as opposed to “few teeth at a time” dentistry · Basil Mizrahi BDS, MSc, MEd Private Practice,...
Transcript of as opposed to “few teeth at a time” dentistry · Basil Mizrahi BDS, MSc, MEd Private Practice,...
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FULL MOUTH REHABILTATION
Basil Mizrahi BDS, MSc, MEd
Private Practice, London, UK
Clinical Lecturer, UCL Eastman Dental Institute
Diplomat, American Board of Prosthodontics
Specialist in Restorative Dentistry and Prosthodontics
www.mizrahi-dental-teaching.co.uk
Benefits of complete arch treatment
More Control • Occlusion
– Can increase the VDO
– Can work in therapeutic healthy jaw position (CR) rather than a tooth dictated position
• Tooth position
– improved aesthetics and function
……as opposed to “few teeth at a time” dentistry
STAGES 1. Records, Planning, Case Discussion 2. Initial basic wax up + Chairside temporisation 3. Foundations + Core restorations 4. Prep and Temp refinement 5. Definitive diagnostic wax-up + Lab provisionals
– (the later the better) 6. Final restorations
Same quality whether 1 or 14 teeth
Stability at all times !
Records, Planning, Case Discussion
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FULL MOUTH INVESTIGATIONS • PA x-rays • U and L silicone imps • Facebow • Initial CR bite registration
INITIAL CR bite
silicone Lucier jig Slightly open VDO
Treatment Planning
TREATMENT PLANNING
optimal inappropriate
This will shift to the right as your practice and
experience grows, your skill level improves and you
are able to grow your patient expectations
acceptable compromise
too much
compromise for dentist
too much time
effort, money for the patient
Patient (simple)
Dentist (comprehensive)
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AIM More dentistry on
Less patients to achieve
Better results
CASE PRESENTATION
Essential (biomechanical)
Without it you won’t treat patient. eg ortho, retreatment of poor endo, apical areas requiring endo
• Patient must agree before tx starts.
Will enhance the aesthetic result – not the biomechanical result. • Decision can be made later on once treatment is under way. eg
doing the adjacent tooth as well, ortho alignement, CTG, aesthetic c/lengthening
Elective (Aesthetic)
MODULAR TREATMENT
• Allow patients expectations to
grow during tx...stepwise approach
and good temporaries
• Don’t burn your bridges and get
into definitive restorations too soon Provisional / Temporary Restorations
VISUALISE BEFORE YOU FINALISE
• Mental vision
• Photos, Digital smile design
• Study model wax-ups
• Mock-ups
– Direct
– Indirect
• Temporaries
Reversible
Irreversible
Usefullness
Empowers the patient to make aesthetic decisions
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Com
pleteTREATMENT
Time
reqd
Time
between
visits
Appointment date FeeIV
sedationLABORATORY Lab fee
Crowns 11, 21
Imps, JRR for new s/models 1 £50
Wax up and shell temps £50
PT 11, 21 4 £200
2 crowns £200
Final PTI 11, 21 1.5 £75
4 wks
Cementation and occl adj 1.5 £75
2 wks
Follow up and occl adj 1 £50
Total 5 £450 £250
Tx Plan sheet Fee Schedule Fee / hr 50 ex lab
Appt 1 hrs Appt 2 hrs Appt 3 hrs Appt 4 hrs Appt 5 hrs Appt 6 hrs Appt 7 hrs Appt 8 hrs Misc cost Tx Lab Total
Anterior
Crow n P + T 3
Refine p+t
and imp 2.5 try in 1 cement 1
Follow
up 0.5 400 100 500
Posterior
Crow n P + T 3 Final imp 1.5 Cement 1 Follow up 0.5 300 75 375
Core buid-up
(direct) core buildup 1.5 75 75
Post and
Core buid-up
(direct)
post and
core buldup 2.5 reline temp 1.5 200 200
Post and
Core build-up
(indirect)
duralay
pattern 2
cement and
retemp 2 200 100 300
Gold onlay P + T 3 Final imp 1.5 Cement 1 Follow up 0.5 300 100 400
Ceramic
onlay P + T 2.5 Final imp 1.5 Cement 1.5 Follow up 0.5 300 100 400
Porcelain
veneer P + T 2 Final imp 1
repair /
recemnt
temps 1 Cement 1.5
Follow
up 0.5 300 100 400
6 Porcelain
veneers w ith
SS P + T 8 Final imp 8
repair /
recemnt
temps 4 Cement 8
Follow
up 1
Follow
up 1 1500 8000 9500
Implant Sx surgery 4 sutures 0.5 follow up 0.5 cmpnts 350 600 400 1000
Implant temp imp 1.5 fit 1.5 follow up 0.5 cmpnts 400 575 300 875
Implant
crow n imp 1.5 fit 1.5 follow up 0.5 cmpnts 400 575 400 975 2850
Perio surgery surgery 3 sutures 0.5 follow up 0.5 200 200
Full dentures
U + L
alginates 1
secondary
impressions 2
JRR and
intra-oral
setup 2.5 try in 1 try in 1 deliver 1
follow
up 0.5
follow
up 0.5
BM w ax
up 400 875 800 1675
6 Indirect
palato-incisal
composite
veneers
U + L
silicones
and JRR 1.5 cementation 8
touch up
labial joins 2 follow up 1
follow
up 1
follow
up 1
BM w ax
up 500 1225 2400 3625
6 Direct
Palato-incisal
composite
veneers
U + L
silicones
and JRR 1.5 application 8
touch up
labial joins 2 follow up 1
follow
up 1
follow
up 1
BM w ax
up and
matrix 1500 2225 2225
Indirect Dahl
on 6 teeth
U + L
alginates
and JRR 1
cement and
incisal
additions 1.5
touch up
labial joins 1.5 follow up 1
BM
fabricati
on 1200 1450 1450
6 Low er ant
comp build-
up
U + L
silicones
and JRR 1.5
comp
buildups 8 follow up 1 follow up 1
follow
up 1
w ax up
and
matrix 1200 1825 1825
Bite splint
U + L
silicones
and JRR 1.5
fit and occl
adj 2 follow up 1 follow up 1
follow
up 1 325 250 575
Initial basic wax up + Chairside temporisation
VDO Look to increase it whenever possible
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VDO Benefits • Gives more restorative room – stronger, with more prep height for retention • Allows levelling of the occlusal plane • Reduces the overbite – improved force distribution
For every 100 change in the angle of disclusion, there
is a 35% change in force applied. L. Weinberg
Int. J. Prosthodont. 1998; 11: 55
Safety of increasing VDO. Abduo, Quintessence Int
2012;43:369–380)
VDO Limitations • Aesthetics • Maintaining anterior contact without over bulking palatal aspects of upper anterior teeth
Initial Basic Wax-up • Similar to what patient comes in with – not looking to change too
much at this stage • Too much change will be taking place to focus this early on
definitive form and function • To allow basic foundation rebuilding stage without too much
disruption
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INITIAL BASIC WAX-UP Anterior Temporisation
Increase VDO on anterior teeth
Posterior Temporisation TEMPORARIES the key to success
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TEMPORARIES Your best friend
Or……. Your worst enemy
You rule your temporaries….don't let them rule you !!
Minimise the Jump
Chairside temps – get as much out of the them before
moving on to lab provisionals. Need to evolve and be modifiable
Laboratory provisionals – almost at final stage. Minimal
modification needed
MINIMISE THE JUMP
Tissue health Impression Fit
MINIMISE THE JUMP
Aesthetics & Function
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MINIMISE THE JUMP
“Diagnostic wax up is rarely the final contour of the anterior teeth. Final determination of incisal
edge position, labial contour and anterior guidance must be worked out in the mouth.” “Functional Occlusion – From TMJ to Smile Design” . P Dawson.Mosby 2006.
TREATMENT OF MORE COMPLEX CASES
aesthetic outcome visualisation before finalisation pushes everyone to higher level increased patient acceptance of proposed treatment
tooth preparation time
impressions tissue health and support
Tx decisions existing restoration removed
Prepare teeth
Chairside temporisation (matrix or shell)
Final impression
Provisional restorations (lab) ?
PATHWAYS to final impression
Modification ?
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Materials
Ethylbutyl methacrylate Bis-acryl
methyl methacrylate
Materials
Ethylbutyl methacrylate Bis-acryl
methyl methacrylate
Materials
Ethylbutyl methacrylate Bis-acryl
methyl methacrylate • Easy to remove and
allows splinting
SPLINTING
convenience
retention
immobilisation
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INADEQUATE embrasures Bis-acryl
REMOVAL of temps
Tungsten Carbide Crown Removers
Kohler 4438
Cameron Cooper
Materials
Ethylbutyl methacrylate Bis-acryl
methyl methacrylate
• Easy to remove and allows splinting
• Modifiable – additions, relines, remarginations
Initial reline of shell temp
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Reline while posts being made Reline after post cementation
Materials
Ethylbutyl methacrylate Bis-acryl
methyl methacrylate
• Easy to remove and allows splinting
• Modifiable – additions, relines, remarginations
• Better in wet environment
• Versatility of mixing and application
• Polishability
TECHNIQUES - CHAIRSIDE FROM MATRIX
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TECHNIQUES – RELINE OF PREFABRICATED CUSTOM SHELL TECHNIQUES – LABORATORY PROVISIONALS
Prefabricated custom shell
Improved aesthetics – morphology, polymerisation and finish
Multiple teeth - reduced intra-oral acrylic, easier handling
PMMA
custom SHELL TEMPS
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SEATING jig FIT checking
incomplete seating
FIT checking
light body impression material
RELINE
PMMA Acrylic Resin Ford – shell fit check and reline
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TRIMMING and CEMENTING Prefabricated custom shell multiple
delayed, informed decision making
light body PVS – fit check reline with pmma
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SHELL TEMP full arch
Soft Tissue Health and Support Margin capture
Emergence profile creation
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You get out from the tissues …what you put into the temporaries
4 weeks
You get out from the tissues …what you put into the temporaries
4 weeks
IMPRESSION
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MARGIN capture The time to be aggressive and
induce trauma (retraction cord, electrosurg),
if necessary is when the temporaries are made – not when the impression is made
Remargination
Remargination – 2nd stage MARGIN capture
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MARGIN capture MARGIN capture
6 weeks
remargination trimming
READ the tissues
Temps in Situ
If you don’t capture the margins…….
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tissue SUPPORT tissue HEALTH tissue SUPPORT
TISSUE support UNSUPPORTED tissue
tissue collapse over retraction cord over aggressive cord packing
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READ the tissues READ the tissues
unsupported tissue covering margin
well supported tissue with full marginal exposure
improved IMPRESSIONS creating TISSUE SUPPORT Acrylic remargination
Composite remargination
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Durability / Stability Temporise as if the patient is going to miss their next appointment
?
Pre-clinical preparation of shell temporary bridges
x x x
x
?
Don’t let the temporaries rule you !!
2 weeks later
Impression for metal-acrylic temps
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Metal / acrylic temporaries
You rule the temporaries !
Long term temporary bridge
x
x
x
x
Acrylic shell
Bulked up contacts
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Metal / acrylic temporary
Metal reinforced for spans longer that 3 teeth
Implant surgery
Original acrylic temp
(surgical guide)
Metal/acrylic temp
4 months later
Stable long-term temporary posts make the post part of the tooth…..not the temp
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Emergency – long term posts
BM
Passively cemented screw post
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Composite core Temporary Crown
Emergency – long term posts Passive cementation
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COMPOSITE core STABILISATION – Xt 14 – 25 implants
– Keep posterior teeth
SHELL TEMP
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INTERIM POSTS PMMA RELINE