Experts Agree: Standard of Care for a Lower Denture Is Two Implants for Retention

The standard of care for the edentulous mandible (no lower teeth) should be the two-implant retained mandibular over-denture (IRMOD).

A survey of U. S. prosthodontic academic experts determined the following opinions:

• Consensus that the IRMOD was superior in 9 of 10 parameters assessed:  retention, stability, speech, chewing efficiency, comfort while eating soft foods and hard foods, confidence in intimate situations, satisfaction and self esteem. 

Conclusions:  An implant retained mandibular overdenture vs. a complete denture only is the first choice of care when restoring an edentulous mandible of a healthy patient or a patient with mild systemic disease.  

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics
5060 California Ave., #170
Bakersfield, CA 93309
(661) 325-1275 |

Can An Implant Replace An Infected Tooth?

A report in the the Journal of Implant and Advanced Clinical Dentistry of a total of 95 patients (42 female, 53 male) age 19-75 (mean 50.5) with 97 screw type implants immediately placed in molar sites at the time of extraction shows 100% success at three years.  The key to the technique is careful extraction techniques to preserve bone and adequate implant stability upon placement due to obtaining maximum bone to implant contact.  The presence of infection in the extracted teeth was not a contraindication.  On average, the implants were restored with abutments and crowns 12-16 weeks after placement.

Source: JIACD, sept/oct2011,vol3,#6,pp37-44  More at www.drtupac.com

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

What is Peri-implantitis?

Risk Factors in Implants Failure

Peri-implantitis is a more serious disease distinguishable from the condition of peri-implant mucositis.  It is characterized by an inflammatory process around an implant, which includes both soft tissue inflammation and progressive loss of supporting bone beyond biological bone remodeling.  It is present when there is bleeding on probing and/or suppuration and detectable bone loss.  Since after all dental implants are placed, the bone undergoes a process of remodeling that results in the loss of an average of 1mm of bone height, the only way to document further bone loss is by comparison to a baseline radiograph obtained at the time of suprastructure placement, or by (if no baseline radiograph is present) using a threshold vertical distance of 2mm from the expected marginal bone level following remodeling post implant placement.  Risk factors include:

• previous periodontal disease--does not affect implant survival rate, but is a more frequent finding in patients with a history of periodontitis
• poor plaque control or difficulty cleaning due to prosthesis design dictated by esthetics, phonetics and function
• residual cement that provides a positive environment for bacterial attachment
• smoking--a 3.6 to 4.6 times greater risk of inflammation
• genetic factors that contribute to patient susceptibility
• diabetes--which affects tissue repair ability and defense against inflammation
• possible bite overload

Diagnosis of Peri-implantitis

The presence of bone loss and probing depth alone is not enough to make the diagnosis.  Only in the presence of bacterial inflammation, is bone loss, seen over time, definitive for peri-implantitis.  Non-surgical therapy has not been shown to be effective in the treatment of peri-implantitis, therefore surgical intervention is necessary, and there are several ways to do it.  An understanding of peri-implant mucositis and peri-implantitis underscores the importance of regular monitoring and professional care for dental implants as well as natural teeth.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Restore Your Smile And Confidence With Dental Implants

Robert Tupac assisted Martha Sanger, periodontist, in the placement of implants and an immediate fixed provisional bridge, at he same time the patient's lower teeth were removed.  This collaboration gives patients in the Central Valley the option of going from an arch of failing natural teeth to an implant supported screw retained provisional bridge in a single appointment.  Both Dr. Sanger and Dr. Tupac are Nobel Biocare partners.

If you or a loved one experience the embarrassment of slipping dentures, an uncomfortable denture fit, lack confidence in speaking and/or laughing Dr. Tupac can provide a solution in a single day.  Call Dr. Tupac and find out how you can enjoy eating and speaking again with confidence.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Live Well By Keeping Dentures Secure

Millions of people visit their dentist each year complaining of dentures "moving around."  They become loose over time because the jawbone supporting them becomes smaller and the denture has less to hold on to.  For many, relining them or making a new set makes them fit snugly again.  Unfortunately though, for some patients, relining or a new set doesn't help.  So what are the options for these patients?  What can be done to keep their dentures in place all day, without the use of messy adhesives?

Dental Implants Changed the World of Dentistry  

The introduction of dental implants has changed the world of dentistry and improved the lives of thousands of patients, including denture wearers.  Implants have been around for over 50 years and the technology has improved to a success rate of 95%.  They can be used in many different ways to aid in the form, function and aesthetics of a patient's smile. The implant is placed in the jaw to simulate the natural root of a tooth.  Once the implant is placed, a restoration is connected on top of it, depending on the need of the patient.  
In the case of denture wearers, implants provide much more stability.  They improve the ability to eat and speak.  Sore spots are reduced.  Most of all, they prevent further bone loss, maintaining facial structure over the years.  Normally, two implants are placed for a lower denture and four implants for an upper denture.  As seen in Living Well Magazine.     

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Treatment May Never Be Finished--Our Committment To You

Living with uncertainty

Science seeks certainty. The problem in medicine and dentistry is that the body is complex and our knowledge is incomplete. Doctors and patients who want certainty can't be satisfied completely. (deBronkart)  

In my own case, my cancer surgeon says there's a 5% chance my cancer will return, so, while my odds are good, there's no way to predict.  So we live, with uncertainty, because we are human.  

Experience tells me that the more complex the treatment plan is, the greater the chance of complications. This is the essence of informed consent, of answering all questions regarding treatment options before one is chosen. 

Closest to success

Expectations have to be realistic when nature is replaced with prosthetics, be it implants, crowns, veneers, partials or dentures. Both dentist and patient giving their best gets the closest to success, especially when things must be discussed anew when treatment isn't working.  Science keeps pushing toward certainty, but disease doesn't wait. 

Treatment is therefore never finished and is a collaboration of patient and practitioner.  

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

What Is Right For You?

I met a new patient this morning.  She is 65 years old, and has extensive bridgework in her mouth.  It all started when she lost one front tooth when she was a teenager and got her first bridge... then had decay, got a new (bigger) bridge, etc... a sequence repeated a number of times during her life.  Add to that various toothaches, root canals, extractions, more dental visits and expense than she can remember, and now she is "done with it."  Instead of having it all done over--again!--with the expectation that five years from now she'd be back in the same place, she decided she wants dentures with implants.  She asked if this was the right thing?  And, after discussing it at length, it is the right thing: for her.  She had done her homework, understood the process, knew the pros and cons and was willing to make what would be a life change for her.  We talked for a long time and one of the sad things that came out was that she was never happy with the outcomes of the previous bridgework, either because it didn't match or new problems quickly cropped up.  We took time to meet her mind as well as her mouth.  She said:  "I am the kind of person who is organized, is neat; I put things in their place.  My teeth have never been like that.  I want them to be like me!" She would rather have dental work than plastic surgery.  We will fabricate for her the teeth she wants.  She will see them in advance and we will not finish them until she approves.  This is what we do.  We recognize that she deserves to be happy with her new teeth, with the way they look and the way they work.  

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Implants Keep Bone Loss from Occurring and Altering How You Look

We stress implants for a very good reason:  it's the only way to prevent bone loss in your jaw when teeth are missing.  Over time, bone loss distorts your appearance, which is obviously something you don't want and we don't want.  Implants are the best way to keep bone loss from occurring and altering how you look. 

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Satisfied Implant Patient

Congenitally missing upper right and left lateral incisors... onlay grafts before placement of Nobel 3.0mm Active implants... then restored with angled abutments and porcelain crowns.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Implant Options for Denture Patients

Bar structure

In the top radiograph, six upper implants (the ones on the sides tilted backwards) and their distribution allows them to be joined by a bar structure that has teeth attached to it and the hybrid bridge is permanently screwed in place.  It can only be removed in the prosthodontic office.  The prosthesis is more like a row of teeth, has minimal soft tissue coverage, and derives all of its support from the implants.  This prosthesis is most like having your natural teeth back again.

Tissue bar

In the bottom radiograph, four upper implants are joined by a tissue bar.  The resulting prosthesis is called a tissue bar overdenture--it is a removable prosthesis that attaches with clips or snaps to the bar for stability and retention when in place, but can be taken out to allow the implants to be brushed and cleaned.  The prosthesis is horseshoe shaped (open in the center of the palate) but does cover the ridge and adequate lateral tissue for additional support.  Sometimes, when there has been a lot of bone shrinkage, the removable prosthesis allows teeth to be better placed for lip and cheek support, esthetics and phonetics.

Implants options

You don't like your complete upper denture and would like to have some implants.  What are your options?  They depend on the amount of available bone you have remaining and the dimensions in your mouth (clearance for your bite, the sizes of the structural components of the prosthesis, and proper arrangement of teeth) that are required.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

New All-on-4 Success Rates

In this month's Journal of Prosthetic Dentistry (JPD), Parel and Phillips report on a study of implant survival rates for 558 jaws treated with 4 implants per jaw in a patient population between 2008 and 2010.  A total of 2,132 implants were placed, with only 48 failures, giving a 97.8% success rate.  Of the few failures, they were 5 times more likely in the upper jaw and more often associated with male patients, poor bone density, opposing natural teeth and the location of the most posterior implant.  Smoking, bone volume, systemic factors, addictive drug use and pathology, including the existence of periapical infections did not appear to be related to failure in this population.

Dr. Tupac has enjoyed universal success with All-0n-4 treatment.

When patients with greater risk had additional implants placed, there were no failures.

Dr. Tupac, Bakersfield's only full time Board Certified Prosthodontist, specializes in taking patients from failing teeth to implant supported fixed bridges and has been successfully treating patients in this manner for many years. 

All treatment, from diagnosis and treatment planning, to extractions and implant insertion, to fabrication and placement of the fixed bridges is accomplished in his office.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Why a Prosthodontist Should Place Your Dental Implant

The Prosthetically Driven Implant Industry 

Todays implant dentistry is prosthetically driven.  A Board Certified Prosthodontist can determine and visualize, by the use of detailed radiographs, CT scanning, implant guides and diagnostic tooth positioning, exactly where the final tooth positions will be.  By doing so, all surgical procedures then become tailored to achieving the best esthetic and functional result possible.  It is not enough to just put an implant into the bone and make an impression and try to make the tooth on top look good.  The direct benefits of implant dentistry are bone preservation, maintenance of facial integrity, restoration of natural biting and chewing capacity and the self confidence that a secure smile can bring. Dr. Tupac is trained in five different implant systems, and can explain which is best for your needs.  Discover your dental implant options at www.drtupac.com

Robert G. Tupac, DDS, FACP, Inc., 
Diplomate, American Board of Prosthodontics
(661) 325-1275 | www.drtupac.com
5060 California Ave., #170, Bakersfield, CA 93309 (map)

Molar Implants at the Time of Extraction

A report in the current issue of the Journal of Implant and Advanced Clinical Dentistry of a total of 95 patients (42 female, 53 male) age 19-75 (mean 50.5) with 97 screw type implants immediately placed in molar sites at the time of extraction shows 100% success at three years.  The key to the technique is careful extraction techniques to preserve bone and adequate implant stability upon placement due to obtaining maximum bone to implant contact.  The presence of infection in the extracted teeth was not a contraindication.  On average, the implants were restored with abutments and crowns 12-16 weeks after placement. 

 Source: JIACD, sept/oct2011,vol3,#6,pp37-44  More at www.drtupac.com

Robert G. Tupac, DDS, FACP, Inc., 
Diplomate, American Board of Prosthodontics
(661) 325-1275 | www.drtupac.com
5060 California Ave., #170, Bakersfield, CA 93309 (map)

Mandibular Fixed Implant Supported bridge

Recently I had the privilege of seeing a 63 year old patient I treated 17 years ago. She had her teeth removed when she was 20 years old, and for the last 30 years had been unable to wear a lower denture.  She was very thin, had digestive problems due to a poor diet and had become a recluse because she was reluctant to leave the house and be out in public with a collapsed face. We placed four lower implants and, according to the original Branemark protocol, fabricated a mandibular fixed implant supported bridge.  Now she dances three nights per week and has a healthy glow about her.  She joked that she has to watch her weight because she can eat anything on the menu.

Robert G. Tupac, DDS, FACP, Inc., 
Diplomate, American Board of Prosthodontics
(661) 325-1275 | www.drtupac.com
5060 California Ave., #170, Bakersfield, CA 93309 (map)

The Importance of Being a Board Certified Prosthodontist

Maintain Regular Cleanings and Exams 

The just published Journal of Prosthetic Dentistry (JPD) Oct., 2011, includes its annual review of scientific literature.  In the implant section, 2010 literature is referenced that shows that periimplantitis (inflammation around implants with bleeding or suppuration on probing, probing depth of more than 5mm or progressive bone loss) is typically a condition of late onset, meaning can occur more than 5 years after implant placement.  Since these infections can occur after many successful years of service, it is clearly important to maintain a regular regimen of dental cleanings and examinations long after placement!

Robert G. Tupac, DDS, FACP, Inc., 
Diplomate, American Board of Prosthodontics
(661) 325-1275 | www.drtupac.com
5060 California Ave., #170, Bakersfield, CA 93309 (map)

Osseointegration Study Club

Osseointegration Study Club of Japan meeting

www.facebook.com/OJOsseointegrationStudyClubOfJapan

Robert Tupac participated in the 25th anniversary meeting of the Osseointegration Study Club of Southern California and Osseointegration Study Club of Japan meeting. A selection of nationally and internationally known presenters focused on the parameters of minimally invasive to total arch regeneration and the latest research on implant surgery and loading. Selected topics included clinical practice of minimally invasive implant dentistry, minimally invasive sinus augmentation procedures, CAD/CAM zirconia abutments, three dimensional bone augmentation, long term clinical results of the All-on-Four concept, experimental determination of peri-implant mucosal stability and its interpretation, the benefits of reduced diameter abutments and implant/soft tissue connection, and the future of implant dentistry. 

With 25 years of experience with implant placement and prosthetics, Dr. Tupac has witnessed the evolution of implant design and surgical technique and prosthetic designs and restorative approaches. These issues affect the short and long term realities of implant restorations, their maintenance and the prevalence and management of complications support for a screw retained provisional fixed bridge placed at the same time the implants are placed. The technique may also be performed at the same time natural teeth are extracted.

Robert G. Tupac, DDS, FACP, Inc.,
Diplomate, American Board of Prosthodontics
(661) 325-1275 | www.drtupac.com
5060 California Ave., #170, Bakersfield, CA 93309 (map)

How Prosthodontics and the NobelGuide Go Together

Today's 3D Techonology

NobelGuide Implant Surgery Planning software allows us to take the 

information from I -CAT scan of a patient's mouth and perform virtual 

surgery on the computer before taking a patient into the actual surgery.

In a presentation to his prosthodontic study group, Robert Tupac analyzed his experience with the long term results of his first 20 NobelGuide cases. The NobelGuide technique begins with the incorporation and assessment of 3D diagnostics, termed cone beam technology. This allows the ability to use a scan of a patient's jaw and apply a computer software program (NobelClinician Software) to create a three dimensional model of the jaw. The program involves virtual placement of dental implants in the image of the bone with clear visualization of selected anatomical structures, prosthetic requirements 
and implant positions. 

This prosthetic-driven planning ensures optimum implant support of the prosthetic restoration. The integrated diagnostics maximize treatment safety and predictability. The computer generated design is then used to fabricate a precise surgical template that is secured in the patient's mouth and through which the implants are placed with tailored surgical instruments. The technique means that implants and a screw retained implant bridge can be placed with minimal surgical exposure and that the patient can receive implants and a fixed prosthesis in one appointment. This technique has proven to be highly successful for those patients who are candidates for the procedure.

Robert G. Tupac, DDS, FACP, Inc., 
Diplomate, American Board of Prosthodontics
(661) 325-1275 | www.drtupac.com
5060 California Ave., #170, Bakersfield, CA 93309 (map)

How Short Implants Succeed

Dr. Sarah Gray reports, in the January 2013 ADA Journal, on a systematic review of the prognosis of short  dental implants placed in partially edentulous patients. The authors reviewed 29 studies of 2,611 short implants.

Their conclusions were that:

• short implants in the upper jaw had a significantly higher failure rate than the lower jaw
• longer implants had a higher survival rate
• failure rates were higher in patients who smoked
• neither implant surface roughness nor bone augmentation had a significant effect on survival rate

For more information, see: www.jada.ada.org

Robert G. Tupac, DDS, FACP, Inc.,
Diplomate, American Board of Prosthodontics
(661) 325-1275 | www.drtupac.com
5060 California Ave., #170, Bakersfield, CA 93309

The All-on-4

Implant Treatment Plan

When people lose their back teeth, the jawbone quickly shrinks.  In the upper jaw, half of the residual bone can be lost in as little as one year, and with the way the sinus cavity enlarges at the same time, the amount of bone remaining is often not enough to hold implants.  In the lower jaw, the posterior ridge shrinks just as quickly.  Bone grafting to recapture this lost volume is unpredictable, costly and takes a long time.

All-On-4

For these reasons, a solution to the problem, called All-0n-4,  was developed by Dr. Paulo Malo.
He determined that the use of long, well-angled posterior implants (as pictured above) both avoided vulnerable anatomical structures (upper sinuses and lower nerves) and offered improved support for the prosthesis by reducing cantilevers.  Together with straight anterior implants, from a bio-mechanical point of view, this arrangement was suitable to support an arch of 12 teeth.

Why only 4?

The use of four implants in an arch reduces treatment complexity, facilitates oral hygiene and allows for a more durable prosthesis.  By using NobelBiocare NobelSpeedy Groovy implants, the greatest variety of implant components is available to ensure a highly esthetic outcome. In our office, we have found this solution to be favored by our patients.  It is a well proven, scientifically validated, bone anchored alternative to the social, emotional and nutritional disappointments caused by removable dentures.

As Per-Ingvar Branemark, dental implant pioneer, says:  

"No one should have to die with their teeth in a glass of water beside their bed."

Robert G. Tupac, DDS, FACP, Inc., 
 Diplomate, American Board of Prosthodontics
(661) 325-1275 | www.drtupac.com
5060 California Ave., #170, Bakersfield, CA 93309

How Implant-Based Solutions Lead to Improved Quality of Life!

How to Improve Quality of Life  

There is no need to be edentulous.  With conventional dentures severe bone resorption may occur.  Because they may fall out at any time, patients lose more than confidence, avoiding certain foods can lead to nutritional deficiencies, and an altered self-image causes an avoidance of social situations.  Dentures restore only 10% of chewing function.  Poorly fitting dentures can cause sore spots and painful blisters.  They often offer only limited lip and cheek support.

Dental implants provide the following functional benefits:

• greater chewing capability
• improved esthetics
• improved speech
• greater comfort
• less bone resorption

and the following emotional benefits:

• improved self image and self-confidence
• improved social life

The above before and after pictures illustrate this difference.

 Robert G. Tupac, DDS, FACP, Inc.,
 Diplomate, American Board of Prosthodontics
(661) 325-1275 | www.drtupac.com 
5060 California Ave., #170, Bakersfield, CA 93309