Communications and Procedures Necessary to Achieve Success with Milled Titanium Bars for Attached Ov...
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Aristides A. Tsikoudakis, DMD Maxillofacial Prosthodontist Lakewood, Colorado Thomas Wade, C.D.T PowerPoint PPT Presentation


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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

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Aristides A. Tsikoudakis, DMD Maxillofacial Prosthodontist Lakewood, Colorado Thomas Wade, C.D.T

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Aristides a tsikoudakis dmd maxillofacial prosthodontist lakewood colorado thomas wade c d t

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

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

Initial Exam

Critical Elements

Extra-oral:

TMJ

Neck

Soft Tissues


Initial exam1

Initial Exam

Intra-oral:

Soft Tissues

Charting

Edentulous evaluation


Initial exam2

Initial Exam

Radiographic Examination

Orthopantogram Vs. Tomogram


Initial exam3

Initial Exam

Diagnostic Casts

Impressions

Jaw relation records

Facebow

Mounting

Tooth selection


Initial exam4

Initial Exam

Diagnostic Casts

If patients existing dentures have adequate form and function then…

Denture Information Transfer


Initial exam5

Initial Exam

Diagnostic Set-Up

Chairside arrangement of anterior teeth

Midline

Labial contour (lip support)

Smile line

Tooth display

Phonetics


Initial exam6

Initial Exam

Lab Hints:

Set-up wax

Positioning technique

Adjusting existing set-up

Photos are always welcome

Casts of existing prostheses


Initial exam7

Initial Exam

Diagnosis:

Pathology

Edentulous

Degree of resorption

Intact alveolar volume, missing clinical crown

Deficient alveolar/soft tissue volume

Skeletal-occlusal relationship


Initial exam8

Initial exam

Establishing Patient Expectations

Listen

Interpret

Confirm


Classification

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

Clinical Steps

1:00

2:00

1:00

1:00

1:00

1:30

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


Objectives1

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

Troubleshooting

“If you don’t have time to do it correctly the first time…

When are you going to have time to do it over?”


Troubleshooting1

Troubleshooting

Accurate impressions: sets level of excellence

Custom tray when indicated

Adhesive (PVS & Alginate)

Proper proportions (alginate & polysulfide)

Read it

Retake if necessary


Troubleshooting2

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


Troubleshooting3

Troubleshooting

Information and Communication

Case info: more is ALWAYSbetter than not enough

gender

age

shade, opposing cast, jaw record

photos (important for tooth selection)

accurate extraction info

cast of existing prostheses


Troubleshooting4

Troubleshooting

Relines and adding teeth/clasp to RPD:

Pick-up impression

Alginate vs. PVS

Proper pouring technique


Treatment planning

Treatment Planning

Collaborative Effort

Surgeon

Restorative Dr.

Lab technician


Treatment planning1

Treatment Planning

Goal:

To devise the most predictable and straight forward approach for meeting the patient’s expectations

Essentially comes down to 2 factors:

Patient expectations

Bone: where and how much


Treatment planning2

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 planning3

Treatment Planning

Decisions: Implant supported vs. Assisted

Selected by patient

Fixed vs. Removable

Depends on: Defect

Interocclusal space

* Surgery: modify existing anatomy


Treatment planning4

Treatment Planning

Once a treatment plan has been devised…

What criteria are used to select appropriate implant system?

What about radiographic/surgical guide?


Treatment planning5

Treatment Planning

Implant system selection criteria:

Splinted vs. non-splinted

Angled implant placement

Guided implant placement


Treatment planning6

Treatment Planning

Radiographic / Surgical Guides


Treatment planning7

Treatment Planning

Radiographic / Surgical Guides

10o


Treatment planning8

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 planning9

Treatment Planning

Implant Supported vs. Implant Assisted

Transition

Composite Defect

Interocclusal Space

yes

no

yes

no

5-8 mm

9+ mm

16+ mm

SRH

OD

PFM

SRH

PFM

OD

PFM

OD

Surgery

PFM

OD

SRH

*Surgical modification


Treatment planning10

Treatment Planning

Guidelines:

Biomechanics (force control)

Reduce forces applied to system

Engineer system to withstand forces


Treatment planning11

Treatment Planning

Guidelines:

Biomechanics (force control)

Bone in premaxilla, premolar and molar area:

conventional implant placement

greatest A-P spread possible


Treatment planning12

Treatment Planning

Guidelines:

Biomechanics (force control)

Bone in premaxilla and bicuspid only:

Angled implants

Sinus graft


Treatment planning13

Treatment Planning

Guidelines:

Biomechanics (force control)

Bone in premaxilla only:

Sinus graft

Zygomatic implant

Implants in cuspid sites


Treatment planning14

Treatment Planning

Guidelines:

Biomechanics (force control)

Bone deficient in all zones:

Zygomatic implants x 4


Treatment planning15

Treatment Planning

Guidelines:

Biomechanics (force control)

Minimize cantilever of substructure

Stress relieving design for implant assisted

Proper material thickness

Reinforcement as needed


Treatment planning16

Treatment Planning

Guidelines:

Biomechanics (force control)

Reinforcement

Stress relieving ?


Treatment planning17

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 planning18

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 planning19

Treatment Planning

Establishing Fees

3-4 x lab cost to Dr.

Dental Fee Analyzer

Chairtime


Treatment planning20

Treatment Planning

Establishing Fees

Ranges

Maxillary Mandibular

PFM (8) $19,100-$27,300PFM (6) $17,700-$25,300

SRH (8) $15,000-$21,400SRH (6) $14,200-$20,400

SRH (4) $13,600-$19,500SRH (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 planning21

Treatment Planning

Questions?

Lakewooddentalimplants.com


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