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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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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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Andrew Ferrier, DDS

Hiding the transition line

Andrew Ferrier, DDS

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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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?

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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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