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By: Snehal G. Patel, MD, MS (Surg), FRCS (Glasg)

  • Associate Attending Surgeon, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, Associate Professor of Surgery, Weill Medical College of Cornell University, New York, NY


Therefore the best solution involved positioning the orthodontic brackets to medications you cant take with grapefruit buy discount divalproex 500 mg on-line facilitate intrusion of the right central incisor (B symptoms breast cancer generic divalproex 250mg, C medications via g tube cheap divalproex 250 mg fast delivery, and D) medications qd buy divalproex 500mg low price. This permitted the restorative dentist to restore the portion of the tooth that the patient had abraded (E), resulting in the correct gingival margin levels and crown lengths at the end of treatment (F). The third step is to evaluate the relationship between the shortest central incisor and the adjacent lateral incisors. If the shortest central incisor is still longer than the lateral incisors, the other possibility is to extrude the longer central incisor and equilibrate the incisal edge. This moves the gingival margin coronally and eliminates the gingival margin discrepancy. However, if the shortest central incisor is shorter than the lateral incisors, this technique would produce an unesthetic relationship between the gingival margins of the central and lateral incisors. If one incisal edge is thicker labiolingually than the adjacent tooth, this may indicate that it has been abraded and the tooth has overerupted. In such cases, the best method of correcting the gingival margin discrepancy is to intrude the short central incisor (see Figure 57-12). This method moves the gingival margin apically and permits restoration of the incisal edges. This allows reorientation of the principal fibers of the periodontium and avoids reextrusion of the central incisor(s) after appliance removal. SignificantAbrasionandOvereruption Occasionally, patients have destructive dental habits, such as a protrusive bruxing habit, that can result in significant wear of the maxillary and mandibular incisors and compensatory overeruption of these teeth (Figure 57-13). The restoration of these abraded teeth is often impossible because of the lack of crown length to achieve adequate retention and resistance form for the crown preparations. One option is extensive crown lengthening by elevating a flap, removing sufficient bone, and apically positioning the flap to expose adequate tooth length for crown preparation. However, this type of procedure is contraindicated in the patient with short, tapered roots because it could adversely affect the final root/crown ratio and potentially open gingival embrasures between the anterior teeth. Figure5713 this patient had a protrusive bruxing habit that had caused severe abrasion of the maxillary anterior teeth, resulting in the loss of over half of the crown length of the incisors (A and B). One possibility was an apically positioned flap with osseous recontouring, which would expose the roots of the teeth. The less destructive option was to intrude the four incisors orthodontically, level the gingival margins (C and D), and allow the dentist to restore the abraded incisal edges (E and F). The other option for improving the restorability of these short abraded teeth is to intrude the teeth orthodontically and move the gingival margins apically (see Figure 57-13). It is possible to intrude up to four maxillary incisors by using the posterior teeth as anchorage during the intrusion process. This process is accomplished by placing the orthodontic brackets as close to the incisal edges of the maxillary incisors as possible. The brackets are placed in their normal position on the canines and remaining posterior teeth. This creates the restorative space necessary to restore the incisal edges of these teeth temporarily and then eventually place the final crowns. When abraded teeth are significantly intruded, it is necessary to hold these teeth for at least 6 months in the intruded position with orthodontic brackets or archwires (or both), or some type of bonded retainer. The principal fibers of the periodontium must accommodate to the new intruded position, a process that could take a minimum of 6 months in most adult patients. Orthodontic intrusion of severely abraded and overerupted teeth is usually a distinct advantage over periodontal crown lengthening, unless the patient has extremely long and broad roots or has had extensive horizontal periodontal bone loss. OpenGingivalEmbrasures the presence of a papilla between the maxillary central incisors is a key esthetic factor in any individual. Occasionally, adults have open gingival embrasures or lack gingival papillae between their central incisors. However, orthodontic treatment can correct many of these open gingival embrasures. This open space is usually caused by (1) tooth shape, (2) root angulation, or (3) periodontal bone loss. If the patient has an open embrasure, the first aspect that must be evaluated is whether the problem is caused by the papilla or the tooth contact.

However treatment xeroderma pigmentosum 250 mg divalproex with visa, only a few studies have critically evaluated the long-term clinical outcome of this procedure treatment 10 buy divalproex 500 mg low price, and most have used a small study population medicine 770 purchase 500 mg divalproex with amex. Short-term to medicine lodge treaty order 500mg divalproex long-term clinical studies of dental implants placed into grafted sinuses demonstrate a similar or even higher survival rate than reported in previous studies for implants placed in the maxilla without a sinus augmentation procedure. The use of bone-substitute graft materials can reduce the morbidity introduced by a second surgical site while maintaining equally good implant success rates. This material has demonstrated osteoinductive potential24 but has not proved to be particularly advantageous in the maxillary sinus bone augmentation. If the amount of available bone in the posterior maxilla is less than 10 mm and greater than 7 mm, the osteotome technique may be indicated. This procedure uses osteotomes (Figure 78-6) to compress bone (internally from the alveolar crest upward) against the floor of the sinus, ultimately leading to a controlled "inward fracture" of the sinus floor bone along with the schneiderian membrane, which should remain intact with the in-fractured bone. Initially, an osteotomy site is prepared with a series of drills (implant preparation) to a depth that is approximately 2 to 3 mm from the floor of the maxillary sinus. Osteotomes are used to increase compressive forces gradually against the floor of the sinus by adding incremental quantities of graft material until the floor of the sinus fractures inward (Figure 78-7). After the controlled inward fracture of the maxillary sinus floor, bone graft materials continue to be slowly introduced, through the osteotomy site and into the maxillary sinus, which continues to elevate the membrane and thus allows a vertical expansion of the bone height in a localized area of the maxillary sinus. Once the sinus membrane is elevated with bone graft material to the desired height, the implant osteotomy can be completed, with a final drill used to finish preparation of the site (lateral walls), and an implant can be inserted. Multiple individual sites can be elevated and prepared simultaneously through separate osteotomy sites. Published reports of this technique have demonstrated increased bone height from 2 to 7 mm (average, 3. If more vertical bone is needed, the lateral wall approach may be more advantageous. In addition to the usual precautions and contra-indications for sinus elevation and bone augmentation procedures, the osteotome technique may be contra-indicated for sinuses that have an acutely sloped floor or septa in the location of the planned osteotomy. An acutely sloped sinus floor will tend to deflect the osteotome in an undesirable direction rather than allowing the osteotome to penetrate into the sinus space, and the presence of septa make it virtually impossible to fracture the sinus floor inward. Box 78-2 provides additional precautions and clinician comments on using the osteotome technique. C, Cross-sectional image in premolar region showing about 6 mm of bone height and presence of maxillary septa. Figure784 Simultaneous implant placement with maxillary sinus elevation and bone augmentation procedure. Figure785 Staged implant placement after sinus elevation and bone augmentation procedure. B, Postsurgical cross-sectional image in premolar region demonstrating more than 17-mm vertical bone height. D, Postsurgical radiograph of implants placed in the previously grafted maxillary sinus (and cuspid site). This tapping can be bothersome to some individuals, especially those patients who are not sedated for the procedure. The tapping procedure tends to be more bothersome for patients with dense cortical bone and for those with loose trabecular bone. Clinical Perspective #2 the osteotome technique requires that the osteotome be properly aligned in the direction of the long axis of the planned implant. Thus, patients must be able to open wide enough to allow a direct insertion of the osteotome into the osteotomy site. Offset osteotomes are available that can facilitate the correct angulation (see Figure 78-6, B). A, Osteotomy prepared with drills to a depth that is near the maxillary sinus floor. F, Bone graft material continues to be added until sufficient height and volume are created in the maxillary sinus.

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With this goal in mind symptoms esophageal cancer divalproex 250 mg with visa, it is often helpful and advisable to medicine zocor cheap 250 mg divalproex free shipping invite patients to treatment 2 lung cancer effective divalproex 250 mg bring their spouse or a family member to medicine 2000 quality 500mg divalproex the consultation and treatment-planning visits to add an independent "trusted" observer to the discussion of treatment options. MedicalHistory A thorough medical history is required for any patient in need of dental treatment, regardless of whether implants are part of the plan. Patients must be in reasonably good health to undergo surgical therapy for the placement of dental implants. Any disorder that may impair the normal wound-healing process, especially as it relates to bone metabolism, should be carefully considered as a possible risk factor or contraindication to implant therapy (see later discussion). A thorough physical examination is warranted if any questions arise about the health status of the patient. Does the patient report a history of recurrent or frequent abscesses, which may indicate a susceptibility to infections or diabetes If a patient reports numerous problems and difficulties with past dental care, including a history of dissatisfaction with past treatment, the patient may have similar difficulties with implant therapy. It is essential to identify past problems and to elucidate any contributing factors. IntraoralExamination the oral examination is performed to assess the current health and condition of existing teeth as well as to evaluate the condition of the oral hard and soft tissues. It is imperative that no pathologic conditions are present in any of the hard or soft tissues in the maxillofacial region. All oral lesions, especially infections, should be diagnosed and appropriately treated before implant therapy. After a thorough intraoral examination, the clinician can evaluate potential implant sites. All sites should be clinically evaluated to measure the available space in the bone for the placement ofimplants and in the dental space for prosthetic tooth replacement (Box 74-1). The mesial-distal and buccal-lingual dimensions of edentulous spaces can be approximated with a periodontal probe or other measuring instrument. The orientation or tilt of adjacent teeth and their roots should be noted as well. There may be enough space in the coronal area for the restoration but not enough space in the apical region for the implant if roots are directed into the area of interest (Figure 74-8). Conversely, there may be adequate space between roots, but the coronal aspects of the teeth may be too close for emergence and restoration of theimplant. If either of these conditions is discovered, orthodontic tooth movement may be indicated. Ultimately, edentulous areas need to be precisely measured using diagnostic study models and imaging techniques to determine whether space is available and whether adequate bone volume exists to replace missing teeth with implants and implant restorations. Figure 74-9 diagrams the minimal space requirements for standard-, wide-, and narrow-diameter implants placed between natural teeth, and Figure 74-10 diagrams the minimal interocclusal space needed to restore implants. Interdental Space Edentulous spaces need to be measured to determine whether enough space exists for the placement and restoration with one or more implant crowns. The minimal space requirements for the placement of one, two, or more implants are illustrated diagrammatically in Figures 74-9 and 74-10. The minimal mesial-distal space required for the placement of two standard-diameter implants (4. The required minimal dimensions for wide-diameter or narrow-diameter implants will increase or decrease incrementally according to the size of the implant. For example, the minimal space needed for the placement of an implant 6 mm in diameter is 9 mm (= 7 mm + 2 mm). Whenever the available space between teeth is greater than 7 mm and less than 14 mm, only one implant, such as placement of a wide-diameter implant, should be considered. Interocclusal Space the restoration consists of the abutment, the abutment screw, and the crown (it may also include a screw to secure the crown to the abutment if it is not cemented). This restorative "stack" is the total of all the components used to attach the crown to the implant. The dimensions of the restorative stack vary slightly depending on the type of abutment and the implant-restorative interface.


The diagnostic strategy for the patient presenting minimal or no signs and symptoms of masticatory system disorders is to treatment internal hemorrhoids 500 mg divalproex sale attempt to medicine in the civil war purchase divalproex 250mg free shipping confirm a stable condition while identifying risk factors medications covered by medicare discount 500 mg divalproex with visa. Careful documentation of past or current trauma and disharmony provide the basis for trend analysis and anticipation of possible future problems symptoms 8 months pregnant generic 250 mg divalproex amex. Warfield in helping me compile the numerous references reviewed during the development of this chapter. Dawson, Gremillion, Parker Mahan, and Okeson provided invaluable foundations through their publications, texts, and lectures. Although there are many others from whom I have learned much, these four exceptional dentists certainly deserve my public appreciation. I would especially like to acknowledge my precious wife, Martha-Anne, whose patience and support were priceless, as always. Becker I, Tarantola G, Zambrano J, et al: Effect of a prefabricated anterior bite stop on electromyographic activity of masticatory muscles, J Prosthet Dent 82:22, 1999. Benoliel R, Eliav E, Elishoov H, et al: Diagnosis and treatment of persistent pain after trauma to the head and neck. Bergdahl J, Anneroth G, Anneroth I: Clinical study of patients with burning mouth. Cathelineau G, Yardin M: the relationship between tooth vibratory sensation and periodontal disease, J Periodontol 53:704, 1982. Mandibular rotations versus hemimandibular translations, J Oral Rehabil 22:865, 1995. Ehrlich R, Garlick D, Ninio M: the effect of jaw clenching on the electromyographic activities of 2 neck and 2 trunk muscles, J Orofac Pain 13:115, 1999. Goupille P, FouQuet B, Goga D, et al: the temporomandibular joint in rheumatoid arthritis: correlations between clinical and tomographic features, J Dent 21:141, 1993. Hirschfield L, Wasserman B: A long-term survey of tooth loss in 600 treated periodontal patients, J Periodontol49:225, 1978. Jacobs R, van Steenberghe D: Role of periodontal ligament receptors in the tactile function of teeth: a review,J Periodont Res 29:153, 1994. Kampe T, Tagdae T, Bader G, et al: Reported symptoms and clinical findings in a group of subjects with longstanding bruxing behavior, J Oral Rehabil 24:581, 1997. Kerstein R: Disclusion time measurement studies: stability of disclusion time-a 1-year follow-up, J Prosthet Dent 72:164, 1994. Kelmetti E, Vainio P, Kroger H: Craniomandibular disorders and skeletal mineral status, J Craniomandib Pract 13:89, 1995. Kopp S: the influence of neuropeptides, serotonin, and interleukin 1B on temporomandibular joint pain and inflammation, J Oral Maxillofac Surg 56:189, 1998. Kubota E, Kubota T, Matsumoto J, et al: Synovial fluid cytokines and proteinases as markers of temporomandibular joint disease, J Oral Maxillofac Surg 56:192, 1998. Kurita H, Ikeda K, Kurashina K: Evaluation of the effect of a stabilization splint on occlusal force in patient occlusions with masticatory muscle disorders, J Oral Rehabil 27:79, 2000. Maixner W, Fillingham R, Kincaid S, et al: Relationship between pain sensitivity and resting arterial blood pressure in patients with painful temporomandibular disorders,Psychosom Med 59:503, 1997. Murakami K, Kubota E, Maeda H, et al: Intraarticular levels of prostaglandin E2, hyaluronic acid, and chrondroitin-4 and -6 sulfates in the temporomandibular joint synovial fluid of patients with internal derangements, J Oral Maxillofac Surg 56:199, 1998. Murray H, Locker D, Mock D, et al: Pain and the quality of life in patients referred to a craniofacial pain unit, J Orofac Pain 10:316, 1996. Pleash O, Wolfe F, Lane N: the relationship between fibromyalgia and temporomandibular disorders: prevalence and symptom severity, J Rheumatol 23:1948, 1996. Mandibular rotations induced by a rigid interference, J Oral Rehabil 22:781, 1995.

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