Communications and Procedures Necessary to Achieve Success with Milled Titanium Bars for Attached Overdentures and Screw Retained Hybrids

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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
• Broomfield, Colorado

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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

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Initial Exam

• Critical Elements
• Extra-oral
• TMJ
• Neck
• Soft Tissues

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Initial Exam

• Intra-oral
• Soft Tissues
• Charting
• Edentulous evaluation

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Initial Exam

• Radiographic Examination
• Orthopantogram Vs. Tomogram

6
Initial Exam

• Diagnostic Casts
• Impressions
• Jaw relation records
• Facebow
• Mounting
• Tooth selection

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Initial Exam

• Diagnostic Casts
• If patients existing dentures have adequate form
  and function then
• Denture Information Transfer

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Initial Exam

• Diagnostic Set-Up
• Chairside arrangement of anterior teeth
• Midline
• Labial contour (lip support)
• Smile line
• Tooth display
• Phonetics

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Initial Exam
Lab Hints
Set-up wax
Positioning technique Adjusting existing set-up
Photos are always welcome Casts of existing
prostheses
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Initial Exam
Diagnosis
Pathology
Edentulous
Degree of resorption Intact alveolar volume,
missing clinical crown Deficient alveolar/soft
tissue volume
Skeletal-occlusal relationship
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Initial exam

• Establishing Patient Expectations

Listen
Interpret
Confirm
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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

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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

100 200 100 100 100 130
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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

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Troubleshooting

• If you dont have time to do it correctly the
  first time
• When are you going to have time to do it over?

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Troubleshooting

• Accurate impressions sets level of excellence
• Custom tray when indicated
• Adhesive (PVS Alginate)
• Proper proportions (alginate polysulfide)
• Read it
• Retake if necessary

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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

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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

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Troubleshooting

• Relines and adding teeth/clasp to RPD
• Pick-up impression
• Alginate vs. PVS
• Proper pouring technique

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Treatment Planning

• Collaborative Effort
• Surgeon
• Restorative Dr.
• Lab technician

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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

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Treatment Planning

• Cases Implant Supported Fixed vs. Removable
• Component stacking phenomenon
• Minimum dimensions
• Metal-ceramic 4.5 to 5mm
• Fixed hybrid 9mm
• Removable 16mm

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Treatment Planning

• Decisions Implant supported vs. Assisted
• Selected by patient
• Fixed vs. Removable
• Depends on Defect
• Interocclusal space
• Surgery modify existing anatomy

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Treatment Planning

• Once a treatment plan has been devised
• What criteria are used to select appropriate
  implant system?
• What about radiographic/surgical guide?

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Treatment Planning

• Implant system selection criteria
• Splinted vs. non-splinted
• Angled implant placement
• Guided implant placement

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Treatment Planning

• Radiographic / Surgical Guides

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Treatment Planning

• Radiographic / Surgical Guides

10o
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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
66112-122, 2008
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Treatment Planning
Implant Supported vs. Implant Assisted

Transition
Composite Defect
Interocclusal Space
yes
yes
no
no
5-8 mm
9 mm
16 mm
SRH OD
PFM
SRH
PFM
OD
PFM OD Surgery
PFM OD SRH
Surgical modification
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Treatment Planning

• Guidelines
• Biomechanics (force control)
• Reduce forces applied to system
• Engineer system to withstand forces

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Treatment Planning

• Guidelines
• Biomechanics (force control)
• Bone in premaxilla, premolar and molar area
• conventional implant placement
• greatest A-P spread possible

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Treatment Planning

• Guidelines
• Biomechanics (force control)
• Bone in premaxilla and bicuspid only
• Angled implants
• Sinus graft

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Treatment Planning

• Guidelines
• Biomechanics (force control)
• Bone in premaxilla only
• Sinus graft
• Zygomatic implant
• Implants in cuspid sites

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Treatment Planning

• Guidelines
• Biomechanics (force control)
• Bone deficient in all zones
• Zygomatic implants x 4

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Treatment Planning

• Guidelines
• Biomechanics (force control)
• Minimize cantilever of substructure
• Stress relieving design for implant assisted
• Proper material thickness
• Reinforcement as needed

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Treatment Planning

• Guidelines
• Biomechanics (force control)

Reinforcement
Stress relieving ?
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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

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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

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Treatment Planning

• Establishing Fees
• 3-4 x lab cost to Dr.
• Dental Fee Analyzer
• Chairtime

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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

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Treatment Planning
Questions?

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