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Consensus Conference Panel Report Crown Height.4
Consensus Conference Panel Report Crown Height.4
Consensus Conference Panel Report Crown Height.4
Implant Dentistry—Part 1
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Carl E. Misch, BS, DDS, MDS,*† Charles J. Goodacre, DDS, MSD,‡ Jon M. Finley, BA, DDS,§
Craig M. Misch, DDS, MDS,储¶ Mark Marinbach, CDT,# Tom Dabrowsky, LDT, RDT,** Charles E. English, DDS,††
John C. Kois, DMD, MSD,‡‡ and Robert J. Cronin, Jr., BS, DDS, MSaa
ental implants serve as a foun- The International Congress of ion was not developed for most is-
dental implants.
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risk of crestal bone loss. In turn, this such as cement, porcelain, and bone
effect may further increase the CHS react strongest to compression and
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and moment forces to the entire sup- weakest to shear components of force.
port system, and increase screw loos-
ening, crestal bone loss, implant Existing Occlusal Vertical Dimension
fracture, and/or implant failure. Be- To determine the interarch space,
cause an increase in the biomechanical the overall issue of occlusal vertical
forces is in direct relationship to the dimension (OVD) must be addressed.
increase in CHS, the treatment plan of Therefore, the issues of CHS must be
the implant restoration should con- considered after the development of
sider stress-reducing options when- this dimension. The patient’s existing
ever the CHS is increased. Methods to OVD should be evaluated early in
decrease stress include:6 implant prosthetic treatment plan be-
cause any modification will signifi-
1. Shorten cantilever length.
cantly modify the overall treatment.
2. Less offset loads to the buccal or
Not only will a change in OVD require
lingual.
at least 1 full arch to be reconstructed,
Fig. 7. The original treatment plan for the 3. Increase the number of implants.
it affects the CHS, and, therefore, the
Brånemark protocol used fewer implants in 4. Increase the diameters of implants.
potential number, size, position,
less available bone (with higher CHS) and 5. Increase the surface area design of
more implants in abundant available bone and/or angulation requirements of the
implants.
(with a smaller CHS). implants. The OVD is defined as the
6. Make removable restorations less re-
Fig. 8. The effect of the crown height sug- distance between 2 points (i.e., 1 in
tentive and use soft tissue support.
gests more implants should be inserted when the maxilla, and the other directly be-
the CHS is high and fewer implants inserted 7. Remove the removable restoration
low in the mandible) when the occlud-
when the CHS is more ideal. during sleeping hours to reduce the
ing members are in contact.5 This
noxious effects of nocturnal para-
dimension requires clinical evaluation
function.
of the patient and cannot be evaluated
8. Splint implants together, whether
body are concentrated in the crestal solely on the diagnostic casts.
they support a fixed or removable
7⫺9 mm of bone, regardless of im- The determination of the OVD is
prosthesis.
plant design and bone density.10 There- not a precise process because a range
fore, implant body height is not an A reduced CHS has biomechani- of OVD is possible without clinical
effective method to counter the effect cal issues related to the strength of symptoms.11 At one time, it was be-
of crown height. In other words, implant material and/or prosthetic lieved that the dimension of occlusion
crown-root ratio is a prosthetic con- components, flexibility of the mate- was very specific and remained stable
cept, which may guide the restoring rial, and retention requirement of the throughout a patient’s life. The OVD
dentist when evaluating a natural tooth restoration. The fatigue strength of a position is not necessarily stable when
abutment. However, the crown height- material is related to its diameter.8 For the teeth are present or after the teeth
implant ratio is not a direct com- example, when a bar is one half as are lost. Long-term studies have
parison. Crown height is a vertical thick in dimension, it is 8 times more shown that this is not a constant di-
cantilever, which magnifies any lateral flexible. In fixed restorations, the mension and often is decreased over
or cantilever force in either a tooth or movement of the material may time without clinical consequence, in
an implant-supported restoration. increase porcelain fracture, screw either the dentate, partially edentulous,
However, this condition is not im- loosening, and/or uncemented restora- or completely edentulous patient. In
proved by increasing implant length. tions. Therefore, when reduced CHS fact, a completely edentulous patient
The higher the CHS, the higher the exists, the material is much more often wears the same denture for more
number of implants usually required likely to have complications. CHS- than 10 years, during which time the
for the prosthesis, especially in the related issues are accentuated by an OVD is reduced ⱖ10 mm, without
presence of other force factors.7 This excessive CHS that places more forces symptoms or patient awareness.
is a complete paradigm shift as com- on the implant/prosthetic system, and The OVD may be altered perma-
pared to the concepts advocated orig- reduced CHS makes the prosthetic nently without the symptoms of pain
inally with many implants in more components weaker. and/or dysfunction. However, this is
dimensional relationship of the max- the dentition. Esthetics is related to First, the amount of freeway space is
illa to the mandible. As a result, the OVD for incisal edge positions, facial highly variable in the same patient,
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OVD difference will change the ante- measurements, and the occlusal plane. depending on several factors, includ-
rior guidance, and the range of func- Function is related to the canine posi- ing head posture, emotional state,
tion and esthetics. tions, the incisal guidance, and angle presence or absence of teeth, para-
The most important effect of of load to teeth and/or implants. Struc- function, and time of recording
OVD on tooth (implant) loading may tural requirements are related to di- (higher in the morning). Second, in-
be the impact on the biomechanics of mensions of teeth for restoration, terocclusal distance at rest varies
anterior guidance.12 The more closed while maintaining a biologic width. 3⫺10 mm from one patient to another.
the OVD, the steeper the anterior As a result, the distance to subtract
guidance and the higher the vertical Methods to Evaluate OVD from the freeway space is unknown
overlap of the anterior teeth. These All the techniques used in tradi- for a specific patient. Therefore, the
conditions will increase the forces to tional prosthodontics are also used to physiologic rest position should not be
the anterior teeth and decrease the risk evaluate and/or establish the OVD. the primary method to evaluate OVD.
of posterior interferences during ec- These techniques most often include Silverman14 stated that approxi-
centric mandibular movements or the objective method of measuring fa- mately 1 mm should exist between the
function. Opening the OVD has the cial dimensions, and/or the subjective teeth when the “S” sound is made.
opposite effects. In general, for the methods of esthetics, resting arch po- Pound15 further developed this con-
dentate patient, it is more risky to sition, and speaking space. There is no cept for the establishment of centric
close an OVD than to open this dimen- consensus on the ideal method to ob- and vertical jaw relationship records
sion because the mandibular anterior tain the OVD. Therefore, this dimen- for complete dentures. Although this
teeth may be positioned more facial, in sion is part art form and part science. concept is acceptable, it does not cor-
a closer relationship to the maxillary Yet, it is critical enough that a final relate to the original OVD of the pa-
teeth in centric occlusion. However, in treatment plan should not be rendered tient. Patients with dentures often
completely edentulous patients re- until a determination has been made wear the same prosthesis for more
stored with fixed implant prostho- relative to this dimension. than 14 years, and during this time,
dontics, a change in OVD in either The maxillary anterior horizontal lose ⱖ10 mm of their original OVD.
direction may have biomechanical and vertical tooth position is evaluated Yet, all these patients are able to say
consequences. Opening the OVD and before any other segment of the “Mississippi” with their existing pros-
decreasing the incisal guidance result- arches, including the OVD. If the thesis. If speech was related to the
ing in a bilateral balanced occlusion maxillary anterior teeth are signifi- original OVD, these patients would
may increase forces to posterior im- cantly malpositioned, the clinician not be able to pronounce the “S”
plants in any mandibular excursion. should obtain further diagnostic stud- sounds because their teeth would be
Closing the OVD may increase the ies, such as a cephalometric radio- more than 12 mm apart. Therefore,
forces to anterior implants during any graph, to determine the relationship of speaking space should not be used as a
excursion. On occasion, a change in the maxilla to the cranial base. The primary method to evaluate OVD.
the OVD may also affect the sibilant patient may have unfavorable skeletal Kois and Phillips11 have noted that
sounds of an individual because it also relationships, including vertical max- the subjective “esthetic” method to es-
changes the horizontal position of the illary excess or deficiency. If the tablish an OVD is the most difficult to
mandible. positions of the natural maxillary an- teach inexperienced dental students so
The OVD is almost never natu- terior teeth are undesirable for any that it is least likely to be initially
rally too large, and, unless some man- reason, orthodontics, orthognathic addressed when teaching the concepts
made interference has been created, it surgery, and/or restoration may be of determining OVD. However, expe-
is within clinical guidelines or de- indicated. Once the position of the rienced clinicians often consider this
creased. Therefore, the restoring den- maxillary anterior teeth is acceptable, method to be a primary factor related
tist most often should determine if the the next prosthetic guidelines require to OVD. Once the position of the max-
OVD needs to be increased. In other the determination of the OVD. illary incisor edge is determined, the
words, the existing OVD is a place to The subjective methods to deter- OVD influences esthetics of the face
start the evaluation, not a position that mine OVD include the use of resting in general.
necessarily must be maintained. This interocclusal distance and speech- Facial dimensions are directly re-
is not a casual decision because in- based techniques using sibilant lated to the ideal facial esthetics of an
shorter cantilever length, less offset with implants and implant prostheses. 359-371.
loads, increased implant number, in- J Prosthet Dent. 2003;90:121-132. 13. Niswonger ME. The rest position of
creased implant diameter, increased 2. Shillingburg HT, Hobo S, Whitsett LD.
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AUTOR(EN): Carl E Misch, BS, DDS, Bericht der Podiumsdiskussion innerhalb der Konferenz zur Erzielung eines Konsens
MDS*, Charles J. Goddaere, DDS, MSD**, in Bezug auf die Richtlinien der Abstandshöhenbildung bei Überkronungen für die
Jon M. Finley, BA, DDS***, Craig M. Misch, Implantierungszahnheilkunde: Teil 1
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AUTOR(ES): Carl E. Misch, Bacharel em Relatório do Painel da Conferência de Consenso: Diretrizes de Espaço de Altura da
Ciência, Cirurgião-Dentista, Médico*, Charles Coroa para Odontologia de Implante: Parte I
J. Goodacre, Cirurgião-Dentista, Médico**,
Jon M. Finley, Bacharel em Letras, Cirurgião- RESUMO: O Congresso Internacional de Implantologista Oral (ICOI) patrocinou uma
Dentista***, Craig M. Misch, Cirurgião- conferência de consenso sobre o tópico de Espaço de Altura da Coroa em 26-27 de junho
Dentista, Médico#, Mark Marinbach, Técnico de 2004, em Las Vegas, Nevada. O painel comunicou em várias ocasiões antes, durante
Dentário##, Tom Dabrowsky, Técnico Den- e após da reunião, tanto como grupo quanto entre indivı́duos. Um consenso de uma
tário###, Charles E. English, Cirurgião- opinião não foi desenvolvido para a maioria das questões. Contudo, diretrizes gerais
Dentista⫹, John C. Kois, Médico, Mestre em emergiram, relacionadas ao tópico. O seguinte artigo é a Parte I de um resumo de várias
Ciência⫹⫹ e Robert J. Cronin, Jr. Bacharel das diretrizes que deveriam ser de benefı́cio para a profissão em geral.
em Ciência, Cirurgião-Dentista, Mestre em
Ciência⫹⫹⫹. *Professor e Diretor de Im-
plantologia Oral, Temple University, Facul-
dade de Odontologia, Filadélfia, PA, EUA,
CEO do Misch International Implant Institute,
Beverly Hills, MI, EUA. **Decano da Facul-
dade de Odontologia da Loma Linda Univer-
sity, Loma Linda, CA, EUA. ***Clı́nica
Particular, Prairie Village, KS, EUA. #Profes-
sor Clı́nico Associado na Universidade de
Nova York, Departamento de Odontologia de
Implante, Nova York, NY, EUA, Clı́nica Par-
ticular, Sarasota, FL, EUA. ##Professor As-
sistente da Temple University, Faculdade de
Odontologia, Presidente dos Laboratórios
Dentários Nu-Life, de Long Island, West
Hempstead, NY 15522. ###Proprietário do
Laboratório Dentário BIT, Pueblo, CO, EUA.
⫹Professor Assistente Clı́nico de Odontologia
Restauradora da Universidade do Tennessee,
Memphis, TN, EUA e Universidade de Okla-
homa em Oklahoma City. ⫹⫹Professor Afili-
ado no Programa Graduado Restaurador na
Universidade de Washington, Clı́nica Partic-
ular, Seattle, WA, EUA. ⫹⫹⫹Diretor do
Programa de Prostodôntica em Nı́vel de Pós-
Doutorado e Professor do Centro de Ciências
da Saúde da Universidade do Texas, San An-
tonio, TX, EUA. Correspondência para: Carl
E. Misch, Cirurgião-Dentista, 16231 Fourteen
Mile Road, Suite 250, Beverly Hills, MI 48025.
Telefone: 248-642-3199, Fax: 248-642-3794.