Communications and Procedures

Necessary to Achieve Success with

Milled Titanium Bars for Attached
Overdentures and Screw Retained
Hybrids
Aristides A. Tsikoudakis, DMD
Maxillofacial Prosthodontist
Lakewood, Colorado

Thomas Wade, C.D.T
Owner, New Horizons Dental Laboratory
Broomfield, Colorado
Objectives
Review of fundamentals
Initial exam and work up
Diagnosis
Patient expectations

Classification of Prostheses
Implant supported
Implant assisted

Case presentation
Detailed examination of restorative and lab components



Initial Exam
Critical Elements
Extra-oral:
TMJ
Neck
Soft Tissues

Initial Exam
Intra-oral:
Soft Tissues
Charting
Edentulous evaluation


Initial Exam
Radiographic Examination

Orthopantogram Vs. Tomogram
Initial Exam
Diagnostic Casts
Impressions
Jaw relation records
Facebow
Mounting
Tooth selection
Initial Exam
Diagnostic Casts
If patients existing dentures have adequate
form and function then

Denture Information Transfer
Initial Exam
Diagnostic Set-Up
Chairside arrangement of anterior teeth

Midline
Labial contour (lip support)
Smile line
Tooth display
Phonetics
Initial Exam
Lab Hints:

Set-up wax
Positioning technique

Adjusting existing set-up
Photos are always welcome

Casts of existing prostheses
Initial Exam
Diagnosis:

Edentulous
Degree of resorption
Intact alveolar volume, missing clinical crown
Deficient alveolar/soft tissue volume
Skeletal-occlusal relationship
Pathology
Initial exam
Establishing Patient Expectations

Listen
Interpret
Confirm
Classification
Implant Supported
Forces are borne entirely by the implants
without support from the soft tissue
Implant Assisted
Support is shared between implants and soft
tissue
Clinical Steps
Number of Visits: 6-8
Preliminary impressions
Verification and master impressions
Ant set-up and jaw records
Wax try-in
Substructure try-in
Clinical remount & delivery



1:00
2:00
1:00
1:00
1:00
1:30


Objectives
Photo Montage
Guided surgery
All-0n-4
Radiographic guides
Milled titanium bars
Troubleshooting common problems
Accurate impressions and proper casts
Information & communication
Treatment planning
Collaboration between surgeon, restorative, lab



Troubleshooting


If you dont have time to do it correctly the
first time

When are you going to have time to do it over?
Troubleshooting
Accurate impressions: sets level of excellence

Custom tray when indicated

Adhesive (PVS & Alginate)

Proper proportions (alginate & polysulfide)

Read it

Retake if necessary

Troubleshooting
Casts

Properly poured and based casts
Heels
Avoid mandibular horseshoe casts
Inspect prior to sending to lab (pack properly)

Selection of appropriate gypsum
Plaster: never
Die stone: splints, implants, RPD
Stone: everything else

Troubleshooting
Information and Communication

Case info: more is ALWAYS better than not enough
gender
age
shade, opposing cast, jaw record
photos (important for tooth selection)
accurate extraction info
cast of existing prostheses





Troubleshooting
Relines and adding teeth/clasp to RPD:
Pick-up impression

Alginate vs. PVS

Proper pouring technique


Treatment Planning
Collaborative Effort
Surgeon

Restorative Dr.

Lab technician


Treatment Planning
Goal:

To devise the most predictable and straight
forward approach for meeting the
patients expectations

Essentially comes down to 2 factors:
Patient expectations
Bone: where and how much

Treatment Planning
Cases: Implant Supported Fixed vs. Removable
Component stacking phenomenon

Minimum dimensions
Metal-ceramic 4.5 to 5mm
Fixed hybrid 9mm
Removable 16mm
Treatment Planning

Decisions: Implant supported vs. Assisted
Selected by patient

Fixed vs. Removable
Depends on: Defect
Interocclusal space
* Surgery: modify existing anatomy


Treatment Planning
Once a treatment plan has been devised

What criteria are used to select appropriate
implant system?

What about radiographic/surgical guide?


Treatment Planning
Implant system selection criteria:

Splinted vs. non-splinted

Angled implant placement

Guided implant placement



Treatment Planning
Radiographic / Surgical Guides

Treatment Planning
Radiographic / Surgical Guides

10
o
Treatment Planning
Guidelines:

Determine visibility of the residual ridge

Presence or absence of composite defect

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 Planning




Implant Supported vs. Implant Assisted
Transition Composite Defect Interocclusal Space
yes yes no no
PFM
OD
Surgery

PFM
OD
SRH

SRH
OD
PFM
5-8 mm 9+ mm 16+ mm
PFM
SRH
OD
*Surgical modification
Treatment Planning
Guidelines:

Biomechanics (force control)

Reduce forces applied to system

Engineer system to withstand forces


Treatment Planning
Guidelines:

Biomechanics (force control)

Bone in premaxilla, premolar and molar area:

conventional implant placement
greatest A-P spread possible



Treatment Planning
Guidelines:

Biomechanics (force control)

Bone in premaxilla and bicuspid only:

Angled implants
Sinus graft


Treatment Planning
Guidelines:

Biomechanics (force control)

Bone in premaxilla only:

Sinus graft
Zygomatic implant
Implants in cuspid sites


Treatment Planning
Guidelines:

Biomechanics (force control)

Bone deficient in all zones:

Zygomatic implants x 4


Treatment Planning
Guidelines:

Biomechanics (force control)

Minimize cantilever of substructure
Stress relieving design for implant assisted
Proper material thickness
Reinforcement as needed


Treatment Planning
Guidelines:

Biomechanics (force control)




Stress relieving ?
Reinforcement
Treatment Planning
Attachment: Criteria for selection

Implant Supported:
Only needed for retention
Minimal height
Easy & inexpensive to replace insert
Readily available
Minimize wear between components




Treatment Planning
Attachment: Criteria for selection

Implant Assisted:
Retention
Minimal height
Easy & inexpensive to replace insert
Readily available
Minimize wear between components
Resilient
Allows for rotation




Treatment Planning
Establishing Fees

3-4 x lab cost to Dr.

Dental Fee Analyzer

Chairtime





Treatment Planning
Establishing Fees
Ranges

Maxillary Mandibular

PFM (8) $19,100-$27,300 PFM (6) $17,700-$25,300
SRH (8) $15,000-$21,400 SRH (6) $14,200-$20,400
SRH (4) $13,600-$19,500 SRH (4) $13,600-$19,500
OD w/Bar (4) $7,000-$10,000 OD w/Bar (4) $7,000-$10,000
OD w/Bar (2) $5,600-$8,000




Treatment Planning




Questions?
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