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tol]anic and saunders 47 48 49 50 51 52 53 54 55 56 57 bowles r artificial saliva j oregon dent assoc 47:18 1978 dykes p harris p and marston a treatment of dry mouth lancet 2:1353 1960 robinson j e dental management of the oral effects of radiotherapy j prosthet dent 14:582 1964 billingsly l effects from radiation therapy of oral carcinoma j am dent hyg assoc 45:305 1971 carl w oral and dental care for the irradiated patient quintessence int dent digest 5:55 1974 halpern i l and freedman a l dental management of the irradiated patient dent surv 51:18 1975 fine l dental care of the irradiated patient j hosp dent pract 9:127 1975 vergo t j and kadish s p dentures as artificial saliva reservoirs in the irradiated edentulous cancer patient with xerostomia a pilot study oral surg 51:229 1981 toljanic j a and zucuskie t g use of a palatal reservoir in denture patients with xerostomia j prosthet dent in press bond w r matthews j l and finney j w the influence of regional oxygenation on osteoradionecrosis oral surg 23:99 1967 mainous e g boyne p j and hart g b elimination of sequestrum and healing of osteoradionecrosis of the mandible 58 59 60 61 62 63 after hyperbaric oxygen therapy report of a case j oral surg 31:336 1973 mcailister t a stark j m norman j m and ross r m inhibitory effects of hyperbaric oxygen on bacteria and fungi lancet 2:1040 1963 hahn g and cargill d a conservative treatment of radionecrosis of mandible oral surg 24:707 1976 starcke e n and shannon i l how critical is the interval between extractions and irradiation in patients with head and neck malignancy oral surg 43:333 1977 wildermuth o and cantril s t radiation necrosis of the mandible radiology 61:771 1953 narang r and wells h the avoidance of osteoradionecrosis of the mandible after extraction of a number of teeth in a patient given radiotherapy for oral carcinoma oral surg 29:656 1970 beumer j curtis t a and morrish r b radiation complications in edentulous patients j prosthet dent 36:193 1976 reprint requests to dr joseph a toljanic hines medical center dental service 160 h m il 60141 modifications of the superstructure for the staple implant luis r guerra d.d.s m.s harold d larsen d.m.d m.ed israel m finger d.d.s m.ed and fernando jaen d.d.s louisiana state university school of dentistry new orleans la .opularized by small t 4 the staple bone plate zimmer warsaw ind has found wide acceptance among dentists as a way to stabilize a mandibular complete denture helfrick et a12 reported a success rate greater than 95 in 250 patients the staple implant is available in three configurations that include an inferior bone plate three or five retentive pins and two transosteal pins that extend into the oral cavity fig 1 included with each implant are four fasteners and two loeknuts the transosteal pins pass through the mandible and are joined together intraorally by a superstructure thus forming a rigid rectangular configuration fig 2 ceka ceka p.v.b.a deurine belgium or dalbo cendres et metaux sa biel-bienne switzerland attachments professor department of removable prosthodontics associate professor department of removable prosthodontics panama city panama 858 p are added to the superstructure at the distal end of each transosseous pin to which a removable prosthesis is attached the superstructure is usually cemented to the transosseous abutments when the removable prosthesis is inserted the prosthesis must not direct loading forces to the staple implant several techniques have been described to make dentures over a staple implant some techniques require the construction of duplicate casts some require placement of the attachments clinically and most require placement of the attachments after the denture has been processed various techniques propose the use of copings connecting bars or attachments in the superstructure3 precious metals are often used for copings and connecting bars attachments are expensive and the procedures are time consuming although we have used these techniques in approximately 50 patients in 7 years economy has suggested the december 1984 volume 52 number 6

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modifications for staple implant fig 1 implant is manufactured in three configurations left to right seven pin modified seven pin and five pin 3 a b fig 3 acrylic resin transfer coping a and fastener b b c fig 2 transosteal pins joined with round bar need for technique changes that do not sacrifice the quality of the prosthodontic rehabilitation this article describes two techniques in which the ultram attachment attachments international san mateo calif is used the male portion of the ultram is plastic and the female portion is a nonprecious alloy the ultram attachment like the dalbo has a spring within the female portion that must be removed to prevent vertical loading of the implant technique no 1 1 fabricate acrylic resin transfer copings over the fasteners fig 3 2 align the fasteners on each transosteal pin so that a flat surface of the fastener is perpendicular to a line that bisects the angle made by lines drawn parallel to the crest of the ridge and the midline of the cast fig 4 there should be 1.5 mm between the base of the locknut and the crest of the ridge if a locknut is not used because of vertical height restrictions 1.5 mm must be maintained between the base of the fastener and the crest of the ridge the journal of prosthetic dentistry b a f ยข fig 4 flat surface of fastener perpendicular directed to line b line c is parallel to residual alveolar ridge and line a is parallel to midline of cast 3 place the transfer copings over the aligned fasteners and make an irreversible hydrocolloid impression in a border-molded custom tray 4 on removal of the impression remove the fasteners from the transosteal pins and place them into the transfer copings in the impression 5 insert a roundhead steel machine screw 4-40 x 3 4 inch into the fastener and place acrylic resin at the 859

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g uerra et al a e c d fig 9 acrylic resin or wax over locknuts is connected by bar fig 5 impression a transfer copings b fasteners c acrylic resin d roundhead machine screw e fig 10 lateral view of washer and male portion of ultra m attachment abciiit fig 6 wax copings b and attachments a on fasteners c r a b fig 7 lateral view of coping and attachment over fastener fig 11 male portion of attachment a fastener b lower half locknut c and washer d a b fig 8 stone b eliminates undercuts beneath attachments and bar retentive portion of attachment is covered with wax a fig 12 attachment coping and bar assembly cemented in place 7 wax the copings and bar and assemble the attachments figs 4 6 and 7 the bar should be 10-gauge round 8 cast the attachments copings and bar in one piece in nonprecious metal 9 verify the assembly on the master cast and in the mouth 10 place the female portion of the attachment on the superstructure on the master cast december 1984 volumes2 number 6 fastener-screw junction fig 5 if the locknut is to be placed on the master cast do not place acrylic resin at the fastener-screw junction 6 pour the impression in dental stone and verify the alignment of the fasteners on the master cast 860

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modifications for staple implant 8 continue as in step nos 11 and 12 of technique no 1 summary two techniques have been described to expedite fabrication and reduce the cost of prostheses made for staple implants the techniques permit placement of a simulated transosseous pin within the master east at the time of denture placement in technique no 1 the coping-bar attachment assembly is cemented fig 12 in technique no 2 the superstructure is placed over the transosteal pins and secured between the locknuts to maintain the base of the lower locknut 1.5 mm from the crest of the alveolar ridge fig 13 technique no 2 permits removal of the superstructure as desired patients should be instructed in proper oral hygiene and denture care references 1 2 3 4 5 small t a survey of experience with the mandibular staple bone plate j oral surg 36:604 1978 small t a use of the mandibular bone plate in the deformed mandible j oral surg 37:26 1979 small t a the mandibular staple bone plate for the atrophic mandible clinical dental sciences rev 73:27 1980 small t a the mandibular staple bone plate for the atrophic mandible dent clin north am 24:565 1980 helfrick j f tofp j s and kaufman m mandibular staple bone plate long term evaluation of 250 cases j am dent assoc 104:318 1982 zimmer m m mandibular staple bone plate a reconstructive operation for the atrophic mandible a technique manual warsaw ind zimmer pp 28-39 fig 13 attachment washer and bar assembly locked in place 11 with stone block out below the attachments and around the bar cover the retentive portion of the attachment with wax fig 8 12 continue usual fabrication of the dentures technique no 2 1 follow step nos 1 through 6 as in technique no 1 2 remove the transfer copings and the fasteners from the screw 3 place an acrylic resin or wax washer over the locknuts and wax a 10-gauge round bar between them fig 9 4 align and attach the plastic portion of the ultram attachment to the washer figs 4 and 10 5 cast the entire assembly in one piece 6 verify attachment alignment on the cast fig 4 and in the mouth 7 place the assembly on the master cast with a locknut below and the lower half of a fastener above fig 11 another locknut can be used in place of the half fastener 6 reprint requests to dr harold d larsen louisianastate university schoolof dentistry new orleans la 70019 the journal of prosthetic dentistry 861

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