communications and procedures necessary to achieve success with milled titanium bars for attached...
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Communications and Procedures Communications and Procedures Necessary to Achieve Success Necessary to Achieve Success with Milled Titanium Bars for with Milled Titanium Bars for Attached Overdentures and Attached Overdentures and
Screw Retained Hybrids Screw Retained Hybrids
Aristides A. Tsikoudakis, DMDAristides A. Tsikoudakis, DMDMaxillofacial ProsthodontistMaxillofacial Prosthodontist
Lakewood, ColoradoLakewood, Colorado
Thomas Wade, C.D.TThomas Wade, C.D.TOwner, New Horizons Dental LaboratoryOwner, New Horizons Dental Laboratory
Broomfield, ColoradoBroomfield, Colorado
ObjectivesObjectivesReview of fundamentalsReview of fundamentals
Initial exam and work upInitial exam and work upDiagnosisDiagnosisPatient expectationsPatient expectations
Classification of ProsthesesClassification of ProsthesesImplant supportedImplant supportedImplant assistedImplant assisted
Case presentationCase presentationDetailed examination of restorative and lab componentsDetailed examination of restorative and lab components
Initial ExamInitial Exam
Critical ElementsCritical ElementsExtra-oral:Extra-oral:
TMJTMJ
NeckNeck
Soft TissuesSoft Tissues
Initial ExamInitial Exam
Intra-oral:Intra-oral:Soft TissuesSoft Tissues
ChartingCharting
Edentulous evaluationEdentulous evaluation
Initial ExamInitial Exam
Radiographic ExaminationRadiographic Examination
Orthopantogram Vs. TomogramOrthopantogram Vs. Tomogram
Initial ExamInitial Exam
Diagnostic CastsDiagnostic CastsImpressionsImpressions
Jaw relation recordsJaw relation records
FacebowFacebow
MountingMounting
Tooth selectionTooth selection
Initial ExamInitial Exam
Diagnostic CastsDiagnostic CastsIf patients existing dentures have If patients existing dentures have adequate form and function then…adequate form and function then…
Denture Information TransferDenture Information Transfer
Initial ExamInitial Exam
Diagnostic Set-UpDiagnostic Set-UpChairside arrangement of anterior Chairside arrangement of anterior teethteeth
MidlineMidlineLabial contour (lip support)Labial contour (lip support)Smile lineSmile lineTooth displayTooth displayPhoneticsPhonetics
Initial ExamInitial Exam
Lab Hints:
Set-up wax
Positioning technique
Adjusting existing set-upPhotos are always welcome
Casts of existing prostheses
Initial ExamInitial Exam
Diagnosis:
Edentulous
Degree of resorptionIntact alveolar volume, missing clinical crownDeficient alveolar/soft tissue volume
Skeletal-occlusal relationship
Pathology
Initial examInitial exam
Establishing Patient ExpectationsEstablishing Patient Expectations
Listen
Interpret
Confirm
ClassificationClassification
Implant SupportedImplant SupportedForces are borne entirely by the implants Forces are borne entirely by the implants without support from the soft tissuewithout support from the soft tissue
Implant AssistedImplant AssistedSupport is shared between implants and Support is shared between implants and soft tissuesoft tissue
Clinical StepsClinical Steps
Number of Visits: 6-8Number of Visits: 6-8Preliminary impressionsPreliminary impressionsVerification and master impressionsVerification and master impressionsAnt set-up and jaw recordsAnt set-up and jaw recordsWax try-inWax try-inSubstructure try-inSubstructure try-inClinical remount & deliveryClinical remount & delivery
1:001:002:002:001:001:001:001:001:001:001:301:30
ObjectivesObjectivesPhoto Montage…Photo Montage…
Guided surgery Guided surgery
All-0n-4All-0n-4
Radiographic guidesRadiographic guides
Milled titanium barsMilled titanium bars
Troubleshooting common problemsTroubleshooting common problems
Accurate impressions and proper castsAccurate impressions and proper casts
Information & communicationInformation & communication
Treatment planningTreatment planningCollaboration between surgeon, restorative, labCollaboration between surgeon, restorative, lab
Troubleshooting Troubleshooting
““If you don’t have time to do it correctly If you don’t have time to do it correctly the first time…the first time…
When are you going to have time to do it When are you going to have time to do it over?”over?”
Troubleshooting Troubleshooting Accurate impressions: sets level of excellenceAccurate impressions: sets level of excellence
Custom tray when indicated Custom tray when indicated
Adhesive (PVS & Alginate)Adhesive (PVS & Alginate)
Proper proportions (alginate & polysulfide)Proper proportions (alginate & polysulfide)
Read itRead it
Retake if necessaryRetake if necessary
Troubleshooting Troubleshooting CastsCasts
Properly poured and based castsProperly poured and based castsHeelsHeelsAvoid mandibular horseshoe castsAvoid mandibular horseshoe castsInspect prior to sending to lab (pack properly)Inspect prior to sending to lab (pack properly)
Selection of appropriate gypsumSelection of appropriate gypsumPlaster: Plaster: neverneverDie stone: splints, implants, RPD Die stone: splints, implants, RPD Stone: everything elseStone: everything else
Troubleshooting Troubleshooting Information and CommunicationInformation and Communication
Case info: more is Case info: more is ALWAYSALWAYS better than not better than not enoughenough
gendergenderageageshade, opposing cast, jaw record shade, opposing cast, jaw record
photos photos (important for tooth selection)(important for tooth selection)accurate extraction infoaccurate extraction infocast of existing prosthesescast of existing prostheses
Troubleshooting Troubleshooting Relines and adding teeth/clasp to RPD:Relines and adding teeth/clasp to RPD:
Pick-up impressionPick-up impression
Alginate vs. PVSAlginate vs. PVS
Proper pouring techniqueProper pouring technique
Treatment PlanningTreatment Planning
Collaborative EffortCollaborative Effort
SurgeonSurgeon
Restorative Dr.Restorative Dr.
Lab technicianLab technician
Treatment PlanningTreatment PlanningGoal:Goal:
To devise the most predictable and To devise the most predictable and straight forward approach for meeting straight forward approach for meeting the patient’s expectationsthe patient’s expectations
Essentially comes down to 2 factors:Essentially comes down to 2 factors:Patient expectationsPatient expectationsBone: where and how muchBone: where and how much
Treatment PlanningTreatment Planning
Cases: Implant Supported Fixed vs. Cases: Implant Supported Fixed vs. RemovableRemovable
Component stacking phenomenonComponent stacking phenomenon
Minimum dimensionsMinimum dimensions
Metal-ceramic 4.5 to 5mmMetal-ceramic 4.5 to 5mm
Fixed hybrid 9mmFixed hybrid 9mm
RemovableRemovable 16mm 16mm
Treatment PlanningTreatment Planning
Decisions: Implant supported vs. Assisted Decisions: Implant supported vs. Assisted
Selected by patientSelected by patient
Fixed vs. RemovableFixed vs. Removable
Depends on: DefectDepends on: Defect
Interocclusal Interocclusal spacespace
* Surgery: modify existing anatomy* Surgery: modify existing anatomy
Treatment PlanningTreatment Planning
Once a treatment plan has been Once a treatment plan has been devised…devised…
What criteria are used to select What criteria are used to select appropriate implant system?appropriate implant system?
What about radiographic/surgical What about radiographic/surgical guide?guide?
Treatment PlanningTreatment Planning
Implant system selection criteria:Implant system selection criteria:
Splinted vs. non-splintedSplinted vs. non-splinted
Angled implant placementAngled implant placement
Guided implant placementGuided implant placement
Treatment PlanningTreatment Planning
Radiographic / Surgical Guides Radiographic / Surgical Guides
Treatment PlanningTreatment Planning
Radiographic / Surgical Guides Radiographic / Surgical Guides 10o
Treatment PlanningTreatment Planning
Guidelines:Guidelines:
Determine visibility of the residual ridgeDetermine visibility of the residual ridge
Presence or absence of composite defectPresence or absence of composite defect
Biomechanics (force control)Biomechanics (force control)
Bedrossian et al. Implant restoration of the edentulous maxilla: a systematic pretreatment evaluation method. J. Oral Maxillofac Surg 66:112-122, 2008
Treatment PlanningTreatment PlanningImplant Supported vs. Implant Assisted
Transition
Composite Defect
Interocclusal Space
yes
yes
no no
PFMODSurgery
PFMODSRH
SRHOD
PFM
5-8 mm
9+ mm 16+ mm
PFM SRH OD
*Surgical modification
Treatment PlanningTreatment Planning
Guidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Reduce forces applied to systemReduce forces applied to system
Engineer system to withstand forcesEngineer system to withstand forces
Treatment PlanningTreatment Planning
Guidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Bone in premaxilla, premolar and molar Bone in premaxilla, premolar and molar area:area:
conventional implant placementconventional implant placementgreatest A-P spread possiblegreatest A-P spread possible
Treatment PlanningTreatment Planning
Guidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Bone in premaxilla and bicuspid Bone in premaxilla and bicuspid only:only:
Angled implantsAngled implantsSinus graftSinus graft
Treatment PlanningTreatment Planning
Guidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Bone in premaxilla only:Bone in premaxilla only:
Sinus graftSinus graftZygomatic implantZygomatic implantImplants in cuspid sitesImplants in cuspid sites
Treatment PlanningTreatment Planning
Guidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Bone deficient in all zones:Bone deficient in all zones:
Zygomatic implants x 4Zygomatic implants x 4
Treatment PlanningTreatment Planning
Guidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Minimize cantilever of substructureMinimize cantilever of substructureStress relieving design for implant Stress relieving design for implant
assistedassistedProper material thicknessProper material thicknessReinforcement as needed Reinforcement as needed
Treatment PlanningTreatment Planning
Guidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Stress relieving ?Reinforcement
Treatment PlanningTreatment Planning
Attachment: Criteria for selectionAttachment: Criteria for selection
Implant Supported:Implant Supported:Only needed for retentionOnly needed for retentionMinimal heightMinimal heightEasy & inexpensive to replace insertEasy & inexpensive to replace insertReadily availableReadily availableMinimize wear between componentsMinimize wear between components
Treatment PlanningTreatment PlanningAttachment: Criteria for selectionAttachment: Criteria for selection
Implant Assisted:Implant Assisted:RetentionRetentionMinimal heightMinimal heightEasy & inexpensive to replace insertEasy & inexpensive to replace insertReadily availableReadily availableMinimize wear between componentsMinimize wear between componentsResilientResilientAllows for rotation Allows for rotation
Treatment PlanningTreatment Planning
Establishing FeesEstablishing Fees
3-4 x lab cost to Dr.3-4 x lab cost to Dr.
Dental Fee AnalyzerDental Fee Analyzer
ChairtimeChairtime
Treatment PlanningTreatment PlanningEstablishing FeesEstablishing Fees
RangesRanges
MaxillaryMaxillary Mandibular Mandibular
PFM (8) PFM (8) $19,100-$27,300 $19,100-$27,300PFM (6) $17,700-$25,300PFM (6) $17,700-$25,300SRH (8) SRH (8) $15,000-$21,400 $15,000-$21,400SRH (6) $14,200-$20,400SRH (6) $14,200-$20,400SRH (4) SRH (4) $13,600-$19,500 $13,600-$19,500SRH (4) $13,600-$19,500SRH (4) $13,600-$19,500OD w/Bar (4) $7,000-$10,000 OD w/Bar (4) $7,000-$10,000OD w/Bar (4) $7,000-$10,000 OD w/Bar (4) $7,000-$10,000 OD w/Bar (2) $5,600-$8,000OD w/Bar (2) $5,600-$8,000
Treatment PlanningTreatment PlanningQuestions?
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