between implants because of the one-piece design, reduced resistance to occlusal loading, and problems related to the apless

surgery. However, among edentulous patients the mini implant will be desirable to address their need for complete dentures, to avoid the cost of standard implants, to address access-to-care issues, to manage medical compromises that may contraindicate the use of traditional surgical procedures or ridge augmentation procedures, and to meet the increased interest in such procedures among general dentists. The current evidence related to mini implants and their short-term, mediumterm, and long-term survival as denitive prosthodontics treatment were reviewed. Methods.Data were collected through an electronic search of articles in English published between January 1974 and May 2012 in the PubMed and Cochrane databases. Nine studies of mini implants were identied that met all inclusion criteria. One was a randomized controlled trial, two were prospective studies, and six were retrospective studies. A systematic analysis was applied, and the data were used to calculate the 1-year interval survival rate (ISR) and the cumulative survival rate (CSR). Results.The nine studies reported on a total of 798 patients and 3095 mini implants. Most of the mini implants were placed using a apless surgical technique, usually in the mandibular anterior region and in support of an overdenture. Follow-up varied between the studies, with the longest being 8.7 years and only two studies providing information for 5 years. The combined life table survival analysis (Table 5) revealed 170 implant failures, with 161 of these occurring within the rst year after implant surgery. The ISR was best for the rst year (94.7%). The CSR was 92.2%. It was not possible to analyze the medium-term or long-term survival of these implants. Discussion.The rst-year ISR was 94.7%, which is encouraging, but the actual survival may be lower because the follow-up period of several implants was reported as less than 12 months. Neither medium- nor long-term

Table 5.Life-Table Survival Analysis Showing Cumulative Survival Rate of Mini Implants for All 9 Studies Combined
Number Number Time of mini Number of of implants Interval Cumulative interval implants failures in surviving survival survival in years in interval interval in interval rate (ISR) rate (CSR)

0-1 1-2 2-3 3-4* 4-5* 5-6* 6-7* 7-8* 8-9*

3095 416 384 178 175 170 110 106 98

161 2 5 1 1 0 0 0 0

2934 414 381 177 174 170 110 106 98

94.7 99.5 99.2 99.4 99.4 100 100 100 100

94.7 94.2 93.4 92.8 92.2 92.2 92.2 92.2 92.2

* Data beyond 3rd year interval were reported in only 2 studies.4.9 (Courtesy of Bidra AS, Almas K: Mini implants for denitive prosthodontics treatment: a systematic review. J Prosthet Dent 109:156-164, 2013.)

survival could be evaluated. Results were complicated by the lack of specicity in the terms mini implant and narrow diameter implant, which makes the accurate comparison of treatment outcomes difcult.

Clinical Signicance.Only the short-term survival of mini implants was clearly indicated, and it appears to be quite high. Further studies are needed that use a standardized denition for what constitutes a mini implant and what is a narrow diameter implant.

Bidra AS, Almas K: Mini implants for denitive prosthodontics treatment: a systematic review. J Prosthet Dent 109:156-164, 2013 Reprints available from AS Bidra, Univ of Connecticut Health Ctr, 263 Farmington Ave, L6078, Farmington, CT 06030; fax: 860-679-1370; e-mail: avinashbidra@yahoo.com

Occlusal Guards
Hard occlusal guards
Background.Hard occlusal mouth guards are used to manage myofascial pain that develops in association with parafunctional habits and to protect natural teeth from damage when the opposing teeth are porcelain. During full mouth rehabilitation, these hard guards can help the clinician assess changes in occlusal vertical dimension. Patients with abfraction lesions can benet from their use to reduce further tooth loss, and occlusal loads can be directed more favorably in patients with dental implantsupported prostheses. Fabricating a well-designed

42

Dental Abstracts

wax model of an occlusal guard is a vital part of guaranteeing the usefulness of these devices. A simplied technique was described that uses a wax model in acrylic and the same method as is employed to construct complete dentures. Fabrication.The initial step is to obtain a set of irreversible hydrocolloid impressions free of voids. Rocking during removal distorts or tears the impression, so a snap removal is advised. Impressions are immediately poured into Resin Rock, which is a resin-fortied die stone more abrasion resistant than other gypsum products and less likely to expand during setting. A facebow transfer is used to relate the maxillary cast to a semi-adjustable articulator, avoiding the need for additional chairside adjustments at the delivery appointment. Centric relation (CR) is documented by making a CR bite record for mounting on the mandibular cast. The CR is captured by softening a piece of extra hard pink base plate wax, then cutting it to the shape of the maxillary arch and placing it over the maxillary teeth. The wax is removed, chilled, then replaced over the teeth and analyzed for stability. Two thicknesses of green Aluwax are attached to the premolar/molar regions of the pink wax, then the Aluwax is softened and the wax index is placed in the patients mouth to record the bite. It is left in place for about 45 seconds, then chilled in cold water before articulating the mandibular cast. Another check is made to verify that the articulated casts t the patients CR bite exactly. Next, the peripheral border of the appliance is outlined in pencil on the maxillary cast. The lingual border should be about 10 mm apical to the free gingival margins, whereas the labial border should end between the incisal and middle thirds of the anterior teeth. A slightly longer border may be used in posterior regions. Any deep undercuts that might prevent seating of the appliance are blocked out by applying stone or plaster directly onto the cast. If all undercuts are minimal, adjustments are made at insertion time. Both casts are placed on the articulator. The clinician develops eccentric guidance and guard thickness using an anterior guide pin in contact with the patients existing custom incisal guidance table, if available, or a mechanical incisal guidance table inserted on the articulator and set at. Extending the incisal pin downward opens the occlusal vertical dimension. The interocclusal space should measure approximately 1.5 to 2.0 mm in the molar region of the casts. Extending the pin about 5.0 to 6.0 mm achieves the correct range. Clearance between opposing casts during protrusion should exceed 1.5 mm; if it is insufcient, tilting the mechanical guidance table (raising the wings) will enlarge it. All lateral excursions should exhibit a clearance of 1.5 to 2.0 mm. Two pieces of pink base plate wax are softened in hot water, superimposed on one another, and folded lengthwise to yield a strip about 15 mm wide. The wax strip

is adjusted to the teeth of the maxillary cast and pressed out until it extends to the edges to the facial/buccal and palatal borders. A warm sharp knife aids cutting wax that reaches beyond the penciled-in lines. If needed, the wax can be resoftened to aid handling. The wax strip is placed once again over the maxillary cast and the articulator is closed until the incisal pin contacts the guidance table. The wax strip should document the mandibular tooth surfaces. A sharp blade helps in removing excess wax until just the indentations of the functional mandibular cusps remain. A 19-mm articulating ribbon (blue side facing the wax) is placed in a Miller forceps to record all occlusal contacts while opening and closing the maxillary portion of the articulator. The blue CR marks should be similar in size. A warm knife is used to atten and smooth the wax until solid CR contacts develop bilaterally for all mandibular buccal cusps. Solid CR marks for the incisors should be maintained if possible. All contacts should be located in the shallow wax depressions. Next, a new piece of articulating ribbon is used to identify potential working and balancing side interferences. The centric lock on the articulator is released, and the ribbon is placed on the left side with the red side facing the wax. The articulator is closed and the incisal pin is moved to the right and left sides to identify any working or balancing interferences. The same procedure is done on the other side of the arch, taking care not to eliminate any CR blue dots, which are used to equilibrate the occlusal guard. Laterotrusive canine contacts will be needed to develop canine guidance and should be retained. All eccentric contacts made by mandibular incisors can be eliminated until the most prominent marks are those made by canines. In the incisor region, only CR marks are preserved. The mandibular canines are mainly responsible for guiding protrusive movement. A new piece of articulating ribbon is used to nd and eliminate all posterior interferences, while preserving all posterior CR contacts. While developing the anterior ramp and canine eminences (Fig 5), the clinician shapes and smoothens all the wax surfaces. An angle of about 30 to 45 degrees to the occlusal plane is ideal, with continuous, smooth contact during both protrusive and laterotrusive excursions. Facially and lingually, the occlusal table should be at least half a cusp wider than the maxillary teeth that are being covered and should extend anteriorly so there is incisal contact in full protrusion of the jaw. Ridges and irregularities are smoothed, extending the wax to nearly the deepest areas of the indentations made by the mandibular teeth. The result is then sent to a commercial dental laboratory, which invests and processes the wax pattern with clear, heat-polymerizing acrylic resin. Delivery, Equilibration, and Post-Insertion Issues. Correct equilibration and patient cooperation are essential

Volume 59

Issue 1

2014

43

Fig 5.Side view of the articulated casts. Wax has been shaped and smoothed to develop an anterior ramp and canine eminences. (Courtesy of Antonelli J, Hottel TL, Siegel SC, et al: The occlusal guard: a simplied technique for fabrication and equilibration. Gen Dent 61:49-54, May/June 2013.)

Fig 6.Acrylic guard. Note pinpoint CR contacts (blue) can be seen on the occlusal surface of the acrylic guard. (Courtesy of Antonelli J, Hottel TL, Siegel SC, et al: The occlusal guard: a simplied technique for fabrication and equilibration. Gen Dent 61:49-54, May/June 2013.)

marks should be those of the mandibular canines. Planar grinding is preferred to spot grinding when removing occlusal locks and indentations. Anterior contacts should be lighter than posterior contacts. Once the guard has been adjusted with the patient reclined, he or she is returned to an upright position and the occlusion is re-evaluated for potential anterior shifting of the mandibular arc of closure. All anterior contacts are adjusted until they are appropriately lighter than posterior contacts. Polishing is avoided because it can cause a loss of contact.

to the success of therapy. At try-in appointments, some deep interproximal embrasures and tooth surface irregularities usually interfere with seating. Soft disclosing wax is melted into the intaglio surfaces of the guard to nd any problem areas. Ideally the intaglio surfaces should be covered by a uniformly thin lm of silicone material, usually 30 to 120 mm thick. A slow-speed No. 8 carbide bur can be used to eliminate binding areas. Another approach is to place the patient in a reclined position, simulating sleep, and use articulating ribbon over the occluding surfaces of all opposing teeth to detect problem areas. The effect of gravity can cause slight posterior repositioning of the mandible. All mandibular CR functional cusp tip and incisal edge contacts are noted (blue side of the ribbon faces the acrylic). If contacts are shown mainly on one side, areas of heavy or premature contacts are attened until solid CR contacts are detected bilaterally over the posterior areas of the guard (Fig 6). A pear-shaped laboratory acrylic nishing bur is useful to eliminate problem areas. Anterior protrusive sliding contacts are identied using the red side of the articulating ribbon, and posterior interfering contacts during protrusion are then removed. All CR blue dots are maintained. Broad, continuous curved contacts should be established on the guard using the mandibular canines and as many incisors as possible during protrusion. Canine guidance movements should also be smooth during disocclusion of the posterior teeth. All posterior laterotrusive and mediotrusive contacts on both sides of the appliance are removed while retaining all blue CR contacts (Fig 7). The predominant laterotrusive

Fig 7.Occlusal view of acrylic guard. Note the narrow protrusive and laterotrusive contacts made by mandibular incisors and canines, respectively. Laterotrusive contacts made by mandibular incisors have been eliminated. (Courtesy of Antonelli J, Hottel TL, Siegel SC, et al: The occlusal guard: a simplied technique for fabrication and equilibration. Gen Dent 61:49-54, May/June 2013.)

44

Dental Abstracts

After insertion, the patient should be instructed in how to use nger pressure to seat and remove the occlusal guard. Once the guard is in place over the teeth, it is seated using biting force. The length of time the guard is worn varies with the patients diagnosis. Those with myofascial pain should wear the guard except during eating and brushing until they experience relief of symptoms. Muscle discomfort fades over the course of a few days. Asymptomatic patients who brux may only require the guard during sleeping hours. Those who suffer myofascial pain on awakening should wear the guard at night. If the patient experiences pain while wearing the guard, its use should be discontinued; a follow-up visit to the clinician is warranted. All patients should be seen 1 to 2 days after initiating the use of a guard to ensure it is properly placed and to resolve any problems that have arisen. If the guard relieves the symptoms, the diagnosis and treatment plan are veried, and further treatment can be undertaken. If symptoms remain, the occlusion should be reevaluated. Patients should be warned that wearing the guard will increase salivation for up to 2 weeks and can affect speech, although this usually resolves within a few days. The guard should be thoroughly brushed after removal using a soft toothbrush to remove food debris. Once it is cleansed, the guard is immersed in water to avoid warping. Biomass levels can be reduced by soaking the guard in sodium hypochlorite, or denture cleansers containing this compound, for 10 minutes or less. At follow-up visits every 4 to 6 months, the guard is examined for wear facets, reequilibrated as needed, or remade if occlusal wear has produced perforation. Maintenance visits are also useful opportunities to remind the patient about appropriate oral hygiene. Discussion.The hard occlusal guard should t well, be comfortable, and exert adequate retention without rocking or becoming unseated with lip and tongue movements. All functional cusps tips should contact evenly and simultaneously in CR. During canine-guided movements, only the mandibular canines should contact. During protrusion, the mandibular canines and as many incisors as possible should contact. The guard should not move with CR closure or any eccentric movement (Fig 8).

Fig 8.Side view of acrylic guard in mouth. Note posterior teeth are clearly disoccluded from the guard during canine guided movement. (Courtesy of Antonelli J, Hottel TL, Siegel SC, et al: The occlusal guard: a simplied technique for fabrication and equilibration. Gen Dent 61:49-54, May/June 2013.)

Clinical Signicance.Parafunction produces signicant harm to the teeth and their supporting structures. Use of an occlusal guard can protect the teeth and counteract the effects of destructive habits. The major indications for using an occlusal guard are (1) bruxing or clenching of the teeth, (2) the presence of porcelain in dental restorations that abrade opposing natural dentition, (3) before full mouth rehabilitation, (4) the presence of tooth abfraction lesions, and (5) dental implant treatment. Soft occlusal guards are not advisable in these situations. They tend to increase masseter muscle activity during maximum clenching and do not signicantly reduce nocturnal bruxism, but rather tend to increase nocturnal muscle activity even in asymptomatic patients.

Antonelli J, Hottel TL, Siegel SC, et al: The occlusal guard: a simplied technique for fabrication and equilibration. Gen Dent 61:49-54, May/June 2013 Reprints available from the Academy of General Dentistry: e-mail: rhondab@fosterprinting.com

Oral Medicine
Risk for vascular events
Background.Vascular diseases are among the leading causes of death in the United States, and oral health care providers need guidance as to when to treat patients who have recently experienced cerebral and cardiovascular events. Traditional recommendations are to postpone nonemergency dental procedures for up to 6 months after

Volume 59

Issue 1

2014

45