as opposed to “few teeth at a time” dentistry · Basil Mizrahi BDS, MSc, MEd Private Practice, London, UK ... doing the adjacent tooth as well, ortho alignement, CTG, aesthetic

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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