Citing Authors Flashcards
(36 cards)
How much does the jaw normally move in open lat pro and retrusion? WHo studied this?
Posselt
What is the normal range of mandibular movements?
• Opening: 45-55 mm – (Rotation-first 20-25mm)
• Laterally: 10mm
• Protrusion: 9mm
• Retrusion: 1mm
Translation begins at 20 mm between max and mand molars
These limits were described by Posselt in 1952. When the jaw is retruded, the incisors move posteriorly and inferiorly (90% of population)
Discuss Combination Syndrome
- Also called as anterior hyperfunction syndrome
- First described by Kelly (1972) and then by Saunders (1978)
Kelly E. Changes caused by a mandibular removable partial denture vs. a maxillary denture. JPD 1972;27:140-150. • Posterior mandibular ridge resorption • Anterior maxillary ridge resorption • Down growth of maxillary tuberosities • Extrusion of mandibular anterior teeth • Papillary hyperplasia
Saunders. The maxillary complete denture opposing the mandibular bilateral distal extension partial denture: treatment considerations. JPD 1979;41(2):124.
• Loss of vertical dimension
• Occlusal plane discrepancy
- Anterior repositioning of mandible
- Poor prosthesis adaptation
- Epulis fissuratum
- Periodontal changes
Is combination syndrome a syndrome?
• Palmqvist, Carlsson and Owell- challenged it in 2003 refusing to call it a syndrome. JPD 2003 Sep; 90(3): 270-5.
- clear indications and little doubt that the removable denture plays an important causative role in the bone resorption process
- Subjects not wearing dentures had more remaining bone.
- Other than kelly No study on changes in the maxillary mucosa with respect to the mandibular dentition status. papillary hyperplasia - “papillary hyperplasia of the hard palatal mucosa” seem to be rare.
- Other than Kelly No other reports have been found regarding extrusion of mandibular anterior teeth in combination with a complete maxillary denture and a mandibular RPD.
- Enlarged tuberosities are often seen together with supraerupted maxillary molars.
- The supraeruption may create enlarged tuberosities without influence of a denture.
- Dorland’s Illustrated Medical Dictionary defines “syndrome” as “a set of symptoms which occur togeth- er; the sum of signs of any morbid state; a symptom complex.”
no randomized controlled trials (RCTs) on combination syndrome were found.
What is the prevalence of combination syndrome?
Shen K, Gogloff RK: Prevalence of the combination syndrome among denture patients. J Prosthet Dent (1989).
1 in 4 prevalence of combination syndrome in Mx CD and MD anterior natural teeth.
-Examined 150 patients with maxillary CD opposing MD over 5yr. 91/150 completely edentulous Nothing 4/91 no prosth Complete denture (87/91) CD/CD 5% natural teeth(59/150) 24% prevalence!! With Class I RPD 22% Without RPD 25%
Of all 5 changes ..... Mx anterior bone loss Hyper mobile anterior ridge Mx alveolar ridge canting MD posterior bone loss Tuberosity elongation
management of abused oral tissues
Lytle RB. The management of abused oral tissues in complete denture construction. JPD 1957;7(1):27-42.
• If the soft tissues beneath dentures are subjected to excessive stress, they not only become deformed and traumatized, but they also become less resilient and do not readily return to their normal form.
• Eliminate or minimize mechanical factors causing abuse by:
1. Correcting faulty occlusion and other denture defects causing instability
2. Relieve all areas causing excessive pressure and deformation
3. In some extreme cases, placing a temporary relining in the dentures after they have been left out overnight will improve stability and help control soft tissue form
4. Minimizing or eliminating stresses by a soft diet and removal of dentures at night
5. Instructing the patient to stimulate the soft tissues by massage
6. Leaving the dentures out of the mouth 48-72 hours prior to making an impression.
The etiology of inflammatory papillary hyperplasia
Ettinger, R.L. The etiology of inflammatory papillary hyperplasia. J Prosthet Dent 34:254-260, 1975.
incidence of papillary hyperplasia 700 pts Looked at denture factors stability, occlusion relief, stomatitis etc. Painless Incidence 13.9% Men>Women Younger>older *Most common in highest part of palatal vault.
Tx: remove the dentures at night, clean the dentures regularly, massage the tissue, and visit the dentist regularly for maintenance visits
Discuss your technique of obtaining posterior palatal seal
I used the T burnisher to palpate the hamular notch areas, asked the patient to say “ah” and see the movement of the soft palate. I marked the line along this line and connected them to the hamular notches. I then transferred the vibrating the line to the record base.(As advocated by Boucher in his textbook)
Why This technique ?
Simple and physiologically sound
Visually confirmed
Predictable-previously successful to me
Describe various techniques for PPS
- Empirical – Transferring Ah line and Scoring cast (Boucher)
- Physiologic- Valsava Manuever, Iowa Wax (Chen, Laney, Milsap)
- Palpation technique- using a ball burnisher and compress the tissues (Terrell and Swenson)
- Arbitrary (semi functional) – Combination of both techniques
- Functional Impression – Class III; to compensate because there is so much movement
What are the ways to determine the movement of the soft palate?
- Say “ah” and draw a line connecting the hamular notches along the VL. (Boucher)
- Valsava Maneuver (Laney)
- Extent can me made with visual exam w/ a ball burnisher (Terrell and Swenson)
Where is the vibrating line?
Chen found that the vibrating line is never posterior to the fovea palatini.
Usually the PPS extends at least to the vibrating line or 1-2mm beyond it.
I used the T burnisher to palpate the hamular notch areas, asked the patient to say “ah” and see the movement of the soft palate. I marked the line along this line and connected them to the hamular notches. I then transferred the vibrating the line to the record base.(As advocated by Boucher in his textbook)
Discuss relevant literature of PPS
- Chen’s study (25% of people had the FP on the vibrating line and 75% had the FP behind the vibrating line, 0% of people had the FP in front of the vibrating line)
- Avant: PPS is a must; No one type of posterior palatal seal that was tested proved to be superior in all subjects. However, the angle-shaped posterior palatal seal was the most effective of the four designs tested (design C)
- Ettinger and Scandrett (review of 3 types; physiologic is the best)
- Barco (lab data clearly showed that a better fitting denture can be made by relining the heat cured denture with an autopolymerizing resin prior to delivery.)
Nikoukari, In a mouth with a flat palatal vault, the vibrating line is usually farther posteriorly.
Discuss Palatal form
Discuss House’s Palatal form
• Class I: 5-13mm distal (more than 5mm of movable tissue available) Ideal for retention
• Class II: 3-5mm distal (1-5mm of movable tissue available) Good retention –
• Class III: 3-5mm anterior (less than 1mm of movable tissue available) Poor retention
Class III difficulties are in tissue movement, typically present in high vaulted patients, and because of the small area for the posterior palatal seal.
Discuss Lateral Throat Form?
Discuss Neil’s Lateral Throat Form?
A classification used to determine lateral throat form. Patient is told to protrude the tongue ¼ of an inch beyond the edge of the lower lip, pulling the palatoglossus muscle forward.
Originally finger movement when tongue brought forward was used to describe this. A mouth mouth mirror inserted in the retromylohyoid space while patient brings tongue forward is the easiest way to check this.
Class I: No tendency to displace the finger - 8-12mm of extension below the mylohyoid ridge (long, wide flange)
Class II: Intermediate functional position - 4-6mm of extension below the mylohyoid ridge – My patient
Class III: The finger is entirely displaced from this area- 2-3mm of extension below the mylohyoid ridge; RARE
Discuss determination of the incisal edge position:
- Based on F and V sounds (Frush, Pound, Landa)
- Lips in repose (Vig and Brundo, Futalej, Peck and Peck, Burstone)
- Existing incisal edge position
What factors affect denture Retention?
(Jacobsen and Krol)
- Adhesion (physical attraction of unlike molecules)
- Cohesion (physical attraction of like molecules)
- Interfacial Surface tension (resistance to separation of 2 parallel surfaces that is imparted by a film of liquid between them)
- Gravity (for lower)
- Border Seal
- Atmosphere Pressure (for upper)
- Mechanical Undercuts, Parallel walls and rotational insertion paths
- Neuromuscular Control
- Intimate tissue contact
- Orofacial musculature – correct position of denture teeth must be in the neutral zone
Is chronic bone loss a problem?
Atwood described it as It is inevitable and has been called “a major oral disease entity.
(Carlsson G)
In patients who received mandibular implant-supported fixed prostheses, bone resorption in the posterior part of the mandible practically ceased.
Sennerby L, Carlsson GE, Bergman B, Warfvinge J. Mandibular bone resorption in patients treated with tissue-integrated prostheses and in complete-denture wearers. Acta Odontol Scand 1988;46:135-40.
Could there be any other factors that cause this bone loss?
Some authors reported that due to great individual differences have been noted, and factors other than the wearing of removable dentures may be involved in the resorption process.15-17
Carlsson GE, Haraldson T. Fundamental aspects of mandibular atrophy. In: Worthington P, Branemark PI, editors. Advanced osseointegration surgery: maxillofacial applications. Chicago: Quintessence Publishing; 1992. p. 109-18.
Xie Q, Ainamo A, Tilvis R. Acta Odontol Scand 1997;55:299-305.
- Association of residual ridge resorption with systemic factors in home-living elderly subjects.
- The effects on residual ridge resorption of the age, gender, smoking, alcohol intake, body mass index, functioning in daily living, and certain systemic diseases of the subjects were investigated.
- asthma due to corticosteroid treatment is to be considered a risk indicator for severe resorption of the edentulous mandible
- alcohol intake in the elderly may be related to a lesser degree of resorption of the edentulous maxilla.
- Female gender is confirmed as a major factor resulting in mandibular atrophy.
Xie Q, Narhi TO, Nevalainen JM, Wolf J, Ainamo A. Oral status and prosthetic factors related to residual ridge resorption in elderly subjects. Acta Odontol Scand 1997;55:306-13.
What if the patient did not wear any prostheses how would her bone look?
(campbell and Jozefoecz)
-Studies showing significant differences in residual alveolar bone between edentulous subjects wearing or not wearing removable dentures.18,19 -Subjects not wearing dentures had more remaining bone.
Campbell RL. A comparative study of the resorption of the alveolar ridges in denture-wearers and non-denture wearers. J Am Dent Assoc 1960;60: 143-53.
Jozefowicz W. The influence of wearing dentures on residual ridges: a comparative study. J Prosthet Dent 1970;24:137-44.
Any rationalle for implant supported fixed helping with combination syndrome?
1988 Sennerby L, Carlsson GE, Bergman B, Warfvinge J.
-mandibular bone resorption stopped in the areas distal to the mandibular foramina after the patients had been provided with fixed Implant prostheses placed anterior to the foramina.
(Wright PS, Glantz PO, Randow K, Watson RM. ) 2002
a fixed implant-supported prosthesis of the same design produced bone apposition in the posterior parts of the mandible, whereas an over- denture supported by 2 implants resulted in a continu- ous resorption of the same areas.!!!
Sennerby L, Carlsson GE, Bergman B, Warfvinge J. Mandibular bone resorption in patients treated with tissue-integrated prostheses and in complete-denture wearers. Acta Odontol Scand 1988;46:135-40.
Wright PS, Glantz PO, Randow K, Watson RM. The effects of fixed and removable implant-stabilised prostheses on posterior mandibular residual ridge resorption. Clin Oral Implants Res 2002;13:169-74.
How do studies measure alveolar ridge resorption?
Carlsson, Hedegard
Most studies have used radiographic cephalometry for measurement of residual ridge height.
- Compared bone resorption of the anterior maxilla in patients wearing a complete maxillary denture with different mandibular status:
Carlsson
In a 21-year follow-up of the same patients, the individual variations were still very large, and there was no support for systematic de- velopment of “combination syndrome.”
32 patients initially treated with a complete denture in the maxilla or mandible.
- clinical and radiographic examinations.
-Tracing of cephalometric radiographs showed wide
variations in bone resorption among patients.
Carlsson GE, Bergman B, Hedegard B. Changes in contour of the maxillary alveolar process under immediate dentures. A longitudinal clinical and x-ray cephalometric study covering 5 years. Acta Odontol Scand 1967; 25:45-75.
Studies comparing maxillary dentures and assorted mandibular conditions
Shen K, Gongloff RK.
- 150 pt mx CD
- “prevalence of symptoms associated with combination syndrome.”
- “Maxillary anterior alveolar bone loss” was nearly nonexistent in the group with complete mandibular dentures as well as in the group with natural dentition including bilateral molars.
- he highest percentage of “maxillary anterior alveolar bone loss” (56%) was noted for the group wearing a Class I man- dibular RPD
- “Combination syndrome changes” seen in 24% of patients with Kennedy class 1 md RPD.
Shen K, Gongloff RK. Prevalence of the “combination syndrome” among denture patients. J Prosthet Dent 1989;62:642-4.
Implants and combination syndrome?
(Lechner) 1996,1999
An Australian implant center
-anterior bone resorption beneath Mx CD opposed by implant-supported mandibular.
- Fixed IS-prosthesis “did not appear to promote a condition similar to combination syndrome.”
(Max,Power,Scott)
- Mx CD, Md IS-OVD
- Combination syndrome changes seen (not as much as Kelly reported) postulated due to lack of supraeruption of teeth.
(Jacobs)
-Mx CD vs Md CD, IS-OVD, IS-FCD.
- CD vs CD (Most bone resorption)
- CD vs IS-CD (Second most bone resorption)
- CS vs
Lechner SK, Mammen A. Combination syndrome in relation to osseointe- grated implant-supported overdentures: a survey. Int J Prosthodont 1996; 9:58-64.
- Gupta S, Lechner SK, Duckmanton NA. Maxillary changes under com- plete dentures opposing mandibular implant-supported fixed prostheses. Int J Prosthodont 1999;12:492-7.
Maxson BB, Powers MP, Scott RF. Prosthodontic considerations for the transmandibular implant. J Prosthet Dent 1990;63:554-8.
34. Barber HD, Scott RF, Maxson BB, Fonseca RJ. Evaluation of anterior maxillary alveolar ridge resorption when opposed by the transmandibular implant. J Oral Maxillofac Surg 1990;48:1283-7.
Advantages of Implant supported Fixed CD, masticatory forces ?
(Stafford D, Glantz PO, Lindqvist L, Strandman )
- a marked improvement in “chewing ability” after implant treatment, as indicated by changes in measured masticatory forces.
- no significantly increased levels of loading were measured by the strain gauges placed in the maxillary dentures.
Stafford D, Glantz PO, Lindqvist L, Strandman E. Influence of treatment with osseointegrated mandibular bridges on the clinical deformation of maxillary complete dentures. Swed Dent J Suppl 1985;28:117-35.
IS- Overdentures Advantages and disadvantages?
Disadvantage
- Not fixed pt requested fixed
- Higher frequency of maintenence complications
- Higher incidence of midline mand overdenture fracture opposing maxillary complete denture. (Jemt, Lekholm)
Haraldson T, Jemt T, Stalblad PA, Lekholm U. Oral function in subjects with overdentures supported by osseointegrated implants. Scand J Dent Res 1988;96:235-42.
