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Tom Salinas Mayo Clinic
Department of Dental Specialties
2018: A Home Away From Home Odyssey
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25
50
75
100
less than 5 Yrs 5-10 YRs 10-15 Yrs 15-20 20 + Yrs
Wisdom Energy
S. Koka 2013
The “Sweet Spot”
Things I have Learned from Patient Care
• Despite all efforts, you cannot legislate to makepeople care.
• You cannot make people value health or education.
• Refined skill, judgement and care is the best offeringfor your patients.
• Empathy, genuine concern, and commonality are thebest basis of communication.
• Never ask anything of your auxiliaries that you arenot willing to do yourself.
Ricardo Vidal DDS,MS http://www.james-gardner.co.uk
Dental Specialties is a department of 8 dental specialists within this multi-specialty medical group practice
Mayo Clinic comprises an integrated multi-specialty clinic and several hospitals
• More than 1.3 million patients in 2017 • Staff physicians and scientists: 4,590
• Residents, fellows and others: 2,400 • Allied health staff: 57,100
The Needs of the Patient Come First
But, what do you actually do at the Mayo Clinic?
Patient care 85%
Education 10%
Research 5%15
Current Trends in Implant
• Routine Use of Dental implants• 15-20% Growth Globally• Single Tooth Replacement #1 Indication• More than 50% of Implants Placed with Bone
Grafting• Reduced Healing and Treatment Periods• CAD CAM Technology Can Be Used in
Certain Areas of Implant Dentistry
Diagnosis
• SAC Classification• Straightforward: Simple procedures; low risk for surgical, prosthetic or
esthetic complications• Advanced: Some risks associated with procedure and may require
some advanced planning to intercept potential problems. • Complex: Case which may require interdisciplinary planning, staged
treatment phases and modification of patient behaviors.
• ITI Assessment tool– http://www.iti.org/?a=1&t=0&y=3001&r=0&n=188&i=&c=25&v=page&o=&s=
Five Core Questions for Diagnosis
• What are the facial proportions and skeletal relationships?
• What are the length and mobility of the upper lip?
• What is the relationship between the gingival line and the horizon?
• What is the length of the maxillary central incisor?
• Is the CEJ palpable in the gingival sulcus?
Global Diagnosis, Robbins and Rouse, Quintessence 2016
Esthetic Outcomes
Belser et al 2009 J periomodified Implant Crown Aesthetic Index (mod-ICAI)
PES WES
Work Flow Choices
Analog/Digital
Digital
Analog
Analog/Digital
Analog/Digital
Diagnostic Wax up
Digital Smile Design www.digitalsmiledesign.com
Digital Treatment Planning
Is it worth it? How much does it cost? What can you do with it?
3 Shape (Implant Studio)
Dental Wings (DWOS with coDiagnostiX)
Exocad (Open Software)
X-Nav (Live Time Navigation)
D2000 Scanner
Scan Diagnostic Casts
Export to STL files
Workflow in Planning Software
Create Surgical Guides/Temps
3 Shape Planning Software
Dental Wings Planning Software
Virtual design for Provisional
Real time design of Surgical Guide
Dental Wings Planning Software
Exocad Software
Surgical Stents• What Information is Needed? CBCT and Digital Impression
data.
• Needed/Worth It? Singles in anterior/complex cases
• Economical Method.(Analog/Digital)
1 2 3 4 5 6 7
PrePlan Fee 99 149 149 189 189 219 219
Set Fee 199 199 199 199 199 199 199
Per site fee 0 49 49 49 49 49 49
49 49 49 49 49
49 49 49 49
49 49 49
49 49
49
$298.00 $397.00 $446.00 $535.00 $584.00 $663.00 $712.00
Lab Fees: Treatment Planning and Surgical Stents
What’s the Cost?
• Stent and CBCT makes 16% of the fee.
Cost?
37%
37%
6%
4%
10%6%
Initial Exam CBCT ImpressionsStent Implant Prosthetics
Live Time Navigation
Cost: $30,000 + $99 per arch
Digital Impressions
• Chairside digital acquisition of data to digital file.
• Tooth Preparation
• Implant Position Transfer
• Edentulous Arch
Bella Tech Encode Healing Abutment
Digital Impression Capture
Kimiyo Watanabe Sawyer, CDT
Trios 3Shape
Fast: 1 arch in about 15 secondsAccurate: One of the highest precision
Cost: $30-45K
Itero
Continuous Capture-Somewhat slower (60sec full arch) Accurate
Cost: $27-30K
Digital Implant Impressions
• Digital Impression post (Intraoral Scan Body)
• High Variability in scanning information
• Limited Data Available to guide choosing for a given clinical situation
• Interaction between Scanner and ISB is not well understood
Intraoral scan bodies in implant dentistry: A systematic review; Mizumoto et al; (J Prosthet Dent 2018) In Press
Digital Impression Practical?• Positives: high fidelity of data
• Models not needed for single implants
• (Accurate, but a check only for proximal contacts and occlusion)
• Negatives:
• Accuracy of multiple implants casts inconsistent
• Abutment Emergence profile/finish line limited with printed models
• Restrictive with Participating Labs
Implant Selection• Nobel Biocare: Branemark, Replace, CC Parallel/
NobelActive.
Component Connection
• Binon et al 1996 pointed out connection of external hex is variable in accuracy by as much as 6 degrees.
The effect of implant/abutment hexagonal misfit on screw joint stability;Int J Prosthodont;1996;9(2):149-160.
Comparison of Implant Connections
• Compared 27 studies of 586 Ext Hex• 1,113 Int Conn • Abutment screw loosening is a rare event in
single-implant restorations regardless of the geometry of implant-abutment connection, provided that proper antirotational features and torque are employed.
Theoharidou A, Petridis HP, Tzannas K, Garefis P. Abutment screw loosening in single-implant restorations: a systematic review. Int J Oral Maxillofac Implants 2008;23(4):681-90.
Comparison of Connections
Bone Response
Soft tissue response
With Platform switching preserve bone?
Straumann Bone Level
Branemark
Comparison of Implant Connections and Bone Loss
• Compared 10 studies of 1,718 Ext Hex• 1,475 Int Conn • Bone loss was not significantly different. (2
studies comparing Astra and Branemark of up to 15 years did not show significant bone loss differences) More studies needed to validate.
Palacios-Garzon et al. Comparison of Marginal Bone Loss Betwee Implants with Internal and External Connections: A Systematic Review Int J Oral Maxillofac Implants 2018;33 580-589.
Implant Selection (Does this matter?)
• Internal/External/tapered Connection
• Platform Switching (Real or Perception?)
• Ease of Prosthetic Delivery (Operator Preference: simplicity, wide selection)
Implant Selection
• Nobel Biocare: NobelActive, CC Parallel and Replace, Branemark
• Straumann: Bone Level, Tissue Level
• Zimmer-Biomet: Certain Prevail, Tapered Screw Vent, T3, Osseotite
• Biohorizons: Tapered Plus, Tapered Tissue level
How is the Ease of Delivery?
• Firm grasp of components
• Easy/simple versatile design for drivers
• Retrieval of abutments
• Easy to Understand Flow Diagrams
Joseph Y. K. Kan, Phillip Roe, Kitichai Rungcharassaeng, Rishi D. Patel, Tomonori Waki, Jaime L. Lozada, Grenith Zimmerman. Classification of Sagittal Root Position in Relation to the Anterior Maxillary Osseous Housing for Immediate Implant Placement: A Cone Beam Computed Tomography Study. Int J Oral Maxillofac Implants 2011;26:873-876.
81% 7% 1% 11%
Consideration for Placement in Esthetic Zone
Class I Class II Class III Class IV
Angled Screw Channel
Angled Screw Channel
25 degree correction
Straumann Angled SolutionASC Limitations
• Can only be used with Certain Implant from Nobel Biocare (Active, Parallel CC, and Replace CC) and Bone Level Straumann
• Can only be used with CAD CAM designed abutments crowns and bridges.
• Need specific driver with abutment screw (Omni-Grip)
How About a Full Arch?
• How many implants? (affordability)
• How much bone available? (distribution)
• How much restorative space? (height)
• What is the opposing? (occlusal pairing)
Space
Distribution
Occlusion
Number of Implants
•Edentulous Maxilla traditionally treated with 6-7 implants for full arch replacement.
• Evidence indicate as few as 4 (10mm) implants for a shortened dental arch. (Where posterior bone limits placement)
Aparicio, Perales, Rangert; Clin Implant Dent Relat Res; Tilted Implants as an alternative to maxillary sinus grafting;2001
Malo, Rangert, Nobre; Clin Implant Dent Relat Res; All on 4 immediate function concept, 2005
Adell 1966 Branemark 1983
All on Four Concept
• Unpublished data from Malo (10 year):
• 648 Edentulous Maxilla: 93.98% (39 failures)
• 1364 Edentulous Mandible: 99.41% (8 failures)
Academy of Osseointegration Presentation 2014
Rigidity?
Zygomatic Implants
Limitations of Zygoma Implants
• There is flexure of these implants when loaded
• Use where there is sufficient inter arch distance
• Where insufficient prosthesis thickness is evident, choose resin to metal restoration.
• Either single piece or segmented prostheses found to be successful.
• Using 4 implants and a non segmented prosthesis created problems with fractured resin teeth and reduced access for adequate hygiene.
• Using 6 implants often involved grafting the posterior to alleviate cantilevers and redundant implant support. Segmented prostheses facilitated divergent implants and ease of repair. Greater prosthesis survival due to posterior implant placement.
• In either approach, prosthesis survival often related to implant distribution
• Maintenance, Repair and Multiple replacement within patient’s lifetime
Treatment Planning Edentulous Maxilla
Implant Selection• Straumann: Bone Level, Tissue Level
machining tolerance, the wedge effect andthe settling effect
machining tolerance, the wedge effect andthe settling effect
Cemented or Screw Retained ?
• Cement Retained Prosthetics easier to fit
• Often work at the abutment level (easier)
• Retrieval difficult/unpredictable
• Difficult to control cement
Screw Retained or Cemented?• Screw Retained Prosthetics difficult to fit
• Connection at the Implant level (difficult)
• Retrieval easier/predictable
• Cement not an issue
• Biomechanics more stable
• Forming tissue profiles easier
• Conceals components
Angle Correction Abutments
Screw DTF
Abutment Level
Rest Support
Screw Retained or Cemented?How about Both?
Treatment Planning Edentulous Mandible
Implant Retained Overdenture Fixed Complete Denture
Implant Supported Overdenture
Ceramometal Fixed Prosthesis
Rules of Cantilevering
• Ovoid Arch
AP
CL For 5 Implant Model, the CL/AP Ratio should be 1.7/1
For 6 Implant Model, the CL/AP Ratio should be 1.8/1
For 4 Implant Model, theCL/AP Ratio should be 1.6/1
Source: McAlarney, M.E. and D.N. Stavropoulos, Determination of cantilever length-anterior-posterior spread ratio assuming failure criteria to be the compromise of the prosthesis retaining screw-prosthesis joint. Int J Oral Maxillofac Implants, 1996. 11(3): p. 331-9.
Abutment ScrewsProsthetic Screws
Abutment ConnectionImplant Connection
Material/Design Choices
Resin/Metal All Ceramic Metal Ceramic
Resin/Metal Prosthesis
Circa 1985
Mayo Clinic, Eastman, University of Toronto, University of Washington,
UTSAHSC, NYU have been active in the clinical application of dental
implants for 35 years
1983
•What’s Changed? • Technology
• Clinical Outcomes Knowledge Base
• Patient Expectation
• Patient Demographic
Interarch Spatial Requirements
Phillips K, Wong KM. Compend Contin Educ Dent 2002;23:750 6
Locator: 8-9 mm
Milled Bar: 10-11 mm
Fixed Complete
Denture: 11-12 mm
Metal Ceramic Fixed Dental Prosthesis: 7
mm
Dolder Bar: 12
mm
Interarch Distance Requirement Resin to Metal
>3 mm Resin*
>3 mm Resin Tooth**
>4 mm Bar Height***
2 mm Hygiene Clearance
12-15 mm minimum requirement
*Choi et al **Wong/Phillips et al
***Salinas et al
Acrylic Resin/Metal Prosthesis Design
• Wrap Around
• Metal based
85
Worn Teeth
85
Wear
• At least one prosthetic Event was experience by 58% of patients
104
9494
Follow up Study on Servicing of Resin-Metal Prostheses
Average time of follow-up 13 years
135
Top 3 Events N(%) Years from Implant Placement
Visits Needed
Fractured Screw
113(18) 7.4 1.4
Fractured Abutment
73(11) 6.4 1.3
Wear 63(8) 13.9 4.6
Hyperplasia 97(57) 3.3 1.4
Mobile Implant 23(14) 3.4 1.7
Infection 15(9) 6.3 2.2
All Ceramic/Zirconia
Clin Oral Implants Res. 2013 Jun;24(6):659-65. Computer-assisted design/computer-assisted manufacturing
zirconia implant fixed complete prostheses: clinical results and technical complications up to 4 years of function.
Papaspyridakos P, Lal K.
Porcelain chipping/fracture was the most frequent technical complication, 31.25% chipping rate.
All Ceramic Design
Metal Ceramic Design
• Screw Retained Cross arch splinted design
142
Telescopic/Screw Retained Design
143
144
• Workflow Pathway–Choose one where communication can transfer easily
–Single versus multiple implants
• Implant Selection–Choose system that allows ease in delivery
–Use internal connection in partial and well distributed arches.
–Flat top implants in complete or limited distributed arches
145
• Prosthesis Design–Screw Retained Preferable
–Use combination when not possible or preangulated abutments
• Material Selection–Use metal ceramic in arches with orthogonally placed implants
–Where flexure or potential movement exists, segment or use resin/metal based or component prosthetics.
146
139
Thank You
Salinas.thomas@mayo.edu
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