FROM THE DESK OF
 ALAN M MELTZER DMD MScD

IMPLANT OVERDENTURES: NEW CONCEPTS AND
UPDATED TECHNIQUES

It has been well documented that implant-related overdentures improve a patient’s quality of life. Furthermore, dental professionals have found that implant overdentures provide predictable resolution of the functional and aesthetic compromises associated with conventional dentures. Some of the specific benefits include improved prosthetic retention and stability, resulting in improved comfort eliminating soreness of the load-bearing tissues, and more stable facial aesthetics.

Because this type of prosthesis is implant retained and tissue supported, some cases including chronic mucosal tenderness or severe knife-edged ridges frequently require additional implants to reduce the load on the soft tissues. Therefore, classically two implants are all that is required in the mandible, but these special circumstances may require three to four mandibular implants. Three or four implants may also be necessary in cases of limited bone quality or quantity. Additional implants are frequently required in cases where narrow-diameter implants have been selected. It is interesting to note that the current standard of care does not require splinting of mandibular implants for overdenture use.

The current attachment of choice is the Locator because of decreased cost, increased hygiene accessibility, decreased space requirements and the fact that it is a resilient attachment. Additionally, Locator attachments can diverge by up to 40 degrees and still be of clinical value.

Unlike the mandible, the current trend is four implants in the maxilla in order to eliminate the need for full palatal coverage. In our practice we recommend a bar connector for the four implants due to the frequent finding of decreased bone quantity and quality, leading to the need for shorter implants coupled with the need for angulation correction. After designing the bar, Locator attachments can be tapped into the bar and used for retention. Generally three to four Locators incorporated into the bar are more than sufficient. If less than four splinted implants are suggested for the maxilla, then full palatal coverage as well as lower retention inserts are required. Therefore, two implants (non-splinted) with lower retention housings can generally be used in the maxilla as long as they are coupled with a well-fitting denture with full palatal coverage.

Restorative: Dr. Robert Bernstein / Colonial Dental Lab

FROM THE DESK OF
 ALAN M MELTZER DMD MScD

UPDATE #2 ON BISPHOSPHONATE-ASSOCIATED
OSTEONECROSIS OF THE JAW (ONJ)

How should a dentist manage a patient receiving IV bisphosphonate therapy?

1. Management should be by a qualified dental specialist.
2. Pain management as required.
3. Report case to all appropriate authorities.
4. Management of infection
   • Oral antimicrobial rinses (0.12% Chlorhexidine).
   • Systemic antibiotics as required.
   • Surgical management.
     • Conservative or delayed.
     • Remove sharp exposed bone edges.
     • Bone sequestra should be removed without exposing uninvolved bone.
5. Dietary supplements to fulfill nutritional needs.
6. Controversial additional options.
   • Stop bisphosphonates.
   • Hyperbaric oxygen.

FROM THE DESK OF
 ALAN M MELTZER DMD MScD

UPDATE #1 ON BISPHOSPHONATE-ASSOCIATED
OSTEONECROSIS OF THE JAW

In 2007, a multidisciplinary task force was formed by the American Society for Bone and Mineral Research on bisphosphonate-associated osteonecrosis of the jaw (ONJ). The full reference may be found at J. Bone Miner Res 2007; 22:1479-1491. This paper, I feel, provides some of the best information available on the subject. I will review the content of the paper here, but suggest everyone read the entire paper.

What is ONJ? ONJ is the presence of exposed bone in the maxillofacial region that does not heal within eight weeks after identification by a healthcare provider.

What is the risk of ONJ associated with oral bisphosphonates taken for osteoporosis? The risk is extremely low and is ranked as between 1 in 10,000 and 1 in 100,000 patient-treatment years. The condition is more common in the mandible than the maxilla.

What is the risk of ONJ in patients with cancer being treated with high doses of IV bisphosphonates? The risk is much higher and is in the range of 10% or less, depending on the duration of treatment.

What is the risk of ONJ in patients being treated with once-a-year IV Reclast for osteoporosis? Unknown.

What are the risk factors for ONJ? The risk factors are: IV bisphosphonates, cancer and associated anti-cancer therapy, dental extractions, oral surgery with bone manipulation, poor fitting dental appliances, intraoral trauma, duration of bisphosphonate treatment, glucocorticoids, alcohol and tobacco abuse, and pre-existing dental disease.

How should a dentist manage a patient already receiving (oral) bisphosphonate therapy?

• Informed consent regarding risks as outlined above and providing copies of articles, such as the one outlined above.
• Stress good oral hygiene with regular dental care.

For patients on long-term bisphosphonate therapy (currently defined as more than three years), the following precautions are advised:

• Patients with periodontal disease should be treated with non-surgical treatment. If surgery is required, then minimal bone exposure and re-contouring can be considered.
• Taking oral bisphosphonates is not a contraindication for dental implant placement. Informed consent should be provided and documented.
• Endodontic (root canal) treatment is preferable to endodontic surgery or extraction.
• While somewhat controversial, there is a suggestion to stop oral bisphosphonates for a period before and after invasive dental treatment

A further discussion of patients receiving IV bisphosphonates will be continued in my next newsletter.

FROM THE DESK OF
 ALAN M MELTZER DMD MScD

OUR NEW WEBSITE

dralanmeltzer.com

Over the past eight months we have constructed what we feel is the most comprehensive implant and periodontal website available.

From the patients’ standpoint there is an abundance of comprehensive written information and videos to help your patients understand the nature of our practice and the services we provide.

Additionally, your patients can download their registration and health history forms and fill them out before they arrive in the office. HIPAA and financial policy forms can also be downloaded.

Your patients can contact us via our website and have any questions they may have answered. Of course, we still are available by telephone as well.

Do your patients need directions? They can simply type in their location, click and they will receive personalized turn-by-turn directions as well as a map and travel time.

From your perspective we maintain a library of articles and newsletters for your review. Coming soon will be dental “How Do I” videos. Such topics as fixture-level impression techniques, construction of clip locator dentures as well as other restorative procedures are just a click away. Back issues of my newsletters are also available.

Our website also provides free advertising for you. A list of all our referring colleagues remains available on our home page. If your name does not appear and you would like it listed, please e-mail us via a patient referral form, INFO FOR DOCTORS >Referral for Doctor or Simply click on “contact us” on the bottom of our home page. We would also be happy to provide a link to your website if you so desire.

We plan on updating our site regularly, providing the latest information for both you and your patients. We are interested in any suggestions for future additions which would prove helpful.

FROM THE DESK OF
 ALAN M MELTZER DMD MScD

IMPLANT MAINTENANCE

As you know, it is my usual practice to provide you periodically with a short monograph on a timely dental topic. However, this month I had the opportunity to read a monograph written by a good friend, Anita Daniels, RDH. I felt that this is an outstanding review of an ideal implant maintenance visit. I hope that you will feel as I do. Also, please share the contents of this article with your hygiene staff.