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The Shortened Dental Arch: An Evidence-Based Treatment Option

By: Prof. Raphael Freitas de SouzaDDS, PhD (Oral Rehabilitation)Professor, Ribeiro Preto Dental School University of So PauloAuthor, the Cochrane Oral Health [email protected]

Prof. Zbys FedorowiczMSc, DPH, BDS. LDS RCS (Eng)Director of the Bahrain Branch of the UK Cochrane CentreAuthor, the Cochrane Oral Health [email protected]

Prof. Vincius PedrazziDDS, PhD (Oral Rehabilitation)Associate Professor, Ribeiro Preto Dental School University of So [email protected]

The loss of teeth is still traditionally seen as an inevitable part of the ageing process. In thisrehabilitation has the capacity to satisfactorily restore function by the replacement of all lost

to anatomical norms. However, recent clinical studies have found that oral and systemic healquality of life or patients satisfaction do not specifically depend on the presence of a full coteeth (Elias & Sheiham, 1998). It has been observed that a large proportion of middle-agedpatients are satisfied with their oral function even after molar loss and that the retention ofanterior and premolar teeth may be sufficient to satisfy the aesthetic and functional requiremajority of elderly patients.Clearly the loss of a large number of teeth or ill fitting or inadequate dentures can have somimpact on quality of life, but limitation in chewing may not always be as readily apparent to(Agerberg, 1988). The shortened dental arch (SDA) represents a frontier between what is
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healthy/comfortable and pathological/uncomfortable for most middle-aged anda elderly people (Fig

(Figure 1)

Possiblesettings for a

SDA (adapted

from Witter etal.,1997). OU-occlusal units

Active patient involvement in clinical decision-making in conjunction with the use of accurate scientinformation is one of the fundamental tenets of evidence-based health care (Adams & Drake, 2006

therefore a patients opinion should be taken into account and combined with other factors i.e. presof oral tissues, systemic status and cost. The maintenance of a SDA may prove advantageous in tepreservation and costs when compared with dental prostheses because it does not necessitate thepreparation of abutment teeth, surgery or the fabrication of dentures. It is conceivable that alteratiefficiency or any impairment of chewing may hinder digestion which in turn may have a compoundion general health. However, chewing impairment may only have a limited effect particularly as modare based on foods with a soft consistency. Even foods which are less readily digestible require less30% of the masticatory performance of a completely dentate subject (Farrell, 1956). Providing thatedentulism does not influence food selection it should not be considered a significant cause for systhealth problems (Ngom & Woda, 2002).

Although this concept arose in developed countries, it is equally valid for populations in developing

i.e. diets and cultures are variable. A study carried out in Tanzania of 725 participants with differenpermutations of the SDA compared 125 participants with complete natural dentition (Sarita et al.,2was found that although some loss of function occurred after the loss of molars the majority of partwere able to adapt adequately. The retention of anterior teeth, premolars and a pair of occluding m(such as, 16 and 46) can provide satisfactory masticatory function. In general, Brazilian people havillustrated their satisfaction with SDA schemes; good results were achieved with the preservation oteeth and three pairs of occluding premolars. Moreover, in the majority of participants the SDA appproved to be more satisfying than the replacement of lost teeth by removable partial dentures (EliaSheiham, 1999).

The loss of teeth has also been implicated as a possible cause of temporomandibular disorders (TMthe expectation that these disorders would be more prevalent as a consequence of the loss of posteteeth. An observational study found an association between missing teeth and articular pain (Cianc

al.,1999). However, the association was discrete and insignificant for participants with a small nummissing posterior teeth. It can be reasonably assumed that TMD, as with nutritional problems, is asonly with extensive loss of occlusal support. Clearly, the stomatognathic system is capable of adequfunction if premolars and anterior teeth are present, but further shortening might be associated witorofacial pain (Budtz-Jorgensen et al.,1985).

The association between the number of teeth in occlusion and signs or symptoms of TMD has not bconfirmed by all investigators (Mejersjo & Carlsson, 1984) which appears to indicate that occlusion be a peripheral factor in the etiology of TMD. A clinical trial by Witter and colleagues (Witter et al.,


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showed that the loss of molars is not a risk factor for TMDs. This appears to confirm that the absenmolars is not relevant to the development of muscular and joint TMD, as long as the insertion of repartial dentures was not able to prevent TMDs in part of the sample. It can be concluded from this that the return of molar support was similar to no intervention if we consider the prevention of TMDdesired effect. It would be safe to assume that the participants would be most likely to develop TMregardless of the presence or absence of molars.

Clearly the stomatognathic system does not need to adhere to the criteria for ideal occlusion for bphysiologically acceptable, providing it conforms to the following principles (Ash & Ramfjord, 1995)

1. Absence of pathological processes;2. Satisfactory function mastication, swallowing and speech;3. Variations of form and function;4. Ability to adapt to structural changes.

Hence if a patient lacks occluding molars, has adequate function, no progressive shifting of teeth, nsubjective complaints about lost teeth and pathological changes are unlikely to be caused by this typartial edentulism, why should dental prostheses be provided? Ethical concerns may also include th

associated with unnecessary provision of removable partial dentures, fixed dentures and implant suprostheses and it could be argued that for this specific case, that the best dentistry is probably nodentistry(Figure 2)(Sheiham, 2002).

(Figure 2)

Disposition of mandibular

teeth compatible with theSDA concept. If the

antagonist teeth are in

function, oral status wouldonly need follow-up. Dentalprostheses are unnecessary

but if requested the patient

should be informed abouttheir advantages anddrawbacks

Dental practice has previously been guided by mechanical concepts and there was a widespread beonly the rehabilitation of former occlusal morphology would provide ideal conditions for our patientswas called the 28 teeth syndrome and in the majority of situations is inappropriate (Kyser, 1989

al.,1997). The search for such an occlusal scheme underestimates the adaptive ability for each patiexample of adaptation, it was found that the loss of molars results in controlled incidence of force bmasticatory muscles and overloading of the TMJs does not occur as a consequence (Hattori et al.,2This illustrates the physiological potential for adaptation of the stomatognathic system. If the humaadapts itself after surgery or trauma by means of complex mechanisms, it would be nave to think thealth would not adapt itself to the damage imposed by the loss of occlusal support. The SDA concejustified by this premise, as it summarizes a successful response by the stomatognathic system to factors.


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References- Adams JR, Drake RE. Shared decision-making and evidence-based practice. Community Ment Hea2006 Feb;42(1):87-105.

- Agerberg G. Mandibular function and dysfunction in complete denture wearers--a literature reviewRehabil. 1988;15:237-49.

- Ash MM, Ramfjord S. Occlusion. 4thed. Philadelphia: W.B. Saunders, 1995.

- Budtz-Jorgensen E, Luan W, Holm-Pedersen P, Fejerskov O. Mandibular dysfunction related to denocclusal and prosthetic conditions in a selected elderly population. Gerodontics. 1985;1:28-33.

- Ciancaglini R, Gherlone EF, Radaelli G. Association between loss of occlusal support and symptomfunctional disturbances of the masticatory system.J Oral Rehab. 1999;26:248-53.

- Elias AC, Sheiham A. The relationship between satisfaction with mouth and number and position oOral Rehabil. 1998;25:649-61.

- Elias AC, Sheiham, A. The relationship between satisfaction with mouth and number, position andof teeth: studies in Brazilian adults. J Oral Rehabil. 1999;26:53-71.

- Farrell JH. The effect of mastication on the digestion of food. Br Dent J. 1956;100:149-55.

- Hattori Y, Satoh C, Seki S, Watanabe Y, Ogino Y, Watanabe M. Occlusal and TMJ loads in subjectsexperimentally shortened dental arches. J Dent Res. 2003; 82:532-6.

- Kyser AF. Shortened dental arch: a therapeutic concept in reduced dentitions and certain high-rigroups. Int J Periodontics Restorative Dent. 1989;9:426-49.

- Mejersjo C, Carlsson GE. Analysis of factors influencing the long-term effect of TMJ-pain dysfunctRehabil. 1984;11:289-97.

- Ngom PI, Woda A. Influence of impaired mastication on nutrition. J Prosthet Dent. 2002;87:667-

- Owall B, Kyser AF, Carlsson GE. Prtese dentria: princpios e condutas estratgicas. So Paulo:Mdicas; 1997.

- Sarita PTN, Witter DJ, Kreulen CS, Vant Hof MA, Creugers NHJ. Chewing ability of subjects with sdental arches. Community Dent Oral Epidemiol. 2003;31:328-34.

- Sheiham A. Minimal intervention in dental care. Med Princ Pract. 2002;11:2-6.

- Witter DJ, De Haan AFJ, Kyser AF, Van Rossum GMJM. A 6-year follow-up study of oral function shortened dental arches. Part II: craniomandibular dysfunction and oral comfort. 1994;21:353-66.

- Witter DJ, Allen PF, Wilson NHF, Kyser AF. Dentists attitudes to the shortened dental arch concRehabil. 1997;24:143-7.

Copyright 2005-2010 Smile Dental Journal ISSN: 2072-473X - e-ISSN: 2072-4748. All Rights Reserved.


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SMILE DENTAL JOURNAL

NEMO - A Prospective, Multi-centre Immediate

Restoration Study

By: Dr. Gerard ClausenBDSc, LDS, MDSc, FRACDS

Dr Gerard Clausen is a specialist prosthodontist in privatepractice in Victoria.He has lectured extensively throughout every State ofAustralia on topics including removable partial dentures,

restorative dentistry, crown and bridge work, and implantprosthodontics.He has run advanced and basic level implant programmes in

Australia and New Zealand and has also given lecture

programmes in China and North America including theImplant Innovations Inc. annual meeting and the Chicago

Dental Society Midwinter meeting in Chicago, Illinois, 1999.

There has been increasing interest in the concept of immediate restoration of dental implaOne of the perceived barriers to implant treatment, particularly when comparedconventional crown and bridge options for fixed tooth replacement, has been the overall tirequired for completion. In the past this has been dictated by the time specified to perstabilization of the implant prior to any functional loading.

Changes in our understanding of the formation of a bone-to-implant interface, combinedmodifications to the surface topography of dental implants, have enabled revisionrecommendations for loading, and hence restoration timing. The concept of early loadingbe appropriate in cases where initial implant stability, tissue profile and occlusal factors perHowever even with shorter treatment times, there is still an interim period in which some fof provisional or temporary appliance must be provided, adjusted, and tolerated bypatient. Immediate restoration may provide a method of eliminating the interim phincreasing the efficiency and helping overcome another of the barriers to treatment.

Immediate restoration in the edentulous case, particularly in the mandibular arch, has b


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subject to clinical evaluation and subsequent reporting in the dental literature. However reportsthat focus on single-tooth or partially-edentulous situations are limited, and often comprisecase reports, rather than controlled clinical studies. The NEMO project arose from the need toassess immediate restoration in single-tooth and partially-edentulous cases, and to do sowithin the parameters of a prospective, multi-centre study, with patients being treated in theprivate practice environment. Concurrently, the project also allowed clinical evaluation of a

CaP nanoparticle surface treatment for dental implants, and in the longer term will enablefurther assessment of this surface regarding crestal bone maintenance and integration.

A standard protocol was circulated and agreed upon prior to the commencement of treatment.Exclusion criteria included simultaneous bilateral tooth replacement, fully edentulous cases,and any medical or psychological issues which may have compromised the ability of the patientto tolerate the procedure. Four centres in three countries (Australia, Europe, USA) treatedpatients, with each centre treating at least 15 cases. Patients were randomly selected,providing a gender and age mix. All implants were restored immediately subsequent toplacement with provisional crowns or bridges, constructed both directly and indirectlydepending on clinical factors, including access and moisture control (Figures 1 and 2).Radiographs, using standardized holders, were taken pre-operatively, at the time of surgery

and initial restoration, and at the time of final restoration. Annual review, both clinical andradiographic, to follow these cases will be maintained over five years.

Initial collation of results confirms that in the appropriate clinical situation, over a broad rangeof clinicians and patients, immediate restoration of dental implants can be predictablyperformed. There are some negative aspects to this treatment approach, including thenecessity to schedule chairside time to fit in with surgical timing, the clinical time required forconstruction of the immediate provisional restoration, and some cases where fracture of theinterim restoration occurred requiring repair.

Fig. 1: Maxillary right canine, rightand left lateral incisors (13, 12, 22sites) with immediate provisional

crowns on the day of implant

surgery.


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Fig. 2: Immediate provisionalrestoration in the maxillary left

canine site.

The advantages of eliminating a removable interim prosthesis and permitting tissue healing

and maturation around a fixed restoration, along with patient satisfaction are significant.

The secondary aim of this project was to evaluate a new implant surface in the immediate

restoration situation.

A databank of information using the standard Implant Innovations Incorporated (3i,USA)Osseotite dual acid-etched surface can be compared to the implant used in this study

by cross-matching sample cases, allowing an assessment of the effect that the new surface

has on factors such as crestal bone maintenance and short and long-term implant

integration, survival and success. The implant used in this study incorporates a discrete

crystalline deposition (DCD) on the surface which is of nanoparticle size, permitting the

advantages of an osseo-inductive coating, yet eliminating the traditional disadvantages of

coated surfaces at macro level. Implant Innovations released this Nano-Tite implant to the

world and Australian markets.

In 2007, and the relevant laboratory, animal and human clinical studies will also be

available.

Implant Dentistry

History and Evolution


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By: Prof. Nabil Barakat, Dr. Roger Bassit

Dept. of OMFS,

School of Dentistry, Lebanese University

Dr. Nadim Aboujaoude: IMPLANT-SUPPORTED PROSTHESIS

From extensive investigations involving both laboratory and clinical experimentation concerthe repair and regeneration of bone and marrow tissue, the fundamentals of and concept ofevolved from studies conducted in Sweden by P-I Brnemark from 1952 through the 1960s

Long-term successful outcomes with osseointegrated dental implants, reported in numeroustudies, have inspired the dental profession to feel confident about their use; what was origand designed for the improved comfort,function, and esthetics of compromised edentulousbecome accepted treatment for patients has now become accepted treatment for patientsmultiple teeth, as well those with significant maxillo-facial defects, whether congenital or frdisease.

Early implant treatment protocols were strict and allowed healing in the absence of functionperiod of 4 to 6 months in order to achieve osseointegration.

The long treatment time, the fact that the patient must use removable dentures or go withimplant healing, and the need for two surgical interventions are examples of drawbacks wiimplant treatment.

In the new millennium, the concept of kiss(keep it simple & safe) has evolved where pafaster, less traumatic & less expensive implant treatment.Immediate loading of implant-supported prostheses is documented with high and predictablThese results indicate that implant integration and bone healing can occur during loading. Hstability has been asserted as a precondition, meaning that sufficient volume and density ofneeded.

It simplifies therapy & reduces the time of edentulousness, avoids wearing of removable demakes the treatment more acceptable to the patient.

Case presentation:A 14-year old female presented to her orthodontist with an 8mm overjet and an agenesis o

orthodontic treatment and end of her growth (17y7m), an implant was inserted in positionabutment was placed at surgery and a provisional crown was constructed and sealed in plaAfter a healing period of 2 months, the final crown constructed and placed.


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IMPLANT-SUPPORTED PROSTHESIS : Dr NADIM ABOUJAOUDE


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Articles -> Smile Magazine Issue 2 May 2006-> Dentistry in Ancient Civilizations

Dated : 2006-05-01

Rate (5/10) vote

Dentistry in Ancient

Civilizations

By: Dr. Alaeddin Abu Khalaf

BDS. MScOrthodontist / private [email protected]

Toothache was treated in ancient world with simplemethods differ according to the civilization. The first development of dental care began inthe Egyptian Empire (Pharos) around 3000 BC. Whereas the rules of Hamurabi brought"an eye for an eye and a tooth for a tooth" law in Mesopotamia. Later on, the Chinese

invented the first tooth brush.

The Center of MEDICINE IN ANCIENT WORLD

EGYPT (The PHAROS)

The first developments in medicine and dentistry occurred in the Egyptian Empire which westablished in 3000 BC around the Nile. Hesi-re, which is believed to be the first tooth exp(dentist) in the world along with Impotek, the God of medicine, they both grew up in Egypwhich was the center of medicine in the ancient world around the year 2600 BC. Manyexcavations around the Egyptian pyramids have shown that the Egyptians paid great atteto teeth cleaning. Moreover, higher class Egyptians had special servants to do their hair aclean their teeth. Also, many prescriptions that were used by the ancient Egyptians tostrengthen their teeth and stop toothache have been discovered during the excavations. Tfollowing prescription is an example of what the Egyptians used to strengthen their teeth:

One measure of ground rock salt One measure of redochre One measure of honey

These measures were mixed well and the mixture was applied to the teeth under pressure
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Many other prescriptions were used by the ancient Egyptians for the relief of the inflammationof gum (gingivitis), tooth erosion, inflammation of the pulp (pulpitis) and relief of toothache.Some of these prescriptions have been still used till today. In Egypt, doctors were known as"sjnw", and they were shown in hieroglyphics scripts with an arrow and an oil jar. Whereas,dentists didn't take the same name "sjnw" and they were not shown in hieroglyphics. Dentists

were symbolled with an eye and a horizontal piece of ivory, and their hierarchic classes wereadded to them. Five wooden tablets (plaques) in the Step Pyramid belong to Hesi-re and they

contain his pictures and titles.

On the Shields Hesi-Re the first dentist and his other title

Tooth for a tooth

MESOPOTAMIA

Mesopotamian diseases are often blamed on pre-existing spirits: gods, ghosts, etc. Howeveach spirit was held responsible for only one of what we would call a disease in any one pthe body. So usually "Hand of God X" of the stomach corresponds to what we call a diseasthe stomach. A number of diseases simply were identified by names, "bennu" for example

Clay tablets contained more than 100,000 cuneiform scripts belonging to the Sumerians,Babylonians and Assyrians who lived in Mesopotamia were collected. In 700 BC, Asurbanithe Assyrian king, collected these scripts in a library built in Ninova. Among these tabletswere some parts about toothache. The laws of Hamurabi, which had been responsible forlack of surgical development, brought social and legal responsibilities to doctors for the firtime. Among these rules that reached us today is "an eye for an eye and a tooth for a toothe person damaged the tooth of another person of the same social class, then his tooth sbe removed. However, if he damaged the tooth of another person of lower social class, he


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fined 166 gr of silver to be paid to the other person.By examining the surviving medical tablets it is clear that there were two distinct types ofprofessional medical practitioners in ancient Mesopotamia who also treated toothaches. Thefirst type of practitioner was the ashipu, in older accounts of Mesopotamian medicine oftencalled a "sorcerer." One of the most important roles of the ashipu was to diagnose the ailment.

In the case of internal diseases, this most often meant that the ashipu determined which godor demon was causing the illness. The ashipu could also attempt to cure the patient by meansof charms and spells that were designed to entice away or drive out the spirit causing thedisease. The ashipu could also refer the patient to a different type of healer called an asu. Hewas a specialist in herbal remedies, and in older treatments of Mesopotamian medicine wasfrequently called "physician" because he dealt in what were often classifiable as empiricalapplications of medication.

First Toothbrush

CHINA

Although the Chinese were a closed society, they were superior in medicine and dentistry. Theoldest medical book known in china "Nei Ching" (the laws of medicine) was devoted to Huang-Ti (the yellow emperor). There are two chapters about toothache and gum diseases in thebook. Nine types of toothache are described in the book. Gargling and gum massage arerecommended for the treatment. Other recommendations include pills made of garlic to stoptoothache, some bat parts to avoid tooth decay and bat's feces to whiten the teeth. Mouthdiseases in Nei Ching are divided into three types: inflammatory diseases, soft tissue diseasesand tooth decay. According to the book, mouth diseases and toothaches causes hot-coldimbalance of the body (fever), while loose teeth results from inflammatory diseases.

In the 13th century medicine was divided into 13 branches and dentistry is one of them.Acupuncture, which has an important role in Chinese medicine, has located 26 acupuncture

points for toothache and 6 points for gum diseases. In addition, a paste made of musk and aginger powder was frequently used in order to whiten teeth in ancient China. The Chinese whowished to have beautiful teeth used their nails, piece of wood and knifes to clear remnants offood from their teeth.The first toothbrush was made by the Chinese in the 15th century. Also they recommended theuse the amalgam which was called the silver dough and placed on decayed teeth. Even today itis said that loose teeth caused by gun diseases are still extracted by the hand in some marketsin China!

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