optical impression technique for implant crown fabrication...for optimal final placement high...

The Journal of Implant & Advanced Clinical Dentistry

Volume 5, No. 12 December 2013

Optical Impression Technique for Implant

Crown Fabrication

New Novel Approach to Guided Implant Surgery

Built-in platform shiftingDual-function prosthetic connection

Bone-condensing property

Adjustable implant orientation for optimal final placement

High initial stability, even in compromised

bone situations

NobelActive™

A new direction for implants.

Nobel Biocare USA, LLC. 22715 Savi Ranch Parkway, Yorba Linda, CA 92887; Phone 714 282 4800; Toll free 800 993 8100; Tech. services 888 725 7100; Fax 714 282 9023Nobel Biocare Canada, Inc. 9133 Leslie Street, Unit 100, Richmond Hill, ON L4B 4N1; Phone 905 762 3500; Toll free 800 939 9394; Fax 800 900 4243Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare.

NobelActive equally satisfies surgical and restorative clinical goals. NobelActive thread design progressively condenses bone with each turn during insertion, which is designed to enhance initial stability. The sharp apex and cutting blades allow surgical clinicians to adjust implant orientation for optimal positioning of the prosthetic

connection. Restorative clinicians benefit by a versatile and secure internal conical prosthetic connec-tion with built-in platform shifting upon which they can produce excellent esthetic results. Based on customer feedback and market demands for NobelActive, theproduct assortment has been expanded – dental professionals will

now enjoy even greater flexi bility in prosthetic and implant selection. Nobel Biocare is the world leader in innovative evidence-based dental solutions. For more information, con-tact a Nobel Biocare Representative at 800 322 5001 or visit our website.

www.nobelbiocare.com/nobelactive

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New data confi rm

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64_NA2010_8125x10875.indd 1 8/1/11 1:37:30 PM

The Journal of Implant & Advanced Clinical Dentistry • 1

The Journal of Implant & Advanced Clinical DentistryVolume 5, No. 12 • December 2013

Table of Contents

Built-in platform shiftingDual-function prosthetic connection

Bone-condensing property

Adjustable implant orientation for optimal final placement

High initial stability, even in compromised

bone situations

NobelActive™

A new direction for implants.

Nobel Biocare USA, LLC. 22715 Savi Ranch Parkway, Yorba Linda, CA 92887; Phone 714 282 4800; Toll free 800 993 8100; Tech. services 888 725 7100; Fax 714 282 9023Nobel Biocare Canada, Inc. 9133 Leslie Street, Unit 100, Richmond Hill, ON L4B 4N1; Phone 905 762 3500; Toll free 800 939 9394; Fax 800 900 4243Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare.

NobelActive equally satisfies surgical and restorative clinical goals. NobelActive thread design progressively condenses bone with each turn during insertion, which is designed to enhance initial stability. The sharp apex and cutting blades allow surgical clinicians to adjust implant orientation for optimal positioning of the prosthetic

connection. Restorative clinicians benefit by a versatile and secure internal conical prosthetic connec-tion with built-in platform shifting upon which they can produce excellent esthetic results. Based on customer feedback and market demands for NobelActive, theproduct assortment has been expanded – dental professionals will

now enjoy even greater flexi bility in prosthetic and implant selection. Nobel Biocare is the world leader in innovative evidence-based dental solutions. For more information, con-tact a Nobel Biocare Representative at 800 322 5001 or visit our website.

www.nobelbiocare.com/nobelactive

© N

ob

el B

ioca

re S

ervi

ces

AG

, 2

01

1.

All

rig

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res

erve

d.

TIUNITE® SURFACE,

10-YEAR EXPERIENCE

New data confi rm

long-term stability.

NOW AVAILABLE

WITH NOBELGUIDE™

64_NA2010_8125x10875.indd 1 8/1/11 1:37:30 PM

9 Partnering for Success: Bilateral Impacted Canines Restored with Dental Implants: A Case Report S. Kent Lauson, Ronald Yarosz

15 A New Novel Approach to Guided Dental Implant Surgery Lambert J. Stumpel

DID YOU KNOW?Roxolid implants deliver more treatment options

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Table of Contents

25 Comparison of Optical and Conventional Impression Techniques for Implant Crown Fabrication Michael McCracken, Dan Holt, PhD

35 Exploring the Confluence of Temporomandibular Disorders with Affective Disorders Paul J. Flaer



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JIACD (ISSN 1947-5284) is published on a monthly basis by LC Publications, Las Vegas, Nevada, USA.

Advancing the science of dental implant treatmentThe aim at Neoss has always been to provide an implant solution for dental professionals enabling treatment in the most safe, reliable and successful manner for their patients.

The Neoss Esthetiline Solution is the first to provide seamless restorative integration all the way through from implant placement to final crown restoration. The natural profile developed during healing is matched perfectly in permanent restorative components; Titanium and Zirconia prepapble abutments, custom abutments and copings and CAD-CAM solutions.

Neoss Inc., 21860 Burbank Blvd. #190, Woodland Hills, CA 91367 Ph. 866-626-3677 www.neoss.com

Esthetiline- the complete anatomicalrestorative solution


Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

Michele Ravenel, DMD, MSTerry Rees, DDSLaurence Rifkin, DDSGeorgios E. Romanos, DDS, PhDPaul Rosen, DMD, MSJoel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDHenry Salama, DMDMaurice Salama, DMDAnthony Sclar, DMDFrank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDSMichael Sonick, DMDAhmad Soolari, DMDNeil L. Starr, DDSEric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDSEmil Verban, DDSHom-Lay Wang, DDS, PhDBenjamin O. Watkins, III, DDSAlan Winter, DDSGlenn Wolfinger, DDSRichard K. Yoon, DDS

Editorial Advisory Board

Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

Founder, Co-Editor in ChiefNicholas Toscano, DDS, MS


Advancing the science of dental implant treatmentThe aim at Neoss has always been to provide an implant solution for dental professionals enabling treatment in the most safe, reliable and successful manner for their patients.

The Neoss Esthetiline Solution is the first to provide seamless restorative integration all the way through from implant placement to final crown restoration. The natural profile developed during healing is matched perfectly in permanent restorative components; Titanium and Zirconia prepapble abutments, custom abutments and copings and CAD-CAM solutions.

Neoss Inc., 21860 Burbank Blvd. #190, Woodland Hills, CA 91367 Ph. 866-626-3677 www.neoss.com

Esthetiline- the complete anatomicalrestorative solution Co-Editor in Chief

Nick Huang, MD

Blue Sky Bio, LLC is a FDA registered U.S. manufacturer of quality implants and not affi liated with Nobel Biocare, Straumann AG or Zimmer Dental. SynOcta® is a registered trademark of Straumann AG. NobelReplace® is a registered trademark of Nobel Biocare. Tapered Screw Vent® is a registered trademark of Zimmer Dental.

*activFluor® surface has a modifi ed topography for bone apposition on the implant surface without additional chemical activity.

**U.S. and Canada. Minimum purchase requirement for some countries.

Order online at www.blueskybio.com

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PGA Fast Resorb - $40.00

PGA - $30.00

Nylon - $20

Silk - $15

Bio ❘ TCP - $58/1ccBeta-Tricalcium Phosphate – available in .25 to 1mm and 1mm to 2mm

Bio ❘One StageStraumannCompatible

Bio ❘ Internal HexZimmerCompatible

Bio ❘ TrilobeNobelCompatible

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BlueSkyBio Ad-JIACD Dec.indd 1 10/26/11 12:59 PM

Wilcko et al

Background: A patient with impacted canines was referred for orthodontic evalu-ation. The orthodontist determined that the location of the canines prohibited orthodon-tic correction and the decision was made to extract the teeth and create space for implants.

Methods: Following removal of the impacted canines, orthopedic expansion appliances were used to increase bone structure of max-illa to create space for implants and improve

constricted arch. After orthodontics was com-pleted, implants were placed with no need to enhance bone structure to support implants.

Results: Aesthetically pleasing results were achieved with ideal arch form and no extraction of permanent teeth other than the impacted canines. Conclusions: This case report documents that collaboration between dental providers can provide pleasing results in difficult situations.

Partnering for Success: Bilateral Impacted Canines Restored with Dental Implants:

A Case Report

S. Kent Lauson, DDS, MS1 • Ronald Yaros, DDS2

1. Private practice limited to orthodontics. Aurora, Colorado, USA.2. Private practice limited to dental implants. Aurora, Colorado, USA.

Abstract

KEY WORDS: Dental implants, orthodontics, prosthetics


Blue Sky Bio, LLC is a FDA registered U.S. manufacturer of quality implants and not affi liated with Nobel Biocare, Straumann AG or Zimmer Dental. SynOcta® is a registered trademark of Straumann AG. NobelReplace® is a registered trademark of Nobel Biocare. Tapered Screw Vent® is a registered trademark of Zimmer Dental.

*activFluor® surface has a modifi ed topography for bone apposition on the implant surface without additional chemical activity.

**U.S. and Canada. Minimum purchase requirement for some countries.

Order online at www.blueskybio.com

CompatibilityInnovation Value

Shipping World Wide

X Cube Surgical Motor with Handpiece - $1,990.00Including 20:1 handpiece, foot control pedal, internal spray nozzle, tube holder, tube clamp, Y-connector and irrigation tube

Bio ❘ Sutures All Sutures 60cm length, 12/boxPolypropylene - $50.00

PGA Fast Resorb - $40.00

PGA - $30.00

Nylon - $20

Silk - $15

Bio ❘ TCP - $58/1ccBeta-Tricalcium Phosphate – available in .25 to 1mm and 1mm to 2mm

Bio ❘One StageStraumannCompatible

Bio ❘ Internal HexZimmerCompatible

Bio ❘ TrilobeNobelCompatible

Bio ❘ZimmerCompatible

Bio ❘NobelCompatible

Bio ❘StraumannCompatible

BlueSkyBio Ad-JIACD Dec.indd 1 10/26/11 12:59 PM

10 • Vol. 5, No. 12 • December 2013

IntRODuCtIOnIn recent years, use of dental implants has become increasingly common and general den-tists are expanding their study and use of dental implants to meet this demand. Unfortunately, in the attempt to fill this need, dentists oftentimes may only be able to offer a compromise result or a treatment plan that involves extensive orthog-nathic surgery and/or full mouth reconstruction.The following case study demonstrates a case in adult orthodontic/orthopedic treat-ment where no orthognathic surgery was used prior to placement of dental implants.

CASE REpORtA 37 year old female was seen as a new patient at the general dentist office with a chief complaint of chipped anterior teeth and an “uncomfortable bite.” Examination showed a malocclusion with a crossbite on the right. Radiographs revealed both upper canines to be palatally impacted. A deci-sion was made to refer the patient for evalu-ation of orthodontic treatment options. The comprehensive evaluation revealed a signifi-cant mid-face deficiency, partial anterior and posterior crossbites, but no TMJ dysfunction.

During the evaluation (Figures 1, 2) it was observed that her upper canine teeth were in an extreme impacted position and would be very challenging to safely bring into posi-tion orthodontically. The options discussed with the patient were to either work to bring them in orthodontically or remove them to be replaced with implants. Attempting to bring them into place orthodontically would add considerable treatment time and would increase risk to the root structures of the

adjacent teeth. It was agreed by the patient that the teeth would be surgically removed which was accomplished without incident.

To address the constricted and underde-veloped maxilla Functional Facial Orthopedics (FFO) was used to accomplish the enhance-ment needed to help to achieve facial bal-ance and allow the full complement of 28 teeth. A removable, maxillary, three-way sag-ittal appliance with anterior bite plate was used to accomplish the orthopedic correc-tion. This took eleven months to achieve, at which time fixed orthodontic appliances were placed. The orthodontic phase of treat-ment lasted 23 months in order to complete the pre-implant objectives. During the final stages of treatment, consultations between the orthodontist and dentist regarding the space needed for the implants were com-pleted. Once the space was considered ideal for the implants and the other orthodontic treatment objectives were achieved, the orth-odontic appliances were removed (Figure 3).

Orthodontic retainers with pontics to main-tain space at the canine sites were placed fol-lowed by regularly scheduled visits for retainer checks during the time the implants were heal-ing. Bilateral canine implants were placed dur-ing this time and after three months of healing, custom abutments were fabricated and two por-celain-fused-to-metal crowns were cemented (Figure 4). Due to the excellent occlusion and arch form development with the orthodontic and orthopedics, there were no compromises in the placement or restoration of the implants. The patient was extremely pleased with the cos-metic and functional results, which continues to be stable at seven years post-op (Figure 5) ●

Lauson et al


Figure 1: Photos before orthodontic/orthopedic treatment.

Figure 2: Panoramic x-ray before orthodontic treatment showing impacted upper canines.

Lauson et al

12 • Vol. 5, No. 12 • December 2013

Figure 3: Photos after the completion of orthodontic/orthopedic treatment.

Figure 4: Panoramic x-ray after placement of implants.

Lauson et al


Figure 5: Photos after the completion of dental implants.

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

CorrespondenceS Kent Lauson, DDS, MS14991 E Hampden Avenue, Suite 300Aurora, CO 80014303-690-0100 www.AOTMJ.com

Lauson et al

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Wilcko et al

Background: Guided surgery holds the prom-ise for very precise implant placement by clini-cians with various skill levels. Implementation of the computer version for smaller cases is cost prohibitive due to mandatory CBCT and CAD/CAM involvement. Model based guided surgery, with a low cost novel system, allows 1-2 implant cases to be treated with an in-office system.

Methods: A fully restrictive surgical guide is fab-ricated, in-office, for same-day surgery. Simple bone sounding is used to acquire the bucco-lin-gual cross-cut information. A simple peri-apical radiograph does reveal the mesio-distal trajectory.

Result: The placement of a single implant is planned following exact parameters. Surgery is a simple drill-press like procedure. Final posi-tion conform the planning. Immediate impres-sions allows for the placement of the definitive restoration at the second visit 6 weeks later.

Conclusion: Controlled implant place-ment following precise determination of the 3 dimensional position of a dental implant is pos-sible with a fully restrictive surgical guide. The 3D Click Guide is a low cost, in-office sys-tem that does not rely on CBCT information, although CBCT can easily integration if required.

A New Novel Approach to Guided Dental Implant Surgery

Lambert J. Stumpel, DDS1

1. Private practice San Francisco, CA., CEO, Idondivi, Inc.

Abstract

KEY WORDS: Dental implants, guided surgery


16 • Vol. 5, No. 12 • December 2013

IntRODuCtIOnA dental implant is an object in space, its posi-tion defined by coordinates in all 3 dimensional planes; x, y and z. In dentistry those planes are termed mesio-distal, buccal lingual and apical coronal. Each plane is defined following its own specific requirements, which are guided by bio-logic and prosthetic restraints. During conven-tional free hand surgery the operator develops an osteotomy in all 3 dimensions mentally com-bining all in one surgical drill path. Guided sur-gery with a fully restrictive surgical guide requires each of these planes to be considered individually based on various cross sections. A fully restric-tive surgical guide can then be fabricated combin-ing each planes trajectory into a surgical guide, which guides bone drills into a singular path.1-9

Conventional peri-apical 2 D radiography easily images the mesio-distal and apico – coro-nal plane. Note though that spatial deformation of the image can occur due to X-ray tube angu-lation. A radiographic image of the 3rd dimen-sion requires more specialized tomographic equipment. The Spiral Computerized Tomo-graph, CT, or the Cone Beam Computerized Tomograph, CBCT. Recent years have seen an explosion of systems made available through vari-ous manufactures; a true advance in dentistry, but as always at a cost that has to be justified.

Considering that 55-60% of implants are placed by the 18-20% of the US dentists placing implants. (Straumann, AG, public investor data 2012), own-ing a CBCT machine might not be economically feasible for many. In addition we see that a grow-ing number of clinicians are placing implants, but with a lower total number of implants placed per operator. This of course has implications for the

surgical skill compared to clinicians placing many hundreds of implant per year. Fully restrictive guided surgery requires less skill compared to freehand surgery, even in absolute terms it might even produce better result.10-12 The development of the workforce, more, less expe-rienced, dentist placing implants would make a good argument for fully guided surgery. At the same time controlling the cost of medi-cal care in relation to the outcome will be a future issue. The “3D Click Guide” has been developed to allow for very precise implant placement that is low cost and easily accessi-ble for the common 1-2 implant cases. Case selection is of the utmost importance, know-ing when to refer, and knowing when to treat should be made before a case is started, not an afterthought of poor treatment planning. The International Team for Implantology (ITI) has developed an excellent classification sys-

Figure 1: 5 soft tissue depth measurements are taken per implant site. Using only topic anesthetic, a short dental needle and an endodontic stopper. Data acquisition is accomplished in under 1 minute.

Stumpel


tem (SAC-system), which will aid the clinician in matching the case, to their clinical ability. The system has 3 main categories: Straight-forward, Advanced and Complex. It even has a web based version of the SAC Assessment Tool, free of charge (www.iti.org). This article depicts a case which would be considered S (straightforward), future articles will show more advanced applications of the 3D Click Guide.

ClInICAl CASEA healthy 45 year old patient presented with a missing lower second premolar. Large torri give the impression of an abundance of bone, but hide a lingual concavity. A stock tray was filled with stiff VPS putty (Examix, GC, Alsip, IL) and cov-ered with a thin sheet of food foil (Saran wrap, SC Johnson, Racine, WI). Once placed in the

Figure 2: The cast is cut at the approximate Mesio-Distal implant axis, to access the cross-sectional view.

Figure 3: The soft tissue readings are transferred, the prosthetics driven Bucco-Lingual implant axis is marked and a hole is drilled indicating the shoulder of the implant.

Figure 4: The Bucco-Lingual- Positioner (BLP) is placed into the drilled hole, and lined up with the desired BL- axis, then secured with cyano-acrylate glue.

Figure 5: The BLP locks in the Bucco-Lingual position and the depth of the shoulder of the implant and is now ready to accept the wing assembly.

Stumpel

18 • Vol. 5, No. 12 • December 2013

mouth finger pressure pushes the putty against the lingual and buccal soft tissue. This will result in a tight adaptation of the soft tissue against the bone. Upon setting, a small portion of new putty was mixed and added to the buccal and lingual

of the impression at the treatment area. Again covered with food foil, and placed back into the mouth. Additional finger pressure will push down the soft tissue and actively overextend the impres-sion. The tray was removed from the mouth, as

Figure 6: The Buccal and Lingual wings are placed for the ideal Mesio-Distal position, while maintaining the previously set Bucco-Lingual. Note that the MD angle is a best estimate.

Figure 7: The finished surgical guide, with the rails exposed once the cross member has been removed.

Figure 8: The Radiographic Implant Replica’s (RIR’s) are not overlapping, indicating a non-diagnostic radiograph.

Figure 9: The RIR’s overlap, indicating a diagnostic radiograph. The selected Mesio-Buccal trajectory should be rotated 3 degrees towards the distal using the yellow rotation-block.

Stumpel


Figure 10: 3 rotation-blocks are available, 0, 3 and 7 degree.

Figure 11: The soft tissue is removed with a diamond bur for flapless implant placement.

was the foil. This pre-impression was now filled with injection VPS material and repositioned. The resulting impression captured a much larger area of the crest then we are commonly used to in dentistry. A topical anesthetic was placed and 5 tissue thickness readings performed, with a 27G Short anesthetic needle (Fairfax Den-tal, Miami, FL) and a rubber endostop (Fig 1).

The impression was poured using dental stone (Earth Stone, Tak System Inc., Whareham, MA) into a base former (Accutray System, Coltene- Whaledent, Inc., Cuyahoga Falls, OH). A dual layer vacuform carrier was created. Using 1mm soft-guard material + 0.75 mm bondable mate-rial, heated together (Essix A+ and model duplica-tion material, Dentsply Raintree Essix , Sarasota, FL). The cast was cut along the Mesio-Distal path of the proposed MD axis for the implant. The cut is based on an estimation of neighboring roots and the center of the tooth that will be replaced.

Using radiograph and anatomical information, next was the transfer of the five tissue thickness readings to the cut face of the cast. The mark-ings connect parallel to the soft tissue (Fig. 2).

The desired BL implant axis was marked on the cast relative to bone volume and central fossa. The desired top of implant determined and a 2 mm hole drilled at the implant axis. The top of the implant is generally 2-3 mm below the buc-cal gingival outline. This placement will place the top surface of the rotation block 9 mm above the shoulder of the implant (9 +1= 10 mm above the drill-guide). The blue Bucco-Lingual Positioner (BLP) was placed in the hole and line up with the drawn axis. Next secured with fast setting Cyano-acrylate glue.(Instant Krazy Glue, Krazy Glue, Columbus, OH) (Figs. 3-5). The correction slot of a buccal wing (Yellow) was placed on top of the BLP. The wings/ Radiographic Implant Rep-

Stumpel

20 • Vol. 5, No. 12 • December 2013

Figure 12: The 2.0 18.7 mm Astra twist drill for an 8.7 mm deep osteotomy. 18.7 minus 10 mm. The prolongation is 10 mm.

Figure 13: The 3.2 18.7 mm Astra twist drill enlarging the osteotomy.

lica’s (RIR’s) cut/bend as needed for passive fit. The Lingual wing (White) was attach and adjusted. The complete assembly positioned on top of BLP. The position between the teeth is good since the teeth can be seen; the set angle is a best estimate, requiring X-ray confirmation. The wings and RIR’s were secured with PMMA ortho-acrylic (Ortho Resin, Dentsply, York, PA) to create an irreversible solid connection (Fig. 6). Once the cross-member was removed, the retention rails were exposed (Fig. 7).

The surgical guide was placed in the mouth and a peri- apical radiograph taken. If the RIR’s are not overlapping (Fig. 8), then the radiograph

is deformed and does not show the true dimen-sions. The adjusted tube head of the X-ray unit showing both RIR’s overlapping; the X-ray image is diagnostic. In this case it was deter-mined that the selected mesio-distal trajectory would encroach on the apex of the premolar (Fig. 9). The 3D Click Guide system allows for instantaneous correction of the only aspect that has been estimated; the mesio-distal inclination. It provides a selection of 3 different rotation blocks that click into the rails of the surgical guide: zero degree (green), 3 degree (yellow) and 7 degree (red) (Fig. 10). In this case a 3 degree yellow block was selected to rotate the

Stumpel


Figure 14: The 8 x 4 Astra Speed implant placed in a semi guided fashion.

Figure15: Birdseye view of the implant in position.

Figure 16: Impression at time of implant placement. Staging the set of the VPS prevents contamination of the surgical site.

Figure 17: The finished screw retained restoration based on an Atlantis Crown Abutment.

trajectory away from the apex of the premolar.After local anesthetic was given, the soft

tissue was removed with a diamond bur. The osteotomy was prepared following the manu-facturers protocol and an 8 x 4 mm implant placed (Osseo-speed, Astra Tech, Waltham, MA) Good initial stability was confirmed with an ISQ of 75 (Figs. 11-15). An impression

coping was placed and a very small quan-tity of thin VPS was applied, this was allowed to set. This prevented impression mate-rial of being pushed into the fresh surgical wound when the full impression was taken. The dental laboratory made the final restora-tion, which was placed at the second appoint-ment, six weeks after implant placement.

Stumpel

22 • Vol. 5, No. 12 • December 2013

Figure 18: The crown is torqued to 25 N/cm. Note the ideal gingival contours.

Figure 19: The screw access hole is positioned exactly as planned for a screw retained resotoration.

Figure 20: The finished restoration, delivered at the second appointment. Six weeks post implant placement.

COnCluSIOnThree dimension implant placement is driven by clinical and prosthetic requirements. The clinical execution in a free handed or limited guided manner is still highly dependent on indi-vidual operator skill. Fully restrictive surgical guides allow operators with less experience to place implants expertly and experienced cli-nicians to do so more expediently. Computer

generated surgical guides are less economi-cal and time consuming for smaller cases. An analog fully restrictive surgical guide was developed for just those cases. The 3D click Guide is an ‘in-office’ model-based surgi-cal concept using data from bone sound-ing measurements or, if desired, CBCT. ●

CorrespondenceDr. Lambert Stumpel450 Sutter Street, suite 2530San Francisco, CA 94108Phone: 415 362 7269Fax: 415 362 0925Mobile: 415 517 4441www.Stumpeldds.com

Stumpel


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DisclosureDr. Stumpel reports that he is the CEO, Idondivi, Inc.

References1. Quinlan P, Richardson CR, Hall EE. A multipurpose template for implant

placement. Implant Dent. 1998;7:113-21.

2. Mizrahi B, Thunthy KH, Finger I. Radiographic/surgical template incorporating metal telescopic tubes for accurate implant placement. Pract Periodontics Aesthet Dent. 1998 Aug;10:757-65

3. Weinberg LA, Kruger B. Three-dimensional guidance system for implant insertion: Part I. Implant Dent. 1998;7:81-93.

4. Atsu SS. A surgical guide for dental implant placement in edentulous posterior regions. Prosthet Dent. 2006 Aug;96:129-33.

5. Shotwell JL, Billy EJ, Wang HL, Oh TJ.Implant surgical guide fabrication for partially edentulous patients. J Prosthet Dent. 2005 Mar;93:294-7.

6. Meitner SW, Tallents RH. Surgical templates for prosthetically guided implant placement. J Prosthet Dent. 2004 Dec;92:569-74.

7. Windhorn RJ. Fabrication and use of a simple implant placement guide. J Prosthet Dent. 2004 Aug;92:196-9.

8. Tsuchida F, Hosoi T, Imanaka M, Kobayashi K. A technique for making a diagnostic and surgical template. J Prosthet Dent. 2004 Apr;91:395-7.

9. Stumpel LJ 3rd. Cast-based guided implant placement: a novel technique. J Prosthet Dent. 2008 Jul;100(1):61-9.

10. Farley NE, Kennedy K, McGlumphy EA, Clelland NL. Split-mouth comparison of the accuracy of computer-generated and conventional surgical guides. Int J Oral Maxillofac Implants. 2013 Mar-Apr;28(2):563-72.

11. Cushen SE, Turkyilmaz I. Impact of operator experience on the accuracy of implant placement with stereolithographic surgical templates: an in vitro study. J Prosthet Dent. 2013 Apr;109(4):248-54.

12. Nokar S, Moslehifard E, Bahman T, Bayanzadeh M, Nasirpouri F, Nokar A. Accuracy of implant placement using a CAD/CAM surgical guide: an in vitro study. Int J Oral Maxillofac Implants. 2011 May-Jun;26(3):520-6.

Stumpel

Wilcko et al

Background: Recent advances in digital technology now allow clinicians to use digi-tal impression techniques to fabricate implant crowns without stone models. However, little data is published on these new techniques. The purpose of this article is to compare clini-cal crowns produced using optical impres-sions and conventional impression techniques.

Methods: Patients were randomized in this prospective clinical trial to either conventional impression or digital impression groups. Con-ventional impressions were made using stan-dard techniques, with an impression coping and polyvinylsiloxane (PVS) impression materials. Digital impressions were made using an opti-cal scanner with a scan body placed on the implant. The following outcomes were recorded: time to insert the crown (seconds), a qualita-tive assessment of crown quality (scale from 1-4; 1=poor and 4=excellent), and whether

the crown required occlusal adjustment.

Results: Eighteen crowns were analyzed in this study, with 9 in each group. The average time to insert a crown manufactured from a digital impression was 120 ± 46 sec.; for the conventional impression group it was 401 ± 334 sec. These were significantly different (p < 0.01). The average qualitative score for crowns made using a digital technique was 3.1 ± 0.6, while the score for conventional impression technique was lower at 2.67 ± 0.7. In the con-ventional group, 5 crowns required occlusal adjustments. In the digital impression group, only one crown required occlusal adjustments.

Conclusions: Single-implant crowns produced with optical impressions took significantly less time to seat clinically than crowns produced by conventional techniques. Both techniques produced clinically acceptable restorations.

Comparison of Optical and Conventional Impression Techniques for Implant Crown Fabrication

Michael McCracken, DDS, PhD1 • Dan Holt, PhD2

1. Professor, University Alabama Birmingham School of Dentistry, Birmingham, Alabama, USA

2. Foundry Dental Center, Bessemer, Alabama, USA

Abstract

KEY WORDS: Optical impression, implant, crowns, digital impression


26 • Vol. 5, No. 12 • December 2013

INTRODUCTIONClinicians strive for more accurate and more efficient impression techniques for prosthodontic restorations. This can be particularly important for implant restora-tions, where the limited mobility of implants demands greater impression precision.

Recent advances in technology have made optical impressions a viable technique for fixed restorations.1, 2 Traditional impres-sion techniques are associated with poten-tial sources for error. Christensen3 cites that flexibility of impression trays, separation of impression material from the tray, and distor-tion of impression during shipping or inade-quate storage can all increase the inaccuracies of the impression prior to pouring. Expansion of dental stone, which can vary from approxi-mately 0.04 to 0.3% (ANSI/ADA 1987), is

another source of error associated with con-ventional impressions. In addition, impres-sions that are lost, or damaged during removal of an improperly poured cast must be retaken, the cost of which for full-arch impressions using a stock tray can be up to 40 dollars.3,4

Although digital impressions eliminate many of the negative characteristics of conventional impressions, their accuracy compared to con-ventional impressions is a matter of some controversy in the literature. Ender and Mehl (2011),5 for example, found no significant dif-ference in the accuracy of digital impres-sions taken by the Cerec AC Bluecam and the Lava™ Chairside Oral Scanner (Lava COS) system and conventional impressions on an in-vitro model. Syrek et al.,6 however, found that the marginal fit of crowns fabricated using the Lava COS was significantly more accurate than

Figure 1: Implant in area of #19. This implant was placed slightly to the buccal, and would benefit from a custom abutment to correct position and present a finish line at the crest of tissue for easy cement removal.

Figure 2: Scan body. PEEK abutments are commercially available to fit a large number of implant platforms. While this is not a Zimmer implant, the prosthetic platforms are identical and this scan abutment can be used for the impression.

McCracken et al


those fabricated from conventional impres-sions. Lee and Gallucci7 performed a study in which second year dental students took both conventional and digital impressions to mea-sure efficiency, difficulty, and operator’s pref-erence for the two techniques. They found the total time to take a conventional impres-sion for a single implant site was nearly twice that to take a digital impression. Students also considered the conventional impressions significantly more difficult to perform than the digital impressions, and the majority pre-ferred digital over the conventional technique.

The scanner used in this study is based on the principle of active triangulation using a laser sheet light projection. Because the light projector and imaging aperture automati-cally move back and forth on a track within the wand, an entire quadrant may be imaged with only three scans (buccal, lingual and occlu-

sal scans).8 Although the digital scanner has been used effectively to make tooth-supported restorations, the utility of the digital impres-sion for implants restorations is unknown.

The purpose of this study was to compare the clinical acceptability of implant crowns fab-ricated from intraoral digital impressions (IOS FastScan; IOS Technologies, INC, U.S.A.), to implant crowns fabricated from conven-tional polyvinylsiloxane (PVS) impressions.

METHODSSingle-unit implant restorations were included in this study. All implants included in the study were single implants with an internal hex connection (Tapered Internal Implant; Bio-Horizons, Birmingham, AL.). Inclusion cri-teria for this trial included the following:

● Patients of age 19 years old or more● An integrated and healthy single

implant suitable for restoration with a cement-retained crown and a custom CAD/CAM titanium abutment

● Opposing contact in the opposite arch on natural teeth or fixed restorations

● At least one proximal contact● Able to provide consent for treatment

Patients were recruited from the existing group of patients within the practice. Once enrolled, patients were assigned to treatment groups using random card selection in a randomized block design. The two treatment groups tested were Conventional Impressions (PVS impres-sions and stone working casts) and Digital Impressions (intraoral optical digital impressions with no stone working cast). The conventional impression was considered the control group.

Figure 3: Scan body in seated on implant. The scan body tightened with light finger pressure on the implant to serve as a marker for the digital impression. This impression registers the position of the implant as well as the timing of the internal hex connection.

McCracken et al

28 • Vol. 5, No. 12 • December 2013

Patients receiving conventional impressions were treated in the following manner: healing abutments were removed from the implants and impression copings were placed; complete seat-ing of the impression coping was verified clini-cally using radiographs and/or direct visualization; wax was placed in the hex driver hole to keep

out unwanted impression material; the impres-sion was made using plastic stock trays (COE Spacer Disposable Tray; GC America, Alsip, Ill.) and a PVS impression material (Capture; Glide-well Laboratories, Newport Beach, Cal.); a light body PVS was syringed around the impression coping, and a medium body material was used to fill the tray; impression copings were removed, attached to an appropriate analog, and inserted into the impression; opposing casts were fab-ricated using irreversible hydrocolloid (Identic Singles Fast Set; Patterson Dental, Pelham, Ala.) and metal stock trays (COE Metal Impression Trays; GC America); casts were hand articulated.

Patients receiving digital impressions were treated in the following manner: the healing abut-ment was removed, and a polyether ether keytone (PEEK) scan abutment was placed (Scan Abut-ment; Glidewell Laboratories); scan abutments are available for a variety of implant platforms and sizes. The quadrant was then sprayed with a non-reflective powder (IOS Fastscan Poweder; Glidewell Laboratories), and scans were captured according to manufacturer’s instructions (IOS Fastscan; Glidewell Laboratories) of the occlusal, lingual, and buccal views of both the mandibular and maxillary quadrant containing the restoration; scans were also made of the distal and mesial interproximal contacts. If the scanning abutment prevented an unobstructed view of the interproxi-mal contacts, it was removed for these scans; last, a buccal scan was made while the patient in the closed into position to serve as a bite registration.

For both groups, cement-retained crowns were fabricated by a single laboratory (Glide-well Laboratories). Crowns were made from monolithic zirconia (Bruxzir; Glide-well Laboratories); abutments were cus-

Figure 4: Scan body, dusted for optical impression. The scan body is sprayed with a non-reflective coating to generate the optical impression.

McCracken et al


tom milled titanium CAD/CAM abutments. Outcome measures for this study were time

of insertion, amount of occlusal adjustments required, and a qualitative assessment (1-4) made by a single, experienced clinician. The cli-nician was blinded to the group or mode of fab-rication for each crown by returning only the abutment and crown to the clinician for insertion.

Time to insertion was defined as the length of time required to remove the healing abutment, seat the custom abutment, and insert the crown with appropriate proximal and occlusal contacts. Time was measured with a stopwatch in seconds. Time required to torque the abutment and cement the restoration was not included. After seating the crown, a qualitative ranking between 1 (poor) and 4 (excellent) was given by the dentist with respect to the overall fit and quality of the crown. The following guidelines were used in the ranking:

● 4 - Excellent. Minimal proximal or occlusal adjustments. Crown is prop-erly contoured and has pleasing emergence profiles and esthetics.

● 3 – Good. Some adjustments required on the proximal or occlusal contacts. Crown is properly contoured with pleas-ing emergence profile and esthetics.

● 2 – Acceptable. Significant adjust-ments to proximal or occlusal contacts required, but crown is usable. Crown has limitations in contours and esthet-ics but is clinically acceptable.

● 1 – Unacceptable. Adjustments in the proximal or occlusal contacts make crown unusable. Crown rocks on abut-ment. Contours are not consistent with physiological requirements and can-not be corrected with adjustments.

Finally, the presence or absence of occlu-sal adjustment was noted for each crown.

STATISTICAl ANAlYSISIndividual Mann-Whitney U tests were con-ducted to determine whether the time to fit a crown differed between the digital and con-ventional categories. Results were considered significant with alpha = 0.05. To dismiss the possibility that two outliers, arising from patients whose crowns took an exceptionally long time to fit (1021 and 886 seconds, both conven-tional impressions) could be responsible for the difference seen in fitting time, the outliers were removed, and the statistical test was run again.

Mann-Whitney U tests were also conducted to determine whether the qualitative ranking given to crowns at the time of delivery differed between the digital and conventional categories.

Figure 5: Crown and abutment. A titanium alloy abutment and monolithic zirconia crown are returned from the lab. Note that no stone model was generated to fabricate this abutment in crown. It was all designed on a computer and milled.

McCracken et al

30 • Vol. 5, No. 12 • December 2013

RESUlTSEighteen implant crowns were analyzed for this study, with 9 in each group. The con-ventional group contained 7 males and 2 females, with an average age (± SD) of 46.6 (± 18.4) years. The digital impres-sion group contained 6 males and 3 females, with an average age (± SD) of 42.4 (± 19.2) years. The conventional impression group contained 7 posterior and 2 anterior resto-rations, while the digital impression group con-tained 5 anterior and 4 posterior restorations.

The average time to insert a crown manufac-tured from a digital impression was 120 ± 46 sec. The averaged time to insert a crown in the

conventional impression group was 401 ± 334 sec. Removing two outliers, the average time to insert a crown in the conventional impression group was 243 ± 130 sec. Time for insertion was significantly different for digital impression and conventional impression groups (p < 0.01).

The average qualitative score for crowns made using a digital technique was 3.1 ± 0.6. The average qualitative score for crowns made using conventional impression tech-nique was less at 2.67 ± 0.7. Although the trend was toward significance, these scores were not significantly different (p = 0.15).

In the conventional group, 5 crowns required occlusal adjustments. In the digi-tal impression group, only one crown required occlusal adjustments. All crowns had appro-priate occlusion following insertion. Stated differently, no crowns were out of occlusion.

DISCUSSIONThis scanning technology examined in this paper has its origins in laboratory processes used to fabricate CAD/CAM abutments. Typically, a clinician might make a conventional implant impression and send it to the lab for a CAD/CAM abutment and crown. To fabricate the abutment, the lab places a scan abutment on the traditional cast, and scans the cast to cre-ate a digital working model. The abutment and crown can then be designed, milled, and seated on the physical cast. It was a small, but innova-tive step, to move the same scan abutment to the mouth, scan in the mouth, and go directly to the design phase with no physical cast.

In this study, the performance of digital impression techniques compared favorably to conventional techniques. The lower time

Figure 6: Abutment is seated on the implant and torqued to 30 Ncm.

McCracken et al


Figures 7-9: Final crown is inserted. Minimal adjustment was needed to place the crown clinically. Appropriate clinical contours are obtained.

Figure 7

Figure 8

Figure 9

for insertion for the crowns made with digi-tal impressions may reflect greater precision of the technique. They simply fit better, espe-cially in regard to occlusal and proximal adjust-ments. Most of the crowns fabricated using a digital impression went to place with no adjust-ments at all. This was something of a surprise to the authors, who considered that the digi-tal technique might produce similar crowns, but not better crowns, than the conventional techniques. These findings are similar to an in vitro analysis of digital impressions for implant impressions5 which documents an accuracy of 55 um (± 21.8) for conventional techniques,

compared to 49 um (± 14) for casts produced with digital impressions. The authors con-clude that accuracy of both methods is similar.

These results contrast to one study that found digital impression techniques were less accurate than traditional techniques.9 However, in this study the healing abutment was scanned, rather than a scan abutment, which may pro-duce more errors. The longer standard impres-sion coping used in our study may provide more surface area and greater length, leading to increased precision. While little is published on the clinical efficacy of digital impressions for implant crowns, may studies examine digi-

McCracken et al

32 • Vol. 5, No. 12 • December 2013

tal impression accuracy for casts and natural teeth, especially when considering in vitro stud-ies. Kim et al. determined digital impressions differed from originals by 17.6 um (± 45.6), while conventional techniques produced casts were accurate to within 23.9 um (± 17.6).10 One clinical study found the marginal gap for crowns produced with digital impressions to be 130 um on the midaxial location, which the authors concluded was an acceptable clinical outcome.11 Another in vitro analysis found mar-ginal discrepancies of about 50 um, and also concluded that these values compared well to conventional techniques.12 Several other arti-cles find that digital impressions produce casts, crowns, and clinical outcomes which com-pare favorably to conventional impressions.13-19

Digital impression techniques offer some efficiency advantages compared to conven-tional techniques. Because digital files are sent electronically, the clinician saves on shipping costs. Also, most laboratories offer reduced fees for digital impression cases as the cost of production is lower because no cast is poured or physically articulated. Digital impressions take less time for beginning clinicians,7 and may offer some esthetic outcome advantages.20, 21

While a difference in seating time was evi-dent in these data, the qualitative assessment was not significantly different. This may be due to the favorable clinical situation associated with the custom milled CAD/CAM abutments. Generally, these abutments facilitated quick and easy crown insertion by effectively correct-ing angulation and position irregularities, and by placing an ideal finish line at the crest of tissue. With a favorable foundation, the overall resto-ration was evaluated positively in many cases.

All restorations were deemed clinically acceptable. Two restorations, both in the conventional impression group, required sig-nificant occlusal adjustment to achieve harmo-nious contacts. While the reason for this was not apparent, it is possible that the centric jaw relationship or mounting was incorrect, lead-ing to inaccuracies in the final restoration.

CONClUSIONSSingle-implant crowns produced with opti-cal impressions took significantly less time to seat clinically than crowns produced by con-ventional techniques. Both techniques pro-duced clinically acceptable restorations. ●

Correspondence:Dr. Michael McCrackenProfessor, UAB School of Dentistry1919 Seventh Ave SouthBirmingham, Alabama 35294Phone (205) 587-9486Email [email protected]

McCracken et al


DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. Priest G. Virtual-designed and computer-milled implant abutments. J Oral

Maxillofac Surg 2005;63(9 Suppl 2):22-32.

2. Miyazaki T, Hotta Y, Kunii J, Kuriyama S, Tamaki Y. A review of dental CAD/CAM: current status and future perspectives from 20 years of experience. Dent Mater J 2009;28(1):44-56.

3. Christensen GJ. Will digital impressions eliminate the current problems with conventional impressions? J Am Dent Assoc 2008;139(6):761-3.

4. Glassman S. Digital impressions for the fabrication of aesthetic ceramic restorations: a case report. Pract Proced Aesthet Dent 2009;21(1):60-4.

5. Ender A, Mehl A. Full arch scans: conventional versus digital impressions--an in-vitro study. Int J Comput Dent 2011;14(1):11-21.

6. Syrek A, Reich G, Ranftl D, et al. Clinical evaluation of all-ceramic crowns fabricated from intraoral digital impressions based on the principle of active wavefront sampling. J Dent 2010;38(7):553-9.

7. Lee SJ, Gallucci GO. Digital vs. conventional implant impressions: efficiency outcomes. Clin Oral Implants Res 2013;24(1):111-5.

8. Logozzo SG, Franceschini A, Kilpela M, et al. A comparative analysis of intraoral 3d digital scanners for restorative dentistry. Int J Med Tech 2011;5:1-3.

9. Howell KJ, McGlumphy EA, Drago C, Knapik G. Comparison of the accuracy of Biomet 3i Encode Robocast Technology and conventional implant impression techniques. Int J Oral Maxillofac Implants 2013;28(1):228-40.

10. Kim SY, Kim MJ, Han JS, et al. Accuracy of dies captured by an intraoral digital impression system using parallel confocal imaging. Int J Prosthodont 2013;26(2):161-3.

11. Brawek PK, Wolfart S, Endres L, Kirsten A, Reich S. The clinical accuracy of single crowns exclusively fabricated by digital workflow-the comparison of two systems. Clin Oral Investig 2013.

12. Seelbach P, Brueckel C, Wostmann B. Accuracy of digital and conventional impression techniques and workflow. Clin Oral Investig 2012.

13. Almeida ESJS, Erdelt K, Edelhoff D, et al. Marginal and internal fit of four-unit zirconia fixed dental prostheses based on digital and conventional impression techniques. Clin Oral Investig 2013.

14. Cook KT, Fasbinder DJ. Accuracy of CAD/CAM crown fit with infrared and LED cameras. Int J Comput Dent 2012;15(4):315-26.

15. Scotti R, Cardelli P, Baldissara P, Monaco C. Clinical fitting of CAD/CAM zirconia single crowns generated from digital intraoral impressions based on active wavefront sampling. J Dent 2011.

16. Touchstone A, Nieting T, Ulmer N. Digital transition: the collaboration between dentists and laboratory technicians on CAD/CAM restorations. J Am Dent Assoc 2010;141 Suppl 2:15S-9S.

17. Ender A, Mehl A. Influence of scanning strategies on the accuracy of digital intraoral scanning systems. Int J Comput Dent 2013;16(1):11-21.

18. Guth JF, Keul C, Stimmelmayr M, Beuer F, Edelhoff D. Accuracy of digital models obtained by direct and indirect data capturing. Clin Oral Investig 2013;17(4):1201-8.

19. Bindl A, Mormann WH. Marginal and internal fit of all-ceramic CAD/CAM crown-copings on chamfer preparations. J Oral Rehabil 2005;32(6):441-7.

20. Joda T, Wittneben JG, Bragger U. Digital implant impressions with the “Individualized Scanbody Technique” for emergence profile support. Clin Oral Implants Res 2013.

21. Lin WS, Harris BT, Morton D. The use of a scannable impression coping and digital impression technique to fabricate a customized anatomic abutment and zirconia restoration in the esthetic zone. J Prosthet Dent 2013;109(3):187-91.

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Wilcko et al

Background: Diagnosis and relief of the symp-tomatology and dysfunction in the temporo-mandibular joint (TMJ) and associated orofacial musculature, known generally as Temporoman-dibular Disorder (TMD), continues to be the con-cern of dental and medical professionals. This critical report paints TMD as an insidious malady with a myriad of symptoms, both somatic and psychological. This psychological symptomol-ogy of TMD is usually expressed as belonging to one of the affective (mood) disorders (e.g., depression or bipolar disorder). Furthermore, the psychogenic symptoms of TMD may undergo somatization, the process of conversion of men-tal symptomology into physical symptomology.

Methods: A demonstrative model of the symp-tomatic course of TMD running alongside that of bipolar disorder is presented. Treatment modes of the disorder are based upon an understand-ing of the far reaching manifestations and inter-actions of mental and somatic disorders and are presented in a flow chart of TMD therapy

Results: TMD symptomatology and underly-ing psychopathology are closely interrelated and often clinically indistinguishable. Psychopa-thology and subsequent somatization impact-ing TMJ function are generally expressed as increased risk of pain related disability, poor treatment outcome, increased health care uti-lization, and potentially iatrogenic treatment. A multi-disciplinary approach of accessing both somatic and psychogenic symptomology in for-mulating a treatment plan for TMD serves the best health interests and wellbeing of the patient.

Conclusions: TMD and affective disorders are interactional and dynamic conditions, involving triggering points, predisposers, and buffering components in psychological and somatic pain progression. However, psychopathology may run an insidious, background course of expression alongside TMD symptomatology. Exploration of the interface of psychological and physical fac-tors of TMD is the key to determining the sever-ity of the overall clinical condition of the patient and the subsequent pathways of treatment.

Exploring the Confluence of Temporomandibular Disorders with Affective Disorders

Paul J. Flaer, DDS, EdD, MPH1

1. Co-Chair, Oral Diagnosis and Treatment Planning Section; Faculty, Residency Program Dade County Dental Research Clinic

Abstract

KEY WORDS: Temporomandibular Disorder (TMD), Affective Disorders, Psychopathology


36 • Vol. 5, No. 12 • December 2013

IntRODuCtIOnThis critical review describes the implications of the diagnosis of psychopathology in conjunc-tion with Temporomandibular Disorder (TMD) as to symptomatology and clinical treatment modes. There appears to be a “duel diagnosis” of psychiatric factors that coexist with physi-cal symptoms of TMD.1 Early studies (i.e., circa 1990) of this “duel diagnosis” did not conclu-sively reveal the connection between psychiat-ric disorders and TMJ dysfunction or orofacial pain.2 However, further studies revealed that

the diagnosis of TMD often includes an underlying chronic mental disorder.3,4

Among individuals seeking treatment for TMD, pain is the most common symp-tom.1 Psychiatric symptomatology may pre-dominate in the TMD patient and be masked by pain or functional dystrophy of the tem-poromandibular joint (TMJ). Psychopathol-ogy, chronic pain, and dysfunction can run an insidious course and background milieu of expression in the life of the TMD patient.5 Therapeutic models of the confluent symptom-

Table 1: Model of Progression of Concurrent TMD & Bipolar Disorder

Flaer


atologies in formulating a comprehensive and ongoing treatment plan are based upon an understanding of the far-reaching manifestations, adaptations, and interactions of these disorders.

As defined in the literature, temporoman-dibular disorder (TMD) is a heterogeneous set of clinical conditions characterized by pain in the masticatory and related muscles of the head and neck, and in the temporomandibu-lar joint itself.6 Physical symptoms include limi-tations in function such as restricted ability to undergo lateral and/or protrusive jaw excur-sions, difficulty opening or closing of the mouth, occlusal disharmony, and/or the presence of clicking, popping, or grating sounds in the tem-poromandibular joint.1 Figure 1 presents a time-line comparing the early symptoms of TMD to the development of a threshold and onto chro-nicity characterized by depression or bipolar disorder and co-occurring physical symptoms.

Psychopathology may run an insidious, back-ground course of expression alongside TMD symptomatology. In the cited literature, chronic pain patients with depression are classified by four levels, i.e., levels 1 through 4 with increas-ing intensity of pain and disability.7,8 In this studied population, as the pain intensity and disability level increase, the type of pain (e.g., back, headache, TMD) appears to follow a simi-lar epidemiological course.7 Earlier studies by the same author classify TMD pain on three axes, i.e., severity of the pain, persistence of the pain, and impact on functional behavior and dis-ability.8 In addition to pain, the symptomatology of TMD includes occlusal disharmony, limited range of motion of the jaw, and subluxation of the TMJ (i.e., the jaw gets locked upon open-ing or closing).1 Although TMD patients report

a plethora of heterogeneous symptoms, the one unifying symptom that permeates all their lives is pain.9 TMD should be assessed and managed as a biopsychosocial determined condition.12,13

MEthODOlOgYA model of the symptomatic course of TMD running alongside that of bipolar disorder is described in Figure 1. Proposed treat-ment modes are based upon an understand-ing of the far-reaching manifestations and interactions of these disorders (Figure 2).

Methods for management of TMD are derived from the arenas of treatment of behavioral medi-cine and health psychology. Psychosocial fac-tors and their effect on cognitive, emotive, and behavioral activity highly impact the well-being of patients with long-standing pain and subse-quently are key elements to be considered in the diagnosis and treatment planning of TMD.14,15

Survey research, in conjunction with struc-tured or unstructured interviews, is often employed in assessing and diagnosing both psy-chogenic conditions and TMD symptomatology.16 Biopsychosocial instruments used in the assess-ment and diagnosis of mental status and/or pain in the TMD patient include the following:16,17

● Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI): These are “pen and pencil” questionnaires that the patient fills out at each visit (taking about five-to-ten minutes to complete).

● Minnesota Multiphasic Personality Inven-tory (MMPI): The MMPI (the classic instrument in this area of assessment) is widely used in psychological research and evaluation. It contains self-report instruments and a depression scale.

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38 • Vol. 5, No. 12 • December 2013

Table 2: Flow Chart of TMD Therapy

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● Research Diagnostic Criteria for TMD Examination and History (RDC/TMD): The instrument is the “gold stan-dard” in history taking and diagnosis of both TMD and somatic conditions.

REvIEW Of thE lItERAtuREMany psychological, physical, and socio-behavioral factors appear to be predictors of TMD.18,19 Early TMD involvement may be associ-ated with the psychological symptoms of mild-moderate anxiety and/or migraine headache.18 Early physical symptoms are generally minor and may present as joint clicking, popping, or grating of the TMJ.19 Advanced TMD patients usually present with significantly more affec-tive (mood) disorders.20 These patients gener-ally see life as very stressful, and subsequently employ nonadaptive coping mechanisms such as neurotic or obsessive-compulsive behavior.21

Psychopathology in the form of anxiety and depression is more prevalent in TMD patients with muscular diagnoses (i.e., myofacial pain, myositis, or myalgia) when compared to those with inter-nal structural derangements of the TMJ (chronic joint or articular disc pathology).22,23 Consider-able psychopathology is usually associated with TMD--a significant concurrentt relationship exists between physical and psychological diagnoses.21

DISCuSSIOnSomatization is defined by the American Psychi-atric Association as the process of conversion of mental states into bodily or physical symp-toms.24 The somatization hypothesis links mul-tiple pain symptoms to the somatic expression of psychiatric and psychosocial functioning.22 Psychological stressors displayed as physi-

cal symptoms or as pain may result in negative behavioral phenomena such as social distress or occupational disability.25 Risks of somatiza-tion impacting the function of the TMJ are gener-ally accompanied by the following conditions.24,25

1) Increased risk of developing pain.2) Increased risk for extended duration of pain.3) Increased risk of pain-related disability.4) Increased risk for poor treatment outcome.5) Increased health care seeking and

utilization.6) Risk of excessive, potentially iatrogenic,

treatment.Epidemiologically, the most common psy-

chological variables associated with TMD are depression, somatization, and anxiety.26 How-ever, associating somatization with numerous self-reported TMD symptoms may misdirect diag-nosis of an underlying psychological etiology.

Bio-psycho-social models of chronic pain can be applied to symptoms associ-ated with TMD.13 Models suggest that physi-ologic, psychologic, and social factors may interact in different ways in TMD--expressing pain or in developing pain-related dysfunction.13 Bio-psycho-social interventions (e.g., pharma-cotherapy, psychotherapy, counseling/mentor-ing) may improve adverse symptomatology in TMD with the following clinical outcomes:13

● Increased ability to control pain.● Decreased disease-related beliefs and

increased generalized coping.● General decrease in both psychiatric and

somatic disability.● Improved coping skills for generalized

symptomatology.● Improved coping skills for depression or

hypomania.

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40 • Vol. 5, No. 12 • December 2013

● Decrease in physical symptoms (e.g., decreased frequency of subluxation, increased range of motion of the jaw).

The presence of multiple and chronic pain sites and/or symptoms are associated with ele-vated levels of anxiety and depression, lower self-esteem, along with increased physical symp-tomatology.8 Furthermore, co-occurrence of pain symptoms at more than one body site is signifi-cantly associated with major depressive disor-der.25 Chronic pain symptoms are associated with three main conditions: poor self-appraisal of health status, increased use of pain medications, and increased incidence of psychogenic disorders.8

Medical policies of major insurance companies often provide coverage for TMD therapy and gen-erally recognize the following treatment modalities and their multidisciplinary applications (Figure 2):

Intraoral splint therapy with revers-ible appliances and subsequent occlu-sal adjustment generally balance the occlusion, and stabilize the oral apparatus.1

● Pharmacological treatment of TMD is largely symptomatic and nonspecific.

● Pharmacological interventions largely employ medications such as non-steroidal anti-inflammatory drugs (NSAIDS) and non-narcotic analgesic drugs27.

● Physical therapy for TMD consists mostly of thermal modalities and jaw manipulation procedures27.

● Biofeedback, acupuncture, relaxation therapy, and stress management are alternative therapies.28

● Cognitive Behavioral Therapy provides adaptation skills by changing how we think as opposed to what we think.23

No discussion of the confluence of mental

disorders and TMD is complete without looking at the possible genetic ramifications of both TMD and affective disorders. Both disorders appear to be linked to genetic dysfunction or hereditary structural anomalies in cellular DNA.24,29 The relatively recent mapping of the human genome has lead to a subsequent “knowledge expansion” about both somatic and mental maladies of the human condition. In the future, such genetic knowledge may play the key part in determining the interrelationships, treatment modes, and prevention strategies for both TMD and affective disorders—especially when these disorders occur concurrently.

COnCluSIOnSChronic pain in TMD, be it of myofacial, arthral-gia, or myofacial with arthralgia in origin can be graded on three axes: 1) the severity of the pain, 2) the persistence of the pain, and 3) the impact on functional behavior.8, 30 The develop-ment of chronic joint or orofacial muscular pain can be characterized as conditions that are comorbid in susceptible epidemiological sub-groups such as demographic (e.g., females; advanced age), post- traumatic (e.g., after extraction of 3rd molars; head injury), or psychi-atric manifestations (i.e., anxiety, depression).30

Patients with TMD may go for years with popping, clicking, and grating in their TMJ and totally ignore the symptoms of their condi-tion. This symptomatology can be translated into myofacial pain exhibiting as hypersen-sitivity or dysfunction during mastication. Usually a strong life stressor precipitates a pathological oral/facial situation—pushing the patient “over the threshold” into painful symp-tomatology and subsequent dysfunction. How-

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ever, as the life stressors subside, so may pain and dysfunction. Pain is the general focus of TMD morbidity--with mental and functional symptomatology as comorbidity. With the advances in genetic studies occurring with the mapping of the human genome and pres-ent DNA research, the future looks bright for not only treatment of TMD and affective dis-orders, but for a cure for these maladies. ●

Correspondence:Paul J. Flaer, DDS, EdD, MPH750 N.W. 20th Street, Bldg. G-110Miami, Florida 33127 USA305-221-7679 (phone)786-364-7463 [email protected]

DisclosureThe author reports no conflicts of interest with anything mentioned in this article.

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