Fabrication edentulous Jack
B. Meyer,
of a prosthesis patients Jr., D.M.D.,*
and Rodney
to prevent C. Knudson,
D.M.D.,
sleep apnea in M.S.**
Wilford Hall U.S. Air Force Medical Center, San Antonio, Tex. This article describes clinical and laboratory technique to use in the fabrication of a prosthesis to prevent sleep apnea in the edentulous patient. The objective of the treatment is to establish a comfortable protrusive and vertical posture of the mandible that prevents or minimizes obstruction of the airway during sleep. During fabrication of the prosthesis, cepbalograms are used to assess spatial changes between the base of the tongue and the posterior pbaryngeal wall. (J PROSTHET D~~~1990;63:448-51.)
T
reatment of obstructive sleepapnea(OSA) varies from taking conservative measuresto performing invasive surgicalprocedures.’Conservative methodsinclude the use of an intraoral prosthesisthat helps the patient maintain correct posture and keep the mandible and tongue in a protrusive position to prevent or minimize tongue collapse into the oropharynx. The prosthesesdescribedin the literature have beenmade for dentate patients293 This article introduces a technique for the fabrication of a prosthesis that prevents sleepapnea in the edentulous patient.
2. Establish a vertical and protrusive jaw position 5 to 8 mm open and anterior to the physiologic rest position. Allow sufficient time for the patient to accommodateto this position. The patient shouldnot strain to maintain this posture and should showno symptoms of muscle temporomandibular joint syndrome. 3. Modify the record bases until uniform contact is achieved in both the most retruded position and the protrusive position at the increasedvertical dimension.
TECHNIQUE 1. On master casts,make record basesand place them clinically to evaluate retention and stability.
The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force, the United States Army, or the Department of Defense. *Lieutenant Colonel, DC, U.S. Army; Fellow, Maxillofacial Prosthetics. **Lieutenant Colonel, DC, U.S. Air Force; Assistant Chairman for Maxillofacial Prosthetics. 10/l/16823
Fig. 1. Radiopaquestring in place for radiographic analysis. 448
Fig. 2. Note significant increase in space (between arrows) from mostretruded mandibular position (A) to protrusive position (B). APRIL
1990
VOLUME
69
NUMBER
4
Fig. 3. Fig. 4. Fig. 5. pletion. Fig. 6.
Interocciusal jaw relation record is made at established protrusive position. Separation between maxillary and mandibular wax patterns. Continuity on buccal and lingual aspects minimizes acrylic resin needed for comProcessed portions of prosthesis are returned to articulator.
4. Embed radiopaque string into the labial surfaces of the wax occlusion rims (Fig. 1) to permit radiographic analysis. 5. Make cephalograms (1) at the physiologic rest position, (2) with the record bases at the most retruded mandibular position, and (3) at the protrusive position. The cephalograms may reveal variations in linear space between the base of the tongue and the posterior pharyngeal wall. An increase in airway space from the most retruded mandibular position (Fig. 2, A) to the protrusive position (Fig. 2, B) may be significant. 6. Make an interocciusal jaw relation record at the protrusive position (Fig. 3) and articulate the casts in a semiadjustable articulator. 7. Leave a 1 to 2 mm separation between the maxillary and mandibular occiusai surfaces when waxing is completed (Fig. 4). This space will allow for placement of acrylic resin on the opposing members of the prosthesis after processing. The buccal and lingual contours of the maxillary and mandibular wax patterns should be TEE
JOURNAL
OF PROSTHETIC
DENTISTRY
continuous (Fig. 5). An orifice is created anteriorly to assist with ventilation. 8. Seal the wax patterns and record bases to their respective casts. Invest and process in heat-cured clear acrylic resin. Before separation from the master casts, remount in the articulator. The in&al guide pin of the articulator should contact the guide table and a continuous space should exist or be provided between the maxillary and mandibular components (Fig. 6). Polish the cameo surfaces of both components before acrylic resin is used to join the opposing members. 9. Use a visible, light-curing resin (Triad, Dentsply, York, Pa.) to complete the union between the maxillary and mandibular segments. Apply bonding agent to the opposing surfaces before the light-cured resin is adapted. While it is in a moldable state, place the resin on the opposmg surfaces and close the articulator to the established vertical position. Remove excess resin before using a light source to cure the material. Direct the light source to both the buccal and the lingual surfaces 449
Fig. ‘7. A visible light source is directed to buccal (A) and lingual (Bf aspects of prostheSk
Fig. 8. Complex prosthesis. Fig. 9. Prosthesis in place. Note orifice created to assist in ventilation. to cure the material su~ciently before its separation from the articulator (Fig. 7). 10. Separate the pros~esia from the casts, place it in the Triad unit for final curing, and finish it (Fig. 8). 11. Use pressure-indicating paste clinically to reveal possible sources of tissue irritation and adjust the positions as needed. In&u& the patient on how to insert the prosthesis properly and how to remove it (Fig. 9). Provide counseling on procedures for care of the prostliesis at home. Complete dentures should be removed for a specific period during the day to avoid or minimize the adverse effects of ~ontinuo~ wear. 12. At Lhe follow-up evaluation, assess the quality of the patient’s sleep and check for the onset of hypersomnofence and other related symptoms. The prosthesis should remain stable and retentive throughout the night, and the patient should be free of myofacial or ~mporom~dib~~ joint symptoms. If dis~omfo~ develops, the prosthesis could be separated and the vertical ~~ension reduced.
450
HUNGARY We have presented a cIinicaI and laboratory technique for the fabrication of a premeds to prevent sleep apnea in the edentulous patient with OSA. By maintenance of the mandible and tongue in a protrusive position during sleep, airway collapse can be irevented or minimized. This prosthesis will be effective only if the suspected site of the obstruction is at the level of the base of the tongue and the posterior pharyngeal wall. If the o~tructive site is at the level of Lhe nasopharynx or the hypopharynx, evaluation and appropriate treatment by an otolaryngologist are warranted. A study should be conduced on patients who wear the prostheses while they sleep. The information gathered should be used to correlate subjective improvement with the number and length of apneic episodes and oxygen saturation. The edentulous patient who has an atrophic mandible and experiences poor denture retention and stability may find it difficult to retain a prosthesis designed to prevent sleep apnea. Co~ideration should be given to the place-
APRlLuwo
VOLUMEth3
NUIIBBEB4
PROSTHESIS
TO PREVENT
SLEEP
APNEA
ment of osseointegrated implants to stabilize and retain both the prosthesis designed to prevent sleep apnea and the complete denture.
2. Cartwright RD. The effects of a nonsurgical treatment for obstructive sleep apnea, the tongue retaining device. JAMA 1982;6:705-9. 3. Haze JJ. Overview of sleep disorders and their implication on dental practice. Funct Orthod 1987;4:15-7. Reprint
REFERENCES 1. Meyer JB, Knudson RC. The sleep apnea syndrome: J PROSTHET DENT 1990;63:320-4.
The longitudinal dental implants:
requests to:
DR. JACK B. MEYER, JR. WILFORD Hw USAF MEDICAL CENTER/SGDP LACKLAND AIR FORCE BASE, TX 78236-5300
part II. treatment.
clinical effectiveness of osseointegrated The Toronto study. Part I: Surgical results
G.A. Zarb, B.Ch.D., D.D.S., M.S., M.S.,* and A. Schmitt, M.SC., D.D.S.** University
of Toronto
Faculty
of Dentistry,
Toronto,
Ont.,
Canada
In this prospective study, 46 edentulous patients who had undergone traditional denture optimization therapy without success were treated with osseointegrated implants according to the surgical protocol described by Dr. P.I. Branemark. Two hundred seventy-four implants were placed in 49 dental arches-43 mandibles and six maxillae. At the time of writing, 4 to 9 years after insertion of the implants, 244 or 89.05% remained osseointegrated. Of the 262 implants in place more than 5 years, 232 or 88.55% were still integrated. The implant success criteria developed in this clinical study endorsed the predictably favorable outcome of the Branemark technique. (J PROSTHET DENT 1990;63:451-7.)
D -.
entists and their edentulouspatients are inclined to believe that well-made complete dentures can be worn satisfactorily and perhapseven indefinitely. Published evidencesuggests,however, that a significant number of denture wearersof all age groups report dissatisfaction with removable prostheses.’ The increasein life expectancy may prolong or increase the risk of such dissatisfaction, particularly becausethe supporting bone tissuesare vulnerable to adverse and resorptive changes2 Dentists’ ongoing concern with their edentulous patients’ predicament has led to considerable refinements in the techniques of denture making. Nevertheless,the introduction of scientifically tenable methods that compensatefor the adversesequelaeof a total absence of periodontal ligament have been far from compelling. Palliative measuressuchas the preprosthetic surgicalrepertoire of soft tissuevestibuloplasty, or ridge augmentation with autogenousor alloplastic bone grafts, are regardedas well intentioned but halfway biotechnology.3 The reported use of dental implants to replace missing teeth permanently hasbeen long on anecdotebut short on
science.4Several implant systemshave been, and continue to be, marketed without prior evidence of their clinical effectivenessand safety or long-term monitoring on a continuing basis.Indeed, until recently, the pursuit of a predictably safeimplant systemhasproved to be elusive.The 1982 introduction to North America of the technique of osseointegration by Branemark5 and his Swedish colleaguescatalyzed a dramatic shift in prosthodontists’ attitude regarding the feasibility and desirability of routine implantations to support dental prosthesesin edentulous patients. Branemark’s proposedtechnique is a compelling synthesis of sound biologic principles and longitudinal clinical testing.6 Endorsement of its acceptability came from the SwedishNational Board of HeaIth and Welfare7 and from the Council on Dental Materials of the American Dental Association (1988)s Recognizing the profound implications of this prosthodontic technique on patient treatment and dentist professional education, we sought to investigate the veracity of Branemark’s published claims. This is the first in a series of reports that analyze the results of a clinical study in an edentulous population group with demonstrated chronic inability to wear dentures. This report dealswith the surgical results.
Supported *Professor **Assistant
MATERIALS
by Ministry and Head, Professor,
of Health of Ontario, Grant Prosthodontic Department. Prosthodontic Department.
10/l/13691
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
PR 882.
AND
METHODS
Forty-six consecutively treated edentulous individuals participated in this study (Table I). They were selected
451
B. Meyer,
of a prosthesis patients Jr., D.M.D.,*
and Rodney
to prevent C. Knudson,
D.M.D.,
sleep apnea in M.S.**
Wilford Hall U.S. Air Force Medical Center, San Antonio, Tex. This article describes clinical and laboratory technique to use in the fabrication of a prosthesis to prevent sleep apnea in the edentulous patient. The objective of the treatment is to establish a comfortable protrusive and vertical posture of the mandible that prevents or minimizes obstruction of the airway during sleep. During fabrication of the prosthesis, cepbalograms are used to assess spatial changes between the base of the tongue and the posterior pbaryngeal wall. (J PROSTHET D~~~1990;63:448-51.)
T
reatment of obstructive sleepapnea(OSA) varies from taking conservative measuresto performing invasive surgicalprocedures.’Conservative methodsinclude the use of an intraoral prosthesisthat helps the patient maintain correct posture and keep the mandible and tongue in a protrusive position to prevent or minimize tongue collapse into the oropharynx. The prosthesesdescribedin the literature have beenmade for dentate patients293 This article introduces a technique for the fabrication of a prosthesis that prevents sleepapnea in the edentulous patient.
2. Establish a vertical and protrusive jaw position 5 to 8 mm open and anterior to the physiologic rest position. Allow sufficient time for the patient to accommodateto this position. The patient shouldnot strain to maintain this posture and should showno symptoms of muscle temporomandibular joint syndrome. 3. Modify the record bases until uniform contact is achieved in both the most retruded position and the protrusive position at the increasedvertical dimension.
TECHNIQUE 1. On master casts,make record basesand place them clinically to evaluate retention and stability.
The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force, the United States Army, or the Department of Defense. *Lieutenant Colonel, DC, U.S. Army; Fellow, Maxillofacial Prosthetics. **Lieutenant Colonel, DC, U.S. Air Force; Assistant Chairman for Maxillofacial Prosthetics. 10/l/16823
Fig. 1. Radiopaquestring in place for radiographic analysis. 448
Fig. 2. Note significant increase in space (between arrows) from mostretruded mandibular position (A) to protrusive position (B). APRIL
1990
VOLUME
69
NUMBER
4
Fig. 3. Fig. 4. Fig. 5. pletion. Fig. 6.
Interocciusal jaw relation record is made at established protrusive position. Separation between maxillary and mandibular wax patterns. Continuity on buccal and lingual aspects minimizes acrylic resin needed for comProcessed portions of prosthesis are returned to articulator.
4. Embed radiopaque string into the labial surfaces of the wax occlusion rims (Fig. 1) to permit radiographic analysis. 5. Make cephalograms (1) at the physiologic rest position, (2) with the record bases at the most retruded mandibular position, and (3) at the protrusive position. The cephalograms may reveal variations in linear space between the base of the tongue and the posterior pharyngeal wall. An increase in airway space from the most retruded mandibular position (Fig. 2, A) to the protrusive position (Fig. 2, B) may be significant. 6. Make an interocciusal jaw relation record at the protrusive position (Fig. 3) and articulate the casts in a semiadjustable articulator. 7. Leave a 1 to 2 mm separation between the maxillary and mandibular occiusai surfaces when waxing is completed (Fig. 4). This space will allow for placement of acrylic resin on the opposing members of the prosthesis after processing. The buccal and lingual contours of the maxillary and mandibular wax patterns should be TEE
JOURNAL
OF PROSTHETIC
DENTISTRY
continuous (Fig. 5). An orifice is created anteriorly to assist with ventilation. 8. Seal the wax patterns and record bases to their respective casts. Invest and process in heat-cured clear acrylic resin. Before separation from the master casts, remount in the articulator. The in&al guide pin of the articulator should contact the guide table and a continuous space should exist or be provided between the maxillary and mandibular components (Fig. 6). Polish the cameo surfaces of both components before acrylic resin is used to join the opposing members. 9. Use a visible, light-curing resin (Triad, Dentsply, York, Pa.) to complete the union between the maxillary and mandibular segments. Apply bonding agent to the opposing surfaces before the light-cured resin is adapted. While it is in a moldable state, place the resin on the opposmg surfaces and close the articulator to the established vertical position. Remove excess resin before using a light source to cure the material. Direct the light source to both the buccal and the lingual surfaces 449
Fig. ‘7. A visible light source is directed to buccal (A) and lingual (Bf aspects of prostheSk
Fig. 8. Complex prosthesis. Fig. 9. Prosthesis in place. Note orifice created to assist in ventilation. to cure the material su~ciently before its separation from the articulator (Fig. 7). 10. Separate the pros~esia from the casts, place it in the Triad unit for final curing, and finish it (Fig. 8). 11. Use pressure-indicating paste clinically to reveal possible sources of tissue irritation and adjust the positions as needed. In&u& the patient on how to insert the prosthesis properly and how to remove it (Fig. 9). Provide counseling on procedures for care of the prostliesis at home. Complete dentures should be removed for a specific period during the day to avoid or minimize the adverse effects of ~ontinuo~ wear. 12. At Lhe follow-up evaluation, assess the quality of the patient’s sleep and check for the onset of hypersomnofence and other related symptoms. The prosthesis should remain stable and retentive throughout the night, and the patient should be free of myofacial or ~mporom~dib~~ joint symptoms. If dis~omfo~ develops, the prosthesis could be separated and the vertical ~~ension reduced.
450
HUNGARY We have presented a cIinicaI and laboratory technique for the fabrication of a premeds to prevent sleep apnea in the edentulous patient with OSA. By maintenance of the mandible and tongue in a protrusive position during sleep, airway collapse can be irevented or minimized. This prosthesis will be effective only if the suspected site of the obstruction is at the level of the base of the tongue and the posterior pharyngeal wall. If the o~tructive site is at the level of Lhe nasopharynx or the hypopharynx, evaluation and appropriate treatment by an otolaryngologist are warranted. A study should be conduced on patients who wear the prostheses while they sleep. The information gathered should be used to correlate subjective improvement with the number and length of apneic episodes and oxygen saturation. The edentulous patient who has an atrophic mandible and experiences poor denture retention and stability may find it difficult to retain a prosthesis designed to prevent sleep apnea. Co~ideration should be given to the place-
APRlLuwo
VOLUMEth3
NUIIBBEB4
PROSTHESIS
TO PREVENT
SLEEP
APNEA
ment of osseointegrated implants to stabilize and retain both the prosthesis designed to prevent sleep apnea and the complete denture.
2. Cartwright RD. The effects of a nonsurgical treatment for obstructive sleep apnea, the tongue retaining device. JAMA 1982;6:705-9. 3. Haze JJ. Overview of sleep disorders and their implication on dental practice. Funct Orthod 1987;4:15-7. Reprint
REFERENCES 1. Meyer JB, Knudson RC. The sleep apnea syndrome: J PROSTHET DENT 1990;63:320-4.
The longitudinal dental implants:
requests to:
DR. JACK B. MEYER, JR. WILFORD Hw USAF MEDICAL CENTER/SGDP LACKLAND AIR FORCE BASE, TX 78236-5300
part II. treatment.
clinical effectiveness of osseointegrated The Toronto study. Part I: Surgical results
G.A. Zarb, B.Ch.D., D.D.S., M.S., M.S.,* and A. Schmitt, M.SC., D.D.S.** University
of Toronto
Faculty
of Dentistry,
Toronto,
Ont.,
Canada
In this prospective study, 46 edentulous patients who had undergone traditional denture optimization therapy without success were treated with osseointegrated implants according to the surgical protocol described by Dr. P.I. Branemark. Two hundred seventy-four implants were placed in 49 dental arches-43 mandibles and six maxillae. At the time of writing, 4 to 9 years after insertion of the implants, 244 or 89.05% remained osseointegrated. Of the 262 implants in place more than 5 years, 232 or 88.55% were still integrated. The implant success criteria developed in this clinical study endorsed the predictably favorable outcome of the Branemark technique. (J PROSTHET DENT 1990;63:451-7.)
D -.
entists and their edentulouspatients are inclined to believe that well-made complete dentures can be worn satisfactorily and perhapseven indefinitely. Published evidencesuggests,however, that a significant number of denture wearersof all age groups report dissatisfaction with removable prostheses.’ The increasein life expectancy may prolong or increase the risk of such dissatisfaction, particularly becausethe supporting bone tissuesare vulnerable to adverse and resorptive changes2 Dentists’ ongoing concern with their edentulous patients’ predicament has led to considerable refinements in the techniques of denture making. Nevertheless,the introduction of scientifically tenable methods that compensatefor the adversesequelaeof a total absence of periodontal ligament have been far from compelling. Palliative measuressuchas the preprosthetic surgicalrepertoire of soft tissuevestibuloplasty, or ridge augmentation with autogenousor alloplastic bone grafts, are regardedas well intentioned but halfway biotechnology.3 The reported use of dental implants to replace missing teeth permanently hasbeen long on anecdotebut short on
science.4Several implant systemshave been, and continue to be, marketed without prior evidence of their clinical effectivenessand safety or long-term monitoring on a continuing basis.Indeed, until recently, the pursuit of a predictably safeimplant systemhasproved to be elusive.The 1982 introduction to North America of the technique of osseointegration by Branemark5 and his Swedish colleaguescatalyzed a dramatic shift in prosthodontists’ attitude regarding the feasibility and desirability of routine implantations to support dental prosthesesin edentulous patients. Branemark’s proposedtechnique is a compelling synthesis of sound biologic principles and longitudinal clinical testing.6 Endorsement of its acceptability came from the SwedishNational Board of HeaIth and Welfare7 and from the Council on Dental Materials of the American Dental Association (1988)s Recognizing the profound implications of this prosthodontic technique on patient treatment and dentist professional education, we sought to investigate the veracity of Branemark’s published claims. This is the first in a series of reports that analyze the results of a clinical study in an edentulous population group with demonstrated chronic inability to wear dentures. This report dealswith the surgical results.
Supported *Professor **Assistant
MATERIALS
by Ministry and Head, Professor,
of Health of Ontario, Grant Prosthodontic Department. Prosthodontic Department.
10/l/13691
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
PR 882.
AND
METHODS
Forty-six consecutively treated edentulous individuals participated in this study (Table I). They were selected
451
