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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