest position following the removal of occlusal contacts. J Prosthet Dent. 1958;8:698-708. Massad JJ, Connelly ME, Rudd KD, et al. Occlusal device for diagnostic evaluation of maxillomandibular relationships in edentulous patients: A clinical technique. J Prosthet Dent. 2004;91:586-590. McHorris WH. Centric relation: Defined. J Gnathol. 1986;5:5-21. Ahuja S, Cagna DR. Classification and management of restorative space in edentulous implant overdenture patients. J Prosthet Dent. 2011;105:332-337. Cagna DR, Massad JJ, Schiesser FJ. The neutral zone revisited: from historical concepts to modern application. J Prosthet Dent. 2009;101:405-412. Seals RR Jr, Kuebker WA, Stewart KL. Immediate complete dentures. Dent Clin
8.
9.
10. 11.
North Am. 1996;40:151-167. Laney WR, Gonzalez JB. The maxillary denture: its palatal relief and posterior palatal seal. J Am Dent Assoc. 1967;75:1182-1187. Naylor WP, Rempala JD. The posterior palatal seal—its forms and functions (I)— Diagnosis. Quintessence Dent Technol. 1986;10:417-422. Lavelle WL, Zach GA. The posterior limit of extension for a complete maxillary denture. J Acad Gen Dent. 1973;21:31. Massad JJ, Cagna DR. Vinyl polysiloxane impression material in removable prosthodontics. Part 3: Implant and external impressions. Compend Contin Educ Dent. 2007;28:554-561.
Dr. Joseph Massad is adjunct associate faculty, Tufts University School of Dental Medicine, and adjunct associate faculty, Department of Comprehensive Dentistry at the UTHSCSA. Dr. Dan Patterson has practiced oral and maxillofacial surgery for 32 years. Dr. Patterson’s practice is currently focused on advanced dental implant procedures, periodontal plastic surgery, and bone regeneration techniques Ms. Brewer is the founder and managing consultant at SkinMedic which was established in 1998. Ms. Brewer earned a MS degree and BS degree in Nursing from Wright State University. Dr. David Cagna is associate dean for postgraduate affairs as well as professor and the director of the Advanced Prosthodontics Program s at The University of Tennessee Health Science Center in Memphis. JOURNAL OF THE TEXAS ACADEMY OF GENERAL DENTISTRY
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