Implant Stent & PMMA Bridge

[k2 Ceramic Studio]

Got an implant case a bit ago and have just been sent some surgery pics so I thought I would share the case. Loads of pics but hope it's not too many. The doc wanted a stent to help with placement of three implants, We make the stents based on the information we get, so any cbvt data, x rays and ridge mapping, these are not surgical stents just a guide to help. He also wanted a post and a temp bridge.

Dear Peter,

Please find enclosed the most recent radiographs from XXXXXXXX

I have sent you some models yesterday. I also have some pre-op study models and photos that will be in the post on monday

This case is pretty complex, xxxxxxx has had some pretty poor dentistry, we have liased with the dental hospital and are basically redoing her whole mouth. The impressions I sent yesterday are with all the failed restorations removed on the upper arch and to try to make a surgical stent for the placement of implants in the UR4, UR2 and UL3. Also we would like a temporary porcelain bridge to restore the UR5-UL4 while the implants integrate.

We removed the grossly carious roots UR3, UR2 and UL3 about 6 months ago now and have been waiting for the sockets to heal. She is due for more radiographs in about 2 weeks to confirm healing of the sockets. If you need further impressions or info we can collect it then.
We removed all the upper restorations on friday, and there was gross caries under all the crowns. You will probably be able to see the cores need some work, but we didn't expect such a poor condition under everything.

The plan as it stands is;

1) new radiographs to confirm healed sockets and decide implant dimensions
2) xla UR4 and immediate placement of 2 part implant
2 part implant UR2 and also UL3
fit temp bridge UR5-UL4 and allow 3/12 for healing of implants
3) after integration of the implants (3/12) then impressions for;
- UR5 crown
- UR4-UR2 implant retained bridge
- UR1 post crown
- UL1 post crown
- UL2 crown
- UL3 implant retained crown
- UL4 crown with core build up.
4) fit upper arch
5) possible post crowns to restore the LR4,5 (we restored with composite for now, the hospital recommended post crowns to restore the bite.

I was considering placing healing collars immediately at the fit of the implants, would this interfere too much with the temp bridge and should I just place cover screws and then remove the bridge after healing and place the collars then? (I was hoping not to have to remove the temp bridge once it was on until we were ready to take impressions for the definitive work).

So..................

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Dear Peter,

Please find enclosed some photos from today's case. I will forward some more at the review appointments.

As a quick overview, the case has been pretty challenging.

The post core fit well and easily; the stent fit really well and the temp bridge fit really nicely and easily.

(All the work was done through Exocad, Pete)

 

[doug]

Nice

 

[k2 Ceramic Studio]

Nice

Thanks Doug

 

[Alistar]

Slick man. Very nice.

Sent from my DROID RAZR using Tapatalk 2

 

[DevonR]

Did you mill the temp bridge on a Vita temp puck? Did it mill the access holes for the implants alright?

Otherwise, looks really nice! Thanks for sharing!

 

[k2 Ceramic Studio]

Did you mill the temp bridge on a Vita temp puck? Did it mill the access holes for the implants alright?

Otherwise, looks really nice! Thanks for sharing!

Hi Devon, Milled it from a Bracon 20mm disk but told the system it was C Cast. We made it so that the access hole opening was only .3mm thick so very easy to open up.We designed this as a temp then once it was scanned in we saved/duplicated the file and then re scanned the model with the drill guides in place. Once the temp bridge was fully designed and saved we then took the bridge file and renamed it as or insitue file for the stent. So once we opened up our stent file we had a copy of the temp bridge to work to so it was very fast to design.

 

[Labwa]

awesome mate.

 

[k2 Ceramic Studio]

awesome mate.

Thanks Labwa, really kind of you

 

[rkm rdt]

I am so impressed with the level of communication that you have with your dr.
Your skills are obvious and advanced but I think besides the degree of difficulty,the detailed instuctions are what stands out to me as an indication of how the lab/dentist relationship is supposed to be.

 

[disturbed]

Very pressed. Nice work, And i don't say that often here.

 

[CoolHandLuke]

the router here has blocked Photobucket so i'll have to get a look at this when i get home tonight.

edited: wow, cool! never seen anything like it.

 

[French Cadman]

Very interesting Pete !

Merci !

 

[Mark Jackson]

Tissue sounding? How were you able to determine bone density with such decay? All this was done off a pano?

 

[k2 Ceramic Studio]

Tissue sounding? How were you able to determine bone density with such decay? All this was done off a pano?

The stents we make are to help the surgeon with placement, they are NOT surgical stents, we have so many jobs come to us were the implant is so badly placed and not because of a lack of bone but a lack of visualising where the teeth should be. Our stents help to take a lot of the guess work out of placement, if only to act as a bleed spot and the rest is down to the surgeon. Guided stents are fantastic and in an ideal world every patient would have one but if they cant afford it then surly this type of help from a lab has got to be better than a surgeon saying "well lets just stick it there it looks an OK spot" you are lucky if its even over a tooth site never mind what type of angle it can come out at. We will work with what ever information we are given. CBVT, PANO, x ray stent,We get a lot of CBVT data with a report and breakdown from an implant specialist as to ideal depth, bone density( a digital guess as you only know once you are in there) and best angulation, we work with our surgeons and reference this data, if they want to use one of our stents then they can if they feel it is not right then they do it free hand. like I said it is only an aid and will never replace the guided surgery that you have heavily invested in.
Last year I attended a 5 day intensive course with lectures and hands on placements,We had to asses every case using opg info, models, ridge mapping and cbvt data, I was the only tech among 9 surgeons from around the world, we had to work as a group and place 80+ implants in the 5 days as well as constant lectures.I am only the second tech in the UK to do this and gained a certificate certified by Royal College of Surgeons, Edinburgh, I have worked with implants from the age of 18 and I attend implant pickups and placements on a regular basis.

Many Thanks Pete

Sorry I forgot to mention that the surgeon liaised with the head implantologist who undertakes all training for the implant company, regarding this case before it came to me.

 

[Mark Jackson]

Thanks for the clarification Pete. We still do some tissue sounding guides occasionally. I was just curious what other reference materials you were given. Thanks.

BTW, Bone density values are very accurate when measured with CBCT.

 

[k2 Ceramic Studio]

Thanks for the clarification Pete. We still do some tissue sounding guides occasionally. I was just curious what other reference materials you were given. Thanks.

BTW, Bone density values are very accurate when measured with CBCT.

I have always been told that Mark but we were told on the course that it was a digital calculation and not an absolute, We were told that you must always proceed with caution just in case of an error.

 

[Mark Jackson]

I have always been told that Mark but we were told on the course that it was a digital calculation and not an absolute, We were told that you must always proceed with caution just in case of an error.

Of course you are right, especially when viewing greyscale images with regular imaging software. Advanced HU algorithms have improved greatly in the past few years with programs such as Simplant. The quality of the scanner makes a difference too. I have had patients scanned on a Sirona machine, showing 3-400 HU at the site, and close to 800 on our Illuma.

 

[k2 Ceramic Studio]

Of course you are right, especially when viewing greyscale images with regular imaging software. Advanced HU algorithms have improved greatly in the past few years with programs such as Simplant. The quality of the scanner makes a difference too. I have had patients scanned on a Sirona machine, showing 3-400 HU at the site, and close to 800 on our Illuma.

Wow! so the Illuma can give twice as much definition as the the Sirona, really interesting stuff. Think I will ask our guys what systems they are sending patients to, as like you have pointed out it can make a massive difference. Thanks for the info Mark.

 

[Mark Jackson]

Wow! so the Illuma can give twice as much definition as the the Sirona, really interesting stuff. Think I will ask our guys what systems they are sending patients to, as like you have pointed out it can make a massive difference. Thanks for the info Mark.

I'm not saying ours has twice the resolution, I'm saying the machine being used, the setting, the way the patient is positioned, all of these things can make a difference, and I've seen two different readings for the same patient from the same scanner, so in a way, your original statement about certain variables is true. The CBCT scanner however AS A RULE can discern differences in material density's which is why we can strip away soft tissue sequentially, and see underlying structures.

We use calibration phantoms to calibrate weekly, and HU is just a comparison with water density, and going up from there. It's the baseline. It's still without a doubt more reliable than any other method....even manual manipulation.