2014 March NO.234 Extra-oral parallelism methods for multiple non-parallel implants and attachments hexed and non-hexed 多顆不平行植體與支柱根在三度空間平行之 唯一方法 口外平行法 陳明時 王茂生 游坤陽 台灣假牙牙醫學會 台灣假牙牙醫學會 台灣假牙牙醫學會 現任會長 / 永久專科醫師 第五屆會長 / 永久專科醫師 一般會員 專科醫師甄審委員會主任委員 中華民國口腔植體學會專科醫師 一 前言 二 問題敘述 全口覆蓋式假牙 Overdenture 目前不 根據陳明時 6 與Sahar Damghani 5 的文獻 論在教學上及臨床上已成為治療全口無牙病 報告 每一顎骨在建構overdenture時最有效 人最適當且最佳的治療選項 The Choice of 且適當的植體數量為4顆 而這4顆支柱根不 Treatment 1,2,4,6 而全口覆蓋式假牙經由搭 論是自然牙根或人工牙根 其前 後植體之 配人工植體或自然牙根而成為前後4顆牙柱根 間距 Inter-Implant Distance 最佳的距離為 Abutment 再接上attachment並且應用直 20/20±2mm 5,6 臨床上 前 後 左 右四 接支撐法 direct loading 的設計也經多篇研究 顆植體無法同時彼此平行且平行於midline 因 報告證實為最佳的overdenture支柱根受力支撐 為 臨床上在狹小的口腔內植牙時所造成植體 13 以往應用間接支撐法 indirect 的axial inclination在三度空間 Frontal Plane, loading 連接自然牙根或人工植體而成的tissue Sagittal Plane, Occlusal Plane 13 都會造成植體 bar對自然牙根或人工植體造成不良的分向量力 主軸角度的傾斜偏差 因此 骨整合 Osseous 及植體承受不當的負荷也經由研究發現這種間 Integration 13 後的植體無法在同一副假牙擁 接承受法的tissue bar或 connecting bar為不良的 有共同的Path of Placement 13 使植體彼此平行 設計 7,8,9,10,11 且平行於midline 再垂直於假牙齒的occlusal 的設計 4,7,8,9,10 plane 6,7 10
Among Dental Specialists 問題 1) axial inclination angle correction attachment 問題 2) angle correction attachment a. b. platform a. b. overdenture attachment 3 <1> vertical resiliency <2> angle correction <3> stability 6,7,8 Sterngold Dental LLC ERA attachment ERA 26 182 12 182 abutment attachment 182 Sterngold analog abutment ERA US Patent NO. 7,281,924 overdenture abutment a. b. A. 外六角型 (External Hexed Implant Fixture) 1. 69 2. 3. 4. 2000 4 ImplaMed ( ) 1 healing abutment thumb knob Sterngold, USA 4 Non-Engaging Impression Coping Sterngold, USA frictional driver 2 1 Panorex 20/20 2mm inter-implant distance 4 external hexed implant fixtures. 2 Non-Engaging Impression Coping screw thread implant body external hex 11
2014 March NO.234 Non-engaging impression coping screw thread 3 Rim Lock Tray Hammacher, Germany close tray impression technique Hydrophilic Vinyl Silicone heavy body medium viscosity light body Non-Engaging Impression Coping implant analog intaglio surface 4 impression coping Soft Gum cast holder master cast ( ) Laboratory Procedures master cast ERA angle guide gauge Sterngold U.S.A. 5 surveyor fixture ERA angle insert attachment implant body midline occlusal plane 6 Master cast angle guide gauge ERA attachment Master cast tissue depth ERA abutment base ERA angle insert attachment ERA abutment base 20N cm torque wrench implant analog 3 Non-Engaging Impression Coping 4 nonengaging impression coping implant analog intaglio surface 5 ERA angle guide gauge 6 0,5,11,17,23,30 ERA attachment 6 Soft Gum master cast ERA angle guide gauge midline occlusal plane 12
Among Dental Specialists 7 frontal plane horizontal plane sagittal plane attachment 8 base hex attachment base 9 ERA attachment/base 20N cm Plastic handle ERA attachment ERA plastic handle attachment base Attachment base mechanical retention 360 frontal plane, sagittal plane, horizontal plane midline occlusal plane 7 attachment base base mesial buccal hex reference line attachment base Staedtler Mars GmbH & Co. Germany attachment resin cement Sterngold, USA ERA attachment reference line 8 ERA attachment base 20N cm torque wrench implant body 9 B. 非外六角型 (Non External Hexed Implant Fixture) 1. 65 2. 2007 Anthogyr 4 O-ring attachment. 3. Wide Platform 5.0mm Regular Platform 4.0mm 22 4. O-ring attachment angle correction, vertical resiliency stability O-ring attachment axial angulation 22 Attachment 22 O-ring attachment angle correction 13
2014 March NO.234 relief retention, support stability 5. overdenture attachment ( ) ERA Implant Abutment Anthogyr Implant tissue depth analog tissue depth Sterngold Custom made ERA Abutment Anthogyr analog 14 4 Anthogyr Platform 8 Custom made ERA Abutment 0 ERA Non- Engaging Impression Abutment ERA attachment ( ) 4 0 ERA Non-Engaging Impression Abutment 4 Custom made ERA Abutment 4.0mm 5.0mm 10 Pin Vise Starrell Model D, USA implant analog ERA Non-Engaging Abutment 20N cm Torque Wrench abutment analog 11 0 ERA attachment resin cement 12 4 ERA abutment/base 0 ERA Non-Engaging Impression Abutment 13,14 Staedtler Mars GmbH & Co. Germany abutments 10 Custom made ERA Non-Engaging Impression Abutment 5.0mm 4.0mm 11 Pin Vise implant analog 20N cm Torque Wrench ERA Impression Abutment Implant Analog 12 ERA Lock Cement Microfill Resin Cement 13 0 ERA attachment Non-Engaging Impression Abutment Implant Analog 14 0 Non-Engaging Impression Abutment 14
Among Dental Specialists 15 ERA Impression Abutment O-ring Attachment 16 ERA Impression Abutment Blue Color O-ring Attachment 17 abutment ERA OV Impression Coping Regular Micro ERA Non-Engaging Impression Abutment ( ) O-ring attachment 0 ERA Non-Engaging Impression Abutment 20N cm Torque Wrench 15,16 ERA OV impression Coping ERA Micro Attachment ERA Regular Attachment 17 Rim Lock Tray close tray impression technique Hydrophilic Vinyl Silicone heavy body medium viscosity light body 0 ERA Non- Engaging Impression Abutment master cast surveyor ERA attachment ( ) Master Cast ERA attachment OV impression coping intaglio pin vise implant analog 0 ERA Non- Engaging Impression Abutment 20N cm Torque Wrench implant analog 13 ERA Non-Engaging Impression Abutment color code ERA attachment OV impression coping 18 abutment Soft Gum cast holder master cast 19 master cast 4 0 ERA Non- Engaging Impression Abutment 4 implant analog master cast 4 custom made ERA abutment 20N cm Torque Wrench implant analog 19 19 cast holder master cast, implant analog ERA abutment (base) 18 0 ERA Non-Engaging Impression Abutment intaglio surface 15
2014 March NO.234 21 ERA attachment midline 20 Occlusal View Lateral View Frontal View ERA plastic handle Frontal View attachment master cast 4 abutment ERA attachment midline occlusal plane abutment 0 ERA attachment 5 ERA angel insert ERA attachment surveyor abutment 11 ERA attachment abutment 11 ERA attachment abutment 17 ERA attachment 20 4 implants ERA attachment angle correction 5 11 17 ERA attachment implant midline occlusal plane attachment path of placement 21 attachment base reference line attachment resin cement ERA attachment reference line attachment base resin cement ( ) ERA abutment O-ring wrench O-ring attachment 22 20N cm Torque Wrench ERA abutment master cast 21 master cast abutments 22 O-ring attachment angle correction 16
Among Dental Specialists ( ) Overdenture attachments implant abutments attachments Implant Supported and ERA Retained Overdenture Discussing: ERA attachment Direct Loading 1. Vertical Resiliency 的重要性 : Overdenture abutments overdenture abutments crossarch abutments lips/cheek retractor abutments midline abutments overdenture support residual alveolar ridge abutments retention overdenture under occlusal loading crest of residual alveolar ridge abutments attachments overdenture attachment vertical resiliency abutment solitary abutment abutment fulcrum point occlusal forces implant abutment natural root abutment Vertical Resilient residual alveolar ridge connective tissue 1.0mm vertical occlusal loading compress 1.0mm connective tissue 0.4~0.5mm Maximal Tissue Coverage Intimate Tissue Contact 0.4~0.5mm vertical resiliency occlusal loading implant abutment crest of residual alveolar ridge support implant body residual alveolar ridge 2. 探討 Tissue Bar 用於自然牙根之適應性 : abutments tissue bar Mobility Periodontal involved weak roots root length root form implant dentistry tissue bar overdenture abutments Stud Type Attachment a. Intraradicular Type Zest anchor b. Extracoronal Type ERA cast coping tissue bar tissue bar 7 preparation clip retention denture base bar 17
2014 March NO.234 relief clip retention reline retention stability tissue bar ERA-RV attachment retention stability ERA attachment 3. 探討 Tissue Bar 用於人工牙根之適應性 : overdenture abutment tissue bar weak abutments prognosis attachment tissue bar vertical support direct loading indirect loading direct loading tissue bar Connecting bar indirect loading tissue bar direct loading tissue bar tissue bar tissue bar 4. 不用 hydrophilic vinyl silicon 材料中 light body 的理由 : Light body resiliency impression abutment impression coping light body medium body medium body impression abutment impression coping intaglio surface 5. 務必使用 rim lock tray 的理由 : hydrophilic vinyl silicon thixotropic wettability reproduction of detail heavy viscosity rim lock tray heavy viscosity tray rim lock mechanical retention tray rim lock tray alginate impression material 6. 務必使用 non-engaging impression coping 的理由 : 360 platform 60 axial angulation platform impression coping 60 screw screw screw thread time impression coping color code impression coping implant analog screw thread time 60 hexed impression coping impression coping implant analog 18
Among Dental Specialists non-engaging impression coping hex screw thread time Fixed Abutment Removable Abutment 7. 務必依序各別由 Master Cast 取下再各別置入口中的理由 : angle correction attachment abutment attachment master cast abutment 20N cm master cast abutment 20N cm implant body screw thread time Conclusions 1. direct loading abutment angle correction attachment midline occlusal plane 2. impression abutment impression coping direct loading References 1. George A. Zarb: Introduction to the Halifax symposium Towards optimized management of the edentulous predicament. J.P.D.Jan.1998 PP.3-4 2. J.S.Feine et al: The McGill consensus statement on overdenture. Quintessence International Vol.34 No.1 2003 PP.78-79 3. MingSheh CHEN: Rationale for the overdentures. Academy of Advanced Prosthodontists in Taiwan, Teaching Manual, Nov. 2011 P.10 4. Harley H. Thayer et al: Photoelastic stress analysis of overdenture attachments. J.P.D.Jun. 1980 Vol.43 No.6 PP.611-617 5. Sahar Damghani et al: The effect of number and distribution of unsplinted maxillary implants on the load transfer in implantretained maxillary overdentures. J.P.D. Jan. 2012 Vol.107 No.6 PP.358-365 6. No.228, 1-2, 2014, P.50-59 7. David R. Federik et al: Effects of overdenture retention designs and implant orientations on load transfer characteristics. J.P.D. Dec. 1996 Vol.76 No.6 PP.624-631 8. Steven J. Sadowsky et al: Effect of anchorage systems and extension base contact on load transfer with mandibular implant-retained overentures. J.P.D. Sep. 2000 Vol.84 No.3 PP.327-333 9. Kent T. Ochiai et al: Photoelastic analysis of the effect of palatal support on various implant-supported overdenture designs. J.P.D. May 2004 Vol.91 No.5 PP.421-427 10. Brian H. Williams et al: Retention of maxillary implant overdenture bars of different designs. J.P.D. Dec. 2001 Vol.86 No.6 PP.603-607 11. Robert Kenney et al: Photoelastic Stress patteres produced by implant-retained overdentures. J.P.D. Nov. 1998 Vol.80 No.5 PP.559-564 12. Sterngold ERA Attachment & Implant Systems: Implant Abutment fitting flyer. 2012 P.8 13. The Glossary of Prosthodontic Terms. Eighth Edition 19