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Post by lernerimplants on Dec 6, 2012 13:33:59 GMT -5
Occlusal Diagnosis: Let's review this case. I know there is limited data. Forget the angled implants. Lets look at the occlusion. Its a keyhole picture. But what we can see is: 1. contact against prepared teeth in the anterior 2. no posterior support in this view 3. what looks like some anterior segment displacement more later Best Sheldon Attachments:
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Post by lernerimplants on Dec 6, 2012 14:28:50 GMT -5
Occlusal analysis: Is this case stable? Is this the vertical dimension? How do I test for that? The answer is fremitus. Fremitus is when you feel push pressure on your finger when you lay them on the facial of the anteriors during maximum intercuspation. Repeated close in a rapid fashion by the patient is indicative of an unstable occlusion. The lingual of the upper anterior teeth would only be moving facially for two reasons that I can think of. The first is that the occlusion is unstable and that the collpasing bite is shoving the incisal edge of the upper anterior teeth into the lingual of the upper anterior teeth. More later. Best Sheldon Attachments:
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Post by jasonl on Dec 13, 2012 10:07:24 GMT -5
Challenging regardless of the choice in restoring, it appears the entire upper arch would be a requirement (pretty much).
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Post by grigore1 on Dec 13, 2012 10:20:03 GMT -5
Hi , nice meeting you!
The case above raise for me the following question,,,,,,,,what was the treatment plan decided by our colleague before placing the two implants ? It is obvious that oclusal forces are not stabilizing and vertical dimension is a changing value. Whatever the restoration will be , the two implants will be overcharged.
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Post by lernerimplants on Dec 24, 2012 13:52:23 GMT -5
Hi Grigore
Thanks for coming on board. I would like to second what you are saying which is why I posted this case. I am trying to get those who are on Implant 101 to recognize that although 80-90% of implant placement, ( at least in North America), are single teeth without significant occlusal disease, a full occlusal workup is needed prior to placing more than one implant. Many would argue , ( and I am one of them), that the simple loss of a tooth requires an occlusal analysis.
Here is an obvious situation, to point out what are the first step in occlusal analysis. Is the occlusion stable or non-stable. Is the occlusal situation contributing to the overall pathology of the case. Many people have different methods of approaching this analysis. Probably most of the approaches are usable. I would just like to posit the first thing I do is check for anterior fremitus. This requires putting your index finger on the facial of the incisors and having the patient bite down in maximum intercuspation. If you feel anterior movement of the teeth, even slightly, this is indicative of an unstable occlusion that is undergoing the process towards loss of vertical dimension, or has lost some vertical dimension already and may continue to do so. A stable occlusion will not have fremitus on the upper anterior teeth. To reiterate what Grigore has stated, it would make sense to complete the occlusal analysis prior to placing the implants.
I would like to repeat what Dr. Morton Amsterdam told us, (only the old guys may know who that is, but in the USA he was a big deal- like Misch is for implants, he was that for occlusion and perio-prosthesis), there are many correct treatments, but only one correct diagnosis. The corollary to that is to make sure you have temporized and stabilized the occlusion, as well as restoring the vertical dimension via the temporization. No permanent restorations should be placed prior to knowing where you will end up. Begin with the end in mind, and in dental rehabilitation, test that end. Or as Dr. Amsterdam used to say, So goes the temporaries, so goes the case.
More to come.
Best
Sheldon
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