How to start with All-on-4s

[Bryce Hiller]

Ok so basically, we'd like to start offering all on 4 dentures. We do a lot of single crown implants (we typically send the case to dentsply for custom abutments),but we have the capability already to do everything in house. We want to mill Trinia bars and fabricate a denture over it.

Where do we even begin with this endeavor? Does anyone offer any kind of training for this? What CAD software is best? We currently have Dental Wings, but are interested in switching to either Exo or 3Shape. We have a 3D printer and a wet mill on the way.

Any help would be greatly appreciated. Thanks!

 

[rkm rdt]

 

[Bryce Hiller]

rkm, are you doing all-on-4s?

 

[rkm rdt]

rkm, are you doing all-on-4s?

Working on the guides at this point.

 

[LGTCDT]

Nobel Biocare in conjunction with Ivoclar offer courses at Ivoclar's training site in Sarasota instructed
by Tom Wade. We attended both courses offered when we started offering. It covers everything you need to
know from beginning including conversion of denture to provisional all the way to bar design and process.
Great courses....we have since made over 200 cases. This is a good profit center for a lab and drives other
business to you.

 

[Bryce Hiller]

Nobel Biocare in conjunction with Ivoclar offer courses at Ivoclar's training site in Sarasota instructed
by Tom Wade. We attended both courses offered when we started offering. It covers everything you need to
know from beginning including conversion of denture to provisional all the way to bar design and process.
Great courses....we have since made over 200 cases. This is a good profit center for a lab and drives other
business to you.

thanks for the info!! Do you know the cost?

 

[LGTCDT]

Its been a couple of years but think it to be $1500. Ask your Nobel rep for any info.
There is also a e-book on the Nobel web site you may be interested in viewing.
The scanners we use are 3Shape and primarily Nobel scanner.
Hope this helps

 

[RCKSTR]

We do all on 4's full ZR, no bar at all

 

[Bryce Hiller]

We do all on 4's full ZR, no bar at all

How steep is the learning curve?

 

[RCKSTR]

It was steep at first. After about 6 we have it figured out, one scan, design mill. In the beginning we were milling it 3 or 4 times to get a success. Had a lot to do with accurately placing the ti cones and controlling the sintering

 

[LGTCDT]

You can mill out for whatever you want to, the course covers mainly the conversion process. This is the key to
linking with surgeons that will refer you to new accounts.
We are making bars w/acrylic, full zirconia and zirconia w/individual crowns.

 

[Jason D]

why trinia when there is already a well documented, reliable material with no drawbacks?
milled pmma over titanium bar is the 'sweet spot' meaning most reproducable and adaptable with long proof of concept...also easiest to adopt as you move from legacy manufacturing methods to digital.
each other option has a significant drawback or lack of long term study.

 

[CoolHandLuke]

why trinia when there is already a well documented, reliable material with no drawbacks?
milled pmma over titanium bar is the 'sweet spot' meaning most reproducable and adaptable with long proof of concept...also easiest to adopt as you move from legacy manufacturing methods to digital.
each other option has a significant drawback or lack of long term study.

except for several very large key drawbacks.

1. titanium is rigid. this means if the implant is under ANY amount of stress it will be so for its (reduced) lifespan. to be long term workable the implant needs to be passive fit. if you load unsplinted implants before osseointegration is done, you are (as we canadians say) hooped.

2. acrylic may be easily repairable and easy to put teeth in, but it breaks with far less masticatory force (edit: far less masticatory force than some other materials suitable for replacing tooth area, as opposed to gingiva or frame resins). its porous and you know why thats bad. it doesnt resist heat deformation.

3. everyone who makes these bars and dentures makes them retentive but slightly loose fitting. because they have to come off. this is why someone invented Locators. you dont want loose fitting but you want it to come off. but locators suck. suck so hard. you are replacing housings and washers every year, sometimes along with dentures themselves, if not implants.

no, ti bars and acrylic dentures are in dire need of technological upgrade. its a travesty how the C and B world have advanced but denturism has not.

at long last Trinia has arrived to champion the cause, however it too has its failings. failings many are working to rectify - me included. we've got our own method to correct for these issues and its a matter of ironing out the process to be easier and have more guarantees of success. all being well, 2018 we're hoping to roll out something. but not yet.

 

[Jason D]

well, I'm not interested in getting into a big debate (surprise!)

As someone who has done full arch implants since subperiostals and plate form blade implants, ti bars with esthetic superstructures have been great and newer tehcnologies have made them the 'best of both worlds'.

Well designed TI bars are second only to spark erosion in accuracy and longevity.
to answer your points:

#1 good bars are passive and do not cause stresses. BAD bars, well that's another matter. Spend more time on verification accuracy and you will spend less time remaking and dealing with failed implants.

#2 makes a classic assumption....incorrectly... that we are talking about heat processed resins, I said nothing of the kind, and we do not put denture teeth on bars..haven't for a while now.

#3 I want passive and stable not loose..I'm not sure where you got these assumptions about slop fit, but I don't know any good labs that think that's the goal.

 

[CoolHandLuke]

good bars are passive and do not cause stresses. BAD bars, well that's another matter.

very true. now can you say with any degree of certainty that the bars coming from a plaster model at +/- 100um, milled in a machine capable of +/- 10um give passive fit? that Nobel course as listed above will tell you passive fit is +/- 2microns.

are we at all certain a 3dprinted structure would be better? i highly doubt it. 3dprinted metals have memory. more so than cast, and milled.

can you say with any certainty that the plethora of labs that would make bars on their 40k machine can do as good as a cnc worth a quarter million, backed by professional cnc machinists?

the solution that labs are adopting is ridiculous and terrible. but its cheap, and its sexy and makes you feel good so it sells.

#2, no you might not put denture teeth on bars but tons of labs will make zirconia super rigid brittle doodads with built in teeth. these things are so durable they will be digging up the bones of people who had them 3000 years from now and go hey look he had one of those zirconia prosthetics, then probably dust it off and teleport it to a museum.

what i'm saying is this rigid structure isn't the best for the patient, and reduces the lifespan of the implant. a SEMI-rigid material like trinia which can deform up to 1.5mm before breaking to undue stress, is far more valuable to labs looking for working solutions on the cheap acrylic can't do that zirconia cant do that. drop a zirconia frame one day see how well it absorbs impact. tell me how its good for anyone and their pocketbook?

the longevity of an all on x case depends entirely on passivity of fit, and if that cannot be guaranteed outside of a cnc worth a quarter million then the obvious solution is to go to a flexible alternative, or buy nobel's premanufactured all on 3 solution and don't think about it. but who wants to do that? nobody. which is great because trefoil isnt marketed to labs anyway, its marketed to surgeons and gp's. nobel wants to actively cut you out of making bars, and cut Panthera out too (if you didnt know they used to be Nobel). Nobel has an ACTIVE interest in sh!tting all over you as a lab because with the more tool you as a lab have for making quality work, the less money nobel makes. I wouldn't go to a nobel course except for a free lunch, and I'd probably complain even about that.

 

[Affinity]

I agree with Jason, I wouldnt be so quick to jump on the trinia bandwagon because its 'the next big thing'. Peek and pekkton have a much longer track record in medical and dental implants but ultimately it comes down to what the Dr prescribes. Im surprised no one has mentioned peek materials, I think in a matter of years we probably wont be using ti for these bars.
Be careful what you wish for, the bigger your plate, the more you have to eat.. if youre on DW and just doing single unit implants ..and just getting started with printing and milling, I would say the learning curve is steeper than you think.

 

[grantoz]

its massive and stressful and incredibly rewarding. dont get caught doing resin as a permanent solution as there will be repairs and a lot of stress people expect things not to break after spending big bucks.

 

[Affinity]

grantoz, this is the part I have a hard time with.. While these big cases are rewarding like you say, Im not sure the stressfullness of it balances out.. Big labs will churn these out for a fraction of what I would do it for.. Pts dont understand why it would cost 2-3x more, even if the Dr does.. If given the choice, I bet most pts. would opt for the cheaper appliance just to be able to afford the implant retention..

On another note, you aint puttin this in my mouth for 10k..

 

[droberts]

CoolHandLuke,

Show the documentation of your comments on a Ti bar. Rigid "reduces lifespan of implant"?

Plus your comments on the Trefoil? I believe you need to attend a course before making judgement...
With the amount of A04's I have fabricated. So far, none would have been a candidate for the Trefoil.
Its a limited option.

 

[Wade Bognuda]

Ok so basically, we'd like to start offering all on 4 dentures. We do a lot of single crown implants (we typically send the case to dentsply for custom abutments),but we have the capability already to do everything in house. We want to mill Trinia bars and fabricate a denture over it.

Where do we even begin with this endeavor? Does anyone offer any kind of training for this? What CAD software is best? We currently have Dental Wings, but are interested in switching to either Exo or 3Shape. We have a 3D printer and a wet mill on the way.

Any help would be greatly appreciated. Thanks!

Go for it!!! Dentures are easy!!! A two day course and you're in!!! BIG MONEY!!!!