Implant Studio, Immediate Load Temp...

[Sarah Downs]

We got a messy one today, lads....

So here's the rundown on what we're trying to accomplish. We have a patient getting implants placed. She has a few teeth on her upper, which are going to be removed so that the arch will become completely edentulous. Like so:

The patient is having implants both in the posterior region and in the anterior region, the area where the teeth will be removed. I know that Implant Studio allows you to remove teeth from the model, will this be an acceptable way to plan the implants and surgical guide for the edentulous arch all at once, or would it be better to have two separate guides, one before and one after the surgeon removes the teeth?

The second, harder issue is that the doctor would ALSO like us to design a PMMA temp for immediate loading. What would be a workflow for designing this with all the correct implant positions and insertion angles? How do I even fit these for temporary abutments without the abutments already in place?

I know this is a lot to ask. If I could even just find someone who would be a good resource on this type of restoration and/or Implant Studio in general, I'd really appreciate the help.

 

[2thm8kr]

 

[2thm8kr]

Ms. Downs, I respect your tenacity to tackle problems and your mettle!!, but this is complex case that should be a team effort and not dumped in your lap to solve all the problems.
Certainly there are people here that have the knowledge and experience to help and it's cool that you thought to come here and ask, however this isn't something that should be taken lightly. There are a multitude of variables to consider. The patient's best interest is a stake, keep that in mind above all else.

 

[Sarah Downs]

The patient's best interest is a stake, keep that in mind above all else.

Trust me, I have the patient's best interests at heart... but very little is in my power right now. I'm being asked to become an expert overnight for a very complicated process.

I'd love to be the person to say that this is too much to dump on me, but my boss is the type to just say 'yes, we can do that' to the doctors, and then tell me to figure it out so we don't look stupid. I don't really get to decide. Nor do I really have the latitude to say, 'this is too much to put on me, we're gonna have to figure something else out.'

Sorry, I'm not trying to dump my problems. I just don't know where to even start (aside from job-searching for another lab )

I'm not doing the actual restoration, mind you. I just need to know the steps so I can lead the designers in the right direction.

 

[2thm8kr]

Trust me, I have the patient's best interests at heart... but very little is in my power right now. I'm being asked to become an expert overnight for a very complicated process.

I'd love to be the person to say that this is too much to dump on me, but my boss is the type to just say 'yes, we can do that' to the doctors, and then tell me to figure it out so we don't look stupid. I don't really get to decide. Nor do I really have the latitude to say, 'this is too much to put on me, we're gonna have to figure something else out.'

Sorry, I'm not trying to dump my problems. I just don't know where to even start (aside from job-searching for another lab )

I'm not doing the actual restoration, mind you. I just need to know the steps so I can lead the designers in the right direction.

I have no gripe with you, but your boss is a dumb arse!! If he as a problem with that he can pm me via your mail and i will give a phone number where he/she can tell me what they really think about me.

 

[Sarah Downs]

You fight for my honor, good sir!

as much as I'd love to see that go down im more worried about keeping my job atm lol

 

[2thm8kr]

You fight for my honor, good sir!

as much as I'd love to see that go down im more worried about keeping my job atm lol

Understood. We all need to eat.

 

[CoolHandLuke]

I'm not doing the actual restoration

see thats kinda the problem.

if you arent making the restorations, you don't quite get the feedback about problems in the design and lessons for next time.

whats asked of you is not feasable. maybe that job shopping wouldn't be too far fetched.

this is problemsatic because all of the design software that is out there will allow you to overcome typical problems in bad ways. for example the Partials module will let you design a partial BEYOND the 20-30 degrees maximum off the Z axis, that would let the partial nest in a block; this means when the frame is made there will need to be hand trimming because undercuts presented themselves in inopportune areas.

just one example.

now, some of the things you are wading into, are patented processes by people like Nobel. these patents are the reason it may seem like adding these functions to implant studio should have been a no-brainer; its more complex than it should be because its not legal to make it simpler.

you will also need a level of familiarity with bone based, and flapless surgery in order to ensure you understand the prescription. however let me give you a quick tip.

if you are NOT opening the bite up with new vertical dimension then maintaining the current bite is super important, so two-staging the guide will be very important.

for this case you'd be designing a 3 piece lego-style guide. piece 1 will cover the teeth, and include a connector to piece 2, piece 2 will be an implant guide that will connect to piece 1 for the posteriors then this piece should stay in place and support the bite while you remove piece 1 and remove the teeth. piece 3 should connect to piece 2 over that same connector and give you implant positions for the anteriors.

adding bone reduction at the same time is a bit of a nightmare.

if you ARE increasing vdo the case just got easier because the posterior piece 2 doesnt need to support the bite, so you can more or less make just two piece guide.

but yeah diving in with both feet is dangerous without training.

 

[Sarah Downs]

I really appreciate your well thought out posts, replies, and advice, CHL. I wish I understood them better, lol. But I understand them better and better every day.

That said, I think I get what you're saying about the vdo, and unfortunately, I'll have to find this information out from the Dr. He's given us very little info to work with. We don't even have a proper RX. Nobody asking me to do this research seems to understand how complicated it is. Talk about having the patients' best interests at heart. They expect us to do this case with nothing.

but yeah diving in with both feet is dangerous without training.

More like I got a rough push in from behind.

 

[2thm8kr]

unfortunately, I'll have to find this information out from the Dr. He's given us very little info to work with.

Get him to reply here or via pm and I'll be happy to give that jack ass a drubbing.

 

[JMN]

They expect us to do this case with nothing.

Situation Normal, All Fouled Up.

The part that's so unbelievably messed up is the guy who can't write a proper prescription went to years of school, supposedly, to learn about oral anatomy.
But then expects just anyone to put some holes in something for him to follow with drill bits into a living human without causing any issues (nerves and blood vessels are real jackass) and at the same time thinks lowly of the person doing stuff he can't imagine, teach or accomplish by himself.

Backhand'im with a fish. Tuna or swordfish ought to do it.

No offense intended with 'just anyone'

 

[CoolHandLuke]

They expect us to do this case with nothing

you can make a mint without this headache, don't be afraid to say no. capitalise on intelligently making cases because remember: even C's get degrees.

or C Y A. make Dr Doorknob sign indemnification clause. don't let your "first case oopsie" be your last.

 

[kcdt]

We got a messy one today, lads....

So here's the rundown on what we're trying to accomplish. We have a patient getting implants placed. She has a few teeth on her upper, which are going to be removed so that the arch will become completely edentulous. Like so:
View attachment 30089
The patient is having implants both in the posterior region and in the anterior region, the area where the teeth will be removed. I know that Implant Studio allows you to remove teeth from the model, will this be an acceptable way to plan the implants and surgical guide for the edentulous arch all at once, or would it be better to have two separate guides, one before and one after the surgeon removes the teeth?

The second, harder issue is that the doctor would ALSO like us to design a PMMA temp for immediate loading. What would be a workflow for designing this with all the correct implant positions and insertion angles? How do I even fit these for temporary abutments without the abutments already in place?

I know this is a lot to ask. If I could even just find someone who would be a good resource on this type of restoration and/or Implant Studio in general, I'd really appreciate the help.

First off. What is the proposed restoration? Placement for AO4 vs metal ceramic crowns vs vs bar over denture vs stud retained denture vs telescoping abutments.

Second, I wouldn't attempt this digitally.
How about an immediate denture, with clear duplicate to act as guide. Temporize/convert the immediate at surgery. Basically AO4 approach.

Otherwise you'e toast IMO

 

[Jack]

I would print the model.
Decided where the implants should go.
lly in the divine positions iow. canines and molars.
But first things first, what do you have for opposing teeth/model?

Duplicate model.

1. Articulate
2. Setup teeth after removing the teeth to be extracted.
3. Process denture.
Take a bite between denture and opposing.
4. After trimming denture duplicate it and pour clear acrylic denture.
Make a groove for placing implants from first molars, premolars down the middle then canines, laterals and centrals on the singular. I tried to download a photo but unsuccessful [emoji51].






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[slotboom.f]

Make immediate temporary denture no front buccal rim, let mother nature do her thing for 3-6 months, after 2 months rebase the denture, after 3-6 months but preferably longer if needed make a set-up with the desired outcome (again no buccal rims)
And do the reversed planning. And you can start after implants are placed with temp composites.and after few months do the finals. This way you and doc will have far better outcome and patient satisfaction. This patient will probably spend quite some money on this and for you (but more for your eager boss( actually employer since only dogs have bosses[emoji39])) it wil be hopefully some very nice natural artistic looking teeth with high patient satisfaction because best advertisement is done mouth to mouth i hope you and the doc make something beautifull of this case!


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[Affinity]

If this is where our industry is headed, the future looks pretty bright!
I’m sorry your boss puts you in a position like this but if you care to have any future in this industry find an owner that gives a chit and can actually teach YOU something. Who is going to plan these implants if not you? Shouldn’t they at least understand the workflow?
Perhaps the patient who’s doling out their life savings for a surgical procedure might not want an amateur asking the internet how to do it. Not to beat the dead horse but frankly it’s almost insulting that you would think a forum post could supplant decades of technical and clinical knowledge required to do a guided case like this. I appreciate your attitude, you actually do care to learn and do a good job so don’t take this wrong.

 

[CoolHandLuke]

If this is where our industry is headed, the future looks pretty bright!
I’m sorry your boss puts you in a position like this but if you care to have any future in this industry find an owner that gives a chit and can actually teach YOU something. Who is going to plan these implants if not you? Shouldn’t they at least understand the workflow?
Perhaps the patient who’s doling out their life savings for a surgical procedure might not want an amateur asking the internet how to do it. Not to beat the dead horse but frankly it’s almost insulting that you would think a forum post could supplant decades of technical and clinical knowledge required to do a guided case like this. I appreciate your attitude, you actually do care to learn and do a good job so don’t take this wrong.

agree it takes a team effort with at least one greyhair in the room. it is wrong that it was left to one person to literally start from scratch.

you can teach yourself most of the simple case work, singles, bridge, and if you have intuitive cognition maybe a full arch with enough practice, but guided surgery is asking a lot. frankly, its asking too much.

 

[Affinity]

Yes CHL, the greyhair! Its hard to get anywhere in this field on your own without the aforementioned 'drubbing' that you get from having someone knock you down a few pegs. I have definitely had my share.. In Switzerland I was told my work was 'huura schiess dreck' .. loosely.. 'whore 5hit dirt' by an old crusty lab owner I worked for.. and it made me better.

 

[JMN]

 

[CoolHandLuke]

i only mean that the team should comprise of at least one highly experienced assistant/denturist who is familiar with surgical techniques, to help as you learn what is good and what is not, in the aspects of designing something like this; there are certain things you should know before placing implants digitally, such as how to analyze bone quality in a scan, how to avoid bad bone, how to see and avoid whatever is left of the PDL after your bone reduction. its a complicated thing juggling this digitally.