Hybrids and materials to use

D

Dimis

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#1
Hey guys
I want to say some thoughts about choosing material for a hybrid and I would love to hear your thoughts and opinions about that.
I'm an inlab technician and lately at the clinic we have a few cases over implants for hybrid design. The last hybrid that we did was with PEEk material and it was my first time using it ,no experience so I made mistakes I believe on the design( thin design ) and it broke . The patient was a heavy bruxist and I thought that PEEK was the best material to use Because of flexibility. Now after these I have to redo it so I will go to the safest route that is metal.
Now my question is when do you guys use PEEK when zirconia and when metal or even lately I've seen titanium and why?
I'm gonna tell you my reasoning and pls correct me if I'm wrong( reminder that I'm not very experienced [emoji4])
So let's start with strength that is the first thing that comes to my mind when I see these giant cases.
So metal has the advantage over all here so my money are on metal. But now I have to think that metal is not biocompatible and aesthetically not so nice as the other materials. But if you think many cases of those are above gingiva level so biocompatibility is not an issue. Now about the aesthetic part the problem is that metal is black and the other are white materials. But metal I'm gonna opaque cover the black color use composite for the tissue like I'm going to use on the other materials and use eMax or zirconia crowns on the opaque abudment teeth. So aesthetically speaking I can have a really good result too.
Another matter that I m thinking now is the weight of the metal in the mouth that the PEEK don't have and zirconia has but in a smaller degree. But again is that really so important for me to risk and do zirconia or PEEK and have the chance of breaking it and redoing it all over( time, money loss).
So these are my thoughts about these subject, maybe I'm not seeing some stuff or even maybe I'm seeing some stuf completely wrong.
I would love to hear your thoughts about how you decide which material to use and where I'm wrong on my thinking so I can improve and be able to decide better next time
Thanks


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CoolHandLuke

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#2
congratulations, you have produced the same mental acrobatics that led many people to using harder and more inflexible materials for their prosthetics.

when the patient is a bruxer, the solution is not to just make a hard product but cure the bruxism first, with TMJ therapies, bite reprogramming. then PEEK or PEKK or PEKKTON will work for prosthetics provided the cure for the patient is maintained.

PEKK and PEEK materials are improving biocompatibility speaking, as there are many joint replacement surgeries that utilize these materials now. knees, shoulder, elbows, many ways it is used.

zirconia is the devil, titanium is the highway to hell. avoid at all costs my friend. stick with PEEK variants, and when the docs make these classic blunders of not trating patients for bruxism first, you can prove the fault does not lie with you.

this is my position and i will defend it to the death
 
JMN

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Purely my opinion. Something, somewhere needs to give. Full arch reconstruction on implants removes all proprioceptive feedback that a patient had, and aside from how sore their oral musculature becomes, and they have no idea how hard they are doing anything. And there are no current technologies to simulate periodontal ligaments to allow the average of 40-100um of movement as the teeth can do.

It's up to the team treating the patient to decide what can give. If a titanium bar with individual Emax or Zirc crowns is the solution, at least the crowns can give up and be replaced, the bone will not be replaced as easily. Maybe I'm overthinking it, but all our material science has been pointing in the harder, stronger, less flexible direction. We need to find some more flexurally-strength-increased materials that can absorb the force, instead of transmitting it.

But what do I know, I'm an uncredentialed knuckdragger.
 
droberts

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No matter what material you use. The next weakest link is going to break, or wear.
Proper treatment planning of the case will bring better success.
 
kcdt

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congratulations, you have produced the same mental acrobatics that led many people to using harder and more inflexible materials for their prosthetics.

when the patient is a bruxer, the solution is not to just make a hard product but cure the bruxism first, with TMJ therapies, bite reprogramming. then PEEK or PEKK or PEKKTON will work for prosthetics provided the cure for the patient is maintained.

PEKK and PEEK materials are improving biocompatibility speaking, as there are many joint replacement surgeries that utilize these materials now. knees, shoulder, elbows, many ways it is used.

zirconia is the devil, titanium is the highway to hell. avoid at all costs my friend. stick with PEEK variants, and when the docs make these classic blunders of not trating patients for bruxism first, you can prove the fault does not lie with you.

this is my position and i will defend it to the death
Bruxing is a stress mechanism controlled by CNS and exhbits in most mammals.
It is also primarily a sleep event. There has never been an established correlation beween TMJ position or occlusion interferences as causal of Bruxing.
If a patient bruxes, all you can do is mitigate the wear and tear.
To suggest otherwise foolhardy.

I say this as a former Pankey alum.
 
kcdt

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congratulations, you have produced the same mental acrobatics that led many people to using harder and more inflexible materials for their prosthetics.

when the patient is a bruxer, the solution is not to just make a hard product but cure the bruxism first, with TMJ therapies, bite reprogramming. then PEEK or PEKK or PEKKTON will work for prosthetics provided the cure for the patient is maintained.

PEKK and PEEK materials are improving biocompatibility speaking, as there are many joint replacement surgeries that utilize these materials now. knees, shoulder, elbows, many ways it is used.

zirconia is the devil, titanium is the highway to hell. avoid at all costs my friend. stick with PEEK variants, and when the docs make these classic blunders of not trating patients for bruxism first, you can prove the fault does not lie with you.

this is my position and i will defend it to the death
You've been flashing your boner for PEEK and PEKK for quite a while now.

We get it.
Once we start to see some longevity and peer reviewed evidence, maybe I'll pay attention.
Meantime it all sounds like marketing koolaide to me.

There's been way to much BS foisted on this industry for me to go traipsing after the latest greatest. Show me it holding up, and what real world maintenance looks like, that's my interest.
 
Jason D

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#7
Bruxing is a stress mechanism controlled by CNS and exhbits in most mammals.
It is also primarily a sleep event. There has never been an established correlation beween TMJ position or occlusion interferences as causal of Bruxing.
If a patient bruxes, all you can do is mitigate the wear and tear.
To suggest otherwise foolhardy.

I say this as a former Pankey alum.
Totally disagree on this one: not about the TMJ position, cuz I agree there is an unclear relationship there.
The part I disagree with is the wear and tear suggestion.
In many cases the solution is an NTI or deprogrammer... agree with it being neurological and a disruption to the feedback loop of the nervous system is a fantastic solution for the patient
 
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Jason D

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You've been flashing your boner for PEEK and PEKK for quite a while now.

We get it.
Once we start to see some longevity and peer reviewed evidence, maybe I'll pay attention.
Meantime it all sounds like marketing koolaide to me.

There's been way to much BS foisted on this industry for me to go traipsing after the latest greatest. Show me it holding up, and what real world maintenance looks like, that's my interest.
Agreed
Show me peek with epithelial cells growing on its surface like polished titanium will do, and I’ll listen to biocompatibility talk Until then Ill stick to titanium thank you very much.
Show me ten year results And I will believe it’s not just the next flavor of the month… Three years ago peek was supposed to be the second coming… Now we are hearing it has solubility issues and limited application… Have you seen some of those provisional abutments made with peak after three years of the mouth? You can stick an explorer into them!
So now “they” say “what? Peek? Oh no we meant pekkton! Yes sir that’s the ticket! Get you some art glass to metal or inceram or sculpture/fibrekor or....”
 
kcdt

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Totally disagree on this one: not about the TMJ position, cuz I agree there is an unclear relationship there.
The part I disagree with is the wear and tear suggestion.
In many cases the solution is an NTI or deprogrammer... agree with it being neurological and a disruption to the feedback loop of the nervous system is a fantastic solution for the patient
Anterior NTI has a specific pain mitigation use.
A deprogrammer gets you to a consistent CR.
So once you've got them out of migraines and put them in CR as a restorative convenience, got you're occlusion non interfering.
They still brux.
You've mitigated negative effects, that's all.

I'm not saying it's a bad idea; I'm saying it doesn't cure the behavior.
 
Jason D

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The NTI studies show a change in the autonomic response. It’s definitely about pain mitigation as well but the proprioception trigger actually decreases both the chemical response (the calcitonin genie related peptides) as well as decreasing muscular activation of Masseter and temporalis contraction.

(Dang it almost sounds scientific with so many big words ;) )

It definitely does not “cure” or prevent bruxism, but is does significantly reduce the clenching force exerted
 
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kcdt

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Purely my opinion. Something, somewhere needs to give. Full arch reconstruction on implants removes all proprioceptive feedback that a patient had, and aside from how sore their oral musculature becomes, and they have no idea how hard they are doing anything. And there are no current technologies to simulate periodontal ligaments to allow the average of 40-100um of movement as the teeth can do.

It's up to the team treating the patient to decide what can give. If a titanium bar with individual Emax or Zirc crowns is the solution, at least the crowns can give up and be replaced, the bone will not be replaced as easily. Maybe I'm overthinking it, but all our material science has been pointing in the harder, stronger, less flexible direction. We need to find some more flexurally-strength-increased materials that can absorb the force, instead of transmitting it.

But what do I know, I'm an uncredentialed knuckdragger.
So far the issue I see with flexibility is delamination of veneering/ bonded materials.
Most stress analysis studies I remember seemed to show that proper A/P was more criticaI also, along with appropriate # of implants to address whatever the opposing arch was.
But the consequence by and large is component breakdown. Screws most often or veneer materials.
Over time implant loss is mainly driven by hygiene.
I don't buy that rigid frames supported by appropriate fixtures causes bone loss.

Of course I could be hopelessly out of date, so I'd like to hear if mistaken.
 
Jason D

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#12
So far the issue I see with flexibility is delamination of veneering/ bonded materials.
Most stress analysis studies I remember seemed to show that proper A/P was more criticaI also, along with appropriate # of implants to address whatever the opposing arch was.
But the consequence by and large is component breakdown. Screws most often or veneer materials.
Over time implant loss is mainly driven by hygiene.
I don't buy that rigid frames supported by appropriate fixtures causes bone loss.

Of course I could be hopelessly out of date, so I'd like to hear if mistaken.
nope I’m right with you and most of the legit studies I see match that description.
 
kcdt

kcdt

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The NTI studies show a change in the autonomic response. It’s definitely about pain mitigation as well but the proprioception trigger actually decreases both the chemical response (the calcitonin genie related peptides) as well as decreasing muscular activation of Masseter and temporalis contraction.

(Dang it almost sounds scientific with so many big words ;) )

It definitely does not “cure” or prevent bruxism, but is does significantly reduce the clenching force exerted
But in the end, you've mitigated pain, the "cure", if you will, is in mitigating how hard they can brux on the cuspid/trigeminal loop. You're not curing Bruxing, you're getting getting the pressure point of the nerve out of the way.
 
G

grantoz

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after doing hundreds of these over 12 years ti bar zi over the top is the way to go .no fractures no lost implants no screws breaking no opposing dentition worn away. you dont immediate load with the tizi option as final tooth position may change etc. use resin while integration is happening. the patient does get some sensation thru the mandible when they bite together more so with a hard a surface like zi .they clench more on resin.i have seen it many times when the patient gets the final issue zi ti hybrid they bump their new teeth together and they say finally these feel like my real teeth.
 
Affinity

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Great discussion. I heard a research prostho from norway or somewhere a few months ago with a study that showed polished zirconia as having the best epithelial attachment but titanium was right there with it. PEEK was not included I dont recall.

I agree that we need more long-term studies, but it seems to be on the right track for the future. If there were major solubility issues I doubt it would be so widely used elsewhere in the body for so long. However oral environment is a much different issue. Was anyone at the pekkton summit in Chicago? I think @Labwa was, they should have had some studies there..

Im also curious as to why no one mentioned a standard acrylic hybrid over Ti bar.. acrylic has some shock absorption to it also especially compared to zirconia.
 
D

Dimis

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Thanks for the responses so far guys. Great to discuss this topic. It can be broad and go many routes for discussion. As far as the treating of the bruxism my doc does know it's their responsibility to treat and that failures falls to them partially. So I like the ti zr hybrid idea although I have limited experience with bars. Are they're options of ti frames with preps on top and Individual zr crowns on top? This is something I would try but then what about the pink on ti, what are my options? Or any other type of frame /crown combos.Thanks again for all the input guys. Again I understand that these monster cases are multifactorial and there's no one solution. I just want to create a better prognosis for survival of my work.
Cheers all


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JMN

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So far the issue I see with flexibility is delamination of veneering/ bonded materials.
Most stress analysis studies I remember seemed to show that proper A/P was more criticaI also, along with appropriate # of implants to address whatever the opposing arch was.
But the consequence by and large is component breakdown. Screws most often or veneer materials.
Over time implant loss is mainly driven by hygiene.
I don't buy that rigid frames supported by appropriate fixtures causes bone loss.

Of course I could be hopelessly out of date, so I'd like to hear if mistaken.
And I may be as well. I have no access to the resources I had 3 years ago.
 
TheLabGuy

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#18
Their is a lot of difference between the high performance polymers out there (some a lot more rigid than others). I only really have experience in Pekkton myself, done a few hybrids with this stuff. I used the BDT Technique on these particular hybrids. The Pekkton did have some give/flexibility, which was great (because I thought heck yeah, it'll act like a PDL when being used with implants). After a few under my belt, I realized pretty quick that you have to have the vertical thickness there to use. Without using a metal substructure (which you can use with Pekkton),I feel a lot better about these type of appliances when you have the proper vertical dimension (15 to 16mm) to work with. The zirconia is so technique sensitive, you must have a rock solid protocol in place, good thing about that stuff...is that once you get that down, the high performance polymers will be nothing for you. As for metal, it's my fail safe, if I can't use others, I always sleep well using metal. Personally, I think once these high performance polymers (Pekkton, Pekk, BioHPP, Trilor) become FDA cleared for permanent use for implant abutments then it will take off here in the states. Think about it, we will be able to mill our own abutments, slap a FDA titanium interface on it and you're making your own abutments for the most part in-house...those polymers mill just like PMMA. For single implants this would be a game changer for little tikes like myself. So far, most polymers out there in the U.S. are only FDA cleared for 'temporary' use...which means it has to be removed at least once a year (which you would do anyways with a hybrid). Trilor-Bioloren recently did get it's FDA clearance for 'permanent' use but I haven't had a chance to use this material yet (love to know if any of you have?). However, the FDA clearance is always changing on these polymers so if you have some new intel...please do share.

Here is a link to some of the clinical side of the things that some of us might not see. Click Here
 
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D

Dimis

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#19
Their is a lot of difference between the high performance polymers out there (some a lot more rigid than others). I only really have experience in Pekkton myself, done a few hybrids with this stuff. I used the BDT Technique on these particular hybrids. The Pekkton did have some give/flexibility, which was great (because I thought heck yeah, it'll act like a PDL when being used with implants). After a few under my belt, I realized pretty quick that you have to have the vertical thickness there to use. Without using a metal substructure (which you can use with Pekkton),I feel a lot better about these type of appliances when you have the proper vertical dimension (15 to 16mm) to work with. The zirconia is so technique sensitive, you must have a rock solid protocol in place, good thing about that stuff...is that once you get that down, the high performance polymers will be nothing for you. As for metal, it's my fail safe, if I can't use others, I always sleep well using metal. Personally, I think once these high performance polymers (Pekkton, Pekk, BioHPP, Trilor) become FDA cleared for permanent use for implant abutments then it will take off here in the states. Think about it, we will be able to mill our own abutments, slap a FDA titanium interface on it and you're making your own abutments for the most part in-house...those polymers mill just like PMMA. For single implants this would be a game changer for little tikes like myself. So far, most polymers out there in the U.S. are only FDA cleared for 'temporary' use...which means it has to be removed at least once a year (which you would do anyways with a hybrid). Trilor-Bioloren recently did get it's FDA clearance for 'permanent' use but I haven't had a chance to use this material yet (love to know if any of you have?). However, the FDA clearance is always changing on these polymers so if you have some new intel...please do share.

Here is a link to some of the clinical side of the things that some of us might not see. Click Here
Thanks lab guy for the info
So from your personal experience peek or other polymers are ok to use only if there is sufficient space more than 15mm.do you have personal cases that are in mouth for years? if yes did you saw any problems when the patients came back for check up?


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TheLabGuy

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Thanks lab guy for the info
So from your personal experience peek or other polymers are ok to use only if there is sufficient space more than 15mm.do you have personal cases that are in mouth for years? if yes did you saw any problems when the patients came back for check up?


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Good questions...I'm only about 2.5 years out that I have in the mouth. The only issue I saw was the pink composite needed the high shine (took two seconds) put back on it. Also, that I concaved the tissue side too much...it wasn't horrible, but I could see where if the patient didn't do her yearly recall it would pose a hygiene issue. However, if you have the proper vertical room, you shouldn't have to concave the tissue side at all. The other ones I wasn't in the office during recall but I haven't heard anything bad either.
 
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