iCare Financial Newsletter – March 2017
By Dr. Richard Winter D.D.S, M.A.G.D, D.I.C.O.I., F.A.D.I., F.I.C.D.
Organizations such as the Academy of General Dentistry, the Academy of Dentistry International and the International College of Dentists are dedicated to bringing dentistry to all of our patients to improve lives.
As dental professionals, we must always strive to help people wherever they are and with whatever resources they may have. Practicing dentists throughout the world should strive to give our patients dignity during their lifelong dental journey. Edentulism is an epidemic and it is classified, by the World Health Organization, (WHO), as an impairment, disability and dysfunction. This disability affects 158 million people globally as of 2010.
This article will show a few cases that demonstrate how we can and must be advocates for our patients that have limited finances. Mini-implants to stabilize partial dentures and dentures can improve lives in a cost effective manner. They can preserve bone, decrease denture sores and improve bite strength. This can result in improved mastication, better digestion and an improvement in the health and mental outlook of our edentulous patients throughout the world. One of the concepts that I lecture on called, “Upgradeable Dentistry” highlights how we can sequentially improve our patients dental conditions based upon their personal, emotional and financial readiness. When patients are given treatment options that are challenging financially, iCare Financial has been one tool that has helped my patients say yes to dental treatment they couldn’t otherwise afford.
Case #1 Richard:
This 82-year-old gentleman had a bridge in his lower arch and a history of traumatic occlusion. The sequelae of his occlusal disease were evident by his past fracture of a bridge in the lower front of his mouth and subsequent replacement with a lower partial denture. The patient reported that the lower partial denture rocked and had hurt since he received it 5 years previously. The patient presented reporting he could no longer wear it as it hurt the gums and the remaining tooth on his lower left; #21. He had fractured crowns on #6 and #27 and wanted to avoid a lower denture as he couldn’t retain his lower partial denture and he was sure he would not be able to wear a complete denture. The problem was that he had a bruxism habit and his current partial denture was ill-fitting and lacked stability and support and moved during mastication. Photos 1,2.
The limited interocclusal space as well as the limited finances meant that a compromised treatment solution was indicated. The patient could not afford to replace the fractured crowns, was on social security and just wanted to be able to eat again without pain. Small diameter or mini-implants are a cost effective way to add stability and support to dentures and partial dentures. Often these procedures can be done with a minimal armamentarium. This includes the implant and keeper cap and a starter kit; which may consist of a pilot drill, a finger driver, thumb wrench and a torque wrench.
The costs of mini-implants can range from $40 to $125 for a mini-implant with a keeper cap. So if a denture is adequately constructed and 4 mini-implants are placed in a mandible or 6 are placed in the maxilla a simple pick up technique can be used to greatly improve a patients comfort. In this case, four 1.8mm implants were placed between tooth #21 and #27 along his atrophic ridge. Photos 3,4.
His existing partial denture was relieved and the metal housings were picked up using Secure(3M, Imtec) hard pick up material. There are many products such as Triad hi-flow (Dentsply/Prosthetics) or Quick Up (Voco America, Inc.) that can also be used with great ease intra-orally. The use of a spacer placed over the mini implant neck will ensure that the acrylic doesn’t get stuck under the retentive portion of the “o-ball attachment” during the pick-up procedure.
Alternatively, impressions can be made of the ball tops, analogs can be inserted into the impression and the lab can set the attachments on the model and incorporate them in a reline of the prosthesis. In this case, the lower partial was remade and proper guide planes and rests were prepared in to the lower bridge and tooth #21, so the patient would have a new mini-implant supported lower partial denture. Photos 5,6. The patient was restored to comfort and the prosthesis has been in function for 6 years to date without discomfort.
Case #2 Cornelia
This 89-year-old woman could not retain her lower denture. She had trouble eating and the amount of denture adhesive she required was making her ill on a daily basis.She had severe mandibular atrophy and the bony dehiscence led to “zingers” or pain from the partial rubbing on the mental foramen while chewing. Photo 7.
The denture was relined with a soft liner (Hydrocast, Sultan Healthcare) to insure a stable fit and gutta percha was sticky-waxed to the denture so a Panorex x-ray could be taken to map the location of the future mini-implants. Photo 8. The gutta percha marked Panorex demonstrated that the proposed positions were at least 5 mm anterior to the mental foramen to account for the possibility of an anterior loop and to maintain a zone of safety during placement. Photo 9a, 9b. The upper denture was connected to the lower with a bite registration to insure the lower denture orientation would not change at the end of the visit. Photo 10.
After the dentures stability was verified the mental foramen were identified by palpation with a ball burnisher. Photo 11. The depression of the mental foramen as well as a jolt can often be identified with palpation and the patient can help by describing when they feel the electrical sensation, as the instrument is pressed against the mental foramen. This is marked with an indelible marker and transferred to the denture intaglio and buccal flange. The indelible marker marks the soft liner; which can be transferred to the mouth. Implant positions can be confirmed as being in the zone of safety and placed centrally within the denture contours.
After rinsing with Chlorhexidine gluconate for 30 seconds twice, anesthesia is performed. A pilot burr or 170 XL burr can be used to peck through the tissue and cortical plate or a flap can be raised to insure implants are placed in the bone and are not fenestrating through the buccal or lingual plate. Photo 13. The use of a finger driver, thumb wrench and torque wrench are used sequentially to slowly advance the mini-implants allowing for bone expansion, as the implants are self-advancing by design. Photo 12.
Mini-implants are removed from the vial and the cover is used to place the mini-implant in the pilot hole. Photo 14. Then when resistance is met the thumb driver is used and when it no longer advances easily the torque wrench is used to perform the last few turns and complete the seating of the implant. After one week of healing the mini-implants appear to be well placed at the tissue was healing nicely. Photo 15
While the technique does allow mini-implants to be activated the day they are placed the author uses tissue conditioner to allow the implants to heal for 3-4 months before activation to decrease the risks that the implants may be overloaded and lead to failure. If the bone is D1 (like Oak) and of good quality and the insertion torque is 35-45 Newton Centimeters they may be activated if desired. If a Panorex is not available an occlusal film taped to a tongue depressor can be held horizontally along the mandible and a lateral radiograph can be taken to verify the implants are all within the symphysis of the mandible. This “poor man’s Cephalometric x-ray can be done very inexpensively and can provide as much information as required. Photo 16. It is ideal to keep the mini-implants parallel to decrease eccentric forces on the implants during insertion, removal and mastication. Photo 17.
After the implants are placed, the denture is hollowed out so there is no contact with the newly placed implants. By keeping them attached to the maxillary arch with a bite registration material, the orientation of the lower denture to the upper denture can be stabilized prior to soft tissue conditioner placement. Photo 18.
Hydro-cast tissue conditioner (Sultan Healthcare, Hackensack N.Y.), is applied to the intaglio of the denture, it is reinserted into the bite registration and the patient is instructed to close gently until fully seated. Photo 19,20. The mini-implants are centered over the existing ridge and the tissue conditioner provides retention until the implants are integrated. The patients are informed that the keeper caps would be activated in four more months. If any of the implants were to become loose they could be replaced prior to performing the pick up or impression procedure. The patient is instructed to sleep in the denture the first evening to accommodate any swelling that may occur the first 24 hours. The tissue conditioner may need to be replaced if it gets too hard but typically by keeping these in a container with a wet washcloth over the container, the soft tissue conditioner can last 2-3 months.
After 4 months, an impression is made of the mini-implants. A partial denture frame is made and the keeper caps are luted to the frame for the try-in and bite-registration visit. If the caps do not fully seat they can be removed and re-luted chairside to the frame with Primotec Pattern resin. (Primotec USA, Westport, CT.) The completed metal reinforced lower implant supported denture is stable and the occlusion is bilateral balanced, with lingualized occlusion to decrease force factors to the dentures and implants. It is important to remember that these small diameter implants are for retention not support. Therefore the principles of denture design are crucial to insure that the dentures are stable and provide optimal esthetics,phonetics and function with the mini-implants providing the retentive element. The patient was quite pleased with the result and looked forward to her 89 dinner where she couldn’t wait to have a steak again!
As dentists, it is our mission to help our patients within the patient’s financial and physiological limitations. Sometimes these choices require compromise due to socio-economic constraints. We must always look for a balance between our patient’s desire to eat and talk and chew without pain and the services and finances available to us. The techniques presented in this article are universal and can be used to improve the lives of our patients by increasing stability, support and retention for patients that suffer from ill-fitting partial dentures or dentures. They can be used all over the world to create improved oral and systemic health. Patient limitations do not have to equate to lack of treatment. If we are advocates for our patients we can perform services that will improve lives.
Dr. Winter is a Master in the AGD and a Diplomate in the International Congress of Oral Implantologists. He holds Fellowships in the Academy of Dentistry International and the International College of Dentists. He graduated from the University of Minnesota School of Dentistry in 1988. Dr. Winter has published numerous articles on implant and reconstructive dentistry emphasizing “Upgradeable Dentistry” and “General Dentistry As A Specialty.” He can be reached for lecture information at firstname.lastname@example.org or visit him online at hamptondentalassociates.com