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:
Pathology
Edentulous
Degree of resorption
Intact alveolar volume, missing clinical crown
Deficient alveolar/soft tissue volume
Skeletal-occlusal relationship
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 don’t 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
patient’s 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
10o
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
no
yes
no
5-8 mm
9+ mm
16+ mm
PFM
OD
Surgery
PFM
OD
SRH
SRH
OD
PFM
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)
Reinforcement
Stress relieving ?
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
PFM (8)
SRH (8)
SRH (4)
OD w/Bar (4)
$19,100-$27,300
$15,000-$21,400
$13,600-$19,500
$7,000-$10,000
Mandibular
PFM (6)
SRH (6)
SRH (4)
OD w/Bar (4)
OD w/Bar (2)
$17,700-$25,300
$14,200-$20,400
$13,600-$19,500
$7,000-$10,000
$5,600-$8,000
Treatment Planning
Questions?
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