1. 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

2. 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

3. Initial Exam Critical Elements Extra-oral:TMJNeck Soft Tissues

4. Initial Exam Intra-oral: Soft Tissues Charting Edentulous evaluation

5. Initial Exam Radiographic Examination Orthopantogram Vs. Tomogram

6. Initial Exam Diagnostic Casts Impressions Jaw relation records FacebowMounting Tooth selection

7. Initial Exam Diagnostic Casts If patients existing dentures have adequate form and function then… Denture Information Transfer

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

9. Initial Exam Lab Hints: Set-up wax Positioning technique Adjusting existing set-up Photos are always welcome Casts of existing prostheses

10. Initial Exam Diagnosis: Edentulous Degree of resorption Intact alveolar volume, missing clinical crown Deficient alveolar/soft tissue volume Skeletal-occlusal relationship Pathology

11. Initial exam Establishing Patient Expectations Listen Interpret Confirm

12. 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

13. 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 1:002:001:001:001:001:30

14. 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

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

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

17. 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

18. Troubleshooting Information and Communication Case info: more is ALWAYS better than not enough genderage shade, opposing cast, jaw record photos (important for tooth selection) photos (important for tooth selection) accurate extraction info cast of existing prostheses

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

20. Treatment Planning Collaborative Effort Surgeon Restorative Dr. Lab technician

21. 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

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

23. Treatment Planning Decisions: Implant supported vs. Assisted Selected by patient Fixed vs. Removable Fixed vs. Removable Depends on: Defect Interocclusal space Interocclusal space * Surgery: modify existing anatomy * Surgery: modify existing anatomy

24. Treatment Planning Once a treatment plan has been devised… What criteria are used to select appropriate implant system? What about radiographic/surgical guide?

25. Treatment Planning Implant system selection criteria: Splinted vs. non-splinted Angled implant placement Guided implant placement

26. Treatment Planning Radiographic / Surgical Guides

27. Treatment Planning Radiographic / Surgical Guides 10 o

28. 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

29. Treatment Planning Implant Supported vs. Implant Assisted TransitionComposite DefectInterocclusal Space yes no PFM OD Surgery PFM OD SRH OD PFM 5-8 mm9+ mm16+ mm PFM SRH OD *Surgical modification

30. Treatment Planning Guidelines: Biomechanics (force control) Reduce forces applied to system Engineer system to withstand forces

31. Treatment Planning Guidelines: Biomechanics (force control) Bone in premaxilla, premolar and molar area: conventional implant placement greatest A-P spread possible

32. Treatment Planning Guidelines: Biomechanics (force control) Bone in premaxilla and bicuspid only: Angled implants Sinus graft

33. Treatment Planning Guidelines: Biomechanics (force control) Bone in premaxilla only: Sinus graft Zygomatic implant Implants in cuspid sites

34. Treatment Planning Guidelines: Biomechanics (force control) Bone deficient in all zones: Zygomatic implants x 4

35. Treatment Planning Guidelines: Biomechanics (force control) Minimize cantilever of substructure Stress relieving design for implant assisted Proper material thickness Reinforcement as needed

36. Treatment Planning Guidelines: Biomechanics (force control) Stress relieving ? Reinforcement

37. 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

38. 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

39. Treatment Planning Establishing Fees 3-4 x lab cost to Dr. Dental Fee Analyzer Chairtime

40. Treatment Planning Establishing Fees Ranges Maxillary Mandibular 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 OD w/Bar (2) $5,600-$8,000

41. Treatment Planning Questions? Lakewooddentalimplants.com