Post on 01-Oct-2020
11/11/2019
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Andrew Ferrier, DDS
Module:
Patient Workup and Treatment Planning
Andrew Ferrier, DDS
Let’s get clinical
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Treatment planning Sequence
• Esthetics
• Restorative Space
• AP spread
• Treatment options
Andrew Ferrier, DDS
Patient work up
• Perform full new patient exam
• Thoroughly review medical hx
• Make over extended alginate impressions
• Make JRR and orientation record for maxillary arch
• Take intraoral and extraoral photographs
Andrew Ferrier, DDS
Patient work up
• Conditions to be aware of:
• Cardiac issues
• Issues with healing
• Smoking
• Diabetes
• Osteoporosis
• Bisphosphonates
Andrew Ferrier, DDS
Intraoral Photographs
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Andrew Ferrier, DDS
Intraoral Photographs
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Extraoral Photographs
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Extraoral Photographs
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Extraoral Photographs
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Esthetic Evaluation
• Measure lip position at maximum “snarl”
• Determine:– Maxillary midline position
– Maxillary central incisal edge position
– Mandibular teeth are based on the maxillary tooth position
• Evaluate how to hide the junction of, the prosthesis and natural tissue
• This will guide bone reduction
Andrew Ferrier, DDS
Esthetic Evaluation
3mm min
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Hiding the transition line
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Restorative Space; Bone Reduction
• The most critical step to ensure prosthetic success
• The restorative prosthesis needs a minimum of 15mm from the
implant fixture to the incisal edge or occlusal plane
• This can be determined from the CT scan in conjunction with
the extraoral photographs
• Necessary for strength of prosthesis and for esthetics
Andrew Ferrier, DDS
Patient CL; Bone Reduction for esthetics
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Bone Reduction
15mm min.
10mm min.
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Blue Print
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Make Immediate Dentures
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Lang Denture Duplicator
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Analog Surgical Guide; Duplicate In Clear Acrylic
15 mm
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Duplicate In Clear Acrylic
Cingulum
Tapered
Palatal and Lingual Views
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Patient CL
30mm min
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Patient CL
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Pt JS
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Pt JS
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Patient JS; Bone Reduction for Restorative Space
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Anterior Posterior Spread
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AP Spread
• Critical to avoid excesses force on the distal implants
• Poor AP spread can lead to excessive cantilevers, which results in prosthetic fractures, bone loss and can cause implant failures
• Minimizing cantilever lengths works hand in hand with ideal AP spread to prevent distal implant overload
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Andrew Ferrier, DDS
Clin Oral Implants Res. 2000 Oct;11(5):465-75.
Magnitude and distribution of occlusal forces on oral
implants supporting fixed prostheses: an in vivo study.
Duyck J1, Van Oosterwyck H, Vander Sloten J, De Cooman M,
Puers R, Naert I.
A total of 13 patients with an implant supported fixed full prosthesis were selected. Occlusal forces on the
supporting implants were quantified and qualified during controlled load application of 50 N on several positions
along the occlusal surface of the prostheses and during maximal biting in maximal occlusion by use of strain
gauged abutments. The test was conducted when the prostheses were supported by all (5 or 6) implants and
was repeated when the prostheses were supported by 4 and by 3 implants only. Despite considerable inter-
individual variation, clear differences in implant loading between these test conditions were seen. Loading of the
extension parts of the prostheses caused a hinging effect which induced considerable compressive forces on
the implants closest to the place of load application and lower compressive or tensile forces on other implants.
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142 41
50
9 8
15mm cantilever & 50N force
Duyck J et al COIR 2000:11:465-475
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50 N force on short cantilever
104 13
50
Duyck J et al COIR 2000:11:465-475
Andrew Ferrier, DDS
Int J Prosthodont. 2010 Nov-Dec;23(6):566-73
Effect of tilted and short distal implants on axial forces and bending moments in implants
supporting fixed dental prostheses: an in vitro studyOgawa T1, Dhaliwal S, Naert I, Mine A, Kronstrom M, Sasaki K, Duyck J.
PURPOSE:
The aim of this study was to evaluate the axial forces (AFs) and bending moments (BMs) on implants supporting a fixed dental prosthesis (FDP) with a distal cantilever (10 mm) compared to an FDP supported by a tilted or short (7 mm instead of 13 mm) posterior implant by
means of in vitro strain gauge measurements.
MATERIALS AND METHODS:
Nine titanium Branemark implants were placed in an edentulous composite mandible. The mechanical loading conditions were evaluated for the following three situations: (1) short distal implants supporting a cantilever, (2) long tilted distal implants, and (3) no distal implants
supporting a cantilever. A vertical load of 50 N was applied at the first molar position, and the resultant AFs and BMs were measured for the
three different situations, three different numbers of supporting implants (three, four, or five), and three different prosthesis materials (titanium, acrylic, and fiber-reinforced acrylic).
RESULTS:
The mean BMs, as well as the maximum AFs and BMs, were significantly higher in the model with a cantilever compared to that having the
tilted or short distal implants (P < .001). There was no significant difference between the models with a distally tilted implant versus a short distal implant.
CONCLUSION:
The use of posterior implants reduced the AFs and BMs on implants supporting an FDP compared to that with a distal cantilever. No
difference in mechanical loading was observed between short or tilted distal implants.
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142 41 9 8
Cantilever will increase loading forces
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These implant conformations offer the same loading
potential
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Andrew Ferrier, DDS
Immediate results that leave a lasting impression!
five implants six implantsfour implants
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Tapered Short Implant
– for resorbed sites
– reduced surgical protocol
– primary stability
– dual affinity Laser-Lok® surface
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AP Spread; Planning Position
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AP Spread; Planning Position
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Minimize Cantilever Lengths
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AP Spread; Planning Position
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AP Spread; Planning Position
AP Spread
Cantilever
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Problems with implants to close together and no AP
spread• Hygiene issues
• Excessive load on implants and components
– Fracture of prosthesis
– Bone loss
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Key Concepts
ALWAYS……..
learn from the past and from the mistakes we all make!!!!!
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Old School
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Home Depot Special
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Shotgun Approach
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What do we normally do?
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Let’s do some implants
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Let’s do some more…
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And some more…
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Finally done?
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At what cost was this accomplished?
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Wow!
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Let’s take it all the way!!!
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Andrew Ferrier, DDS
15mm
Treatment Planning
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10mm
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Treatment Planning
3mm
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Correct incisal edge position
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Correct incisal edge position
15mm
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Super eruption and excess vertical overlap
Correct incisal edge position15mm
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Treatment Planning
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Treatment Planning
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Execution
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3mm
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Treatment Planning
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Treatment Planning
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Proceed with caution
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Difficult cases
• Skeletal Class II
• Vertical Maxillary Excess
• Large Defect Cases
• Combination Syndrome
• Issues with VDO
• Difficult sequencing
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Class II Relationships
• Modifiable into pseudo class I
• Class II div II (Retrocline Maxillary Incisors)
• Leave in Class II
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LO
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LO
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LO
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JB
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JB
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JB
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SP
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SP
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SP
15mm
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Vertical Maxillary Excess
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Proceed with caution
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Smile line
Alveolaplasty
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Proceed with extreme caution
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A bit complicated
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Quad Zygoma
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Great patient right?
Andrew Ferrier, DDS
Think again
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Combination syndrome
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Combination syndrome
10mm
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Is this patient a good candidate?
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Evaluating VDO
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Vertical Dimension
• Carefully evaluate a patient like this
• Do we open the VDO?
• What is the alternative?
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Wax Rim
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Only open VDO if patient has adequate freeway space
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What do we do if the patient has inadequate freeway
space?
10mm
5mm15mm
15mm
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Sequencing
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Intraoral Photographs
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Lower Arch Provisionalized
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Upper Arch Provisionalized
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Provisionals
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Complex
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Intraoral Photographs
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