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Perspectives in Prosthodontics:

1970-2010


InCelebrationofthe40thAnniversaryofthe
AmericanCollegeofProsthodontists

2010bytheAmericanCollegeofProsthodontists.Allrightsreserved.

Nopartofthisproductmaybereproducedinanyformorbyanymeanswithout
writtenpermissionfromthepublisher.

Requestsforpermissiontoreprintormakecopiesofanypartofthispublication
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AmericanCollegeofProsthodontists
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www.prosthodontics.org


Acknowledgments

TheAmericanCollegeofProsthodontistsextendsitsthankstothemany
individualswhocontributedtothedevelopmentofthismanuscript.

40thAnniversaryTaskForce
StevenJ.Sadowsky,DDS,FACP,Chair
CurtisBarmby,DDS,FACP
LawrenceE.Brecht,DDS
LyndonCooper,DDS,PhD,FACP
SreenivasKoka,DDS,MS,FACP
WilliamKuebker,DDS,MSD
JohnMurrell,DDS,MBA,FACP
DavidL.Pfeifer,DDS,MS,MEd,FACP
ThomasSmith,DMD,FACP

















Foreword

The 40th anniversary of the American College of Prosthodontists is an


opportunitytocelebrateprosthodonticinnovation.Thelast4decadeshaveseen
seismic changes in diagnostic methodologies, restorative care options, material
science,applicationoftechnology,andtheuseofevidencebasedpracticeasthe
foundation for treatment planning. As we enter the Age of Information,
Malcolm Gladwell, keynote speaker for the 40th Annual Session in Orlando,
Florida, has noted, The key to good decision making is not knowledge. It is
understanding. We are swimming in the former. We are desperately lacking in
the latter. As master diagnosticians and endpoint providers, prosthodontists
have become leaders in adopting an evidencebased approach to assess new
strategies in the delivery of services to our patients. The process, however, has
required a renaissance of thinking and breaking down old, well established
models and principles as we assess quantum changes in such fields as implant
dentistry, maxillofacial prosthetics, allceramic restorations and digital
applications.

Newunderstandingmustovercometheinertiafueledbyentrenchedideas.The
longaccepteddentalmodelhasnotbeeneasilydiscarded.Albrektssonetal1 has
underscored this tendency in his editorial, A Requiem for the Periodontal
Ligament Revisited, that a clinicians lack of willingness to accept the
fundamentaldifferencesbetweenanevolvedattachmentmechanismforatooth
and the implantbone complex, has led to obsolete etiological explanations for
periimplantitis.However,evidencehashelpedtodissolvereveredshibboleths.
Forexample, Blanes2 hasreportedinasystematicreview thatcrowntoimplant
ratios of 2:1 do not influence crestal bone loss or mechanical complications,
unlike natural teeth. Also, 5year clinical trials3, 4 and in vitro studies5, 6 have
demonstratedthattiltedimplantsupto45degreeshaveahighsurvivalrateand
biomechanically transmit a reduction of stresses in the periimplant bone,
contrarytoorthodoxthinking.

Arguably, implants have led to the most dramatic improvements in quality of


life in the sphere ofmaxillofacialprosthetics.Butearlyon,placing implantsin
irradiatedbonewasconsideredtoorisky.Mindsetswerestillmiredinthe1978
Harvard Conference7 detailing the limitations of blade endosteal implants.
However,with careful managementof the remaininghard andsoft tissuesand
later the use of hyberbaric oxygen, endosseous treatment philosophy changed.

i
Nowimplantretainedprosthesesforthecraniofacialcancerpatienthavebecome
derigueur.Infact,Colellaetal,inasystematicreview8,havereportedrespectable
implant survival rates with both pre and postimplantation radiation therapy.
More recently, the field maxillofacial prosthetics has been slow to embrace
advanced digital technologies, despite the promise of more accurate modeling.
Newparadigmsarelagginginacademiccurriculaandtheclinicalsetting.

The use of allceramic crowns for posterior restorations has been met with
suspicionbymetalceramiccrownenthusiasts.However,Pjeturssonetal9,ina
systematic review of 5year survival of densely sintered alumina crowns and
reinforced glassceramic crowns, found no difference in complication rates
compared to metalceramic crowns. Longstanding flexural strength concerns
with allceramic restorations have been countered with the introduction of Y
TZP ceramic. However, until established PFM protocols were changed for both
coolingparametersofveneeringceramicsandframeworkdesignforzirconium
based restorations, longterm clinical success was not achievable.10 The
replacement of traditional techniques for fabrication of allceramic restorations
alsohasbeenresisted,butCAD/CAMgeneratedallceramicmolarcrownshave
been reported with a survival rate of 94.6% up to 7 years.11 Using this new
technology, optimized processing parameters prevent the formation of
microstructuraldefects.12 Finally,theprospectofdigitalimpressionscompletely
replacing traditional intraoral impressions is still an anathema to many
prosthodontists. But, da Costa et al13, have demonstrated no differences in the
marginalgapwithinlaysmadewithanopticalimpressionorwithanelastomeric
impression material. Advances in science and technology continue to offer
viablealternativesinpatientcarewiththeprospectofeclipsingtheprecisionand
reliabilityofpresentprocedures.

The articles written by the contributors to this anniversary retrospective well


chronicle the advances in patient care since the inception of the American
College of Prosthodontists. The next 40 years will surely bring exponential
changetotheentireareaofprosthodonticsandhowweembracethosechanges
will define our specialty. It is apparent that intransigence and premature
adoptionaretwosidesofthesamecoin.Animmutablequestionremainswhen
considering change: Is there evidence to show that new technologies enhance
the prospect of meeting patients needs with predictable, enduring, and
affordabletreatment?

StevenJ.Sadowsky,DDS,FACP

ii
References
1. AlbrektssonT,BrunskiJ,WennerbergA.Arequiemfortheperiodontalligamentrevisted.
IntJProsthodont2009;22:12022.

2. BlanesRJ.Towhatextentdoescrowntoimplantratioaffectthesurvivalandcomplications
ofimplantsupportedreconstructions?Asystematicreview.ClinOralImplantsRes2009;20
Suppl4:6772.

3. FortinY,SullivanRM,RangertBR.TheMariusimplantbridge:surgicalandprosthetic
rehabilitationforthecompletelyedentuloiusupperjawwithmoderatetosevereresorption:
a5yearretrospectiveclinicalstudy.ClinImplantDentRelRes2002;4:6977.

4. AparicioC,PeralesP,RangertB.Tiltedimplantsasanalternativetomaxillarysinusgrafting:
aclinical,radiologicandperioteststudy.ClinImplantDentRelRes2001;3:3949.

5. BeggT,GeertsGA,GryzagoridisJ.Stresspatternsarounddistalangledimplantsintheall
onfourconceptconfiguration.IntJOralMaxillofacImplants2009;24:66371.

6. DelFabbrom,BelliniCM,RomeoD,FrancettiL.Tiltedimplantsfortherehabilitationof
edentulousjaws.ClinI,plantDentRelatRes2010May13.[Epubaheadofprint].

7. LinkowLI,KohanPA.Benefitsandrisksofendostealbladeimplants(HarvardConference,
June1978).JOralImplantol1980;9:944.

8. ColellaG,CannavaleR,PenteneroM,GandolfoS.Oralimplantsinradiatedpatients:a
systematicreview.IntJOralMaxillofacImplants2007;22:61622.

9. PjeturssonBE,SailerI,ZwahlenM,HammerleCHF.Asystematicreviewofthesurvivaland
complicationratesofallceramicandmetalceramicreconstructionsafteranobservation
periodofatleast3years.PartI:singlecrowns.ClinoralImplantsRes2007;18Suppl3:7385.

10. SwainMV.Unstablecracking(chipping)ofveneeringporcelainonallceramicdentalcrowns
andfixedpartialdentures.ActaBiomater2009;5:166877.

11. BindlA,RichterB,MormannWH.Survivalofceramiccomputeraided
design/manufacturingcrownsbondedtopreparationswithreducedmacroretention
geometry.IntJProsthodont2005;18:21924.

12. GuessPC,ZavanelliRA,SilvaNRFA,BonfanteEA,CoelhoPG,ThompsonVP.Monolithic
CAD/CAMlithiumdisilicateversusveneeredYTZPCrowns:comparisonoffailuremodes
andreliabilityafterfatigue.IntJProsthodont2010;23:43442.

13. DaCostaJB,PelogiaF,HagedornB,FerracaneJL.Evaluationofdifferentmethodsofoptical
impressionmakingonthemarginalgapofonlayscreatedwithCEREC3D.OperDent
2010;35:3249.

iii
TableofContents

Foreword
ARetrospectiveonProsthodonticProgress.............................................................................. i

Chapter1
TheImplantRestorationoftheEdentulousPatient.................................................................7

Chapter2
TheDevelopmentofDentalImplantTherapyforPartialEdentulism ...............................16

Chapter3
AnOverviewofMaxillofacialProsthetics...............................................................................32

Chapter4
AdvancementsinMaxillofacialProsthetics ............................................................................40

Chapter5
MaxillofacialTraumaticInjuries ...............................................................................................51

Chapter6
AllCeramicRestorations:Vision,DiscoveryandPredictability .........................................54

Chapter7
TheEvolutionofCeramicRestorationsAContemporaryPerspective............................63

Chapter8
ComputerBasedTechnologyintheProsthodonticPractice ................................................72

Chapter9
DigitalTechnologyinProsthodonticsHistoricalandFuturePerspectives.....................82

iv

Chapter1TheImplantRestorationoftheEdentulous
Patient

StevenJ.Sadowsky,DDS,FACP

Introduction
The1980smarkedawatershedmomentinprosthodonticswiththeintroductionofthe
osseointegration concept to North America, irrevocably changing rehabilitative
approachesfortheedentulouspatient.AlthoughtheadmodumBranemarkdesignhas
achievedunparalleledlongitudinalimplantsuccessandprostheticstability,1therehas
been over the last three decades an emergence of a new set of outcomes measures
related to quality of life concerns.2, 3 These data have led to permutations of the
originalprototypeandneedforalgorithmsinthediagnosisanddifferentialtreatment
planningfortheedentate.Completedentureprinciplescontinuetobethefoundation
for developing the restorative blueprint.4 Objective determinants such as hard and
soft tissue quality/quantity of bone, jaw anatomy, morphology and class, antagonist
dentition and loading forces will aid in the choice of prosthesis.5 Subjective
determinants such as the patients expectations of retention security, esthetics,
hygiene access, maintenance and costs will also aid in selecting the appropriate
design.6

7
ImplantRestorationoftheEdentulousMandible
In the latter part of the 1980s, a 2implant overdenture design was introduced and
foundtobeefficacious,forboththesolitaryanchorandbaranchoragesystem.7, 8 In
2002,TheMcGillConsensusestablishedthe2implantmandibularoverdentureasthe
firstchoicestandardofcareforedentulouspatients.9`Infact,a10yearclinicaltrial
demonstrated no differences in clinical or radiographic indices, maintenance, or
patient satisfaction with a 2 or 4implant overdenture design.10 However,
Fitzpatrick 11,inasystematicreviewoftheliterature,counteredtheMcGillconsensus
by noting that considering dentist and patientmediated outcomes, a universal
intervention for the edentulous mandible has not been demonstrated. The following
examplesmakethis point.Asinglesymphyseal implantdesign for geriatric patients
has been reported to achieve high implant survival and patient satisfaction, with
limitedsurgicalandfinancialexposure.12, 13 Whentheresidualheightoftheanterior
mandibleprecludestheuseofimplantswithatleastalengthof8.5mmandawidthof
3.5 mm, a 4implant array is recommended to maximize implant survival.14, 15
Furthermore, the decision to provide an overdenture design or a fixed implant
completedentureiscontingentonamyriadoffactors.Patientswithmarkedposterior
residualridgeresorption16, 17,taperedmandibulararchform18,TMD19,orcombination
syndrome20maybenefitmorefromafixedratherthanaremovableprosthesis.Onthe
other hand, patients with offridge relations5, concerns regarding facial or dental
esthetics, 21 hygiene access considerations, 22 or cost containment priorities23 may be
best treated with an overdenture. However, longterm costs of overdentures due to
maintenance may surpass the initial advantage of lower upfront fees compared to a
fixed prosthesis.2426 That being said, the aftercare burden investigations on
overdentures have been focused on solitary anchors or the Dolder bar design.
Krennmair et al27 and Dudic et al28 have independently demonstrated lower
mechanicalcomplicationswithamilledbarsubstructure.Additionally,thecomputer
numeric controlled (CNC) process has been shown to offer superior fit to the
conventional lost wax technique (1315 microns vs. 43180 microns) and may
minimizebiomechanicalcomplications.29,30

More recent design developments in fixed prosthetic designs using implant
supported fixed metalceramic reconstructions31 and CAD/CAM milled titanium
frameworkwithallceramiczirconiumoxidecrowns,32mayofferimprovedaesthetics,
phoneticsandcastingaccuracy.However,longtermstudiesarenotavailabletoassess
theirbenefit/costcalculus.Whiletheapplicationofceramicrestorativematerialsresist
progressive wear often seen in denture teeth,33 fracture may pose a significant
aftercareburden,especiallyiftheprosthesisisnotreadilyretrievable.
Theeffectivenessofimmediatelyloadingtheedentulousmandible,within1week, 34
has been reported in the literature over the last decade. However, despite the

8
advantages of immediate restoration of function and decreased patient treatment
visits, 35 controversy persists whether the regimen improves patient satisfaction and
cost effectiveness.36 In fact, increased complications have been reported when an
immediate loading approach was used for both removable and fixed designs,
compared to the conventional timetoloading protocol.37, 38 Notwithstanding these
considerations, patients may present with conditions which would optimally be
treatedwithanimmediateloadprotocolsuchastransitioningfromadentuloustoan
edentulous state,39 compromised anatomy,40 somatogenic gagging 41 or psychogenic
disabilities.Carefulpatientselectionwillmaximizesuccessfuloutcomes.Hostrelated
factors which may compromise either implant stability or wound healing capacity
should preclude using this treatment regimen.42 These include metabolic diseases,
heavysmoking,parafunction,boneaugmentationtoimplantsite,drug/alcoholabuse,
antiblastic chemotherapyor steroids.4346 Aboveall,immediate loadprotocolsrequire
primary stability (e.g. 45 Ncm insertion torque value, 54 Implant Stability Quotient
using resonance frequency analysis)4749 and low surgical trauma for predictable
osseointegration.

ImplantRestorationoftheEdentulousMaxilla
The maxillary fixed implant complete denture has been documented with high 15
yearimplantsurvivalrates,50butitwassoonevidentthatthisprototypicdesignagain
did not have universal application. To address such patient needs as unfavorable
maxillomandibular relations, concerns regarding facial and dental esthetics, speech
competency, hygiene access and cost containment issues, the maxillary overdenture
designevolved.Infact,patientswhoreportedchronicproblemswiththeirmaxillary
dentures, preferred a longbar overdenture design to a fixed implant complete
denturebymorethan2to1.51Buthistorically,thistreatmentmodality hassuffered
fromrelativelyhighimplantfailure 5254andahighaftercareburden26duetoreduced
bonequalityandquantity,divergentimplantaxes,offsetpositioningoftheteethand
generally higher loading forces.55 Moreover, this modality is characterized by a
limited portfolio of strong hierarchical evidence.56 However, specific design
considerations have been proposed to improve the maxillary overdenture implant
survivalandcomplicationrates.

Whiletherearenodefiniteguidelinesforthenumberofimplants,thereappearstobe
a consensus that at least 4 implants are favorable for a palateless design.5759 The
recommendedminimumlengthfortexturedimplantsis10mm60,althoughFerrignoet
al, 61 found in a 10year prospective study a 93% implant survival rate for maxillary
overdentures supported by 12 mm long implants and a 91.6% survival rate when
supported by 10 mm long implants. Heterogeneity in research methodology has
plagued an objective assessment of whether an unsplinted or splinted anchorage

9
systemispreferredfromthestandpointofmeanboneloss.Thedecisiontoselectthe
unsplinteddesignmaybepatientandclinicianmediatedasitrequireslessspace,is
easier to clean, is more economical and is simpler to reline than a Dolder bar
substructure.55However,longitudinalstudieshaveshownthemilledbardesigntobe
superior to the solitary anchor or Dolder bar system for both implant survival and
mechanical complications.27, 28, 6163 In patients with limited residual alveolar
resorption, a premium on natural crown contours, and adequate financial
wherewithal; a full arch metal ceramic reconstruction may be an appropriate
prosthetic alternative. Fiveyear cumulative implant survival with this design has
been reported to be 98.5%, when an average of 7.5 implants of 14.5 mm length has
beenimmediatelyinstalled,withamaximumcantileverlengthofnomorethan1012
mm.64 There is little evidence that implant survival or success is affected directly by
prosthesis type based on current designs studied for at least 5 years. Prosthesis
maintenancedoesappeartovarywithdifferentprosthesisdesigns.65

Only limited data are available on immediate load on the maxilla and is not
sufficiently supported scientifically.66 However, Romanos et al67 completed a 5year
study in 2009, on immediate functional loading in the edentulous maxilla, using a
progressive thread design and platform switching, demonstrating a 96.6% implant
survival.Primarystability,crossarchstabilizationandasoftdietwereemphasizedin
the protocol. The application of new implant surface treatments such as nanometer
scale calcium phosphate may hold promise as shortterm effectiveness in immediate
loadscenarioshasbeendemonstrated.68

Despitethelackoflongtermstudiesofsufficientmethodologicalrigor,therehasbeen
abroadinterestinboththeTeethinaDayprotocol69andtheAllonFour70conceptfor
immediatelyrestoringtheedentulousmaxilla.Theapplicationofcomputergenerated
diagnostic and treatment regimens have expanded the application of the immediate
loadprotocol.71, 72 Thenextdecadewillofferasubstantiveperspectiveontheefficacy
ofthesedigitalinnovations.

Dr.Sadowskyisthe40thAnniversaryTaskForceChairandProsthodonticPracticeand
Patient Care Division Director of the American College of Prosthodontists. Dr.
Sadowsky recently was appointed Implant Director at the University of the Pacific
SchoolofDentistry.HeisaDiplomateoftheAmericanBoardofProsthodonticsandisa
member of the editorial boards of the International Journal of Maxillofacial Implants,
International Journal of Prosthodontics and Journal of Prosthetic Dentistry. Dr.
SadowskyisactiveintheAcademyofProsthodontics,AmericanProsthodonticSociety
and the Pacific Coast Society for Prosthodontics. He has published 15 articles in peer
reviewed journals, many of which focus on treatment planning considerations for the
implantrestorationoftheedentulouspatient.

10
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52.BergendalT,EnqquistB.Implantsupportedoverdentures:alongitudinalprospectivestudy.
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53.JemtT,ChaiJ,HarnettJ,etal.A5yearprospectivemulticenterfollowupreporton
overdenturessupportedbyosseointegratedimplants.IntJOralMaxillofacImplants1996;11:291
8.
54.JohnsRB,JemtT,HeathMR,etal.Amulticenterstudyofimplantoverdenturessupportedby
Branemarkimplants.IntJOralMaxillofacImplants1992;7:51322.
55.AkcaK,CehreliMC,UysalS.Marginalbonelossandprostheticmaintenanceofbarretained
implantsupportedoverdentures:Aprospectivestudy.JOralMaxillofacImplants2010;25:13745.
56.SadowskySJ.Treatmentconsiderationsformaxillaryimplantoverdentures:Asystematic
review.JProsthetDent2007;97:3408.
57.MericskeSternR.Treatmentoutcomeswithimplantsupportedoverdentures:clinical
considerations.JProsthetDent1998;79:6673.
58.NaertI,GizaniS,vanSteenbergheD.Rigidlysplintedimplantsintheresorbedmaxillato
retainahingingoverdenture:aseriesofclinicalreportsforupto4years.JProsthetDent
1998;79:15664.
59.EckertSE,CarrAB.Implantretainedmaxillaryoverdentures.DentClinNorthAm
2004;48:585601.
60.MericskeSternR,OetterliM,KienerP,etal.Afollowupstudyofmaxillaryimplants
supportinganoverdenture:Clinicalandradiographicresults.IntJOralMaxillofacImplants
2002;17:67886.
61.FerrignoN,LauretiM,FanaliS,etal.AlongtermfollowupstudyofnonsubmergedITI
implantsinthetreatmentoftotallyedentulousjaws.PartI:Tenyearlifetableanalysisofa
prospectivemulticenterstudywith1286implants.ClinOralImplantsRes2002;13:26073.

13
62.KrennmairG,KrainhofnerM,PiehslingerE.Implantsupportedmaxillaryoverdentures
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Prosthodont2009;22:18192.
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prostheses.IntJOralMaxillofacImplants1998;13:81925.
65.BryantSR,MacDonaldJankowski,KimK.Doesthetypeofimplantprosthesisaffect
outcomesforthecompletelyedentulousarch?IntJOralMaxillofacImplants2007;22(Suppl):117
39.
66.ChiapascoM.Earlyandimmediaterestorationandloadingofimplantsincompletely
edentulouspatients.IntJOralMaxillofacImplants2004;19:769.
67.RomanosGE,NentwigGH.Immediatefunctionalloadinginthemaxillausingimplantswith
platformswitching:Fiveyearresults.IntJOralMaxillofacImplants2009;24:110612.
68.OstmanPO,WennerbergA,AlbrekssonT.ImmediateocclusalloadingofNanoTitePREVAIL
implants:aprospective1yearclinicalandradiographicstudy.ClinImplantDentRelat
Res.2010;12:3947.
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report.JProsthetDent2005;93:812.
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prosthodonticimplantplanningandplacement.PartI.Theconcept.JProsthodont2006;15:518.
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prosthodonticimplantplanningandplacement.PartII.Aclinicalreport.JProsthodont
2006;15:11722.

14


Chapter2TheDevelopmentofDentalImplant
TherapyforPartialEdentulism

LyndonF.Cooper,DDS,PhD

PartialEdentulism,itsScopeandHistoricalOutcomesofTreatment
ThecurrentstatusofpartialedentulismintheUnitedStatesmaybereflectedby
information gathered in the Third National health and Nutrition Examination
Survey (NHANES III) that estimated the prevalence and distribution of tooth
retention and tooth loss among adults over the age of 18. From 1988 to 1991,
approximately1/3ofthepopulationhadretainedalloftheirteeth.However,the
mean number of teeth was 23.5 for dentate persons. These people most
commonlyretainedalloftheiranteriorteeth.Thisindicatesthatthereexisttens
ofmillionsofpartiallydentateindividualsintheUSandthatalargeproportion
oftheseindividualsaremissingposteriorteeth(Marcusetal1996).Thisfinding
reiterates that, based upon a survey of a regional laboratory production, the
majority of removable partial dentures were for Kennedy class I and class II
scenarios(Curtisetal,1992).Whentheprevalenceoftoothlosswasexaminedin
Europe, Muller et al (2008) also concluded that the aging population displayed
reduceddentitioninneedofprosthodontictreatment.Theyconcludedthatthe
WorldHealthOrganizationgoalofretentionofatleast20teethattheageof80
yearswasnotyetuniversallyattained.

15
Thechallengeofrestoringfunctionandestheticstothepartiallydentatepatient
has historically been met using removable partial dentures. As late as 2006, a
survey of US dental schools confirmed universality of training students in
removable partial denture techniques, including the use of border molding of
impressionsandtheuseofsemiadjustablearticulators,aswellastheprocessof
surveyingcasts.Over80percentofschoolsmaintainedasetnumberofclinical
requirements for removable partial dentures and this suggests that during the
current period, dentistry includes the treatment of partial edentulism using
removablepartialdentures(PetropolisandRashidi,2006).

Despitetheeducationofdentistsintheapplicationandtechniqueofremovable
partial dentures, there exist defined limitations in the treatment of partial
edentulism using removable partial dentures. Patient reported outcomes have
revealed that there is low acceptance of esthetics and function (chewing), and
that patients have dissatisfaction with retention and comfort. Hummel (2002)
concluded that for a large population of individuals treated with removable
partialdentures,only1/3werefreeofsignificantdefectsthatincludedmovement
(lifting upon unilateral or bilateral force) and loss of retention as indicated by
dislodging upon moderate opening of the mouth. The outcomes of tooth
replacement using removable partial dentures have also been questioned. A
retrospective evaluation of abutment tooth survival with a removable partial
dentures had the poorest 10year survival rate (Aquilino et al 2001). More
recently, Miyamoto et al (2007) revealed that among all treatments of teeth,
removablepartialabutmentsexperiencedthehighestfailurerate.

The treatment of partial edentulism involving removable partial dentures
remains a large part of dental therapy. This is despite evidence that the
treatment is poorly accepted by patients and there are biological consequences
that negatively affect the support of alveolar bone and adjacent teeth. The
prescription of dental implants to improve the major limitations of lack of
stability, retention and longterm success of removable partial dentures has a
historyindentistryofover50years.

InitialEffortstoReplaceRemovablePartialDenturesUsingaDentalImplant
Concept
In the 1960s and 1970s, clinicians began to explore the possibility of replacing
removable partial dentures with implantsupported fixed dental prostheses.
While subperiosteal implants were being utilized for the edentulous patient,
blade implants were designed specifically for placement in the posterior
mandibularalveolarridgeforsupportoffixeddentalprostheses.Thereislittle

16
clinical data to consider when reviewing this treatment strategy. However, in
1987, the Veterans Administration Cooperative Dental Implant Study was
introducedandin1989,thesuccessofimplantsupportedfixeddentalprosthesis
reported a 5 year success rate a 84.2% and compared favorably to a reported
74% success rate for the removable partial dentures. It must be noted that
differentradiographiccriteriaforbonelosswereutilizedindeterminingsuccess
than is applied today. Importantly, when patient satisfaction was considered
after5years,someincreasedsatisfactionwasmeasuredforpatientstreatedusing
implants. These early efforts to improve the treatment of the partially dentate
patient by avoiding a removable partial denture met with some success. Early
predictions included that blade implants and the anatomic advantages for
placement in the narrow mandibular ridge would not be displaced by
osseointegrated implants (Babbush1986). However, the biologic reality and
clinical longevity of the blade implant itself required careful evaluation.
Smithloff and Fritz (1987) indicated that only 50% of blade implants evaluated
over15yearswerefreeofboneloss,bleedingonprobingorradiolucency.The
1988consensusconferenceondentalimplantsincludedadiscussionofthemerits
ofosseointegratedendosseousdentalimplantsandsocalledfibroostealblade
implants(Weiss,1988).Withlittleclinicaldatatosupporttheapproachforblade
implants, the ultimate result of the discussions that occurred during that
consensusconferenceincludedtheadoptionofsuccesscriteriawhichultimately
excluded the use of blade implants from mainstream use in support of dental
prostheses.

Thus, in the mid1980s, the demand for rehabilitation of the partially dentate
patient using alternatives to removable prostheses was growing. Yet, the
profession lacked sufficient alternatives to the removable partial denture that
were supported by evidence. The advances that were promised by
osseointegratedendosseousdentalimplantswereemerginginwelldocumented,
retrospectiveandprospectivecohortstudiesinvolvingedentulouspatients.The
translationofthistechnologytothepartiallydentatepatientwasneeded.

TheEstablishmentofOsseointegratedDentalImplantTherapyforTreatment
ofPartialEdentulism
Theintroductionofosseointegrateddentalimplantshashadaprofoundeffecton
Prosthodontics. Beyond its biologic and clinical advantages, its introduction
changed the process of choosing one or another technique based on evidence.
While the initial studies by the Branemark team were cohort studies and not
randomized controlled studies involving a wide range of patient outcomes, the
data concerning implant survival supported the use of implants in the

17
parasymphysealmandibleofedentulouspatients.Bythemid1980stheoriginal
reports of Adell (1981) and the replicate studies of Zarb (1983) were well
disseminated. Endosseous implants supporting crossarch splinted dental
prostheses in edentulous subjects were accepted. The transition of this
technology from the edentate patient to the dentate patient required additional
consideration.

The application of osseointegrated implants for partial edentulism was
introducedinseveralpapersduringthelate1980s.Jemtetal(1989)reportedon
treatment of 244 patient between 1968 and 1988. They demonstrated for 876
Branemarkimplantsthelossof24fixtures(3%)withaprosthesisstabilityrateof
98.7%.Thisresultwasconsistentwiththeirobservationsconcerningimplantsin
edentulous subjects. In a retrospective cohort study of van Steenberghe et al
(1989),133fixturesin38patientswereexamined.Someimplantswereconnected
to natural teeth. This study revealed 87% and 92% success for maxillary and
mandibular implants, respectively and suggested that osseointegrated implants
couldbeusedintherehabilitationofthepartiallydentatepatient.

Inasubsequentevaluation,Naertetal(1992)reportedontheobservationsof509
implantsplacedtosupport217fixeddentalprostheses.Thelowfailureratesand
theacceptablemarginalbonechangesreportedinthismediumtermfollowup
encouraged the use of endosseous implants for the treatment of partial
edentulism.Afewofthemajorconcernsinthisstudyincludedtheconnecting
of teeth to implants and the use of porcelain for the prostheses veneers.
Regardingtheporcelainasanocclusalmaterial,theadvantagesofestheticsand
longevity were considered advantages without risk to the implant or
implant/bone interface. They further suggested that there may be no risk in
connecting teeth with implants, however they further indicated that
freestanding implant prostheses should be made whenever possible. (They
reconsidered this comment in an up to 15 year follow up of these patients and
demonstrated greater implant failure when implant and teeth are connected
(Naert et al. 2002)). Finally, the authors indicated that active efforts to prevent
abutmentscrewlooseningandfractureshouldincludetheuseofpassivefitting
frameworks,thelimitationofbendingmomentsandproperfasteningofscrews.
Today, these early lessons remain central concerns when treating the partially
dentatepatientusingendosseousimplants.

Several other investigations concerning implants used for partial edentulism
were included in a metaanalysis of Lindh et al (1998). Nineteen studies were
included and 2116 implants supporting fixed dental prostheses were involved.

18
The cumulative survival rate for implants supporting fixed dental prostheses
was approximately 97% at inception and 93.5% at five years after implant
loading. They concluded that the shortterm survival rates were comparable
with that of implants in edentulous jaws and represented a strong clinical
argumentforrestoringpartiallydentatepatientswithimplants.

ZarbandZarb(2002)reportedonthelongterm(1015year)outcomeofimplant
supported posterior fixed dental prostheses supported by implants. They
recordedtheoutcomeof25patientswhoreceived106Branemarkimplantsand
46 prostheses. The cumulative success rate was 94%. Their 515 year data
revealed lower survival for men than women (88% vs 97%) that failed to reach
statistical significance. The authors recommended the use of implants larger
than10mmandof3.75mmdiameter.Theysuggestedtheoptimalapplicationof
three implants for each prosthesis. They favored use of freestanding implant
prostheses. In a more comprehensive report of the Toronto experience, Attard
and Zarb (2003) reported on 130 patients treated with 432 Branemark dental
implants and 174 prostheses. At 15 years, the implant and prosthesis survival
rates were 91.6% and 89%, respectively. They further revealed a lower, 76.3%
survivalratefor5mmdiameterimplants.

These studies are examples of many reports that have provided a level of
evidence to treat partially dentate patients with endosseous dental implants.
Many are cohort studies and there exist no examples of comparative studies
comparing different modalities of treatment or comparing implant prosthesis
treatment of partial edentulism to no treatment. However, the aggregate data
demonstrate treatment of partially dentate patients with osseointegrated dental
implantprosthesesisassociatedwithalevelofimplantsurvivalandprosthesis
successthatmaybeacceptedbythepatientandclinician(Figure1).

FourMainConcernsRegardingImplantSupportedFixedDentalProsthesisin
theTreatmentofthePartiallyDentatePatient

1)Implantsinthepartiallydentateenvironmentwithemphasisonperiodontal
diseaseasariskfactorforperiimplantitis

Theconceptthatimplantsaresubjecttoplaquemediatedinflammatorydisease
of bone and periimplant mucosa is well established (Mombelli 1993).
Contemporarythinkingconcerningperiimplantitishasbeensummarizedinthe
ConsensusreportoftheSixthEuropeanWorkshoponPeriodontology(Lindheet
al 2008). Periimplant mucositis occurs in a majority of subjects restored with

19
implants and the incidence of periimplantitis affecting supporting bone occurs
in 12 40% of sites. The risk factors include poor oral hygiene, diabetes and
smoking,aswellasahistoryofperiodontitis.Thisissupportedbyamorerecent
systematicreview(Safiietal2009).Thus,thereremainscurrentconcernforperi
implantitis in the treatment of partially dentate patients with dental implants.
Serino and Strom (2009) indicated that local factors including accessibility for
oral hygiene is associated with the presence or absence of periimplantitis.
Implantmalpositionandpoorprosthesisdesignarefactorsthatcanbecontrolled
toaidoralhygieneandreduceriskofperiimplantitis.

The impact of periodontal pathogens is of interest in the partially dentate


implantpatientandissuggestedtobeakeydifferencebetweenthedentateand
edentateimplantpatient.Intheyear2000,Hultinetalreportedonkeybiological
outcomes for implant prostheses in treatment of partial edentulism. The study
involved a 10year evaluation of 15 patients treated with 2 6 implants. They
observed no difference between implants and teeth and revealed periodontal
pathogens were present at implants with marginal bone loss. The authors
concludedthatosseointegrateddentalimplantscanbemaintainedwithexcellent
longtermresultsinthepartiallydentatepatient.

Wennstrom et al (2004) directly considered implant outcomes for partially


dentate periodontitissusceptible patients. Treatment of 51 patients with
moderatetoadvancedchronicperiodontistswasperformedusnigmachinedand
Ti02gritblastedimplants.Aftera5yearprospectiveevaluation,theobservedan
overallimplantfailurerateof2.7%.Themeantotalbonelevelchangeoverthe5
yearintervalwas0.41mmanddidnotvarybetweenimplantswithmachinedor
rough surfaces. There remain many questions concerning the risk factors that
contribute to periimplant mucositis and periimplantitis that are beyond the
scope of this discussion. Periimplantitis is a relevant concern and should be a
focusofimplanttreatmentforpartiallydentatepatients.

2) Implant survival in the posterior maxilla and mandible where bone


quantityandqualityarerelativelydiminished.

Anatomicpostionoftheinferioralveolarnerveintheposteriormandibleandthe
sinuses in the maxilla limit the height of bone available for dental implant
placement. Additionally, the quality of bone in the posterior mandible and
maxillaarefrequentlytypeIIIandtypeIVbone.Sincetheinceptionofprognosis
basedonbonequalityandquantity,therehasbeenconcernforreducedimplant
survivalinlowqualityandquantitybone.

20
Inthemaxilla,thereissupportforsinusgraftingtoincreasethebonevolumefor
longerimplantplacement(NkenkeandStelzle,2009).Inthemandible,thereis
little clinical data and less widespread support for lateral nerve transposition
procedures (Chrcanovic and Custdio , 2009). When the prospect of vertical
boneaugmentationwasconsideredinarecentsystematicreview,therewerefew
studies demonstrating that either guided bone regeneration, distraction
ostogenesis or onlay bone grafting reproducibly produced the volume of bone
anticipated. The authors concluded that the generalizablity of the approach is
limited at this time (Rocchietta et al 2008). This was reiterated in a recent
Cochrane systematic review concerning the efficacy of horizontal and vertical
bone augmentation (Esposito et al 2009). On an individual basis and with
consideration of local factors that affect outcomes, different approaches to
increase the height of bone available for implant placement may be used to
enhance treatment of partially dentate patients in conjunction with subsequent
dentalimplantplacement.

In partially dentate patients needing posterior rehabilitation, the use of short


implantswithimprovedsurfacetopographyisnowofgrowinginterestandmay
be beneficial in the treatment of partial edentulism. In a study of 1,287 short
implants(<8.5mm),ahighsuccessrateof98.8%overafollowupperiodof47.9
(+/24.5months)wasreported(ref).Similarly,Maletal(2007)andGrantetal
(2009) concluded that 7 8.5 mm implants achieved high survival rates in the
shorttomidterm.Theconcernforshortimplantsurvivalinlowqualityboneof
the posterior maxilla has been addressed by many clinical scholars with
suggestionsforimprovingoutcomesthroughproperplanning,useofadditional
shortimplants,theselectionofproperloadingprotocolsandthedevelopmentof
controlledocclusalschemes(Bahat,2000).

The use of short implants implies reduced vertical bone dimension following
alveolarresorption.Thisisfrequentlyassociatedwithlongclinicalcrownsand
relatively small implant/crown ratios. Implied is a long bending moment that
could affect the prosthesis or implantabutment connection as well as the
implantboneinterface.Inaretrospectiveclinicalevaluation,Blanesetal,(2007)
demonstratedthatimplantsurvivalwasnotaffectedbyimplantcrownratiosof
1:1.5to1:2.0.

3)Implantprosthesesfunctionincircumstanceswherehighmagnitudeforces
maybeexertedoverlargebendingmoments.

Theforcesonimplantsandabutmentsareassociatedwiththeimplantnumber,
theirdistributionandtheprosthesismaterial(Ogawaetal2010).Evidencethat

21
there are limitations in prosthesis success when implant treatment of the
KennedyClassIIscenarioisperformedwasprovidedbyWennerbergandJemt
(1999). They reported high implant and prostheses survival but recorded 5%
screwfractures,13%screwlooseningandhighlightedproblemswhenprostheses
includedcaninetoothreplacementandwhenonlytwoimplantswereinvolved.
Theseearlyresultsindicatedimplant/abutmentconnectiondifficultiesthathave
resultedinevolutionarychangesinabutmentscrewsandmaterials.Theyhave
alsoinfluencedimplant/abutmentdesign.Braggeretal(2001)revealedtechnical
complications of implant supported fixed dental prostheses were associated
withbruxersandrevealedthatthereweremoreporcelainfracturesonprostheses
associated with implants than those associated with teeth. More recent reports
concerning Morse taper and conical interfaces show low prosthetic component
complications(Manganoetal2009)

While not directly focused on the partially dentate patient, Salvi and Brgger
(2009) reviewed the mechanical /technical risk factors on implantsupported
prostheses.Bruxism,andthelengthofthereconstruction,aswellasahistoryof
repeated complications were associated with increased complications. They
foundthatthecrownimplantratio,thenumberofimplantssupportingthefixed
dental prostheses and the type of retention were not associated with increased
mechanical / technical complications. Interestingly, none of the mechanical
/technicalriskfactorswereassociatedwithimplantsurvival.

Amostrecentsystematicreviewofsurvivalandcomplicationratesforimplant
supported fixed partial dentures with cantilevers showed that this treatment
solution is associated with implant fractures (Zurdo et al 2009). The technical
complicationsforcantileverfixeddentalprosthesesoccurredwithafrequencyof
1336% compared to 012% for noncantilever prostheses. The most common
complicationsincludedminorporcelainfracturesandbridgescrewloosening.It
is clear that treatment of partial edentulism using fixed dental prostheses
supported by implants involves complications that require surveillance as well
as intervention. This concern should be weighed in relationship to the
observations concerning partial denture complications, implant supported
overdenturemaintenancecomplicationsandthelimitationsoftoothsupported
fixeddentalprosthesistherapy.Thereremainsnodirectcomparisonofmidto
longterm outcomes of treatment of partial edentulism using implants,
removableorfixeddentalprosthesesattheleveloftheimplant,theprosthesisor
thepatient.

4)The functional relationship of teeth and dental implants in adjacent


anatomicandfunctionalenvironments.

22
The development of dental implant therapeutic solutions for treatment of
KennedyclassificationIandIIpartialedentulismmayhavebeeninfluencedby
the initial experiences using blade implants that typically included blade
implants as terminal abutments for tooth and implant supported fixed dental
prostheses. It is generally recommended to avoid such prostheses (Lang et al,
2004).Amongtheearliestcomplicationsrevealedfortoothandosseointegrated
dental implant supported prostheses was relative tooth intrusion. Apparently,
teeththataresupportedbyaperiodontalligamentanddentalimplantswithan
osseointegratedtissueinterfaceresolvefunctionalloadsindifferentways.The
natural tooth appears to intrude, resulting in tooth prosthesis debonding or
disruptionofinterconnectors.

This phenomenon occurs sporadically and it is controversial. For example,


Gunne et al (1997) observed no risk of tooth intrusion when implants were
connected to natural teeth in situations where these mandibular tooth and
implantsupported prostheses opposed maxillary dentures. However, Naert et
al (2002) revealed a statistically significant greater risk of implant failure when
teethandimplantswereconnected.Thisdataandotherclinicalreportssuggest
thattheintrusionofthetoothabutmentcontributedtoimplantfailure.Arecent
review of the literature concerning this phenomenon made the following
conclusions concerning tooth and implant connections: 1) rigid connectors
achieve betteroutcomeswithregardto toothintrusion,but mayinvokegreater
marginalbonelossandprobingdepthattheabutmenttooth(indirectcontrastto
thissuggestion,Linetal(2007)recommendthatnonrigidconnectormaymore
efficiently compensate for the dissimilar mobility between the implant and
natural teeth under axial loading forces, but with the risk of increasing
unfavorable stresses in the prosthesis) 2) a toothand implantsupported
prosthesis is associated with higher implant failure rates, lower prosthesis
durability and greater complications that demand intervention, and 3) the
clinicalevidencefororagainst theconnectionofendosseousimplantand tooth
abutments is limited. It has been suggested that the freestanding implant
supported fixed dental prostheses is the safest clinical option, although under
particular clinical conditions, alternatives involving a combined tooth and
implantsupportedfixeddentalprosthesismaybeconsidered(Lindh,2008).

Contemporary Experiences Support Continued Treatment of Partial


EdentulismUsingOsseointegratedEndosseousDentalImplants

Thisbriefreviewofthehistoryofdentalimplanttreatmentofpartialedentulism
with a focus on the Kennedy Class I and II situation has revealed a broad

23
assumption that the dissatisfaction with removable partial dentures and the
problems attributed to them can be effectively addressed by the use of dental
implantstosupportfixeddental prostheses.Theacceptanceofosseointegrated
endosseous dental implants provided alternative methods of restoring the
partially dentate patient using freestanding fixed dental prostheses. The
concerns regarding periimplantitis, functional discrepancies between teeth and
implants supporting the prostheses, and the potential high risk for endosseous
implantsplacedinlowvolumeanddensitybonetosupporthighforcesexerted
over relatively long lever arms have not been dismissed. Fortunately,
prosthodonticsandthedisciplineoftreatmentplanninghaveprovidedarobust
foundation for conservative treatment of the partially dentate patient using
endosseous implants. Despite the important, yet unanswered questions
regarding implant therapy for the partially dentate patient, predictable implant
survival and lasting prostheses with manageable complications may be offered
to partially dentate patients seeking comprehensive and satisfying dental
rehabilitation.

Dr.CooperistheStallingsDistinguishedProfessorofDentistryoftheDepartment
ofProsthodonticsattheUniversityofNorthCarolinaatChapelHill.HeisChair,
ActingDirectorofGraduateProsthodonticsandtheDirectoroftheBoneBiology
andImplantTherapyLaboratory.Dr.CooperisPresidentoftheAmericanCollege
ofProsthodontistsandisaDiplomateoftheAmericanBoardofProsthodontics.
HereceivedtheACPs2004Clinician/ResearcherAwardandtheIADRs2009
DistinguishedScientistAwardforProsthodonticsandImplantology.Dr.Coopers
laboratoryfocusesonbonebiology,adultstemcellboneregeneration,andclinical
evaluationofdentalimplanttherapies.Thelaboratoryreceivesfundingthrough
NIHandbyindustrycollaboration.Theirresearchfindingshavebeenpresentedin
over80publicationsandinmorethan200nationalandinternationalpresentations.Theseeffortsintegrate
basicandclinicalresearchtoimprovepatientcare.

24
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LangNP,PjeturssonBE,TanK,BrggerU,EggerM,ZwahlenM.Asystematicreviewofthe
survivalandcomplicationratesoffixedpartialdentures(FPDs)afteranobservationperiodofat
least5years.II.CombinedtoothimplantsupportedFPDs.ClinOralImplantsRes2004;15:643
53.
LinCL,WangJC,ChangWJ.Biomechanicalinteractionsintoothimplantsupportedfixedpartial
dentureswithvariationsinthenumberofsplintedteethandconnectortype:afiniteelement
analysis.ClinOralImplantsRes2008;19:10717.
LindhT.Shouldweextractteethtoavoidtoothimplantcombinations?JOralRehabil2008;35
Suppl1:4454.

25
MalP,deArajoNobreM,RangertB.Shortimplantsplacedonestageinmaxillaeand
mandibles:aretrospectiveclinicalstudywith1to9yearsoffollowup.ClinImplantDentRelat
Res2007;9:1521.
ManganoC,ManganoF,PiatelliA,IezziG,ManganoA,LaCollaL.Prospectiveclinical
evaluationof1920Morsetaperconnectionimplants:resultsafter4yearsoffunctionalloading.
ClinOralImplantsRes2009;20:25461.
MarcusSE,DruryTF,BrownLJ,ZionGR.Toothretentionandtoothlossinthepermanent
dentitionofadults:UnitedStates,19881991.JDentRes1996;75:68495.
MiyamotoT,MorganoSM,KumagaiT,JonesJA,NunnMETreatmenthistoryofteethinrelation
tothelongevityoftheteethandtheirrestorations:outcomesofteethtreatedandmaintainedfor
15years.JProsthetDent2007;97:1506.
MombelliA.Microbiologyofthedentalimplant.AdvDentRes1993;7:2026.
MllerF,NaharroM,CarlssonGE.Whataretheprevalenceandincidenceoftoothlossinthe
adultandelderlypopulationinEurope?ClinOralImplantsRes2007;18Suppl3:214.
NaertIE,DuyckJA,HosnyMM,QuirynenM,VanSteenbergheD.Freestandingandtooth
implantconnectedprosthesesinthetreatmentofpartiallyedentulouspatientsPartII:Anupto
15yearsradiographicevaluation.ClinOralImplantsRes2001;12:24551.
NkenkeE,StelzleF.Clinicaloutcomesofsinusflooraugmentationforimplantplacementusing
autogenousboneorbonesubstitutes:asystematicreview.ClinOralImplantsRes2009;20Suppl
4:12433.
OgawaT,DhaliwalS,NaertI,MineA,KronstromM,SasakiK,DuyckJ.Impactofimplant
number,distributionandprosthesismaterialonloadingonimplantssupportingfixedprostheses.
JOralRehabil2010Mar2.(incomplete?)
PetropoulosVC,RashediB.RemovablepartialdentureeducationinU.S.dentalschools.J
Prosthodont2006;15:628.
PjeturssonBE,TanWC,ZwahlenM,LangNP.Asystematicreviewofthesuccessofsinusfloor
elevationandsurvivalofimplantsinsertedincombinationwithsinusfloorelevation.JClin
Periodontol2008;35(8Suppl):21640.
RangertBR,SullivanRM,JemtTM.Loadfactorcontrolforimplantsintheposteriorpartially
edentuloussegment.IntJOralMaxillofacImplants1997;12:36070.
RocchiettaI,FontanaF,SimionM.JClinPeriodontol2008;35(8Suppl):20315.Clinicaloutcomes
ofverticalboneaugmentationtoenabledentalimplantplacement:asystematicreview.
SafiiSH,PalmerRM,WilsonRF.RiskofImplantFailureandMarginalBoneLossinSubjectswith
aHistoryofPeriodontitis:ASystematicReviewandMetaAnalysis.ClinImplantDentRelatRes
2009May7.[Epubaheadofprint]
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Implants2009;24Suppl:6985.
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plaquecontrol.ClinOralImplantsRes2009;20:16974.Epub2008Dec1.
SmithloffM,FritzME.Theuseofbladeimplantsinaselectedpopulationofpartiallyedentulous
adults.A15yearreport.JPeriodontol1987;58:58993.
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partialdentureswithcantilevers:asystematicreview.ClinOralImplantsRes2009;20Suppl4:59
66.

26

Figure 1a. Condition of FPD three years prior to complication. Note recurrent caries at distal
marginoftooth#20andperiodontalinvolvementof#18.Itisnotedthattheopposingdentitionis
athreeunitimplantsupportedFPDreplacingteeth#1214.Thecausesoffailurehereinclude
both caries and periodontitis. This underlying biologic status must be considered in assessing
replacementofteethusingdiverseprosthodonticalternatives.

27

Figure1b.AfterfailureofthetoothborneFPD,twoimplantswereplacedinthepositionoftooth
#20 and #18 with intention to support the FPD observed in this radiograph. The implants
selected provide for the largest implant/abutment interface the selected system provided
(AstraTech 4.5 mm implants) and utilized unitary abutment components of robust design (no
separate abutment screw). The implant placement was properly organized in existing bone to
limitbendingmomentsactingattheimplant/abutmentinterface.

28

Figure 1c. The implants, the abutments and the FPD framework were designated, placed and
constructedaccordingtocontemporaryunderstandingofbiologicandphysicalrequirementsfor
longevity. The implant placement was properly organized in existing bone to limit bending
moments acting at the implant/abutment interface. However, bone levels prior to implant
placement require the implant / prosthesis ratio of nearly 1:1. A cement retained construction
was selected for convenience, but screw retention for this prosthesis was possible. The
frameworkfullysupportstheceramicveneerwithoutimposingonesthetics.

29

Figure 1d. The definitive prosthesis reveals adequate access to the prosthesis / abutment
interface. The relative absence of plaque suggests effort of the patient in maintaining this
prosthesis and the remaining dentition. Note that the occlusion has been reevaluated at this
recallappointmenttoassurethatcontactsarepresentinmaximiumintercuspationpositionand
that disclussion occurred in excursions. Oral hygiene and maintenance are reinforced and
potentialfunctionalalterationsareevaluatedateachrecallvisit.Attentiontodetailsinplanning,
executionandrecallofpartiallydentateimplantpatientsisnecessary.

30


Chapter3AnOverviewofMaxillofacialProsthetics

S.RoyCohen,DDS,FACP

Maxillofacialprosthodontics,whosegoalistopreserveandrestorethehardand
soft tissues of the mouth and extraoral structures , has undergone significant
changesoverthelast40yearsasnewtreatmentmodalitieshavebeenintroduced
andnewmaterialshavebecomeavailable.Theprinciplesofprosthodonticshave
notchangedbuttheimprovementsinmaterialsandthedisciplinesofmedicine
and surgery have aided in advancement in the preservation and restoration of
oralandperioralstructures.Theabilitytorestorebothcongenitalandacquired
defectsandpreventfurtherlosshasbeenenhancedbytheimprovementsinthe
science of materials, the earlier detection of disease, the addition of
osseointegration,1,2 CAD/CAM 3,4 technologies, materials science and many
others.

Acquired defects usually are divided by causation into disease, trauma or
congenital anomalies. The early detection of cancers 5 and locally invasive
tumors and the improvement in cancer treatments from surgical techniques to
radiation therapy, with and without chemotherapy, have decreased the size of
the oral and perioral defects that remain. Additionally, collateral destruction of
healthytissuesthatoccurredintheattempttoeradicatethediseaseandadvances

31
in plastic surgery have improved the rehabilitative outcomes. The use of both
radiation and chemotherapy as separate modalities or in concert has decreased
the defect size and many times eliminated the need for a restoration. The
addition of high energy radiation6 for cancer treatment with the addition of
standalone chemotherapy or chemotherapy, including the use of cisplatinum 7
forsensitizingcancerstoradiationtreatment,havereducedposttreatmentdefect
sizes.Thetreatmentoftheresidualdefectsisaidedbytheuseofosseointegrated
implants in the defect or nondefect side to aid in retention. This advance has
added to the success of the prosthetic rehabilitation and improved patient
functionandsatisfaction. 8, 9Theadditionofimplantstoaidintheretentionof
intraoral prosthesis including removable complete and partial dentures that
include obturators has increased their effectiveness and in many cases has
eliminated the use of adhesives. 10, 11 The addition of osseointergration and the
useofsupportingbarshaveallowedfacialprosthesestogainretentionwithout
theuseofglues.Thishasimprovedtheretentionoftheprosthesisandextended
the longevity and esthetic appearance of the prosthesis. The prosthesis can be
madethinnerwithoutthefearoftearingtheprosthesisandlackofglueincreases
the length of time the prosthesis has a natural appearance. Primary stability,
retentionandtreatmentoutcomeareenhancedwiththeuseofattachmentsthat
retaintheprosthesessecurelyintheoralenvironment.12,13Advancesinsurgery
includingtheuseofvascularsurgicalgraftshaveimprovedtreatmentoutcomes.
The use of threetissue layer vascular grafts, including epithelium, bone and
muscle, to restore mandibular integrity has improved facial contours and
function of the final prosthesis.14 In addition, these grafts could be used for
integratingwithdentalimplantstosupportafixedorremovablepartialdenture
or complete denture. 15, 16 Postcancer treatments that leave the patient with a
softpalatedefecthavetraditionallybeentreatedwithremovableappliancesand
obturators. More recently many of these defects have been treated surgically,
however the outcome of the traditional prosthodontic treatments using a
removable appliance and obturator has equal patient satisfaction and objective
speechquality.17

The advancement in passive automobile restraints has diminished the numbers
offacialacquireddefects,butthetraumatotheheadandfaceoccurringduring
combatconflicts 18hasincreasedtheneedfortheprosthodonticaidinthepost
surgical restoration of military wounded. Osseointegration and CAD/CAM
technologies, as well as the advancements in bone grafting using both
autogenous bone and cadaver bone, have aided in the rehabilitation of these
defects.Adultstemcellshaverecentlybeenusedtoinfuseahardmatrixusedto
replace native bone 19 and soon will support the growth of new bone in the

32
proper dimensions in the proper place. The use of these types of grafts allows
the restoration of bony integrity and the use of osseointegreted implants to
supportaprostheticrestoration.

Thetreatmentofcleftpalateandcraniofacialdefects,inadditiontothetreatment
of patients with developmental defects such as ectodermal dysplasia, has
improved with the advancements in materials and the addition of
osseointegration. Forty years ago the maxillofacial prosthodontists had a key
rollinthetreatmentofcleftpalateandcraniofacialanomalies.Whiletheroleis
stillimportanttothecleftpalateteam,therolehaschanged.Thelipwasusually
closed and the craniofacial defects managed surgically, however the hard and
soft palate defects were left ungrafted after the rehabilitation surgery. 20 In
addition, the alveolar cleft was usually left unrepaired and the maxillary arch
waswithoutcrossarchintegrityorstability.Maxillaryprosthesesthatobturated
thehardandsoftpalatewereusedtocompletethetreatment.Aspeechbulbwas
added to the prosthesis to allow for an increase in oral pressure to produce
proper speech. In the late 1960s, advancements led to surgical corrections of
the hard and soft palate. 21 In late 1960s and early 1970s, the hard and soft
palates were closed and the alveolar cleft was grafted with autogenous bone
grafts. 22 After the union of the segments, fixed restorations could be delivered
with confidence, 23 knowing that the segments would not need to be splinted
throughthefixedprosthesis.However,splintingthemaxillarysegmentswitha
fixed bridge could lead to early failure of the teeth. With the advent of Resin
bonded fixed prosthesis described by Livaditus and Thompson, in 1982, 24 a
procedurewasdevelopedtoreplacethemissingadultteethwithacombination
of a fixed bonded bridge and a detachable pontic, without the need for full
coverage restorations on the abutment teeth.25 This improvement allowed the
preservation of tooth structure while restoring both the residual hard and soft
tissuedefects.Asosseointegrationbecamemoreacceptedbytheprofessionand
theoutcomesmorepredictable,implantswereusedtoreplacethemissingteeth
in the cleft defect.26 The maxillofacial prosthodontists role in the treatment of
cleftpalateandcraniofacialanomalieshasbecomemorefocusedonguidingthe
rest of the team towards the goal of a complete rehabilitated dentition and
normal scaffolding for the facial plastic reconstruction. The use of fibrin glue
and chondrocytes to mold cartilage has been reported 27. This cartilage can be
usedforscaffoldingtoimprovetheplasticsurgicaloutcomesinrehabilitationof
the cleftcraniofacial patient. The prosthodontist is also involved in facial
molding both before the closure of the lip and after to increase the columella
lengthandbetteradaptationofthesegmentsforthehardpalateclosure.28

33
Prosthodontic care of the radiation patient has had two paradigm shifts in the
last 40 years. The first was the use of fluoride to reduce decay after radiation
treatmentdevelopedatTheUniversityofTexasDentalScienceInstituteandMD
AndersonHospitalinHouston,Texasinthelate1970s 29andthesecondwasthe
useofhyperbaricoxygentopreventandtreatosteoradionecrosis. 30Atthetime,
the loss of a tooth after radiation could be a life threatening condition. 31 After
externalbeamradiationtotreatoralcancersbecamewidespread,thecariesrate
from the xerostomia caused by the radiation would increase to unmanageable
levels. With the advent of daily topical fluoride applications, the caries
incidencefromxerostomiainducedbyradiationdecreasedthelossofteeth,and
therefore the danger to the patient also diminished. Fluoride trays and
aggressive caries control was imperative. Teeth subjected to a dry oral
environmenthavehistoricallybeenatrisk,however,newproductshavebecome
availabletosuppressthedemineralizationandenhanceremineralization.Oneof
these is casein phosphopeptideamorphous calcium phosphate (CPPACP).32
Splintingofteethwasusedtomaintaintheteethinthearchtoavoidextraction
andnecrosisofthejaws.Withtheadventofhyperbaricoxygentheneedtohold
on to teeth at all costs was no longer imperative. Included in the normal
protocolforextractionswiththeadditionofantibiotics, 33theuseofhyperbaric
dives reduce the danger of tooth loss leading to necrosis for the postradiation
patient.Theadditionofhyperbaricoxygenhasalsoallowedtheintroductionof
implantsupportedprosthesestorestoretheedentulousandpartiallyedentulous
patient 34, 35. This has been particularly helpful to the edentulous patients with
xerostomia postradiation therapy. The patients ability to successfully wear a
denture is diminished by the oral condition including dry mouth and friable
tissues; however, the use of osseointegrated implants has facilitated treatment
withbothfixedandremovableprostheses.

Maxillofacialprosthodontistshavebeensupportingradiationoncologistsduring
thelast40yearsmakingradiationcarriersforradiationseedsandstentstomask
areas to reduce total radiation.35 In addition, templates are fabricated for
positioningandforoptimizingandconcentratingtheradiationtoirregularbody
parts like the ear or nose. Prosthodontists have also made radiation carriers to
position radiation seeds in juxtaposition to a tumor for direct concentration
radiation levels. These carriers can be made with or without shields at the
prescriptionoftheradiationoncologist.36,37,38

34
The future of maxillofacial prosthodontics will change as material, medical/
surgical care and the needs of our patients change. The basic principles of
preserving what remains and restoring what is missing will always guide the
profession. With the addition of new modalities of bone formation, enhanced
repairs and growth of new tissue, maxillofacial prosthodontists in the future
mayusemorenaturalreplacementsformissingpartsthanwehaveusedinthe
past. Our future is bright and the next forty years will see as much or more
changeaswehaveseeninthepast.


Dr.CohenreceivedhisDDSfromNewYorkUniversityCollegeof
Dentistryin1975.Hethenpursuedacertificateinprosthodonticsat
HarvardUniversityandhismaxillofacialresidencyattheVAinNewYork.
HeisinfulltimeprivatepracticeinCherryHill,NewJersey.Dr.Cohenis
aDiplomateoftheAmericanBoardofProsthodonticsandaFellowofthe
AmericanCollegeofProsthodontists.

35
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14.NealDFutran,EduardoMendezDevelopmentsinreconstructionofmidfaceandmaxilla.
LancetOnco2006(Vol.7,Issue3,Pages249258).
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Dent1996(Vol.76,Issue4,Pages350355).
16.NealD.Futran.Retrospectivecaseseriesofprimaryandsecondarymicrovascularfreetissue
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369376).
17.RiegerJ,BohleG,HurynJ,TangJ,HarrisJ,SeikalyH.SurgicalReconstructionVersus
ProstheticObturationofExtensiveSoftPalateDefects:AComparisonofSpeechOutcomes..IntJ
Prosthodont2009;(Vol22,Issue6Pages566572).

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18.Reed,B.;Halo,R.Gliddon,M.;Ericson,M.Maximizingoutcomesformaxillofacialinjuries
fromimprovisedexplosivedevicesbydeployedhealthcarepersonnel;.;ADFHealth2008;9;36
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20.CosmanB,FalkA.DelayedHardPalateRepairandSpeechDeficiencies:ACautionary
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23.ImmekusJ,AramanyM;AfixedremovablepartialdentureforCleftPalatePatients.J
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ProsthetDent1987Jan;57(1):7881.
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27.Ting,V;Sims,C;Brecht,L;McCarthy,J.;Kasabian,A;Connelly,P;Elisseeff,J;Gittes,G;
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30.MarxRE.OsteoradionecrosisofJaws:ReviewandUpdate.
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31.GaisfordJ,RueckertF.OsteoradionecrosisoftheMandible;PlasticandReconstructive
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32.Rankin,K.;Jones,D.;Redding,SOralhealthinCancerTherapy:AGuideforHealthCare
Professionals,SecondEd.;DOEP.ORG2003.
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Moon,R;Piantadosi,C;MultiModalitySurgicalandHyperbaricManagementofMandibular
Osteoradionecrosis.IntJofRadOnc2009;75(3):717724.
34.Taylor,T,Worthington,P.Osseointegratedimplantrehabilitationofthepreviouslyirradiated
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35.ArcuriM,FridrichK,FunkG.TaborM,LaVelleW.Titaniumosseointegratedimplants
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37
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38

Chapter4AdvancementsinMaxillofacialProsthetics

JohnWolfaardt,BDS,MDent,PhD;ThomasJ.VergoJr.,DDS;LawrenceE.
Brecht,DDS,TerryM.Kelly,DMD,JeffreyE.RubensteinDMD,MSand
RobertGillis,DMD

MaxillofacialProsthetics(MFP)isthesubspecialtyofProsthodonticsthatrestores
formandfunctionofdefectsoftheheadandneckregionsecondarytocongenital
and developmental or acquired oncological and traumatic anomalies. MFP,
morethananyotheraspectofProsthodontics,hasaverycloserelationshipwith
the medical profession, so it is not surprising that one of the most significant
advancement experienced in MFP is linked to advancements in surgical
reconstructive techniques. Likewise, advancements in technology have had a
profoundimpactedonMFP.ExpandeduseofimplantsintheMFPpatienthas
had an equally profound impact on the MPF restoration of form and function.
TheassignmentofCPTcodesforthemostcommonproceduresinmaxillofacial
prosthetics standardized the procedural terminology. And, lastly, prospective
clinical trials to develop new treatment techniques and assess outcomes have
improvedtreatmentstrategies.

AdvancedDigitalTechnologies
Contributor:DrJohnWolfaardt,BDS,MDent,PhD.
Advanceddigitaltechnologies(ADT),asagentsofchange,offersmaxillofacial
prosthetics/prosthodontics,theopportunitytobecomethemostsignificant

39
componentofdentistryindeliveryofcareinsupportofrestoringformand
function.Moreover,ADTdrawsmaxillofacialprostheticsintonotonly
interdisciplinaryactivityinsurgeryoftheheadandneck,butalsointoafar
widerinteractionwithdiversesurgicalandmedicaldisciplines.Inthisrespect,
ADToffersmaxillofacialprostheticsandprosthodonticsremarkableexpansionof
opportunityincaredeliveryandfuturediscovery.

ThefuturevalueofKnowledgeWorkhashadaprofoundeffectuponsocietyand
corporatethinkingoverthepast50years.Aprimarytooloftheknowledge
worker,anindividualwhoisvaluedforhis/herabilitytointerpretinformation
withinaspecificsubjectarea,isdigitaltechnologiesandtheconnectivitythey
provide.PeterDrucker1providedconsiderableinsightintotheimportanceof
knowledgeworkforthecorporateworldduringthe20thCentury,andthislegacy
continues.Itisexpertknowledgeoftheuseofthesetechnologies,astools,that
definesaknowledgeworkersabilitytoparticipateinandcontributetoan
economy.Itisthisfactthatthesurgicalandsurgicallyrelateddisciplineshaveto
graspwithsomeurgency.Forthemostpart,muchofmaxillofacialprosthetics,
asitispracticedtoday,usestechnologyandmanualprocessesthathave
remainedlargelyunchangedforoversixdecades.Thisremainssoinaperiod
thathasseenincredibletechnologicaladvancesinrelatedareassuchasdigital
imaging,minimallyinvasivesurgery,navigation,robotics,andthelike.
Curiously,maxillofacialprostheticsisparticularlywellpositionedtobecomethe
technologicalintegratorwithADTsasitismaxillofacialprostheticsthathasthe
interconnectingclinicalrolewithabroadbaseofknowledgeofthevarious
surgical/medicaldisciplines.

TherangeofADTtechnologyoptionsinvolveapanoramaofnewapplications
suchasimaging(CTScanning,CBCTScanning,MRImaging,Sonography),
simulationapplications(surgicalsimulationsoftware,implantinstallation
simulationsoftware),prototypingapplications(rapidprototyping,rapid
manufacturing),prototypinghardware(additive,subtractive,widevarietyof
materials),scanners(probe,photogrammetry,laser),colorscanningand
formulation,3Dhapticdesigntools,endoscopy,navigationandrobotics.These
andothertoolsmakeforanastonishingarrayofADTsavailabletothe
maxillofacialprosthodontist.Itisnolongerunusualforthemaxillofacial
prosthodontisttoconsiderdigitaldesignofatumorresectionandtoplana
microvascularreconstructionforajawwithrapidprototypingtools,orto
constructanobturatorfromaCTscanwithprintingoftheobturatorpattern,
designacranioplastywithahapticinterfacetoolordesigningandconstructing
elementsofanauricularimplantorautogenousreconstructionwithimagingand

40
prototypingtools.Whilethisworkisbecomingincreasinglycommonplace,the
questionremainsastowhymanymaxillofacialprosthodontistscontinueto
functioninlargelymanuallydrivenenvironments.Thereisriskinthissituation
continuingandthethreatliesinPeterDruckerscautionthatthosewhodonot
transitiontoKnowledgeWorkwillfindobsolescence.1Thechallengesto
adoptionofADTsbymaxillofacialprosthodonticsarerealandrequireattention.
ManyofthetechnologiesareborrowedfromIndustry,arenotadaptedtoclinical
useandaretruetoChristensens2conceptsofbeingdisruptivetechnologies.The
utilizationofthetechnologieshasrunaheadofdevelopmentofhealtheconomic
understandingofADTs.Willingnesstopaybyfundholdersremainsachallenge
asdoescostoftechnologyacquisitionandmaintenance.Perhapsthemajor
hurdleremainsthelackofformalteachingtoresidentsofADTutilization,the
managementofdisruptivetechnologiesandthebusinessmodelsfortechnology
adoption.Afurtherimportantneedisdevelopmentoftechnologiststooperate
manyoftheADTsystems.Thisisanalogoustoaradiologisthavingsophisticated
digitalimagingtechnology,butnoradiationtechnologisttooperatethe
equipment.Theseareimportantmatterstoresolveasitmaybespeculatedthat
ADTswillplayacriticalroleinattractingyoungergenerationstothefieldof
prosthodonticsandmaxillofacialprosthetics.Thisisattributedtothe
understandingthatmorerecentgenerationsdonotwanttobetrappedbetween
themanualanddigitaltechnologyeras.

ForallthechallengeswithADTadoption,itisbeyondremarkablehowvery
rapidtheadoptionandhowtransformativeadvanceddigitaltechnologyhas
beentothefieldofmaxillofacialprosthetics.Wenowfindprofessional
developmentactivitiesandinternationalconferencesdedicatedtoADTsinhead
andneckreconstruction,thefirsttextonmedicalmodelingbyBibb3,aMasterof
Scienceprogramestablishedinsurgicaldesignandsimulation,4andcurricula
beingrevisedtoincorporatedigitaltechnology.Thesechangesheraldthe
fundamentalshiftsthatwillmovemaxillofacialprostheticsthrough
transformativechangetoafutureoffunctioninginadigitalworldof
technologiesthataredevelopingandconvergingatanincrediblepace.The
importanceoftheProsthodontistsroleinthistechnologyconvergencecarries
strategicvaluetohealthcare.Thestrategicvalueofparticipationintechnology
convergencewasamplifiedbyRoccoandBainbridge6.
ADThasbroughtprofoundchangetomaxillofacialprosthetics.The
implementationofthischangeandwhereittrulydeliversvalueisunderdebate.
Remarkabletoo,isthattechnologyrichdevelopingcountriesfacedwithlarge
patientnumberssuchasChinaandIndiaareshowingincreasinginterestin
ADTs.ThisisattributedtothepotentialADTholdsforcatalyticinnovation

41
potentialtochangecaredeliveryonanexponentialscalewithdrivingdowncost
andmakingcareavailabletolargenumbersofpatients.Maxillofacialprosthetics
isthoughttobeinextricablylinkedtoadvanceddigitaltechnologiesasthe
foundationknowledgeworkdomainofthedisciplineforthefuture.

MandibularDefects
Contributor:ThomasJ.Vergo,Jr.,DDS
Curtis and Cantor1 originally coined the term the forgotten patient in
maxillofacial prosthetics in their classic article reviewing the clinical treatment
optionswhentreatingapatientwithadiscontinuousmandible.Overtheyears
many authors 26 have described intraoral prosthesis designed to either
prosthetically reposition the residual mandibular segment into a more
favorable occlusal relation or to accept the deviated mandibular position and
provideaneccentricocclusion.Nowhereistheskillofdiagnosisandtreatment
planningmorecomplexandtherangeoftreatmentchoicesgreaterthenwiththe
patient who has undergone surgical resection (or traumatic loss) of part of the
mandiblewhenconsideringprosthodonticrehabilitation.7

Significant advances have been made in the area of microvascular and
reconstructive surgery over the past 30 years. However, mandibular defects
remain a difficult challenge for reconstructive surgeons. The challenge is to
restore airway support, oral competence, verbalization, mastication,
deglutination, and acceptable aesthetics, allowing the patient to return to
society.8

Treatment strategies range from a postsurgical wait and see attitude on the
part of the treating surgeon for a given length of time to rule out a recurrent
tumor to immediate or postradiation surgical reconstruction to restore the
continuityofthemandibleusingpelvicbonegrafts,graftsfromthelateralpartof
the scapula or part of the fibula include the blood vessels to ensure the blood
supplyofthegraft;allwithorwithouttheaidofimplantstostabilizetheintra
oralprosthesis.

A recent longitudinal (withinsubject), prospective study by Garrett, et al,9


lookedatpatientswhounderwentpartialmandibulectomysurgeryresultingin
lateral or anterior composite defect, which were reconstructed with a free flap.
Implantplacementinthegraftbonewasdelayedandaconventionalremovable
prosthesis (CP) was fabricated and evaluated by the patient. After
approximately 4 months of functioning with the conventional prosthesis,

42
implants were then placed in the graft bone, implant supported prosthesis (IP)
fabricatedandevaluated.

Most of the study conclusions were predictable: 1) the patients masticatory


ability after partial mandibulectomy and reconstructive surgery approached
presurgical levels when restored with the CP and IP; 2) however, the
masticatory performance scores withboth prostheseswere similar to thoseof a
conventionaldenturewearer3)WhileEMGandjawmovementsvariedgreatly,
increased stability with the IP may permit greater muscle effort on the defect
side,4)masticatoryfunctionwiththeIPwassignificantlygreaterthanwiththe
CP on the defect side, 5) chewing ability and denture satisfaction and security
showed the greatest change with IP supported denture treatment and 6) 29%
acceptingCPassufficient!

Of the 36 subjects enrolled with malignant tumors, 16 (44%) experienced


recurrence, metastasis or death within 13 months following
ablative/reconstructive surgery. Therefore, one of the unexpected conclusions
was that caution must be taken in deciding the timing of extensive implant
prosthetic procedures suggesting that CP should be provided for the 1st year
postsurgery and assessed for cancer treatment outcomes, functional levels and
patientexpectationsbeforeconsideringimplants.

NasoalveolarMolding(NAM)
Contributor:LawrenceEBrecht,D.D.S.
NasoalveolarmoldingorNAM(aformofpresurgicalinfantorthopedics)was
developed to help improve the functional and esthetic outcome in infants born
withcleftlip,alveolusandpalate.ItwasadvancedbytheteamattheInstituteof
Reconstructive Plastic Surgery at New York University Medical Center in the
mid1980sandhassignificantlyimprovedtheappearanceofchildrenbornwith
either a unilateral or a bilateral cleft. While presurgical infant orthopedics was
originaldevelopedintheearly1950sbyaprosthodontist,McNeil,thetechnique
fell out of use. Studies have shown that nasoalveolar molding reduces the
severityofthecleftdeformitynonsurgicallyandthereforeallowsthesurgeonto
perform a less extensive surgical procedure in repairing the cleft. Usually, only
onesurgicalprocedureisrequiredtorepairthelip,noseandalveolusfollowing
NAM therapy. If the palate is also cleft, a separate surgery is still required to
close the palatal defect. The result is less scarring and significantly improved
facialestheticswhenobjectivelyevaluated.

43
NAM treatment has also shown to reduce the overall number of surgeries a
patientwillusuallyhavetoundergoduringtheirlifetimetoachieveanimproved
estheticoutcome.Intheunilateralcondition,thereisareductionintheneedfor
subsequentalveolarbonegraftingatage8or9byover70%andinthebilateral
condition,thereisanapproximately40%reductionintheneedforbonegrafting.
Similarly,theearlyimprovementinnasalestheticsnearlyeliminatestheneedfor
earlynasalrevisionsurgeryatthetimethatachildentersschool.Italsoappears
that noses that have been treated by NAM follow a growth pattern that tracks
paralleltonormal,noncleftnoses.

Nasoalveolarmoldingprovidesmaxillofacialprosthodontistswiththeabilityto
vastly improve the course of facial development for infants with cleft lip and
palate while reducing the number and extent of surgical procedures they must
undergototreattheircondition.14

RVU
Contributor:TerryM.Kelly,DMD
TheassignmentofCPTcodesforthemostcommonproceduresinmaxillofacial
prosthetics in 1993 marked the inception of a concerted effort by the American
AcademyofMaxillofacialProstheticstostandardizetheproceduralterminology
that would ultimately serve as the template for coding and reimbursement for
theseproceduresaspartofthehealthcaresystem.

The original version of the CPT system was introduced in 1966 as a method to
standardizemedicalprocedureterminologytofacilitatecommunicationbetween
physicians, hospitals, and laboratories. At the time, the prevailing method of
compensationforhealthcareservicesintheMedicaresystemreliedoncharged
based data in a relative value scale that was fairly similar to the customary,
prevailing, and reasonable system used in the insurance industry. In 1985, the
HCFA (Health Care Financing Administration) initiated reform of the
reimbursementprocessintheMedicaresystemwhichledtothedevelopmentof
the RBRVS (Resource Based Relative Value System) by a Harvard economist.
Thiswasdesignedtocorrectthearbitrariness,inaccuracies,anddiscrepanciesin
the reimbursement process, by recognizing the shared components of all
procedures included in the decision making process. By 1992, the RBRVS was
implemented as the basis for reimbursement within the Medicare system. The
AAMPwaswellawareoftheimplicationsthatthisheldforthefutureofthesub
specialty. As such, the AAMP created two workshops which convened in
Chicago, IL in November 1992, and February 1993, designed to evaluate the
newly assigned CPT coded procedures 2107621088, generating data for

44
development of RVUs to be submitted to the AMA for consideration and
assignmentofvaluesforeachcode.ThefinalrulewaspublishedintheFederal
Register in 1996, assigning unique, individual values to each CPT coded
procedure which would now serve as the basis for reimbursement within the
Medicare system. The AAMP continues to work to address concerns regarding
particularcomponentsoftheRBRVSsuchasRVUpe(practiceexpense),toensure
the data is accurate and reflects the modern day practice of maxillofacial
prosthetics.13

CraniofacialProstheses/Implants
Contributor:JeffreyE.RubensteinDMD,MS
Prosthodontic management of patients experiencing compromise/loss of facial
anatomy resulting from surgical resection of tumors, trauma, or congenital
anomalies represents a challenging area of rehabilitation from a functional,
esthetic and psychological perspective. Attempts to replace missing facial
structuresdatebackasfarastwothousandyearsagobasedonanecdotalreports,
historical records, and archeological findings. More recently adhesive and or
mechanically retained extraoral prostheses were considered the standard of
care.However,surveysofpatientssotreatednotedthatretentionorlackthereof
wastheratelimitingstepfortheiracceptanceofsuchtreatment.1,2

The remedy for compromised retention of facial prostheses was introduced in


the late 1970s by P.I. Brnemark et al, a natural extension from that of
osseointegrated implant rehabilitation for the edentuolous patient.3 The initial
introductionoftheuseofthecraniofacialimplantsintheUnitedStateswasfirst
reportedbyDr.StevenParelintheinauguraleditionoftheInternationalJournal
of Oral and Maxillofacial Implants.4 The U.S Food and Drug administration
mandatedamulticenterprospectiveclinicaltrialbeforesanctioningclinicaluse
ofthecraniofacialimplant.Thisstudywasconductedamongst19participating
centers and the results of this clinical trial led to their FDA approved clinical
application. The application of craniofacial implants to retain facial prostheses
thenwaswidelyappliedandretrospectivereviewsofthiseffortwerereported.6,7
Among the findings from these retrospective reviews was the fact that varying
levels of craniofacial implant success was noted for treatment sites and as well
patients having been irradiated demonstrated a higher failure rate than those
whohadnotbeensotreated.

Aswell,thetypesofretention/prostheticdesignswereinvestigated. 8Whilethe
majority of craniofacial implant retained extraoral prostheses are retained by
clipsand/ormagnets,theuseofanarrayofattachmentshasbeenappliedtothis

45
treatmentapproach.Littlescientificevidencehasevolvedthusfarastowhatthe
optimal approach is for retaining extraoral prostheses despite now having a
mechanism to do so. In sum and substance, the introduction and use of
craniofacialimplantstoprovideamechanismforretainingextraoralprostheses
representsamajoradvance inthe management of patients needing this type of
rehabilitativeintervention.Thefuturedevelopmentsinthisarenaofferexciting
opportunitiestofurtherdevelopandimprovecurrentmethodologiesforimplant
retainedcraniofacialimplantprosthodontics.

FutureConsiderations
Contributor:RobertGillis,DMD
Itshouldbeemphasizedthatmanyaspectsofmaxillofacialprostheticshavehad
little or no advancement. Facial materialshave beenrefinedwhen compared to
the materials that we began using 35 years ago, however there has not been
development of a new material. Although we emphasize early detection in
ourfightagainstheadandneckcancer,curerateshavenotimprovedin40years.
Perhaps we need to stress physicians doing oral screenings in the atrisk
populationssincetheyseethesepatientsseventotentimesmorefrequentlythan
dentists in patients who are found to have head and neck cancer.: We need to
initiate studies to provide data for a more comprehensive regimen to include
antimicrobial rinses, varnishes, remineralization products and appropriate
restorativematerialsto improvecariespreventioninxerostomia patients. And,
lastly,withtheadvancementswehaveexperiencedinsurgicalreconstructionof
the head and neck defect patient, we need to develop protocols and
recommendations for the most effective surgical and prosthetic reconstructive
measuresbasedonoutcomes.

Dr.VergocompletedhisProsthodontic&MaxillofacialProstheticstrainingatthe
V.A.Hospital/UBandRoswellParkMemorialHospital,Buffalo,NY.Heretired
fromTuftsin2004asDirector:DivisionsProsthodonticsandProfessorEmeritus.
HepracticeswithTheDentalGroupatPostOfficeSquare,BostonandEmirzian,
Mariano&Associates,EastLongmeadow,MA.Hehaslecturedextensivelyand
haspublished40articlesinrefereedjournals.HeholdsmembershipintheACP,

theAP,theAAMP(PastPresident),theISMR,theACDandtheGNYAP.

LawrenceE.Brecht,DDSistheDirectorDentalServicesattheInstituteof
ReconstructivePlasticSurgeryatNewYorkUniversityLangoneMedicalCenter
andtheDirectorofCraniofacialProstheticsattheInstitute.Heisalsothe
DirectorofMaxillofacialProstheticsatNewYorkUniversityCollegeof
Dentistry,Hemaintainsapracticelimitedtoprosthodonticsandmaxillofacial
prosthetics.

46

Dr.KellyattendedtheUniversityofIllinois,andgraduatedfromSouthernIllinois
UniversitySchoolofDentalMedicinein1984,receivingtheDentsplyAwardfor
outstandingachievementinfixedprosthodontics.Followingaresidencyprogramin
ProsthodonticsatLouisianaStateUniversity,Dr.Kellycompletedafellowshipin
MaxillofacialProstheticsatM.D.AndersonHospitalandCancerInstitutein1987.
Thatsameyear,heacceptedafacultypositionintheDepartmentofSurgeryatthe
UniversityofSouthFloridaCollegeofMedicine,andbecametheDirectorof
MaxillofacialProstheticsattheH.LeeMoffittCancerCenterinTampa,FL.Dr.
Kellyreceivedthe1989AnnualResearchAwardoftheAmericanAcademyof
MaxillofacialProsthetics,andbecamecertifiedbytheAmericanBoardofProsthodonticsin1991.Dr.Kelly
isaPastPresidentoftheAmericanAcademyofMaxillofacialProsthetics,FloridaProsthodontics
Association,andaRegionalDirectoroftheAmericanCollegeofProsthodontists.
JeffreyRubensteinisProfessorandtheDirectorofMaxillofacialProstheticServiceat
theUniversityofWashingtonSchoolofDentistry.HecompletedhisB.A.
atRutgersCollege,D.M.D.atTuftsUniversity,G.P.R.atLancasterCleftPalate
ClinicandobtainedhisM.S.andCertificateinProsthodontics
fromM.D.AndersonHospitalandtheUniversityofTexas.In1980hejoinedthe
FacultyatHarvardSchoolofDentalMedicineparticipatingintheDepartmentof
ImplantDentistry.Since1989hehasbeenafulltimefacultymemberintheSchoolof
DentistryattheUniversityofWashington.Dr.RubensteinisaDiplomateofthe
AmericanBoardofProsthodonticsandFellowoftheAmericanCollegeof
Prosthodontists.HeisamemberoftheAcademyofProsthodonticsandtheAcademyofOsseointegration.
HeisalsoamemberandpastpresidentoftheAmericanAcademyofMaxillofacialProstheticsandthe
WashingtonStateSocietyofProsthodontics.
Dr.RobertGillisisa1966graduateoftheCollegeoftheHolyCross.Heearnedhis
DMDdegreein1970fromtheUniversityofMedicineandDentistryofNew
Jersey.HecompletedarotatinginternshipintheU.S.PublicHealthServiceand
servedasastaffofficerfortwoadditionalyearsatNorfolk,Virginia.Hecompleted
athreeyearcombinedresidencyinProsthodonticsandMaxillofacialprostheticsat
theMayoGraduateSchoolofMedicineandreceivedanMSDfromtheUniversity
ofMinnesota.From19761978hewasonthefacultyatUCSanFranciscofunded
byanationalCancerInstitutegrant.From19781983Dr.GillisservedasDirector
ofDentistryachievingtherankofclinicalassociateprofessoratUCDavis,School
ofMedicinedepartmentofOtorhinolaryngology.Hehashadaprivatepracticein
Sacramentofrom1978tothepresent.Dr.Gillisisamemberofanumberofotherprosthodontic
organizationsincludingtheAmericanCollegeofProsthodontics,theAcademyofProsthodontics,the
AmericanAcademyofMaxillofacialProsthetics(pastpresident)andthePacificCoastSocietyfor
Prosthodontics(pastpresident).HeisadiplomatoftheAmericanBoardofProsthodontics.Heisamember
oftheSacramentoDistrictDentalSociety,CaliforniaDentalAssociationandAmericanDental
Association.HeisaFellowoftheAmericanCollegeofDentists.

47
References

AdvancedDigitalTechnologies

1.DruckerPF.ManagementChallengesforthe21stCentury.1stEd,HarperBusiness,
HarperCollins:NewYork,1999.
2.ChristensenCM.TheInnovatorsDilemma.HarperBusinessEssentials,Harper
Collins:NewYork,2003.
3.BibbR.MedicalModelling:TheApplicationofAdvancedDesignandDevelopment
TechniquesinMedicine.CRCPress:BocaRaton,2006.
4.GrantJ.personalCommunication,2009
5.WolfaardtJF.PersonalCommunication,2009.
6.RoccoMC,BainbridgeWS.ConvergingTechnologiesforImprovingHuman
Performance.NationalScienceFoundation/DepartmentofCommerceSponsored
Report,KluwerPublishers:Norwell,2003.
7.ChristensenCM,BaumannH,RugglesR.SadtlerTM.DisruptiveInnovationfor
SocialChange.HBRStoplight:MakingaRealDifference,HarvardBusinessReview,
Dec2006,94101.

MandibularDefects

1. Curtis,T.A.,Taylor,R.C.andRositano,S.A.:Physicalproblemsobtainingrecordsof
maxillofacialpatients.J.ProsthetDent34:539,1975
2. 2.Sharry,J.:CompleteDentureProsthodontics,ed2.NewYork,1968,McGrawHillBookCo.
3. Rosenthal,L.E.:Theedentulouspatientwithjawdefect.DentClinNorthAm8:773,1964.
4. Schaaf,N.G.:Oralreconstructionoftheedentulouspartialmandibulectomypatient.J.
ProsthetDent36:292,1976.
5. Vergo,Jr.,T.J.andSchaaf,N.G.:Evaluationofmandibularmovementsinthehorizontal
planmadebypartialmandibulectomypatientsApilotstudy.J.ProsthetDent47:310,1982.
6. Curtis,T.A.andCantor,R.:Theforgottenpatientinmaxillofacialprosthetics.J.Prosthet
Dent31:662,1975.
7. ClinicalMaxillofacialProsthetics.EditedbyThomasD.Taylor,Chapter11,Copyright2000,
QuintessencePublishingCo,Inc,Illinois.
8. MandibularReconstruction,Plating,Author:JesseESmith,MD,Coauthor(s):Keith
Blackwell,MD;YadrankoDucic,MD,FRCS(C),FACS,eMedicine,Updated:Mar16,2009
9. GarrettN,RoumanasE,etal.Efficacyofconventionalandimplantsupportedmandibular
resectionprostheses:Studydesignandtreatmentoutcomes.J.ProsthetDent2006;96:1324.

NasoalveolarMolding(NAM)

1.Lee,CTH,Garfinkle,JS,Warren,SM,Brecht,LE,Cutting,CB,&Grayson,BH:
NasoalveolarMoldingImprovesAppearanceofChildrenwithBilateralCleftLip/Palate,Plast.
Reconstruct.Surgery122(4):11311137,2008.
2.Grayson,BH,Santiago,PE,Brecht,LE,&Cutting,CB:PresurgicalNasoalveolarMoldingin
InfantswithCleftLipandPalate.CleftPalateCraniofacialJournal36:486498,1999.

48
3.Maull,DJ,Grayson,BH,Cutting,CB,Brecht,LE,Bookstein,F,Khorrambadi,D,Webb,JA&
Hurwitz,D:LongTermEffectsofNasoalveolarMoldingonThreeDimensionalNasalShapein
UnilateralCleftsCleftPalateCraniofacialJournal36:391397,1999.
4.Cutting,CB,Grayson,BH,Brecht,LE,Santiago,P,Wood,R,&Kwon,SM:Presurgical
ColumellarElongationandPrimaryRetrogradeNasalReconstructioninOneStageBilateralCleft
LipandNoseRepairPlast.Reconstruct.Surg.101:630639,1998

RVU

1.WiensJP,CowperTR,EckertSE,KellyTM.Maxillofacialprosthetics:apreliminaryanalysisof
ResourceBasedRelativeValueScale.JProsthetDent.1994Aug;72(2):15963.
2. Wiens JP, Russell JC, VanBlarcom CB. Maxillofacial prosthetics: vital signs. J Prosthet Dent.
1993Aug;70(2):14553.
3.Cowper,ThomasR.TherelativevalueofproviderworkformaxillofacialprostheticservicesJ
ProsthetDent.1996Mar;75(3):294301.

CraniofacialProstheses/Implants

1.Jani,RM,SchaafNG.Anevaluationoffacialprostheses.JProsDent1978;39:546
550
2.ChenMS,UdagamaA,DraneJ.Evaluationoffacialprosthesesforheadandneck
cancerpatients.JProsDent1980;46:538544
3.TjellstrmA,RosenhallU,LindstromJ,HallenO,AlbrektssonT,BrnemarkPI.
Fiveyearexperiencewithskinpenetratingboneanchoredimplantsintemporalbone.
AcataOtlaryngol1983;95:568575
4.ParelSM,HoltR,BrnemarkPI.Osseointegrationandfacialprosthetics.IntJOral
andMaxillofacImp1986;1:2729
5.TolmanDE,TaylorPF.Boneanchoredcraniofacialprosthesisstudy.IntJOral
MaxillofacImp1996;11:15968
6.ParelSM,TjellstrmA.TheUnitedStatesandSwedishexperiencewith
osseointegrationandfacialprostheses.IntJOralandMaxillofacImp1991;6:7579
7.WolfhaardtJF,WilkesGH,ParelSM,TjellstrmA.Craniofacialosseointegration:
theCanadianexperience.IntJOralMaxillofacImp1993;8:197204
8.Rubenstein,JE.Attachmentsusedfortheimplantsupportedfacialprosthesis:asurvey
ofU.S.,CanadianandSwedishcenters.JProsthetDent1995;73:2626

49


Chapter5MaxillofacialTraumaticInjuries

JonathanP.Wiens,DDS,MSD,FACP

Traumaisthefifthleadingcauseofaccidentaldeath.Therearetwiceasmany
unintentionalinjuriesasintentionalinjuries.Injuryincidenceforages5to44will
exceedallotherdiseaseincidencesforthesameagegroup.Traumafrommotor
vehicleaccidentsistheleadingcauseofdeath(41,000/year)andresultsin1.3
millionfacialinjuriesannually.Fatalfirearmsinjurieshavebeenestimatedat
33,000peryear,whilenonfatalheadwoundsareestimatedat100,000year.
Wartimeinjuriesfromprojectilesandexplosiveblastswillcreategreaterinjuries
duetothemagnitudeoftheevent.

Theprosthodontistwillparticipateinmanagingthecareofmaxillofacial
traumaticinjuriescausedbyphysicalcontact,heat,electricalandchemical
agents.Traumaticinjuriesofthemaxillofacialregionwillvaryfromdiscrete
areastoextensiveavulsionofbothhardandsofttissues.Localizeddefects
typicallyresultinavulsedteethandalveolarbonethatmaybemanagedby
surgicalandprosthodonticreconstruction.

Traumaticinjuriesoftencreatepartiallyedentulouszonesthatarebothtooth
boundandnonlinear.Theaccompanyingalveolarboneydefectsaremore

50
extensivecomparedtotoothlossfromdentaldiseases.Injuriestoteethmaybe
classifiedas1)fractures,2)irreversiblepulpitis/periodontalattachmentlossand
3)subluxationsand/oravulsionsthatresultintoothloss.Theseanatomical
limitationsincreasethedemandupontheremainingdentalalveolarstructures.
Traumaticimpactsmayalsocreateobliqueforcesthatresultindistantinjuriesto
themuscles,temporomandibularjointandcondyles.Theseinjurieswillcreate
difficultiesinnormaljawfunctionandreconstructiveefforts.Moreextensive
oralfacialinjurieswillincludelossofmaxillomandibularcontinuitytopossible
centralnervoussystemdeficitsthatimpactsensorydeprivation,velopharyngeal
andtonguefunction.

Treatmentgoalsforthetraumapatientincludepsychologicalcounseling,oral
intakeandcircumoralcompetence,mobilesensatetongue,closureofpalateand
maxillomandibularrealignment,andtherestorationofphysicalappearance.
Treatmentplanningwillrequirecarefulassessmentforbonegrafting,implant
placementandcrownrestorationswithfixedandremovabledentalprostheses.


JonathanP.WiensreceivedhisDDSfromtheUniversityofDetroitandcompleted
advancedprosthodontictraininginfixedandremovableprosthodonticsand
maxillofacialprostheticsattheMayoGraduateSchoolofMedicine.Dr.Wiensisa
DiplomateoftheAmericanBoardofProsthodonticsandcurrentlyservesasa
BoardExaminer.HeisthePresidentElectoftheAmericanCollegeof
Prosthodontists.

51
References

1. HickeyAJMaxillofacialprosteticrehabilitationfollowingselfinflictedgunshotwoundsto
theheadandneck.JProsthDent.55:78;1986
2. WiensJP.Theuseofosseointegratedimplantsinthetreatmentofpatientswithtrauma.J
ProsthDent1992;67:670.
3. WiensJP.MVAAcquiredMaxillofacialDefects:StatisticsandProsthodonticConsiderations.J
ProsthetDent1990;Feb63(2):172181.
4. JohnBeumerIII,ThomasA.Curtis,MarkT.Marunick.MaxillofacialRehabilitation:
Prosthodonticandsurgicalconsiderations.IshiyakuEuroAmerica,Inc.;1996.Chapter11.
5. TidemanH,SammanN,CheungLK.Functionalreconstructionofthemandible:Amodified
titaniummeshsystem.IntJOralMaxillofacSurg1998;27:339345.
6. Dentalimplantsinreconstructedjaws:Patientsevaluationoffunctionalandqualityoflife
outcomes.IntJOralMaxillofacImplants2003;18:127134.
7. HeronMP,HoyertDL,MurphySL,XuJQ,KochanekKD,TejadaVeraB.Deaths:Finaldata
for2006.Nationalvitalstatisticsreports;vol57no14.Hyattsville,MD:NationalCenterfor
HealthStatistics.2009.
8. CentersforDiseaseControlandPrevention.Motorvehicleoccupantinjury:strategiesfor
increasinguseofchildsafetyseats,increasinguseofsafetybeltsandreducingalcohol
impaireddriving.AreportonrecommendationsoftheTaskForceonCommunityPreventive
Services.MMWR2001;50(No.RR7):
9. CentersforDiseaseControlandPreventionHeadsUp:FactsforPhysiciansAboutMild
TraumaticBrainInjury(MTBI),2002.AvailableonlineJanuary2003.
10. JagodaAS,CantrillSV,Wears,RL,etal.ClinicalPolicy:NeuroimagingandDecisionMaking
inAdultMildTraumaticBrainInjuryintheAcuteSetting,2002.
11. NationalInstitutesofHealthConsensusDevelopmentConferenceStatement:Rehabilitation
ofPersonswithTraumaticBrainInjury,1998.
12. ThurmanDJ,etal.TraumaticBrainInjuryintheUnitedStates:AReporttoCongress.Centers
forDiseaseControlandPrevention,1999.

52

Chapter6AllCeramicRestorations:Vision,Discoveryand
Predictability

RobertKelly,DDS,MS

Fortuitously, the Colleges first 40 years coincides with both an astounding


improvement in our ability to recreate the optical and functional characteristics
ofnaturalteethaswellaswithmyowninvolvementindentistryandmaterials
science(56years).Sothiscontributionprovidesmetheopportunitytopresent
a first person viewpoint on an unprecedented evolutionary period of our
ceramicresourcesandourestheticandfunctionalcapabilities.Suchperspective
necessarily blends both the historic and the scientific, thereby also providing
potential insights into coming attractions. My intention is to focus mainly on
earlierworkand discoveries sinceknowledgeof these pioneeringcontributions
isbecominghazyandlost.

OneofmyfavoritelecturedeviceswhensofteningupCeramics101audiences
by weaving in the history of ceramics use in dentistry, is to ask a loaded
question: During anytime from 1774 through today, our incorporation of
ceramics into dental practice resulted from (1) borrowing craft art or (2)
incorporating high technology? This then necessitates agreeing upon a
definition of both. Craft art is usually understood as involving materials or
methods derived from jewelers and artisans. High tech is a bit more
complicated,includingthelikesof:(1)capitalizingonrecentscientificliterature

53
outside of dentistry (engineering, chemistry, materials science); (2) coopting a
recent invention from an unrelated industry/profession; or, (3) involving an
inventionunknowneitherwithinoroutsideofdentistry.Mosthandsgoupfor
craftartaswouldminebeforeIengagedinanhistoricalreviewofceramicsin
dentistry for a 2001 meeting of the Academy of Prosthodontics. The answer is
clearlyhightechateveryimportantdevelopmentalstage,includingthelast40
years. Another universal characteristic is that all major developments in
ceramicswereresponsivesolutionstospecificproblems.Problemsofhygiene,
fit, esthetics, fracture, and the extension of clinical indications have engaged
visionary dentists for centuries, most often in collaboration with a
science/engineeringpartner(oralchemist!).

DispersionStrengtheningofGlassesDr.JohnMcLeanandGeneralElectric

In1965,dentistrywaspresentedwithapivotalpaperduetotheinterestofJohn
McLean to introduce polycrystalline ceramics (particularly alumina) as a
framework material for allceramic prostheses.1 Dr. McLean worked with T.H.
Hughes, a materials scientist with the Warren Spring Laboratory, Stevenage,
England.Ithadbeenknownfordecadesthatmetalalloyscouldbestrengthened
by the uniform addition (dispersion) of small, hard particles (e.g. carbides in
highstrengthsteel).Itwasnotuntilthelate1950sandearly1960sthatceramic
engineersbegantorealizethatglassescouldbedispersionstrengthenedaswell.
Addingsmallparticlessuchasaluminumoxide(alumina)toaglasscouldeither
weaken or strengthen the system depending on particle size, volume fraction,
differences in thermal expansion behavior (glassalumina) and chemical
reactivity. Early works on the intricacies of dispersion strengthening of glass
werebeingexploredin1959through1962.24Workaimedatunderstandingand
modeling the newly developed strengthening effect of dispersed particles in
glassbeganabout1966andcontinuedthroughabout1983.59

By 1962, knowledge that glasses could be strengthened by crystalline particles


was appearing at the textbook level and was known to Dr. McLean and T.H.
Hughes by experimentation as well.10 In about 1967, Vita Zahnfabrik (Bad
Sckingen,Germany)introducedthealuminafilledfeldspathicglassformulation
ofDr.McLeanandT.H.Hughesasthefirstcommerciallysuccessfulsubstructure
ceramic(VitadurN)alongwithaspeciallymatchedveneeringporcelain(Vitadur
Alpha). Both of these variously became called aluminous porcelains by the
dentalcommunity.

54
Alsoin1965,GeneralElectricswitchedtoaluminafromsandasthefillerintheir
porcelainbased insulators for hightension power lines for improved strength.
This places dental materials on the cutting edge in either adapting emerging
sciencefromceramicengineeringliteratureorinfollowinganunrelatedindustry
in technology development. Yes, this counts as high technology under the
abovedefinitionbyeither(1)capitalizingonrecentscientificliteratureoutsideof
dentistry (engineering, chemistry, material science) or (2) coopting a recent
invention from an unrelated industry/profession. In addition Dr. McLean,
clearly a visionary dentist, collaborated with an engineering partner to address
problemsoffracture,estheticsandfit.

NonShrinkingCeramicsIDrs.SozioandRileyEncounterAdolphCoorsCo.

The next exciting development in dental ceramics involved not just a novel
materialbut,moreimportantly,thefirstintroductionofanyadvancedceramics
processing equipment into the dental laboratory since the electric porcelain
furnace in 1905. It is also another clear example of visionary dentists
collaborating with a materials science colleague in search of solutions for
dentistry.

Ralph Sozio and Ted Riley took the problem of ceramic shrinkage to Brian
Starling of Coors Biomedical. Most people only associate Coors with their
delightful beverage, not realizing the firms longstanding role in ceramic
engineering.TheAdolphCoorsCompanyhasamongitssubsidiariesCoorsTek
(formerlyCoorsPorcelainandthenCoorsCeramics),CoorsBiomedical,andwas
involved in endowing the Colorado Center for Advanced Ceramics at the
ColoradoSchoolofMinesin1988(giftofthewidowofHermanCoors).Inclose
collaborationwithprosthodontistsSozioandRiley,CoorsBiomedicaldeveloped
a novel transfer molded ceramic (pressed) and an abrasionresistant epoxy
die.11,12Theceramic(Cerestore)wasconsideredtobenetshapemeaningthat
therewasnochangeinshapefromunfiredgreenwaretothefiredpart(i.e.non
shrinking). The refractory components of the material included Al2O3 (60
mass%),MgO(9mass%),andabariumaluminosilicateglass(13mass%).Inits
green state this material also contained enough silicone resin (12 mass%) and
kaolinclay(4mass%)toimpartsufficientplasticityfortransfermoldingat160C
ontoanepoxyreplicaofthepreparedtooth.13Itsnetshapecapabilityfollowing
firing up to 1300 C was ascribed to the formation of magnesium aluminate
spinel(havingalowerdensitythantheparentoxides),butmorelikelyinvolved
oxidation of the silicone resin with an expansion of a closed pore phase.13 In
essence this ceramic expanded within its closed mold like a little loaf of bread.

55
Unfortunately the high volume fraction of closed pores limited its
strength/toughness, and the licensee, Johnson & Johnson, removed it from the
marketwith3to4yearsofitsintroduction.

Both transfer molding (pressing) and microprocessorcontrolled firing were


introduced into dental laboratories establishing a milestone in the evolution of
that industry from craft art to its complexion today mixing artistry and
automated technologies. Audiences I speak to today have no memory of
Cerestore. Hopefully this article begins to revive knowledge regarding this
pivotalexampleofhightechnologyleadershipprovidedbyDrs.SozioandRiley
in their involvement with Brian Starling and Coors Biomedical on behalf of
prosthodontics.

NonShrinkingCeramicsIICorningInc.DiscoversDentistry

In 1957 Corning Incorporated developed a novel class of ceramic materials in


which toughening filler particles were precipitated and grown inside of a clear
starting glass; these materials were termed glass ceramics. In 1972 David
Grossman of Corning reported on the development of a specific glass ceramic
thatcouldbemachinedwithordinarytools.14Thisceramic,tradenamedMacor,
contained interlocking flakes of tetrasilicic fluromica crystals (55%) in a
borosilicate glass (45%) and had the appearance of porcelain or ivory.
CollaborationondentalapplicationsofMacorbetweenCorningandPeterAdair
(first with Biocor, Inc. and later Dentsply International) were first reported in
1984.15Armamentariumforcrownfabricationincludedaspecializedcentrifugal
glass casting machine and a dedicated ceramming oven to crystallize the clear
glass castings. This dental ceramic was tradenamed Dicor, a conjugation of
DentsplyInternationalandCorning.Colorwasaddedbysurfacestainsand
opacity was developed by a reaction between the glass casting and ceraming
investment that created a surface layer (25 m to 100 m thick) containing
porosityanddiopsidecrystalwhiskersorientedperpendiculartothesurface.16,17
Thislayersignificantlyweakenedtheceramicanditsremovalwasnotindicated
for reasons of fit and esthetics (becoming increasingly grey due to higher
translucency).16,17 Relatively high clinical failure rates led Corning to withdraw
itssupportoflaboratorycastDicorinthelate1980sorearly1990s.Aversion
fortheCERECCAD/CAMsystemcontainingahighervolumefractionofsmaller
crystals(70vol%)withinternalcolorandopacityremainedavailablethroughthe
late1990s(Dicor/MGC).18

56
High technology or craft art? Here dentistry tapped into the technology giant
that invented glass ceramics, invented lowloss fiber optics for data
communicationandfabricatedthemirrorfortheHubbleTelescope.

NonShrinkingCeramicsIIIFromBeerSteinstoNetShapeProstheses

German beer steins are complex, thinwalled ceramic objects with fanciful
surface ornamentation. Crowns are complex, thinwalled ceramic objects with
fancifulsurfaceornamentation.Steinsaremadebypouringdilutewaterbased
slurriesofceramicparticlesintoaporousgypsummold;aprocesstermedslip
casting. As water is transported through the mold wall ceramic particles are
packed against the form. When the stein walls are sufficiently thick, excess
slurryispouredoffandthemoldsetasidetodry,allowingthesplitmoldtobe
separatedandthesteinreadiedforfiring.

In1990,HeinzClausefromVitareportedonthedevelopmentofanovelceramic
having the physical properties of 100% alumina that could be made to net
shape.19 Using ultrasonification and dispersing agents, a rather concentrated
slipofaluminawasmadethatwasnextbrushedontoporousgypsumdiesof
the prepared tooth. When sufficient wall thickness was achieved any excess
alumina could be carved away and margins refined. During a first firing the
alumina underwent an initial sintering without shrinkage, involving neck
formation between touching particles by surface diffusion and differential
sintering of some colloidal sized particles (submicrometer).20 The gypsum die
shrunk away from the still porous but nottoofragile coping that was
subsequentlyinfiltratedinasecondfiringwithacoloredhighlanthanumcontent
borosilicate glass. The lanthanum both decreased the viscosity of the glass
(aidinginfiltration)andincreasedtherefractiveindexoftheglassclosertothatof
thealumina(increasingtranslucency).21

Variations of this ceramic system involved the substitutions for alumina of: (1)
magnesiumaluminatespinel(MgAl2O4)whichincreaseditstranslucency(lower
refractiveindexthanalumina)butwasnotasstrong;and,(2)amixtureof70%
aluminaand30%transformationtoughenedzirconia.InCeramisstillavailable
todayandstandsasthefirstallceramicsystemtoachievelongtermsuccessin
clinical trials, indicated for any single anterior or posterior crown.22 It is still
availablebyslipcastingbutalsobyCAD/CAMmachining(aswillbediscussed
below). Vita has received numerous inquiries from industries outside of
dentistry regarding their clearly high tech ceramic developed specifically for
dentalprostheses.

57
Nonshrinking Ceramics IV and Beyond, Prostheses Becoming Engineered
StructuresCloselyMimickingNature

Dentistry also learned how to better use ceramics clinically, both for increased
longevityandesthetics.Forexample,Dr.KenMalamentamassedanastounding
clinical database that signaled, among other things, the survival improvement
brought by bonding and use of a stiff buildup/core material.23,24 My own
contributions included applying fracture surface analysis (fractography) to
identify failure origins in clinically failed crowns and threeunit fixed partial
dentures.25,26Thisworkwascoupledtodevelopmentofvalidatedfiniteelement
modelsofclinicalstressstatesatfailure.26,27

Threedimensional (3D) data sets of prepared teeth began to be used for


prosthesis design and computerdirected machining, first in 1987 in a chairside
system developed by Dr. Werner Mrmann and Marco Brandestini.28,29 Work
beginning about 1996 by Gauckler (ETHZrich) and Luthy (Dental Institute,
Univ. Zrich) used 3D data to generate oversized parts to be machined from
partiallysinteredzirconiablocksthatwouldshrinktonetshapeduringfiring.30
Various sophisticated automated systems have extended dental laboratory
machiningofprosthesesframeworkstoalumina,zirconiaandglassceramics.31

Esthetic versatility has increased as well with a variety of allceramic systems


nowvettedthroughclinicaltrialsasbeingindicatedforanteriorteeth.22These
systems offer a range of translucencies and internal color control. Handheld
spectrophotometers offer advantages in shade taking and new shade systems
having more uniform and rational coverage of natural tooth color space are
improvingtraditionalshadetaking.32,33

Summary

There has never been a period of such rapid development in dental ceramics
regarding materials, processing, structural engineering and esthetics as during
thepast40years.Quiteanumberoftheinnovatorsarewellknownwithinthe
American College of Prosthodontists. Our partnerships with industry and
external scientists remain a hallmark of these innovations, as has been the case
since 1774 and will likely characterize future progress. As to the question of
hightechnoquestionremains!

58
J.RobertKellyteachesprosthodonticsandbiomaterialsandisDirector,Dental
ClinicalResearchCenteratUCONN.Hisacademiccredentialsincludethe
D.D.S.,anM.S.(dentalmaterials)theD.Med.Sc.(oralbiology)andaCertificate
inprosthodontics.HeisViceChairmanoftheADAsStandardsCommitteeon
DentalProductsandPresidentelectoftheAmericanAcademyofFixed
Prosthodontics.

59
References
1.McLeanJW,HughesTH.Thereinforcementofdentalporcelainwithceramicoxides.BritDent
J1965;119(6):251267.
2.FulrathRM.Internalstressesinmodelceramicsystems.JAmCeramSoc1959;42(9):423429.
3.GrossmannLN,FulrathRM.Xraystrainmeasurementtechniquesforceramicbodies.JAm
CeramSoc1961;44(11):567571.
4.StudtPL,FulrathRM.Mechanicalpropertiesandchemicalreativityinmulliteglasssystems.J
AmCeramSoc1962;45(4):182188.
5.HasselmanDPH,FulrathRM.Proposedfracturetheoryofadispersionstrengthenedglass
matrix.JAmCeramSoc1966;49(2):6872.
6.EvansAG.Thestrengtheningofbrittlematerialscontainingsecondphasedispersions.Phil
Mag1972;26(Ser8):13271344.
7.BiswasDR,FulrathRM.Strengthandfractureinglassmatrixcomposites.JAmCeramSoc
1965;58(1112):526527.
8.FaberKT,EvansAG.CrackdeflectionprocessesI.Theory.ActaMetall1983;31(4):565576.
9.FaberKT,EvansAG.CrackdeflectionprocessesII.Experiment.ActaMetall1983;31(4):577
584.
10.BinnsDB.Somephysicalpropertiesoftwophasecrystalglasssolids.I.ScienceofCeramics,
Vol1.London,AcademicPress,1962,pp315334.
11.SozioRB,RileyEJ.Theshrinkfreeceramiccrown.JProsthetDent1983;49(2):182187.
12.SozioRB,RileyEJ.Shrinkfreeceramic.DentClinNorthAm1985;29:707717.
13.StarlingLB.Transfermoldedallceramiccrowns:theCerestoresystem.InProc.Conf.
RecentDevelopmentsinDentalCeramics:CeramicEngineeringandScience,WJOBrien,RG
Craig(eds),Columbus,OH:AmCeramSoc.1985;6(12):4156.
14.GrossmanDG.Machinableglassceramicsbasedontetrasilicicmica.JAmCeramSoc
1972;55(9):446449.
15.AdairPJ,GrossmanDG.Thecastableceramiccrown.IntJPeriodontRestDent1984;4:3245.
16.CampbellSD,KellyJR.Theinfluenceofsurfacepreparationonthestrengthandsurface
microstructureofacastdentalceramic.IntJProsthodont1989;2(5):459466.
17.DenryIL,RosenstielSF.FlexuralstrengthandfracturetoughnessofDicorglassceramicafter
embedmentmodification.JDentRes1993;72(3):572576.
18.GrossmanDG.StructureandphysicalpropertiesofDicor/MGCglassceramic.InIntSymp
ComputerRestorations:StateoftheartoftheCERECmethod.WHMrmann(ed.)
Chicago:Quintessence.1991,pp103115.
19.ClauseH.VitaInCeram,anewsystemforproducingaluminumoxidecrownandbridge
substructures(German).QuintZahntech1990;16:3546.
20.HornbergerH,MarquisPM.MechanicalpropertiesandmicrostructureofInCeram,a
ceramicglasscompositefordentalcrowns.GlastechBerSciTechnol1995;68:18894.
21.BansalNP,DoremusRH.Handbookofglassproperties.Orlando,FL:Academic,1986;pp.
305,604.
22.DellaBonaA,KellyJR.Theclinicalsuccessofallceramicrestorations.JAmDentAssoc
2008;139(Suppl):8S13S.
23.MalamentKA,SocranskySS.SurvivalofDicorglassceramicdentalrestorationsover14
years:PartI.SurvivalofDicorcompletecoveragerestorationsandeffectofinternalsurfaceacid
etching,toothposition,genderandage.JProsthetDent1999;81(1):2332.
24.MalamentKA,SocranskySS.SurvivalofDicorglassceramicdentalrestorationsover16
years.PartIII:effectoflutingagentandtoothortoothsubstitutecorestructures.JProsthetDent
2001;86(5):511519.

60
25.KellyJR,GiordanoRA,PoberRL,CimaMJ.Fracturesurfaceanalysisofdentalceramics.
Clinicallyfailedrestorations.IntJProsthodont1990;3(5):430440.
26.KellyJR,TeskJA,SorensenJA.Failureofallceramicfixedpartialdenturesinvitroandin
vivo:analysisandmodeling.JDentRes1995;74:12531258.
27.KellyJR.Clinicalfailureofdentalceramicstructures:Insightsfromcombinedfractography,
invitrotesting,andfiniteelementanalysis.In:FischmanG,ClareA,HenchL,editors.Ceramic
TransactionsVolume48,Bioceramics:MaterialsandApplications.Westerville,OH:American
CeramicSociety,1995,pp125136.
28.MrmannWH,BrandestiniM.[Cerecsystem:computerizedinlays,onlaysandshellveneers]
articleinGerman.ZahnarztlMitt1987;77(21):24002405.
29.MrmannWH,BrandestiniM,LutzF,BarbakowF.Chairsidecomputeraideddirectceramic
inlays.QuintessenceInt1989;29(5):329339.
30.FilserF,KocherP,LuthyH,SchrerP,GaucklerLJ.Reliabilityandstrengthofallceramic
dentalrestorationsfabricatedbydirectceramicmachining(DCM).InJComputDent2001;4(2):89
106.
31.KellyJR.Dentalceramics:Whatisthisstuffanyway?JAmDentAssoc2008;139(Suppl):4S7S.
32.KimPusateriS,BrewerJD,DavisEL,WeeAG.Reliabilityandaccuracyoffourdentalshade
matchingdevices.JProsthetDent2009;101(3):193199.
33.ParavinaR.Performanceassessmentofdentalshadeguides.JDent2009;37S:e15e20.

61

Chapter7TheEvolutionofCeramicRestorationsA
ContemporaryPerspective

ArielJ.Raigrodski,DMD,MS,FACP

Ceramic materials and ceramic restorative systems have been continuously
evolving,andespeciallyoverthelasttwodecadestheyhavemadeasignificant
impact on patient care in the prosthodontic practice. These materials were
gradually incorporated for several clinical indications such as ceramic laminate
veneers(CLVs),ceramiconlaysandinlays,ceramiccrowns,ceramicfixedpartial
dentures (FPDs), and ceramic implant abutments and ceramic screwretained
implantframeworks.

Over the years, increased patients demands for metalfree toothcolored
restorations, innovations and improvements in ceramic materials, dental
adhesives, computer assisted design/computer assisted manufacturing
(CAD/CAM) technology in terms of both software and hardware, have all
contributed to facilitating the clinical success of ceramic restorations. However,
the use of these materials is not without limitations and careful treatment
planning, material selection, and laboratory fabrication are all critical for
enhancingclinicalsuccessandreducingthelikelihoodofcomplications.1

Different ceramic materials present with specific mechanical and optical
properties,whichmayaffecttheirselectioninvariousclinicalscenarios(suchas
translucent vs. discolored abutment teeth, or adequate vs. inadequate gingival

62
healthwhichmayprecludeadequatebondingprocedures)aswellassomeofthe
clinical procedures including preparation design and delivery procedures
(conventionalluting vs.adhesivecementation).1However, allceramic materials
mustmeetbiomechanicalandestheticrequirementswhichwillultimatelyaffect
thepredictabilityandlongevityoftheprospectiverestoration.2

OneofthemostconservativerestorativetreatmentmodalitiesistheCLV.These
restorationsareindicatednotonlyfortreatingseverelydiscoloreddentitionbut
also for the restoration of fractured and worn dentition, as well as malformed
teeth.3

With studies demonstrating the efficacy of bonding porcelain to enamel (as
strong as natural dentition),4 as well as the efficacy of techniques to facilitate
improved bonding to dentin,5 the use of porcelain laminate veneers may be
expanded to more challenging clinical scenarios. These may include restoring
endodonticallytreatedteethwithrelatively conservative endodonticaccess and
adequate residual tooth structure or as part of fullmouth reconstructions
restoring mandibular incisors (biomechanical advantage over complete
coverage) or/and the worn dentition.6 In addition to the advantage of tooth
structure preservation, in certain clinical situations, the classic preparation
design for a porcelain laminate veneer allows the placement of the finish line
above the gingival crevice. This, in addition to having a higher probability of
having the finish line placed in enamel, may facilitate the health of the
dentogingival complex7 while also promoting a perfect blend of the restoration
withtheunderlyingtoothstructuretakingadvantageofthecontactlenseffect.8

CLVs have been fabricated either out of feldspathic porcelain or leucite


reinforced feldspathic porcelain or lithium disilicate using several different
techniquessuchastherefractorydieorplatinumfoil,waxingandheatpressing,
or CAD/CAM technology. Several retrospective clinical studies have
demonstrated acceptable survival and clinical success for CLVs manufactured
with different fabrication techniques and different ceramic materials with a
followupperiodrangingfrom5to16years.913Waltonsstudysubstantiatedthe
longterm effectiveness of his regimen while emphasizing the preservation of
enamelandbondingtoenamelasakeyforclinicalsuccess.13

As with CLVs, attempting to achieve conservative patient care and functional


and esthetic restorations in the posterior segments has contributed to the
developmentandincreasinguseofceramicinlaysandonlays.Theserestorations

63
are fabricated mostly with either feldspathic porcelain, leucite reinforced
feldspathic porcelain, or lithium disilicate, via CAD/CAM technology or via
waxing and heat pressing. Although, inlay and onlay tooth preparations are
consideredmuchmoreconservativeascomparedtocompletecoveragecrowns14,
restorations must be adequately bonded to tooth structure to reduce the
likelihood of fracture and to facilitate restorations longevity. Several clinical
studies demonstrated adequate clinical success for ceramic inlays and onlays
manufacturedandbondedwithdifferenttechniqueswithfollowupperiodsfor
upto12yearsinbothprospectiveandretrospectivestudies.1518

Highstrength ceramic systems for crowns and FPDs have been available to
clinicians for several decades while continuously evolving. Generally, these
systems use various highstrength core materials which present with different
mechanical and optical properties. These are designed and manufactured via
different technologies such as waxing and heat pressing, slipcasting, and
CAD/CAM technology for the fabrication of core materials as well as for the
fabrication of complete contour restorations.1 With the advent of CAD/CAM
technology,variousdesignandfabricationtechnologieshavebeendevelopedfor
enhancing more consistent and more predictable restorations in terms of
strength, marginal fit, adequate support for the veneering porcelain, and
esthetics. Mostly these high strength copings are to be veneered with either
traditionalporcelainlayeringtechniqueorwithwaxingtothecorematerialand
heat pressing. The continuous evolution in adhesive systems and composite
resin cements also plays a major role in the ability of clinicians to deliver
predictably highstrength allceramic restorations with considerably adequate
longevity.

During the past two decades several retrospective and prospective clinical
studies, both from the private practice and university setting, have been
published evaluating the success and longevity of ceramic crowns and ceramic
FPDs in both the anterior and posterior segments. Several materials have been
used in these studies with varying success for different indications while
demonstratinglimitationsofsomeofthesematerials.

Anterior crowns made of leucitereinforced glassceramicbased crowns


demonstrated a high clinical success.19 These restorations demonstrated high
translucency and rely on a successful bond between the ceramic coping, the
compositeresin cement and the tooth structure for strength and longevity.
Copings are fabricated either using waxing and heatpressing or CAD/CAM
technologyfromprefabricatedblanks.

64
Anterior and posterior crowns made of lithium disilicate glassceramics coping
demonstrated a high success when used for fabricating crowns in the anterior
and posterior segments.20,21 These restorations are considered relatively
translucent and are designed and fabricated either via waxing and heat
processing or via CAD/CAM technology. Crowns can be made as either crown
copings which are subsequently veneered with porcelain or as a fullcontour
design with subsequent staining to facilitate strength. Although the initial
attemptsduringthelate1990stousethematerialforFPDs(replacingamissing
tooth up to the 1st bicuspid) have resulted in limited success, 21 a recent clinical
study demonstrateda successfuloutcome when usingthis material foranterior
andposteriorFPDs.22

Glass infiltrated materials have been used with a hightemperature, sintered
aluminaglassinfiltrationaswellasCAD/CAMtechnologyforbothcrownsand
for FPDs. The glassinfiltrated alumina has been used with some success for
anterior and posterior crowns23.24, as well as for threeunit anterior FPDs with
limited success.2426 Glassinfiltrated magnesium alumina which presents with
higher translucency and lesser mechanical properties than glass infiltrated
alumina has been used successfully for anterior crowns exclusively.27 Glass
infiltrated alumina with 35% partially stabilized zirconia demonstrated better
mechanicalpropertiescomparedtoglassinfiltratedaluminawithhighopacity.28
Clinical studies demonstrated successful use in terms of survival of posterior
FPDswiththesetypesofframeworks.29,30

Densely sintered highpurity aluminumoxide has been the first glassfree
material to be designed and processed via CAD/CAM technology for semi
opaque crown copings which were later veneered with special veneering
porcelain.31 Several clinical studies have demonstrated the successful use of the
materialforbothanteriorandposteriorcrowns.3133

The most recent ceramic core material is zirconiumdioxide. It is a glassfree
highstrength ceramic material which was introduced for the fabrication of
anteriorandposteriorcrowncopingsandFPDframeworks.2 Zirconiumdioxide
infrastructuresaremainlydesignedandprocessedwithCAD/CAMtechnology.

Severalzirconiumdioxidebasedrestorativesystemsareavailableforcrowns
andFPDs.Prospectiveclinicalstudieshaveevaluatedposteriorzirconiumoxide
basedFPDsforupto5years.3436Althoughmostlysuccessful,onecomplication
insomeofthestudieswasminorveneeringporcelainchippingofveneering
porcelain(cohesivefracture)mainlyon1stand2ndmolarswhichdidnotrequire

65
replacementoftherestorations.Thesemayberelatedmainlytolackofadequate
supportoftheveneeringporcelainbythezirconiumdioxideframeworks,dueto
earlysoftwarelimitations.Also,failureshavebeenrelatedtoincorrectfiring
temperaturesandcoolingratesbecausezirconiumoxideisapoorheat
conductor,thus,generatinginternalstresswithintheveneeringporcelain.A
recentclinicalstudydemonstratedsimilarsurvivalforzirconiumdioxidebased
posteriorFPDsascomparedtoametalceramiccontrolafter3yearsoffollow
up.37Currently,zirconiumdioxideframeworksmaybelayeredusing
conventionallayeringoffeldspathicporcelainwithmatchingcoefficientof
thermalexpansion.38Inaddition,similarporcelainmaybepressedontotothe
zirconiumdioxideframeworksintheattempttoreducecohesivechippingofthe
veneeringporcelainwhichhasbeendemonstratedinaclinicalstudy.39

Finally,inthequesttofacilitatesofttissueestheticsinimplantdentistry,theuse
ofceramicsasanabutmentmaterialforimplantdentistryhasbeensuggested.
Initially,aluminumoxidecylindershavebeenusedaspreparableabutments
withlimiteddegreeofsuccess.40Subsequently,withtheadventofzirconium
dioxideandCAD/CAMtechnology,zirconiumdioxidehasbeenintroducedas
eitherpreparable,semicustomized,orasCAD/CAMcustomabutments.These
havebeenintroducedwithdifferenttypesofinterfaces(zirconiumdioxideor
titanium)withtheimplantplatformasdemonstratedbydifferentsystems.
Advantagesofzirconiumoxideasanabutmentmaterialaremainlyrelatedtoits
biocompatibility41,42aswellasitsabilitytocauselittlechangetothesofttissue
color,minimizingsofttissuediscoloration.43However,theremaybesome
limitationswhichmayneedfurtherinvestigationsuchastheminimalrequired
thicknessoftheaxialwallsoftheabutment,abutmentsizeasrelatedtoimplant
diameter,andtheabutmentimplantplatforminterfaceanditsresidualeffecton
theimplantplatform.44Inaddition,thescrewabutmentinterfacemaybeof
importanceasrelatedtothelongevityoftheseabutments.Severalclinical
studieshavedemonstratedshorttermsuccessintermsoffunctionandesthetics
withzirconiumdioxideabutments,4547whileothershavequestionedthebenefits
ofzirconiumdioxideandceramicrestorationsinimplantdentistry.48Inaddition,
recently,screwretainedrestorationswithzirconiumoxideservingasboth
abutmentandframeworkinoneunit.Whiledemonstratingsomepromise,
furtherresearchisrequiredtoclarifyandformguidelinesaswellasindications
andlimitationsforusingzirconiumdioxideforimplantabutments.

Insummary,differenttypesofceramicrestorationspresentwithmany
advantagesfortheclinicianandpatient.However,ceramicrestorationsmustbe
carefullyusedforthecorrectindicationsbasedonscientificevidencewhile

66
understandingtheiradvantagesandlimitations.Thoroughunderstandingofthe
differentmaterialsavailableaswellasthedifferenttreatmentmodalitieswith
ceramicrestorationsiscritical.Carefuldiagnosisofpatientsandsoundprinciples
oftreatmentplanningiscrucialforthelongevityandsuccessofpatientcarewith
ceramicrestorations.

Dr.RaigrodskiisaProfessorandDirectorofGraduateProsthodonticsatthe
DepartmentofRestorativeDentistryattheUniversityofWashington.Heisa
memberoftheeditorialreviewboardsofPracticalProceduresandAesthetic
Dentistry,theJournalofEstheticandRestorativeDentistry,theJournalof
Prosthodontics,andtheJournalofProstheticDentistry.Dr.Raigrodskiisa
graduateoftheHebrewUniversityinJerusalemIsrael.Hereceivedhiscertificate
inProsthodonticsatLouisianaStateUniversitySchoolofDentistry,wherehealso
completedafellowshipinimplantsandesthetics,andanMSdegree.Heisa
DiplomateoftheAmericanBoardofProsthodontics,afellowoftheAmerican
CollegeofProsthodontists,AfellowoftheInternationalCollegeofDentists,a
memberoftheAmericanAcademyofFixedProsthodontics,theAcademyof
Osseointegrationandotherprofessionalorganizations.AcoeditoroftheEnglishversionofthebookAll
CeramicAtAGlancepublishedin2007;heauthorednumerousscientificarticlesaswellasachapterin
Dr.MichaelCohensInterdisciplinaryTreatmentPlanningbookpublishedin2009byQuintessence.Dr.
Raigrodskisresearchfocusesinallceramics,CAD/CAMtechnology,andimplantdentistry.Helectures
bothnationallyandinternationally,andholdsaprivatepracticeinKenmore,WA.

67
References

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Michael Cohen , Editor. In: Interdisciplinary Treatment PlanningPrinciples, Design,
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2. Raigrodski AJ. Contemporary materials and technologies for allceramic fixed partial
dentures:areviewoftheliterature.JProsthetDent.2004;92:55762.

3. BelserUC,MagneP,MagneM.Ceramiclaminateveneers:continuousevolutionof
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DentJ.1995;178:33740.
7. ChenYW,RaigrodskiAJ.Aconservativeapproachtotreatmentplanningforyoung
adultpatientswithporcelainlaminateveneers.JEsthetRestDent2008;20(4):22336.
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9. FriedmanMJ.A15yearreviewofporcelainveneerfailureacliniciansobservations.
CompendContinEducDent.1998;19:6258,630,632.
10. FradeaniM.SixyearfollowupwithEmpressveneers.IntJPeriodonticsRestorative
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11. FradeaniM,RedemagniM,CorradoM.Porcelainlaminateveneers:6to12yearclinical
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12. WiedhahnK,KerschbaumT,FasbinderDF.Clinicallongtermresultswith617Cerec
veneers:anineyearreport.IntJComputDent.2005;8:23346.
13. LaytonD,WaltonT.Anupto16yearprospectivestudyof304porcelainveneers.IntJ
Prosthodont.2007;20:38996.
14. EdelhoffD,SorensenJA.Toothstructureremovalassociatedwithvariouspreparation
designsforanteriorteeth.JProsthetDent.2002;87:5039.
15. FradeaniM,AquilanoA,BasseinLLongitudinalstudyofpressedglassceramicinlays
forfourandahalfyears.JProsthetDent.1997;78:34653.
16. SjgrenG,MolinM,vanDijkenJW.A10yearprospectiveevaluationofCAD/CAM
manufactured(Cerec)ceramicinlayscementedwithachemicallycuredordualcured
resincomposite.IntJProsthodont.2004;17:2416.
17. FrankenbergerR,TaschnerM,GarciaGodoyF,PetscheltA,KrmerN.Leucite
reinforcedglassceramicinlaysandonlaysafter12years.JAdhesDent.2008;10:3938.
18. GuessPC,StrubJR,SteinhartN,WolkewitzM,StappertCF.Allceramicpartialcoverage
restorationsmidtermresultsofa5yearprospectiveclinicalsplitmouthstudy.JDent.
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19. FradeaniM,RedemagniM.An11yearclinicalevaluationofleucitereinforcedglass
ceramiccrowns:aretrospectivestudy.QuintessenceInt2002;33(7):503510.

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20. MarquardtP,StrubJR.SurvivalratesofIPSempress2allceramiccrownsandfixed
partialdentures:resultsofa5yearprospectiveclinicalstudy.QuintessenceInt.
2006;37:2539.
21. ValentiM,ValentiA.Retrospectivesurvivalanalysisof261lithiumdisilicatecrownsina
privategeneralpractice.QuintessenceInt.2009;40:5739.
22. WolfartS,EschbachS,ScherrerS,KernM.Clinicaloutcomeofthreeunitlithium
disilicateglassceramicfixeddentalprostheses:upto8yearsresults.DentMater.
2009;25:e6371.
23. PrbsterL.SurvivalrateofInCeramrestorations.IntJProsthodont.1993;6:25963.
24. WassermannA,KaiserM,StrubJR.ClinicallongtermresultsofVITAInCeramClassic
crownsandfixedpartialdentures:Asystematicliteraturereview.IntJProsthodont
2006;19:355363.
25. VultvonSteyernP,JnssonO,NilnerK.Fiveyearevaluationofposteriorallceramic
threeunit(InCeram)FPDs.IntJProsthodont.2001;14:37984.
26. OlssonKG,FrstB,AnderssonB,CarlssonGE.Alongtermretrospectiveandclinical
followupstudyofInCeramAluminaFPDs.IntJProsthodont.2003;16:1506.
27. FradeaniM,AquilanoA,CorradoM.ClinicalexperiencewithInCeramSpinellcrowns:
5yearfollowup.IntJPeriodonticsRestorativeDent.2002;22:52533.
28. HeffernanMJ,AquilinoSA,DiazArnoldAM,HaseltonDR,StanfordCM,VargasMA.
Relativetranslucencyofsixallceramicsystems.PartI:corematerials.JProsthetDent.
2002;88:49.
29. SurezMJ,LozanoJF,PazSalidoM,MartnezF.ThreeyearclinicalevaluationofIn
CeramZirconiaposteriorFPDs.IntJProsthodont.2004;17:358.
30. EschbachS,WolfartS,BohlsenF,KernM.ShortCommunication:ClinicalEvaluationof
AllCeramicPosteriorThreeUnitFDPsMadeofInCeramZirconia.IntJProsthodont.
2009;22:4902.
31. OdenA,AnderssonM,KrystekOndracekI,MagnussonD.Fiveyearclinicalevaluation
ofProceraAllCeramcrowns.JProsthetDent1998;80(4):4506.
32. OdmanP,AnderssonB.ProceraAllCeramcrownsfollowedfor5to10.5years:a
prospectiveclinicalstudy.IntJProsthodont.2001;14:5049.
33. FradeaniM,DAmelioM,RedemagniM,CorradoM.FiveyearfollowupwithProcera
allceramiccrowns.QuintessenceInt.2005;36:10513.
34. RaigrodskiAJ,ChicheGJ,PotiketN,HochstedlerJL,MohamedSE,BilliotS,etal.The
efficacyofposteriorthreeunitzirconiumoxidebasedceramicfixedpartialdental
prostheses:aprospectiveclinicalpilotstudy.JProsthetDent2006;96:23744.
35. TinschertJ,SchulzeKA,NattG,LatzkeP,HeussenN,SpiekermannH.Clinicalbehavior
ofzirconiabasedfixedpartialdenturesmadeofDCZirkon:3yearresults.IntJ
Prosthodont.2008;21:21722.
36. MolinMK,KarlssonSL.Fiveyearclinicalprospectiveevaluationofzirconiabased
Denzir3unitFPDs.IntJProsthodont.2008;21:2237.
37. SailerI,GottnerbJ,KanelbS,HammerleCH.RandomizedControlledClinicalTrialof
ZirconiaCeramicandMetalCeramicPosteriorFixedDentalProstheses:A3yearFollow
up.IntJProsthodont.2009;22:55360.
38. AshkananiHM,RaigrodskiAJ,FlinnBD,HeindlH,ManclLA.Flexuralandshear
strengthsofZrO2andahighnoblealloybondedtotheircorrespondingporcelains.J
ProsthetDent.2008;100:27484.

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39. BeuerF,EdelhoffD,GernetW,SorensenJA.Threeyearclinicalprospectiveevaluationof
zirconiabasedposteriorfixeddentalprostheses(FDPs).ClinOralInvestig.2009;13:445
51.
40. PrestipinoV,IngberA.Esthetichighstrengthimplantabutments.PartI.JEsthetDent.
1993;5:2936.
41. DegidiM,ArteseL,ScaranoA,PerrottiV,GehrkeP,PiattelliA.Inflammatoryinfiltrate,
microvesseldensity,nitricoxidesynthaseexpression,vascularendothelialgrowthfactor
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zirconiumoxidehealingcaps.JPeriodontol2006;77:7380.
42. WelanderM,AbrahamssonI,BerglundhT.Themucosalbarrieratimplantabutmentsof
differentmaterials.ClinOralImplantsRes.2008;19:63541.
43. JungRE,SailerI,HmmerleCH,AttinT,SchmidlinP.Invitrocolorchangesofsoft
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44. NguyenHQ,TanKB,NichollsJI.Loadfatigueperformanceofimplantceramicabutment
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45. GlauserR,SailerI,WohlwendA,StuderS,SchibliM,SchrerP.Experimentalzirconia
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regions:4yearresultsofaprospectiveclinicalstudy.IntJProsthodont.2004;17:28590.
46. CanulloL.Clinicaloutcomestudyofcustomizedzirconiaabutmentsforsingleimplant
restorations.IntJProsthodont.2007;20:48993.
47. NothdurftFP,PospiechPR.Zirconiumdioxideimplantabutmentsforposteriorsingle
toothreplacement:firstresults.JPeriodontol.2009;80:206572.
48. ZembicA,SailerI,JungRE,HmmerleCH.Randomizedcontrolledclinicaltrialof
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Chapter8ComputerBasedTechnologyintheProsthodontic
Practice

DavidGuichetDDS

Introduction
Thecontinuedimprovementofcomputerbasedclinicalhardwareandsoftware
applicationshasenabledthecomputerbasedprosthodonticpracticemodel.
Todayprosthodonticgraduatesareusingelectronicrecords,havingnever
utilizedaphysicalchartorfilmbasedradiographs1,2.Newercapabilitieslike3D
digitaldiagnosticimaging,implantplanningsoftwareandcomputergenerated
surgicalguidesempowerprosthodontiststoestablishthemselvesaseffective
leadersprovidingoptimaltreatmentsolutionsforbothsimpleandcomplex
restorativeprotocols.Thepurposeofthispaperistoprovideanupdateonthe
clinicalapplicationofcomputertechnologycurrentlyavailableforthediagnostic
managementofprosthodonticpatient.

Althoughthebenefitsarerecognized,manycliniciansavoidincorporating
computertechnologyintotheirpractices3,4.Sometransitioncautiouslyintothe
digitalrealminordertobenefitfromtheadvantagesthatnewertechnology
promises.AnentirerangeofpracticeprofileshasbeendescribedbyFarman5.
Theyarecharacterizedbythedegreeofdigitalintegrationintothepatientcare
settingrangingfromnocomputerintegrationtocompletelypaperless/chartless.

71
Thischangeisnoteasyformostdentistsandstaffbecauseitinvolvesacultural
shift.

Diagram1:TheIncreasingLevelsofDigitalIntegration

Identification,Evaluation,andInfrastructure
Inordertointroducenewtechnologytoapractice,itisnecessarythatathorough
evaluationandtestingoftheproposednewapplicationtakesplacepriortobeing
introducedintothepractice6.Theapplicationmustbeinstalledandtestedand
keymembersofthestaffmustbetrainedandaccountableforthetrainingof
otherstaffmembers.Additionally,oncethedecisionismadetointroducethe
digitalprocess,occasionallyhardwareupgradeswillberequired.

Itisnecessarytoinstallarobustandsecurenetworkinfrastructure.Thisincludes
afileserver,harddrivebackups,anuninterruptablepowersource,andastable
hardwirednetworkbaseduponahighspeedgigabyteswitch.Clinical
workstationsmonitorsmustbelargeenoughtoprovideeffectivevisualaccessto
twoprogramssimultaneously.A22inchwideflatpanelLEDmonitorona
movablearmisnowconsideredaminimumrecommendedconfiguration.In
ordertoachieveanergonomicviewingpositionofthescreen,itmustbe
adjustableandmovableforvisualaccesstothepatient,dentistandstaffmember
whenseatedorstandingduringconsultationorexamination.Oncethedigital

72
infrastructureisinplace,oneisinapositiontoincorporatetheclinicalsoftware
applicationthatbestfitsyourpracticesneeds.Itisbesttomakethedecisionsin
manageablestepsthatallowforaneffectiverolloutofthenewsoftwareor
process.

TheCriticalStartupApplication
Whentransitioningtoadigitalbasedpractice,thedoctorshouldidentifya
softwareapplicationthatwouldprovideavaluedbenefit.Onemightcallthis
TheCriticalStartupApplication.Trendssuggestthatformostofficesthefirst
clinicalapplicationintroducedisdigitalphotographyordigitalradiography7.

Initiallythesoftwareapplicationanddatausuallyresideonalaptoporcartthat
ismovedfromroomtoroom.Typicallythisiskeptseparatefromthepractice
managementdatabaseanditsdataisstoredlocallyandmaynotbeintegrated
withthemainsystemdatastorage,backupandsecurityprotection.This
approachiscosteffectivebutitcarriesriskandinefficiency.Thelocaldatastored
couldbelostintheeventofaharddrivefailure.Regularbackupsmustbe
scheduled.Thelackofanintegrateddatabaseresultsinduplicatesindataentry,
aspatientnamesandidentifiersarerequiredcausingredundancybyaddinga
separatedataset.Nonlinkeddatasetstypicallyresultinbottlenecksandare
limitedinscaletoverysmallpracticeenvironments.Staffmemberscannotaccess
thephotographsandradiographswhilecommunicatingwithapatient,ifthey
resideonalaptoporacart.Intime,asecondorathirdapplicationmaybe
identifiedwhichwillserveasanincentivetobuildouttheclinicalhardware
networktoboostefficiencyandsecurity.Oncethebackofficenetworkisbuilt,
newapplicationscanbeaddedveryeffectivelywithoutadditionalhardware
expenses.

InstallationandIntegration
Thetransitiontoacompletelyelectronicrecordishighlightedwithdecisions
aboutwhereinformationbelongs8,9.Doctorsandstaffmembersmustbeableto
answerfundamentalquestions.Whatinformationisneededandwheredoes
thatinformationreside?Whereisthepatientsmedicalhistoryandlistof
medications?Istherestorationonthebrokentooththeonethatweprovided?
Whenwasthepatientlastseeninouroffice?

Whenattemptingtoretrieveinformationfromaphysicalchart,onesimply
accessestheinformationbyopeningthechart,turningthepagesandreading.In
anelectronicrecord,informationisaccessedusingmouseclickswhichopen
digitalpages.Inadigitalrecordthesameinformationisavailablethatisina

73
physicalchart,butitisaccessiblefrommultiplelocationswithintherecord.
Additionallytheinformationcanbemined,sortedorsearched.Informationcan
beviewedbycategory,toothnumber,date,orothervariableslikecompleted
treatmentorplannedtreatment.Therefore,questionsaboutapatientscondition
areusuallysimpletoanswerwhenusingtheelectronicrecord.Allthisispossible
fromanycomputerintheoffice,withouteverhavingtoretrieveaphysical
record10.

TheIntegratedImagingSuite
Itisveryimportanttohaveapracticemanagementsoftwarethatispairedwith
gooddigitalradiographysoftware.Theintegrationofthebusinessmanagement
packagewiththeradiographypackagecreatesanimagingfoundation.That
meansanyphotographsthatareincludedinthepatientsradiographicrecordare
taggedtothepatientsdigitalrecord.Forgreatestefficiencyanintegrated
imagingsuiteoffersapracticethemoststableandserviceableplatform.Afully
integratedsystemalsoallowsyoutoseamlesslyattachimagesdirectlyto
insuranceclaimswithoutanythirdpartyinterface.

Todaymostpracticemanagementsoftwarepackageshavepartneredwithdigital
radiographicimagingcompaniestocreateanintegrated
radiographic/photographicimagingsuite.PracticeWorksandSoftDenthavea
partnershipwithKodak.EagleSofthasapartnershipwithSchick.Dentrixhas
partneredwithDexis.Therefore,dependingonyourfavoritepractice
managementpackage,onemightgetthebestsupportwithanestablished
partnerbrand.Thebenefitisthatyouwillhaveasupportedandprovensystem.

Additionally,aswithdigitalradiography,digitalphotographycanbedelegated
totrainedstaffprovidingthepractitionerwithefficientandenhanceddiagnostic
information.Oneadvantageofstartingwithdigitalradiographyisthatthe
linkedimagingsoftwarecanserveasafoundationforthephotographicimages
atanoadditionalcost.

TheKeyBenefits:
EfficiencyandWorkflow
Inordertobestbenefitfromdigitaltechnologyandtheefficienciesitoffers,an
organizedworkflowmustbeestablishedforstandardproceduressuchasthe
newpatientexam.Thefollowingisadescriptionofanewpatientworkflowthat
hasproveneffectiveinaprosthodonticgrouppractice.Itinvolvesastandardized
seriesofeventsthataremanagedandanewpatientexaminationtemplate/digital
formiscompletedintheclinicalsetting.Anorganizedworkflowincluding

74
educationvideos,andexaminationtemplatesareallutilizedtomanagethenew
patientexperiencewhilebuildingthedigitalrecord.

Priortoseeinganewpatientintheoffice,atreatmentcoordinatorwill
extensivelyinterviewthepatientandindicatethereasonforthevisitinthe
digitalphonerecord/journal.Anappointmentismadeintheonlineappointment
book.Oncethepatientpresentstotheoffice,areceptionistscansthepatient
medicalhistoryanddemographicinformationdocumentsintothedigital
documentcenter.Aregistereddentalassistanthasreceivedtheauthorizationto
takethepatientsdigitalpanoramicradiographanddigitalextraoraland
intraoralphotographs.Oncedigitalimaginghasbeencompletedthepatientis
givenawalkingtourofthepracticeandthenseated.Whileuploadingthe
photographicimagestothedigitalrecordthepatientwatchesasixminuteonline
FloridaProbePeriodontaleducationalvideo.Thenthepatientsphotographsand
radiographsareopenedupontothe22inchLCDwhileandthepatient
interviewbegins.Anexaminationtemplateislaunchedfromthedigitalchart
whichpromptstheRDAthroughaseriesofquestionsaboutthepatient.The
patientseestheirphotographsonthemonitorwhilethedentalassistant
discussesthepatientschiefconcernsandreviewsthepatientsdigitallyscanned
medicalhistory.Thedentististhenintroducedtothepatientwhilethedental
assistantrepeatsthepatientsentirepertinentprofile,inthepresenceofthe
patientwhilethedentistisreviewingthephotographsandradiographs.Within
momentsthedentisthasbeenintroducedtohighqualitydigitalinformation
aboutthatpatientwithaminimumoftimeinvested.Theuniversalapplicationof
anelectronichealthrecordisaprimaryfocusofthefederalgovernmenttobe
establishedby2015andthereforeadigitalplatformwillultimatelybenecessary.

PatientEducationandTreatmentPlanning
Thedoctorreviewstheradiographsandphotographswhilemakingtreatment
planningnotes.TheDexisalertfunctionsareusedtoannotateareasofconcern
ontheintraoralradiographs(FMX).Whiletheperiodontalexamisbeing
performed,TheFloridaProbesoftwaregivesaudiblewarningsthatinformthe
patient.Thentherestorativechartingiscompletedwhilecorrelatingthe
diagnosticinputwiththepatientsconditioninordertodevelopanappropriate
treatmentplanthatdirectlyaddressesthepatientsconcerns.Launching3d
softwareassistsinclarifyingthesteps,benefits,alternativesandpossible
limitationsofthetreatment.Pullingupphotographsofotherpatientstreated
withsimilarneedsisapowerfulprognostictool.Thenthepatientistransitioned
tothetreatmentcoordinatorwhoispreparedtodiscussthebenefitsofa
comprehensiveapproach,stagingoptions,andcosts.He/shecanaccessallthe

75
patientsdigitalinformationandalibraryofcompletedtreatments,usingatablet
PCorLaptoptoreinforcetreatmentacceptance.Ifthedentistdoesnothavea
libraryoftheircompletedwork,patienteducationalsoftwarepackagescanbe
accessed,suchasConsultPRO,ImplantDocs,BiteFX,Casey,Dentrix
PresenterorGuru.

Educationmodulesarelinkedtothepatientschartandstoredasapermanent
partofthedigitalrecord.Annotationsarealsostoredontheimageandarehave
adigitallysealed,timestampedimageofthevideovignetteandthenotesfrom
thatday.Theseentriesserveasverypowerfultestamenttothepatientsdigitally
signedcomprehensiveinformedconsent.Otherstepslikedigitallysignedoral
sedationconsentandpharmaceuticalprescriptionsarerecordedandprinted
directlyfromthetreatmentplanningandpharmaceuticalmodulesandare
permanentlystoredasapartoftheelectronicrecord.Physicalprintoutsofthe
planandcorrespondingconsentsandprescriptionsaregiventothepatientwho
isthenappointedintheonlineappointmentbookaccordingtotheproposed
treatmentsequenceinthedigitaljournal.

Ifthetreatmentplaninvolvesanumberofimplants,boththe2dandthe3d
CBCTvisualizationsoftwareaddonshaveadigitallibraryofmajor
manufacturersimplantstoclarifyappropriatesizesandshapes.Theradiograph
iscalibratedaccordingtothemagnificationfactorforthegivenimageandisthen
usedasaguidelinefortreatmentpossibilities.Implantsfromthelibrarysetinto
thepanoramicorconebeamradiographcanserveasareminderoftheintended
planandserveasarecordoftheconversationwiththepatient.Collaborative
implanttreatmentplanningsoftwarealsoallowsthecolleaguesaswellasthe
patienttovisualizethepositionofthemandibularnerve,thesinuses,the
availablebone,thevarioussizesandshapesofimplantsthataremost
appropriateforthegivensituation.

ImprovedClinicalResults
Oncethedigitalinfrastructureisinplace,applicationscanbeaddedtothe
practiceverycosteffectively.Forexample,ifinonescommunityaradiographic
laboratorypurchasesaconebeamscanner,onecanpurchase3Dimplantimaging
softwaretocomplementtheconebeamdatainordertoviewandeditthosefiles.
Some3Dsoftware,suchasFacilitateViewcanbedownloadedfreefromthe
Materialise/AstraFacilitateWebsite.

Virtualaccessofthedigitalradiographyandconebeamtechnologyfacilitates
implanttreatmentdecisions.Interdisciplinaryteammembersmaycollaborateon

76
CBCTdatapriortoperformingprocedures.Theposition,thedepth,inclination
andorientationthataveryhighlyskilledsurgeonmaybeabletodoonlyaftera
greatdealoftraining,theyoungersurgeonmaybeabletoaccomplishwitha
flatterlearningcurveandwithaminimumelevationofflaps.Usingwebbased
passwordprotectedfiletransferservices,likeyousendit.com,
transferbigfiles.comorsendbigfiles.com,CBCTlabsmaytransferpatientdata
bypassingphysicalmailandphysicalCDdatastorage.

Remoteaccesssoftware,likeGoToMyPC.comorLogmein.com,isanunexpected
advantageofapplicationsservingthedigitaloffice.Viacommunicationoverthe
Internet,onecanaccessthescheduleandpatientclinicaldatafromanywhere.
Onecanbeathomeandinmomentslogintolookatthepatientschedule,
reviewradiographs/treatmentplans,prescriptions,laboratoryorimplant
orderingneeds.

AnonlineElectronicHealthrecordthatispasswordprotected,HIPPA
compliant,andsecurealsoenablesinterdisciplinaryteamcollaboration.
TeamLinx.comorUSHealthRecord.comanapplicationserviceprovideroffers
interdisciplinaryteammembersandstudygroupmembersaccesstoan
interdisciplinaryElectronicHealthRecordforcomplextreatmentsequencingand
treatmentcoordination.DiagnosticcodingwithICD9andADACodesmayalso
allowfordataminingoftheelectronicrecords.Thismightbeusedtorevealing
informationaboutpatientriskortreatmentprognosisfromsimilarlytreated
patients.Theelectronicrecord
willbethewayofthefuturesoanyinvestmentindigitaltechnologynowwill
likelyserveasaplatformforthefuture.

OvercomingChallenges
Themoreonetransferstheirpracticeprocessesintodigitalrealm,themore
dependentonebecomesuponmaintainingandtroubleshootingtheirdigital
infrastructure.Itisofcriticalimportancetohaveaccesstoawelldisciplined
dailybackupprocedureandtouseindustrystandardprocesses.Practice
managementsoftwarecompanieshaveaccesstomanyservicetechnicianswho
applyindustrystandardprocessestoinsurethatyoursystemisfunctionaland
secure.

Identifyingtechnologicallysavvystaffmembersiskeytoperformingdata
backupsandtroubleshootingwhenproblemsarise.Ifaclinicalworkstationgoes
down,awirelesslaptopcanbeusedeffectivelytokeeptheteamrunning.Afree
softwareserviceincludedwithMicrosoftWindowscalledRemoteDesktop

77
allowsthelaptoptoaccessanotherfunctionalcomputerintheofficeuntila
solutiontotheoriginalproblemcanbeapplied.RemoteDesktopcanbeinstalled
quickly.

Brandnamevendorsincludeonlineassistancewheremanyproblemscanbe
addressedefficientlywithanexperttechnicianviatheweb.Inthetechnology
worldthereisaconstantleapfroggingofhardwareperformanceandmemory
hungryfeaturesthatsoftwaredevelopersoffer.Newsoftwareupgradesmay
makeoldercomputersslowtoacrawlnecessitatingupgrades.Realizingthat
thesepossibleslowdownsoccuroftennecessitatesupdatingolderhardware
workstations.Twoapproachestohardwarearecommonlyused.Oneisto
purchaseallthecomputersinthesystematthesametimeandlimitthe
upgrades.Analternativeapproachistohavehighprioritycomputers
workstationsandusethenewestcomputersthere,withatrickledownofthe
oldercomputersfornonpatientpurposes.

Conclusion
Thedigitaldentalpracticerequiresstafftraining,infrastructureandclinical
software.Customizedclinicalsoftwarecanimprovecommunicationwithinthe
officeteam,increasepatientacceptanceoftreatmentplans,makestaffmore
productive,allowaccesstopatientrecordsfromanywhereandenablebetterand
fasterdeliveryofcare.Patientsexpecttodaysdentalofficeteamtofunctionwith
thelatesttechnology.Theywantaccesstoonlineinformationaboutyourpractice
andtobeabletodownloadpatientforms,suchasthosefortheirhealthhistory,
financialinformationandappointmentdates.Allofthisispossiblewithtodays
technologicaladvancesinclinicalsoftwareandasecurecomputerhardware
infrastructure.

Dr.GuichetisaDiplomateoftheAmericanBoardofProsthodonticsanda
graduateoftheMaxillofacialProstheticsResidencyatUCLA.Hecompleteda
ProsthodonticResidencyattheVAMCWadsworthinWestLA,aGPRatthe
VAMCinLongBeachCA,andreceivedaDDSfromUCLA.Dr.Guichet
servedasprogramchairfortheAcademyofOsseointegration,editorforthe
AcademyofOsseointegrationNewsandaspastpresidentoftheOsseointegration
Foundation.HeisaregionalDirectorfortheAmericanCollegeof
Prosthodontics.Heisamemberofmanyprosthodonticorganizationsandis
currentlyservingaspresidentelectofhislocaldentalsociety.Togetherwithhis
brotherandfatherhemaintainsaprosthodonticpracticeinOrange,California
wherehehasdevelopedandinstalledacomprehensivedigitalclinicalrecords
process

78
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8.SchleyerT,SpallekH,HernndezPJ.Aqualitativeinvestigationofthecontentofdentalpaper
basedandcomputerbasedpatientrecordformats.
AmMedInformAssoc2007;14:51526.

9.SchleyerTK,ThyvalikakathTP,MalatackP,et.al.:Thefeasibilityofathreedimensional
chartinginterfaceforgeneraldentistry.JAmDentAssoc2007;138;10721080

10.ThyvalikakathTP,MonacoV,ThambuganipalleHB,SchleyerT.Ausabilityevaluationoffour
commercialdentalcomputerbasedpatientrecordsystems.JAmDentAssoc2008;139:163242.

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Chapter9DigitalTechnologyinProsthodonticsHistorical
andFuturePerspectives

DavidGratton,DDS,MS

Sincethedawnofthenewmillennium,aplethoraofnewdigitalprosthodontic
technologieshavebeendevelopedtoenhancepatienttherapies.Conventional
dentaltherapieshavebeenaugmentedorreplacedwithnewmaterialsand
technologiesthatadecadeagoweremostlyadreamoratbest,stillonthe
drawingtable.Everyaspectofprosthodonticdentistryhasbeenaffected,from
increasedefficiencyandaccuracychairsideandinthelaboratorytohigh
strength,longlasting,estheticallypleasingprosthesesthatmeetever
heighteningpatientdemands.

Thepurposeofthisdiscussionistooutlinetherelevanttechnologiesthatare
directlyandindirectlyinvolvedwithprosthesismanufactureanddelivery.Many
ofthesetechnologiesaddressthefabricationofdentalprosthesesandcanbe
broadlycategorizedaschairsidesystems,laboratorybasedsystems,and
centralizedindustrialsystems.Thechairsidesystemscanbefurtherclassifiedas
chairsidedigitalimpressionsystemsandchairsidedigitalimpression/milling

80
systems.Thelaboratorysystemstypicallyscanstonedies,althoughsome
systemsnowclaimtheabilitytoscanconventionalimpressions.Singleand
multiunitprosthesesaretypicallymilledusing3,4,or5axismillingengines.
Thelargecentralizedindustrializedsystemsarefocusedonautomationand
production.Theboundariesbetweenthesebroadcategoriesarebecoming
blurred,asmarketforcesaredemandingtheconvenientexchangeofdigitaldata
betweensystemsandplatforms.Theadvantagesofusingprosthodontic
CAD/CAMtechnologiesforpatientcareinclude:introductionofnewmaterials,
reducedlaborinvolvement,costeffectiveness,andqualitycontrol.1

OfthefourpioneeringdentalCAD/CAMsystemstheFrenchSystem
developedbyDr.Duretin1971,2theSwissSystemdevelopedbyDr.Mormann,3
theMinnesotaSystem,4andtheSwedishSystemdevelopedbyDr.Andersson5
duringthe1980stheSwissSystemknowntodayastheCERECSystemandthe
SwedishSystemknowntodayastheProceraSystemcontinueasviablesystems.
TheCEREC1introducedtodentistryin1985wasuniqueinitsabilitytotakea
digitalintraoralimpression,createaprosthesisusingCADsoftware,andthen
milltheprosthesischairside.6Currently,intheNorthAmericanmarketthere
existfourchairsidesystems,twoofwhichalsoallowchairsidemanufacturingof
prostheses(CEREC,SironaDentalSystemsGmbH,Bensheim,Germanyand
E4D,D4DTechnologies,Richardson,TX,USA)andtwoofwhichonlyallowfor
thedigitalimpressions(iTero,CadentLtd,OrYehunda,IsraelandLavaCOS,3M
ESPE,St.PaulMN,USA).

TheCERECACsystemscannerusesavisiblebluelightfromlightemitting
diodes(LEDs).Thescannerhasaworkingfocallengthof515mm.Aseriesof
stillimagesiscapturedofthepowderedpreparation.Therestorationisthen
designedandmilledorcastscanbefabricatedthroughstereolithography.The
E4Dusesaredlaserlightoscillatingat20,000Hztocaptureimagesofthe
preparation.Powderistypicallyrequired.Therestorationisdesignedandsent
tothemillingunitforfabrication.TheLavaC.O.S.scanneremploys192LEDs
and22lenseswithapulsatingbluelighttocapturevideousingactivewavefront
samplingtechnology.Lightpowderingisrequired.Castsarecreatedusing
stereolithography.TheiTerosystem(nopowderneeded)usesalaserlightsource
andparallelconfocaltechnologytocapturethedigitaldata.Castsarethenmilled
ona5axismillingengineforuseintraditionallaboratorytechniques.However,
thedatacanalsobeexportedtoaCAD/CAMsystemforthefabricationofa
frameworkorfullcontourprosthesis.

81
InlaysandonlaysfabricatedfromfeldspathicceramicusingtheCERECsystem
havedemonstratedan88.7%survivalrateprobabilityforupto17years.7Crowns
manufacturedfromfeldsparceramicblockswiththeCERECsystemhaveshown
acumulativeKaplanMeiersurvivalof97.0%and94.6%forpremolarsand
molarsrespectively.8

Themarginalfitofcrownsandfixedpartialdenturesfabricatedfromlaboratory
basedCAD/CAMhasbeenthesubjectofseveralinvitroinvestigations.Onesuch
studiedassessedthemarginalfitoffourunitzirconiumoxidefixedpartial
denturespreandpostveneerporcelainfirings.Threesystemswereevaluated:
Everest(KaVoDentalGmbH,Biberach,DE),Procera(NobelBiocareHolding
AG,ZurichFlughafen,SUI),andLava(3MESPE3MESPE,St.PaulMN,USA)at
threetimeperiods:beforeporcelainfiring,afterporcelainfiring,andafterglaze
firing.ThemeanverticalmarginalgapinmicrometersfortheEverestsystem
were:63.37,65.34,and65.49;fortheLavasystemwere:46.30,46.79,and47.28;for
theProcerasystemwere:61.08,62.46,and63.46fortherespectivetimes.The
authorsconcludedthatthethreezirconiumoxidebasedceramicCAD/CAM
systemsachievedcomparableandacceptablemarginalfit,notingthatthegap
measurementsofLavasystemwerestatisticallysmallerthanthoseforthe
EverestandProcerasystems.Themarginalfitofthezirconiumoxidebased
ceramicfixedpartialdenturesremainedconstantaftertheporcelainfiringcycles
andtheglazecycles.9

DigitalocclusalrecordingdevicessuchastheTScanIII(Tekscan,South
Boston,MA,USA)havebeenusedtoevaluatethedistributionoftimeandforce
inocclusalbalanceandcanbeusefulasadiagnosticscreeningmethodfor
occlusalstabilityinintercuspalposition.10Inthecomputeraideddesignprocess
forcreatingacrown,sophisticatedmathematicalalgorithmsallowforpatient
specificfeaturebasedadjustmentsoflibrarytoothmorphologyprovidedthat
sufficientdatahasbeencollectedoftheproximal,opposingandcontralateral
teeth.ThroughtheuseoftheNURBS(nonuniformrationalBspline)surfaceand
asetofBsplinecurves,globalfeaturessuchascrownheightandcrownwidth
aremodifiedfirst,thenspecificocclusalfeaturessuchascusps,fossa,and
marginalridgesareadjustedtofinalizethecrowndesign.11Thisconceptofthe
biogenerictoothhasbeenshowntoofferasignificantlygreaterdegreeof
crownmorphologynaturalnessandwassignificantlyquickerindesigning
partialcrownscomparedwithconventionalsoftware.Itwasconcludedthatthe
biogenerictoothmodelgeneratesocclusalmorphologyofpartialcrownsina
fullyautomatedprocesswithhighernaturalnesscomparedwithconventional
interactiveCADsoftware.12Inconsiderationofthedynamicmovementsofthe

82
mandible,contemporarydentalCADsoftwaresystemsarebeginningto
incorporatevirtualarticulation1314andutilizedynamicmotioncaptureto
optimizetheCADdesignsuchthattheprosthesiswillfunctionalwithinthe
constraintsofthestomatognathicsystem.15

Spectrophotometersandcolorimetershavebeendevelopedtoaidtheclinicianin
takingacorrectshade.ComparingtheVitaEasyshade(Vident,Brea,CA,USA)
toconventionalvisualmeansofshadeselection,ithasbeennotedthatthe
spectrophotometermethodresultedinafivetimesmorelikelymatchtothe
originalshadecolor.However,itwasconcludedthatthesystemdoesnotsolve
alltheproblemsinherentinshadeselectionandthatthesystemrequiresfurther
refinement.16Crownsfabricatedusingdedicatedspectrophotometrictechniques
havebeenshowntohaveasignificantlybettercolormatchanddecreasedrateof
rejectionasaresultofcolordiscrepancycomparedwithcrownsproducedusing
conventionalshadeselectionmethodologies.17Asthesecomputerassisted
methodsofshadeselectioncontinuetobevalidatedclinically,importingthis
dataintodentalCAD/CAMsystemswillallowprecisepositioningofmilled
prosthesesfrommulticoloredceramicblocksandultimatelytheabilitytolayer
ceramicpowdersthroughtheinkjetprincipleorlasersintering.

CAD/CAMtechnologyisprevalentwithinimplantprosthodontics,
encompassingthedesignandfabricationofsurgicalguides,18designand
fabricationofcustomabutmentsandframeworks,andevensurgicalguidance
duringimplantplacement.19Theblendingofconebeamcomputedtomography
dataoftheosseousstructuresandopticalscansofintraoralhardandsofttissues
(takenwitheitheranintraoralscanneroralabbasedgypsumscanner)allowfor
notonlyaCAD/CAMsurgicalguide,butalsothedesignandmillingofthe
definitiveabutmentpresurgery.20Inasystematicreviewinvestigatingthe
existingevidencefromhumanclinicaltrialsinvolvingprostheticimplant
CAD/CAMtechnology,onlyfiveofthe885articlesreviewedmetthedefined
searchcriteriathreeforCAD/CAMframeworkandtwoforCAD/CAM
abutments.Theauthorsconcludedthatthepreliminaryproofofconceptfor
CAD/CAMimplantframeworksandabutmentshadbeenestablished.However,
thestudiesweretoopreliminaryandunderpoweredtogeneraterelevant
conclusionsastothelongtermsuccessandsurvivalofCAD/CAMframeworks
andabutments.21

Withanynewtechnologythereisasequenceofconsumeradopters:early
adopters,earlymajority,latemajority,andlaggards.22Theearlyadoptersdesire
moretechnologyacceptingdifficultyinoperation,basicesthetics,andflux,while

83
thelateadoptersdemandefficiency,pleasureandconvenience.Thisisrealized
throughhumancenteredproductdevelopmentanddesign.23Currently,digital
prosthodontictechnologiesaretransitioningthroughthislaterphaseofproduct
development,becomingeasiertolearnandadapttoclinicalpractice,enhancing
patientcomfort,andprovidingforefficientprosthesisfabricationworkflow.

ThroughtheleadershipofcurrentAmericanCollegeofProsthodontists(ACP)
PresidentDr.LyndonCooperandtheAmericanCollegeofProsthodontists
EducationFoundation(ACPEF)asymposiumcenteredondigitaltechnologies
pertainingtoProsthodonticswasconvenedattheUniversityofNorthCarolina
inJanuary2008.24ThisgatheringofkeyProsthodonticopinionleadersanddigital
technologyindustryleadersexploredthecurrentandemergingprosthodontic
technologies.Presentationsanddiscussionsfocusedonfivetopics:Diagnostic
Imaging,IntraoralDataCapture,CustomImplantAbutment/Prostheses,
ProsthesisFabrication,andTreatmentPlanningSoftware.Membersoffocused
breakoutsessionsdeliberatedonfourkeyquestions:WhatcantheACPdoto
promotetechnologytransferindentalschoolsandprivatepractice?Whatwill
theworkingmodelbebetweenlaboratories,dentists,andcompanies?What
researchneedsshouldbepromoted?Whatistheroleofdigitaldiagnosticsin
prosthodonticsandhowshoulditbeintegrated?Strategieswerediscussedthat
couldaidintheadoptionofthesedigitaltechnologiesbyProsthodontistsand
generaldentists,suchthatProsthodontistsarerecognizedastheleadersindigital
dentistry.Answerstoanaudienceresponsequestionnairehighlightedthat
considerableeffortwillberequiredtoclosethegapbetweenwhatisperceivedto
bepossible,whatispossibletoday,andwhatwillbepossibleinfuture.When
asked,Whenwilldigitalimpressionsreplaceconventionalmethodsformaster
impressions?,thirtyfourpercentoftheparticipantsrespondedwithin35years
and53%ofrespondentsindicatedwithin510years;however,whenasked,
Whenwillstoneandplasterbecomeobsoleteinthedentallaboratory?,forty
fourpercentofrespondentsindicatednever.If87%ofrespondentsindicatedthat
digitalintraoralimpressiontechniqueswouldreplacecurrentanalog
techniques,whatarethe44%ofrespondentswhoindicatedthatstoneand
plasterwouldneverbecomeobsoleteusingthestoneandplasterfor?The
conferenceconcludedwiththispurposefulremarkfromDr.Cooper:
Prosthodontistsareinnovationleadersandhaveformednewpartnershipsin
therapidlychangingtechnologyindustry.Togetherwewillbringclinical
improvementstothedentalcommunitybycarefultestingandevaluation,
documentationand,especially,education.

84
Whilethousandsofdentistsandtechnicianshaveintegrateddigitaltechnologies
intotheirpracticesandlaboratoriesoverthepastdecade,thousandsmorehave
yettotakemorethanafirststep.Thus,todaysprosthodontistsshareagreat
responsibility,andagreaterprivilege,toleadthedigitaldentistryrevolution
bothinresearchandinpractice,andtocontinuetomovedreamstothedrawing
table,andthentoreality.

DavidGratton,DDS,MS,AssistantProfessor,DepartmentofProsthodontics,
andClinicalDirector,CenterforImplantDentistry,atTheUniversityofIowa.
HeisaFellowoftheInternationalTeamforImplantologyandAssociateFellowof
theAcademyofProsthodontics.Hisscholarlyactivityincludesevolvingdigital
technologiesandCAD/CAMmaterials.

85
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