Tom Salinas Mayo Clinic

Department of Dental Specialties

2018: A Home Away From Home Odyssey

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25

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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.

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139

Thank You

Salinas.thomas@mayo.edu