By Hugh Flax DDS, AAACD, FICOI Atlanta, GA

Transcription

AACD 2015 State of the Art
5/8/2015
FOR HANDOUT GO TO
www.HughFlax.com
STATE-OF-THE-ART TECHNIQUES IN
COSMETIC RESTORATIVE
DENTISTRY”
BY HUGH FLAX DDS, AAACD, MICOI
ATLANTA, GA
“IF I HAVE SEEN FURTHER IT IS BY
STANDING ON THE SHOULDER'S OF
GIANTS.”
SIR
ISAAC NEWTON
THANK YOU
• GC AMERICA
• MICROCOPY
• YOU
Hugh Flax
All materials copyrighted by Hugh Flax DDS
and referred sources
5/8/2015
DISCLOSURES
• Huge proponent of “Responsible Esthetics”
• Leading edge vs. Bleeding Edge
• Products that I mention I use all the time
and like to share what is working for me
(companies that are sponsoring or
contributing products for this presentation
only for that reason)
• Learning-sharing new and reinforcing
“time-tested” knowledge and learning
from each other
USA TODAY STUDY (1997) OF
ATTRACTIVENESS AND SELF ESTEEM
WHAT WOULD YOU CHANGE ABOUT YOUR
PHYSICAL APPEARANCE ?
Summary In today’s rapidly changing world , technology and procedures are
constantly evolving that allows dental teams to deliver better, more
predictable, and oftentimes, more cost effective results that make patients
and practices happier clinically and entrepreneurially.
The proverbial “elephant in the room” demands that we continue to stay
competitive in this arena. Learn what these new developments in technologies
and materials are so that you and your cosmetic practice will continue to
thrive.
Learning objectives:
• Understand how digital technology will get your patients more emotionally
involved in their care and will decrease your time and stress
• Discover materials that will strengthen your patient’s teeth and cement their
long-term success
• Learn about newer laser technology that cuts and preserves tooth structure
better than ever.
• See how to do advanced implant treatment by prescription instead of by
accident
IF YOU COULD CHANGE ANYTHING IN
YOUR FACE WHAT WOULD IT BE ?
• Nose
• Eyes
• Teeth
• Chin
• Weight
• Lips
• Height
• Head shape
• Face
• Hair
ABC-TV’S
“EXTREME MAKEOVER” SHOW !
Hugh Flax
5/8/2015
TODAY’S CHALLENGES OF ESTHETIC DENTISTRY
• ESTHETICS
• BIOLOGY
• FUNCTION
• ECONOMICS
1. Expectations of patients
2. Chairtime
3. Minimally invasive
4. Affordability
5. Durability/ Reparability
TIME FOR CHANGE
• Diversity
• How we build value for people and meet
expectations
• The speed and volume of providing information
and care
• How to fit someone’s budget-time and financial
• How we perform dentistry
EXTREME CUSTOMIZATION
• LEVERAGING TIME
• INNOVATING
• BE CREATIVE
EXTREME
CUSTOMIZATION
“Innovation distinguishes between a leader
and a follower.”
Steve Jobs
JIM ROHN
Hugh Flax
STONE TOOLS
COMPUTER MOUSE
5/8/2015
CREATIVITY
You need to understand how
human beings bring
together their brains and
enable their ideas to
combine and recombine, to
meet and, indeed, to mate.
In other words, you need to
understand how ideas have
sex.”
"Don't think. Thinking is the
enemy of creativity. It's selfconscious, and anything selfconscious is lousy. You can't try to
do things. You simply must do
things."
http://www.ted.com/talks/lang/en/matt_ridley_when_ideas_have_sex
.html
INTERDISCIPLINARY CARE
ESTHETICS
PERIODONTAL
SUPPORT and
CONTOURS
FUNCTION
BIOMECHANICS
3 D CT Scan Courtesy of Kai-hung Fung, MD
PERIO
ORTHO
LAB
GIVE ‘EM WHAT THEY WANT !!!
“Do what you do so well that people can’t
resist telling others about you”
Walt Disney
JCD
WINTER
2015
Hugh Flax
5/8/2015
COMMUNICATE VISUALLY
ANYTHING TO ANYONE ,AT
ANYTIME !
WHY NOW?????????
FACT: In 2009, in the USA, video content views surpassed
text content views
WHY NOW?????????
FACT: From Mashable.com New Study Shows the
Mobile Web Will Rule by 2015
WHY NOW???
COURTESY CHRISTIAN COACHMAN
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5/8/2015
BOTTOM LINE
Hugh Flax
ANALYTICAL
Hugh Flax
5/8/2015
EMOTIONAL
5/8/2015
Pink Esthetics
ESTHETIC FACTORS
WAYS TO MANAGE PINK
TRADITIONAL
• ELECTROSURGERY
• SCALPEL REDUCTION
• OPEN FLAP CROWN
LENGTHENING
• FREE GRAFTING
• CONNECTIVE TISSUE
GRAFTS
Hugh Flax
INNOVATIVE
• LASER REDUCTION
• CLOSED FLAP GUM LIFT
• TUNNEL GRAFTING
(Allen;Salama;Mahm; VISTA;Pin Hole)
• PEDICLE GRAFT
• ADD WITH PINK RESTORATIVE
Macro-multiple teeth/ large areas
Micro-1-2 teeth / small areas
•
•
•
•
Midline
Facial thirds are ideally equal
Interpupillary line
Maxillary Tooth Position
1)
Labial-support maxillary lip and balance of face
2)
Vertical canine position in repose—level with the lip (Misch/
Kois)
3)
Centrals-1-2 mm below the horizontal line drawn from canine to
canine
4)
Canine tip in line with ala of the nose
5)
Posterior occlusal plane meets labial angle forming a 90 degree
angle
GOAL : APPLY KNOWLEDGE WITH CREATIVITY TO START
THINKING / DRAWING OUTSIDE THE LINES ON MONDAY
5/8/2015
34 yo working
mother of 2 children
BIOMECHANICAL RISK ?
“JUST WANT TO HAVE THE SMILE I USED TO HAVE”
Hugh Flax
5/8/2015
http://www.highlandmetals.com
Hugh Flax
5/8/2015
SMOOTH ROUND
PREPARATIONS
Axial—KS0; KS1 and KS1L coarse
Fine flame shaped
Lingual- Egg or pear shaped (coarse/ fine)
Final polish –rubber point
LumiSmile White Highlights:
• 32%, 22%, 16% Carbamide Peroxide
• Formulated to minimize sensitivity
• Long unrefrigerated shelf life*
• Flavored with real peppermint oil
• Refill kits available
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5/8/2015
IT’S NOT ABOUT THE PAINT ! ! !
IT’S ABOUT THE ARTISTRY
THAT YOU DO WITH IT! ! !
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5/8/2015
GENERALIZED WEAR CASE
WHEN A LASER IS USEFUL
ESTHETIC RISK?
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5/8/2015
UNSTABLE CHEWING
ENVELOPES/ OCCLUSIONS
Kois Continuum #8
What pattern of wear?
BIOMECHANICAL?
BONE LEVELS?
KOIS CONTINUUM #8
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“EVALUATION OF SHEAR BOND STRENGTH OF RESIN CEMENTS TO
CERAMICS CONDITIONED WITH DIFFERENT CERAMIC PRIMERS”
CHAIYABUTR Y. KOIS JC, KOIS CENTER RESEARCH 2013
“EVALUATION OF SHEAR BOND STRENGTH OF RESIN CEMENTS TO
CERAMICS CONDITIONED WITH DIFFERENT CERAMIC PRIMERS”
CHAIYABUTR Y. KOIS JC, KOIS CENTER RESEARCH 2013
• For Lithium disilicate ceramic , silane with additives [extra adhesive
resin or phosphate monomer] demonstrated significantly lower
bond strength than that of pre-hydrolized silane solution.
• For Lithium disilicate ceramic , silane with additives [extra adhesive
resin or phosphate monomer] demonstrated significantly lower
bond strength than that of pre-hydrolized silane solution.
• For zirconia ceramic, the application of phosphate-containing
primer significantly enhanced the bond strength of resin cement.
CEMENTATION PROTOCOL FOR COHESIVE RESTORATIONS
A NEW PLAYER IN THE MARKET
CEMENTATION
Low risk biomechanics-Bonded cementation
High risk biomechanics-Glass ionomer
TOOTH TREATMENT
1)Particle abrasion with 27 micron
aluminous oxide at 40 psi 0.015hp
2) Rinse with Consepsis
LITHIUM DISILICATE (Single crowns)
1)Clean with Phosphoric Acid (3040%) 60 seconds
2)Rinse with water
3)Apply silane solutions: 60 seconds
4)Dry thoroughly
ZIRCONIA (for 3-4 unit bridges)
1)Particle abrade with 27 micron
aluminous oxide
2)Maximum of 20 psi}
METAL (PFM; Gold)
Particle abrasion with 50 micron
aluminous oxide at 80 psi
3) Coat with Metal Primer {MDP}
A
F
T
E
R
T
R
Y
I
N
Solution Based Dentistry
…aimed at addressing common clinical challenges
 Optimal Self-cure Mode: Innovative initiator system (chemical)
•
1. DUAL-CURE, SELF-ADHESIVE
2. DOUBLE-BARREL AUTOMIX SYRINGE
3. HIGH WEAR RESISTANCE AND COLOR STABILITY
4. EASY HANDLING MAKES IT SIMPLE TO PLACE
5. LOW WATER SORPTION AND IS HEMA-FREE, DELIVERING EXCEPTIONAL COLOR STABILITY
6. ABILITY TO USE THE CEMENT IN BOTH POSTERIOR AND ANTERIOR CASES WITHOUT HAVING TO WORRY
ABOUT ESTHETICS.
7. EXCESS CEMENT IS EASILY REMOVED IN ONE PIECE AFTER ONLY A 1 TO 2 SECOND TACK CURE FOR
MAXIMUM CONVENIENCE.
8. THE PROPRIETARY PHOSPHATE MONOMERS OF G-CEM LINKACE PROVIDE A HIGH BOND DURABILITY
TO ZIRCONIA RESTORATIONS THAT ACTUALLY INCREASES OVER TIME.
“At the end of the evaluation period, 11of the 13 evaluators said they would definitely
or probably recommend G-CEM LinkAce to colleagues.” DPS VOL. 7 No. 9
Hugh Flax
 High bond durability to Zirconia in ONE Step: Proprietary phosphate
monomers (save the step of needing to place MDP)
 Exceptional Color Stability: Very low water sorption and HEMA-free
 Unsurpassed Wear Resistance: Small homogenously distributed particles
 Easy Excess Cement Removal: Only 1-2 second tack cure
5/8/2015
Optimal Self-cure Mode:
In many clinical situations, light simply cannot pass
through indirect restorations
Tensile Bond Strength to Dentin / Self-cure
20 min
10 min
5 min
5000 TC
G-CEM LinkAce™
G-CEM LinkAce™
RelyX Unicem 2 Automix†
Maxcem Elite†
Maxcem Elite†
1 day
SpeedCEM†
SpeedCEM†
0
2
4
6
8
0
10
2
4
MPa
1100 mW/cm2
50 mW/cm2
0 mW/cm2
6
8
10
MPa
50 mW/cm2
Source: GCC R&D Internal Data
5000 TC = 5,000 thermal-cycle (5-55 °C)
Mpa = Megapascal
† Not a registered trademark of GC
America
Pereira et al., 2013, Sao Paulo University, Brazil
Durable bond to IPS e.max (Lithium Disilicate)
TENSILE BOND TO IPS E.MAX (LITHIUM
DISILICATE)
Maxcem Elite†
Multilink Automix†
RelyX Ultimate†
5
10
15
20
25
30
35
40
45
MPa
0.8
BETTER
0
HYGROSCOPIC EXPANSION
1
1 day
LINEAR EXPANSION
COEFFICIENT [%]
5000 TC
G-CEM LinkAce™
0.6
0.4
0.2
G-CEM LinkAce™
RelyX Unicem 2
Automix†
Maxcem Elite†
SpeedCEM†
0
0
7
14
21
28
35
DAY
5000 TC = 5,000 thermal-cycle (5-55 °C)
MPa = Megapascals
† Not a registered trademark of GC America
Prepared teeth
HF acid etching of IPS e.max
(lithium disilicate) crown
Primer application
Seating of the crown
Tack cure for 1-2
seconds
Removal of excess
cement
† Not a registered trademark of GC
America
Dispensing
G-CEM LinkAce™ into crown
20 second light-cure all
surfaces and margins
for final results
Source: Dr. Javier Tapia, Spain
IPS e.max crowns pre-treated and handled
according to manufacturer’s instructions
Hugh Flax
5/8/2015
SEQUENCE:
8,9, 7,10
Cuspid bicuspids each side
FMR PREVENTIVE MEDICINE
GET TIME/FORCE OCCLUSAL INFORMATION
WITHOUT RELYING ON SURFACE “PAPER
MARKS” OR PATIENT/DOCTOR PERCEPTIONS
USE THE T-SCAN
BETTER TIMING & BALANCE
LESS WEAR/FRACTURES
BETTER COMMUNICATION/DOCUMENTATION
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5/8/2015
SALAMA, COACHMAN, GARBER, CALAMITA,ET AL
Int. Journ of Perio and Restorative Dentistry Vol 29 No 6 2009; 573-581
Think 3D with color and contour gums-artificial and natural
CHECK
THIS NEXT
ONE
OUT
USING TRANSITIONAL BONDING FOR INTERDISCIPLINARY CARE
Hugh Flax
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5/8/2015
5/8/2015
GC GRADIA GUM shades
Shade spectrum
Gum Opaque (3)
•orange, light red,
dark red
Gum Opaque
Modifier (1 gel)
•red
Gum (5 pastes)
•transparent, light
orange,
•dark orange, light
reddish,dark
reddish
• Highly filled and durable for fracture resistance in thin areas
• The fillers are coated with a silane coupler that allows for
predictable bonding to substrate (which is already
enhanced by the Composite Primer)
Gum Modifier (7
gels)
•6 shades +
transparent
Gum Trans (1 gel)
•rosa transpa
Gum Veins (1)
183
HOW TO BOND GRADIA GUM
GC Ceramic Primer is used to
bond Gradia Gum to Ceramic.
GC Composite Primer is used to
bond Gradia Gum to
Composite/Acrylic.
GC Metal Primer ll is used to
bond Gradia Gum to Metal.
185
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CADDY WOMPUS JOURNEY
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5/8/2015
BOTTOM LINE:
1) No implants over 4.3 mm in the anterior zone
2) Lingualize the implant placement
3) Fill the gap with 50/ 50 mix DMFB/ cortical bone
4) Consider a connective tissue graft
Hugh Flax
OPTIONS:
1) Do nothing
2) Remove implant (s)
3) Augment the tissue and restore (single? splinted?)
and add pink
5/8/2015
MICROGINGIVAL PORCELAIN ENHANCEMENTS
• Create a “palette” of colors/ blends Mockup
• Sandblast with Prepstart (27 micron AlO2)
• Porcelain etch with Ultradent HF (60 sec) and rinse thoroughly
• Silane (airdry for 1 min)
• GC Composite or Ceramic Primer-cure for 1 min
• Place restoration in the mouth
• Apply composite and blend
• Polish and/or glaze
“Good-to –great organizations avoid
technology fads and bandwagons, yet
they become pioneers in the application
of carefully selected technologies…used
technology as an accelerator of
momentum not the creator of it”
Hugh Flax
5/8/2015
Cosmetic Restorative Clinical
Applications
Hard Tissue Procedures
BOTTOM LINE:
(for adult & pediatric patients)
CO2 and Erbium
lasers create clean
and precise cuts on
enamel -
•Desensitization for bleaching
•Cavity Prep - Classes I-VI
•Caries and Restorative Material Removal
10 µm
•Roughening & Etching
ENAMEL
Scanning electron micrograph of enamel cut with
YSGG Hydrokinetic™ system. This surface
shows hydroxyapatite columns (and
interprismatic substance specific to this enamel
structure) free of any mechanical or thermal
damage. (x3500)
•Enameloplasty
•Bony recontouring
No smear layer,
crystalline structure
preserved
*All of the above slides were performed at a magnification
of x3500 on a Jeol SEM model T-20.
LASER ANALGESIA
Proposed mechanism of action
Reducing the action of the sodium potassium pump at
the cellular level thereby slowing or even stopping nerve
conduction in the pulpal tissues long enough to
“painlessly” ablate enamel and dentin without the use of
anesthesia in most cases
Lasers in Dentistry (Miserdino and Pick)
Quintessence Publishing 1995
Chapter 19 Modern optics and Dentistry
page 287
“ For example, radiation scattered in enamel and dentin
can be entrapped by these natural waveguides and
transported to the pulp chamber”
Wavelength Determines Absorption
Absorption Determines Ablation
CLINICAL PARADIGM SHIFT
Low Absorption
High Absorption
• Micro dentistry (conservative care)
• Minimally invasive soft/hard
tissue treatment
• Little to no need for anesthesia
High Absorption = Efficient Ablation
Hugh Flax
5/8/2015
How Does this Apply for Hard Tissue Ablation?
WHAT’S SO DIFFERENT ABOUT SOLEA?
New unique wavelength 9.3 µm
 Vaporizes enamel
Erbium @ 2.7 or 2.9 µm
 Cuts soft tissue like native CO2 (10.6 µm)
• Low HA Absorption/High H20 Absorption
• Deep HA Penetration:
20 micrometers
• Low Repetition Rate:
5 – 30 Hz
CO2 laser that is cleared by the FDA for hard and soft
tissue use
Erbium (2.78 µm)
CO2 @ 9.3 µm
Computer controlled advanced technology
 Galvo optimized cutting patterns for the laser
• High HA Absorption/High H20 Absorption
• Shallow Penetration:
2 micrometers
• High Repetition Rate:
up to 10,000 Hz
 Variable Speed Foot Pedal facilitates control
CO2 @ 9.3 µm:
• Low Penetration/Very High Repetition
• Strong Analgesia/High Speed Cutting
CO2 (9.3 µm)
 Computer Aided Preparation (CAP) System
enabling variable spot sizes and variable
speed foot pedal (allows cutting and relaxation
of tissue)
95% of Solea procedures
anesthesia free
98% Solea patients feel no
pain
 Integrated computer controls aid in cutting
The CO2 laser operating at l¼9.3 has two principal
advantages over other lasers when applied to
ablation of
tooth structure.
The first advantage is that the CO2 laser
can operate efficiently at high repetition rates well
into the kHz regime. CO2 lasers can be operated
with lower single pulse energies and irradiation
intensities and the repetition rate can be increased
for higher cutting rates.
The second advantage is the very high absorption by
the mineral phase that can be exploited for the
modification
of the irradiated surfaces to produce a layer that exhibits
increased resistance to demineralization. The walls of a
restored cavity are susceptible to secondary caries by
microleakage of acids, bacteria, and cariogenic substrate
between the restoration and the walls .
What Makes Solea so Effective?
CAP for Perfect Energy Delivery &
Distribution:
What Makes Solea so Effective?
Simple to Use: Short Ramp Up Time
Choose Tissue
Select Spot Size
Galvos Create Patterns – Unique to Solea
Dictate Speed, Precision and Sensation based on:
•
•
•
•
•
Points per pattern
Pulses per point
Order of execution
Max repetition rate
Pulse width scale
.25mm
.5mm
.75mm
1.00mm
1.25 mm XC
Variable Speed Foot Pedal:
• Vary cutting speed on the fly
• Significantly increases control
Change Speed On the Fly
Hugh Flax
5/8/2015
Class II Laser Preparation
Hugh Flax
5/8/2015
Application of
Oxygel –ClO2
and aloe
BW Kalore
Hugh Flax
5/8/2015
WHY NOW?
• Desire to go digital with impressions—lots of choices; wanted the complete pkg.
• Confluence of more user friendliness (impressions/ design/ milling) and better
material choices (esthetics; seal; strength; bonding mediums)
• CEREC-30 years experience and Sirona’s desire for “CAD/ CAM for everyone”
• Expand the breadth of options for our patients
Restorative (crowns; partial crowns; and inlays)…..YOU CAN BE CONSERVATIVE
Implant surgery and restoration ( crown down approach)
Ortho impressions ( Clear Correct; Invisalign 6/15)
Digital waxups and integration with DSD
• It’s FUN and DELEGATABLE
• Create a WOW experience-One Visit/ One Shot/ No temp
Saves time and increased case acceptance
Hugh Flax
5/8/2015
CERASMART IS A REVOLUTIONARY
BLOCK FROM GC. IT COMBINES
EXCEPTIONAL STRENGTH AND
UNPARALLELED AESTHETICS. BEST
OF ALL, IT VIRTUALLY WILL NOT
CHIP, HAS A FASTER MILLING TIME,
AND IS THE EASIEST MATERIAL TO
FINISH.
The ADA accepts these materials as ceramic under CDT code D2740
Mechanical Properties, University of Boston
Mechanical Properties of New Chairside CAD/CAM Materials
Conclusion: At the 95% confidence level, FNC had significantly higher values for
flexural strength and modulus of resilience (p<0.05), as well as significantly lower
values for flexural modulus (p<0.05) compared to all the remaining materials tested.
Source: Mechanical Properties of New Chairside CAD/CAM Materials, Awada A., Nathanson D., J
Dent Res Vol 93 (Spec Iss A): 714,2014
BOTTOM LINE : Thanks to its specific filler treatment, the fillers included in Cerasmart are homogeneously dispersed,
which provides high wear resistance, high strength and long-lasting gloss
Hugh Flax
5/8/2015
Finishing & polishing
1. Grind off the connector
2. Use medium silicone point
3. Use fine silicone point
4. Use diamond paste such as GRADIA DIAPOLISHER Paste for high
gloss
Treat with hydrofluoric acid (5%) for 60 seconds or Phosphoric acid (35-37%) can be also used for
the purpose of cleaning the surface, preferably scrubbing with a microbrush for 10-15 seconds.
Repair of Cerasmart restorations
1. Roughen
Slightly roughen the bonding
area (restoration and exposed
tooth structure) using a coarse
diamond point or carbide bur
2. Silane the
restoration
3. Bond the exposed
tooth
Apply a bonding agent such
as G-aenial Bond on the
exposed tooth tissue, dry and
light-cure following
manufacturer’s instructions
Apply silane coupling agent on the
restoration such as Ceramic Primer
II and gently dry.
If other primer is used, followed the
manufacturer’s instruction
4. Apply the
composite
OUR FIRST CERASMART
Apply the chosen restorative
material and light-cure it
according to the
manufacturer's instructions.
GC G-ænial Universal Flo is recommended in order to repair the surface of Cerasmart
restorations since it is based on the same technology.
263
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




Hugh Flax
Shake the bottle
Dispense
Apply a thin layer with a
brush
Do not air blow
Cure light-curing device
having a wavelength in
the range of 400-430 nm
for 40 sec (exceptions
Kerr Demi Ultra and 3M
Elipar 10 S)
5/8/2015
THE BU$INESS OF MAKING YOUR
PRACTICE PROFITABLE
You Got
A Problem
With That ??
Recare Reminders bring your
patients back to You!
$605,462.00 from past
Appointments
Your patients
can confirm
by email and by text!
Hugh Flax
5/8/2015
Newsletters
keep your Brand
in front of your Patients!
RECURRENT DECAY/ CRACKS PRESENT
DOCUMENTATION
Collecting patient reviews at t
he point of service is
the most cost-effective
and least expensive
marketing available.
Hugh Flax
5/8/2015
Getting those reviews
consistently placed on the
review sites that matter
materially impacts the
growth of a practice.
Patients participate when
the request is simple and
immediate.
Independent Solo Dentists
•
•
•
•
•
NeoDiamond is America's highest-rated, #1 selling
diamond bur.
• 20% more diamond cutting surface for a faster cut
with less chair time.
• NeoDiamond is individually packaged, sterilized,
and color-coded with Quick Grit ID for safety and
convenience.
Corporate Dentistry
•
100% - 1977
76% - 2006
69% - 2010
65% - 2012
57% - 2014
•
•
7 New Corporate locations Every
Day
In 2 Years the number of large
Dental Group Practices has risen
25%
52% of dentistry is produced in
Group Dental Practices
*ADA Health Policy Resource Center
What’s your plan?
Get the benefits of a group practice while remaining
fiercely independent.
1-888-890-9990
www.SmileSource.com
FINAL HYBRID
PROSTHESIS
WHAT IF?
INTERIM FIXED
HEALING
“PROTOTYPE”
EXTRACTIONS/ IMPLANT PLACEMENT
Hugh Flax
IMPLANT PLACEMENT
GRAFTING/
SINUS LIFTS
•
EXTRACTIONS/
IMMED DENTURE
5/8/2015
Journal of Implantology
Vol. 30 No.5 (2004) 283-288
ABUTMENTS TO BE SHORT, MULTIANGLED
ABOUT 1 mm SUBGINGIVAL---LOCATIONS PRESCRIBED
BY SURGICAL GUIDE—
POSITIONS BASED ON WHERE TEETH ARE SUPPSED TO GO
ZYGOMA
MY EPIPHANY
55yo female
CC “Front teeth
unstable and
shifting; ready to
overhaul teeth”
• Very anxious
about pain and
treatment affects
on appearance
and speech
• Med HxCongenital heart
disease (no
premed)
Arthritis;
Bells Palsy
• Dental HxRCT;Perio SX
C&B; Bonding;
Episodic Care
since 2003
•
•
A Case of “Retrospective Thinking”
Hugh Flax
5/8/2015
TREATMENT PLANNING FUNDAMENTALS
OF DENTISTRY
•
Biomechanics-decayed multiple teeth with crowns/root
canals
•
Periodontal support-generalized severe bone loss and
1° occlusal traumatism (OT)
•
Occlusal/ Function-occlusal dysfunction causing 2° OT
•
Habits-clenching and bruxing
•
Medical management-None needed (despite med hx)
•
Esthetics-display 10-12 upper teeth with moderate
gums; midline unstable due to flaring of upper teeth
due to osseous breakdown and functional overload
TREATMENT PLAN
Immediate Upper / Lower Overdentures
(extractions and grafting)
Supported by endodontically treated #
6,11,21,22,27,28
Potential implants or attachments
Hugh Flax
5/8/2015
BOTTOM LINE RESULTS
•
Improved appearance—”beauty is in the eye of the beholder”
•
Eliminate periodontal infection
•
Better bite
•
Unstable and uncomfortable
•
Patient challenged by labial flange and palate
•
Difficult proprioception
•
Facial tissue affected by Bell’s Palsy
•
Demanding patient with demanding lifestyle
•
WAS THIS THE RIGHT “TREATMENT OF CHOICE”?
•
DID SHE GET WHAT “SHE” WANTED?
“Good
judgment comes from experience, and often experience comes
from bad judgment.”
Rita Mae Brown
STARTING ALL OVER AGAIN
BLEND OF CLASSIC PROSTHETICS
WITH NEW TECHNOLOGY AND MATERIALS
We need good information
ESTHETIC FACTORS
• Midline
• Facial thirds are ideally equal
• Interpupillary line
• Maxillary Tooth Position
1) Labial-support maxillary lip and balance of face
2) Vertical canine position in repose—level with the lip (Misch/ Kois)
3) Centrals-1-2 mm below the horizontal line drawn from canine to canine
4) Canine tip in line with ala of the nose
5) Posterior occlusal plane meets labial angle forming a 90 degree angle
Hugh Flax
5/8/2015
NEW
CLINICAL
DATA
Hugh Flax
5/8/2015
MOUNTED IN CR WITH APPROPRIATE FREEWAY SPACE
Ostectomy recommendation
Canine position matching archform
MOUNTING PLATE BY IVOCLAR FOR STRATOS
—CAN USE WITH KOIS FACIAL ANALYZER
Hugh Flax
14 mm the recommended prosthetic
distance from incisal edge to implant
platform for strength of materials
(Misch Text :233-275)
Midline position and archform
that matches platform
5/8/2015
ANTERIOR GUIDANCE
IMPLANT PROTECTED OR SHARED PROPRIOCEPTION
IN PROTRUSION and LESS ANTERIOR WEAR OR TORQUE
CT IMAGING :
COMMUNICATION BETWEEN ORAL SURGEON and RESTORATIVE TEAM
Hugh Flax
5/8/2015
INPUT FROM LAB
• ALVEOLECTOMY GUIDE—to “prescribe” how much bone
to remove to hide seam, allow for implants and proper
thickness for restorative materials
• SURGICAL GUIDE FOR IMPLANT PLACEMENT—allow for
abutment orientation to be in proper position esthetically
and to decease non-axial loading for implant
osseointegration
• ORIENTATION BITE-index upper and lower
• VERTICAL DIMENSION MEASUREMENT- reverify at
beginning of surgery with Ivoclar guide
SURGICAL GUIDE—clear version of projected prosthesis
REVERIFY
VERTICAL
LANDMARKS
AT THE TIME
OF SURGERY
•
Mark positions of implants
•
Verify for the surgeon the location ( bucco-lingual; mesio distal, emergence
trajectory)
•
Want to stay with the “window: that is ideal
In the cingulum or just lingual on the anterior palatal
Abutment orientation under the maxillary lingual cusps and the mandibular buccal
cusps to decrease axial forces and blueprint future position of milled substructure bar
Place implants
•
UPPER SIX
Anterior pre-maxilla (2)
Anterior to sinus wall ( 2)
Zygoma (2)
LOWER FIVE
Anterior mandible—3 overlapping and with divergent angulations AND mesial
to buccal nerve approx. 5mm “safe zone” (A,C, E positions)
•
Hugh Flax
Bilateral bicuspid positions 2
Abutments low profile and oriented for easy access for screw retrieval and the
screws toward the lingual and not in the occlusal or toward the facial
5/8/2015
LUTING FOR IMMEDIATE LOAD-creating reliable accuracy for locating
implant position and esthetic function orientation
• Highly reliable; compatible bond to acrylic that
avoids errors in accuracy between implants---less
complications in seating “framework” during the
immediate stage
• Because the patient is closing into bite index (no
access to the lingual) a “self cure” is mandatory
material is mandatory
PRE-”LUTING” OF UPPER
1)PAINT TEMPORARY CYLINDERS WITH ACRYLIC TO ADAPT TO
GROOVES (DECREASE SLIPPAGE OR BUBBLES)
2)PLACE THESE INTO THE ANTERIOR LOCATIONS AFTER REMOVING
ABUTMENTS
3)CORE THE IMPRESSIONS AT THESE LOCATIONS
4)CUT DOWN THE CYLINDERS TO FIT THE “HOLES”
LUTING PROSTHESIS TEMPORARILY TO THE
IMPLANTS
• MIX UNIFAST ACRYLIC (GC)
• FILL SYRINGE
(GET RID OF AIR BUBBLES BY VENT HOLE)
• INJECT AROUND TEMP CYLINDERS
(NOT INSIDE)
• PT CLOSES (INTO BITE)
• AFTER HARDENING, UNSCREW
THE TEMP CYLINDERS
• AND COVER IMPLANT WITH ABUTMENT
OR IMPRESSION COPING FOR NEXT STEP
SEND UPPER IMPRESSION TO LAB FOR “CONVERSION”
( WHILE LOWER SURGERY—OSTECTOMY; DIRECTED IMPLANT
PLACEMENT-- DONE WITH PROSTHETIC PROCEDURES IN EXACT
ORDER—ORIENTING IMPRESSION OF LOWER PROSTHESIS WITH
MEDIUM BODY CLOSING INTO BITE WHILE UPPER LOCKED IN PLACE;
CORE/LUTING OF LOWER PROSTHESIS; AND OPEN CUSTOM TRAY
IMPRESSION OF LOWER IMPLANTS
REMOVE FLANGES
Hugh Flax
PLACE GINGIFAST
(ZHIRMACK)
MATERIAL TO FILL TO “
IMPLANT PLATFORM”
Hugh Flax
5/8/2015
5/8/2015
RETROSPECTIVE CONCLUSIONS
• Better materials (restorative and graft materials; implant design) and
understanding of biomechanical principles, as well as, better 3 D diagnostic
protocol make this modality a reasonable choice for the more driven patient
who is less tolerant of a flange or palate
• Due to the difficulty and time intensiveness, it is critical to assemble a “team” to
make this predictable:
1) Removable lab specialist who knows smile design principles
(“pretreatment facial analysis” ), functional loading with awareness of
proprioception that is more rigid than tradition removable, and meticulous
with guides and “conversion”
2) Surgeon has a humble prosthetic awareness (bone removal for
prosthetic thickness i.e. “ treatment by prescription”); can place
pterygomaxillary implants to give posterior support distal to sinus; and
office team is mutually supportive of restorative team
• Time intensiveness will improve by better preplanning with 3 D printing of
alveoloectomy guide; implant surgical guide; and indexing prosthesis to stable
landmarks)
CONTACT
INFORMATION
HUGH FLAX,DDS
(404) 255-9080
Thank
You
Email: h.flax@FlaxDental.com
For lecture info
on cosmetic dentistry, implants and lasers
http://www.catapultelite.com/flax.php
ANY QUESTIONS ????
Hugh Flax

By Hugh Flax DDS, AAACD, FICOI Atlanta, GA

Transcription

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