not too strong you know how the floor thank you very much tabs pleasure to be here again with you for this webinar hosted by micro devil today we want to deal with prosthetic aspects of all four cases and we want to present both the digital workflow and the traditional workflow first of all let's explore exactly what we mean by it all on for type of case in this scenario for implants typically possibly more but usually for implants replaced in the maxilla or the mandible often with little-to-no grafting the two anterior implants are placed in the traditional vertical positions but the two posterior implants are placed in a tilted or a posterior lis angulated position to create a trust form for the final appliance teeth may be extracted prior to this and then the implants are placed once the implants are in position then we will have these abutments connected into the implants these are called multi-unit abutments that allow us to build our appliances on these abutments the abutments are angled depending on the angulation of the implants and typically the posterior implants being more tilted require more angulation for the multi-unit abutments what we're doing there is basically paralleling up the path of insertion for our appliances everything that we build from that point again will be connected to these multi-unit abutments what we viewing here are titanium cylinders and these are connected with additional screws into the multi-unit abutments the titanium cylinders will serve as connection options for our temporary appliance these will be connected or picked up in a premade denture appliance holes will become drilled into the denture exposing the titanium cylinders then once the denture is in position with the correct occlusion that's been checked then these titanium cylinders will be picked up with either cold cure or Auto polymerizing acrylic or like cured material but once again those titanium cylinders will then become part of this denture the denture will then be converted by a series of laboratory procedures so once the titanium cylinders are connected to the Tetra base then the denture itself will be reformed with the palatal area cut out the flanges cut down and through a quite a bit of laboratory work the denture will be converted to a temporary bolt down appliance that is then delivered to the patient the patient is able to walk out of the operatory with a bolt down stable anaesthetic appliance so I wanted to illustrate that sort of procedure with these animations first to give you a little flavor for the conversion to a temporary appliance now let's look at doing this clinically so here we have two dentures two immediate dentures if you will that have been we have constructed the patient will have all of the remaining maxillary and mandibular teeth removed and these dentures will then be fitted and converted to the bolt down temporary on four appliances you see some ball clasps that allow us to connect those dentures together into orally so that we can maintain the patient's vertical to me and occlusion it is important that the implants are going to be stable for us to be able to convert to a bolt down appliance so the implants will be torque tested to confirm that they are stable enough for us to do this procedure here we are at the time of surgery teeth have been removed and quite a bit alveolus in some cases will also be removed if we close up a little bit you see a replica of the maxillary denture in place here and you can also notice that this is the approximate amount of alveolar removal crystal removal that is being done to give us enough room to build the final all-on-four place appliance with a titanium bar as well as adequate thickness of acrylic to give it strength against breakage we're looking now at the upper and lower dentures which have been realigned with an impression material over the multi-unit abutments so you can see these access openings here are imprints of the multi-unit abutments the denture will now have holes cut through those areas to expose the titanium cylinders that will be connected to the multi-unit abundance so the upper and the lower dentures will have these holes drilled out here we have two holes cut in the maxillary and two holes in the mandibular to expose the anterior titanium cylinders in our procedures the anterior most cylinders are connected or picked up first and then we go back and pick up the posterior titanium cylinders here we have two titanium cylinders that have been connected into the multi-unit abutments as you can see the tissues have been sutured together and we're ready to do the pickup procedure with acrylic material again those temporary cylinders will be picked up with acrylic and the denture base here showing the mandibular option on the maxillary option we see a one of the holes cut very well and you see the titanium cylinder extruding through that d'être base at this point some auto preliminary Singh self cure acrylic has been mixed a monomer and powder mix to a fairly thin consistency placed into a mono jet syringe and that will then be injected by the surgical dentist in this case into the denture base and around the titanium cylinders you can also use a light cured material if you prefer that type of material whatever your your choice is for picking up the titanium cylinders before the denture is actually removed from the mouth then we also get a new bike registration at the proper vertical dimension because much of the remaining procedure will be done extra orally or indirectly in a laboratory procedure while the patient waits for us to convert the denture so bike registration material here as you see then the dentures are unscrewed titanium cylinders have been connected into the multi-unit abutments with their own screws by loosening and unscrewing those we've now removed the maxillary and the mandibular dentures in the laboratory we now have connected the analogs into the titanium cylinders these are analogs or replicas of the multi-unit abutments so at this point we now have in hand a new bike registration we have previously mounted the dentures with a face bowl on a semi adjustable articulator and we will now be doing all of our laboratory work with the mountings from that the previously mounted dentures we have now boxed the dentures with the multi-unit abutment analogs and titanium cylinders in place and now we'll pour casts in a fast setting stone to be able to give us new working cast or our conversion from the full dentures into the temporary all on Thor's the impression is also mixed our poured with a fascinating stone and slurry water to further accelerate the stone set so we'll get set stone in about 10 to 15 minutes we've now separated that impression and cast with the denture connected to it here we have the red circle around the maxillary cast and we will be able to remount that to the original mounting that we had because we have made a an occlusal index from the original mounting of the dentures so we will mount the upper cast to the occlusal index and then mount the lower cast to the upper with the bike registration that we've made in the mouth once that is all set we now have mounted casts and dentures in place ready for the conversion from the dentures into the temporary all-fours here the technician that's working with this is making a sill tag shim around the facial portion of all of the denture and that we'll use be used as stop as we realign the tissue side of the dentures so we've got our sill tech shims in place and it's time now to cut down the dentures so we'll cut off the posterior portion and quite a bit of the flange once that is all trimmed we have now reconnected the former dentures to the cast that we Accord and so you can see quite a bit of space from the tissue side of the of the denture to the newly formed Ridge after the alveolar reduction we will fill in that deficit with cold cure acrylic so with those dentures that have been cut down bolted into the new master cast if you will we're mixing up a new mix of self curing acrylic and then that will be injected underneath the remainder of the appliance and again using that silt axiom as a facial stop to hold the placement of the realign acrylic in place once we've gotten all of that injected underneath as well as added some tissue excuse me to tooth colored acrylic around some of the access openings this here where the cursor is moving shows a lot of the excess acrylic that has been used to line the tissue side of the temporary column for all of that including the cast will then be placed into a pressure pot at 35 30 psi into a pressure pot for about 10 minutes to accelerate the curing of the acrylic and also to give it a denser consistency we've now removed the cured acrylic and temporary on pores from the castes and at this point we will start trimming and contouring this excess material both lingual and facial to simulate the final temporary autumn force once we've cut down away the remainder of what is now the new temporary all-on-four is polished with a abrasive polisher and then standard pumice is used to finish the policy polishing process just as we would a full denture prior to returning these newly converted temporary all on floors to the mouth we will also have a mouth guard constructed so from day one once the patients start using a mouth guard for both arches during sleeping periods mouth guard was trimmed and polished as well in the conventional method and here we have the final polished tissue side of one of the temporary all on Ford's notice the smooth and convex surfaces that are important to allow us to minimize the amount of food collection or debris collection on the tissue side here we have the upper left maxillary converted temporary aalam for lower right the converted temporary mandibular all on for ready to return to the mouth they're placed in a disinfecting type of solution and you see the screws that allow us to bolt the temporary appliances into the multi-unit abutments in the mouth so this whole procedure constitutes about an hour and a half to two hours plus or minus while the patient is just awaiting having these returned here we see the maxillary and the mandibular temporary all on fours reconnected to the multi-unit abutments occlusion has been adjusted and the patient is ready to be dismissed one of the things I'd like to point out I do like to have a little bit of an over jet with very little if any overbite so I want to avoid connection with the anterior for teeth to avoid breakage of those teeth while the patients in they're temporary I do want to use linearized occlusion approach if possible and also to provide some customized exclusion when the patient moves in excursive movements so this is the way the patient goes home this was taken about a week after the surgical procedure and a few other views so what we typically can wind up with is a very aesthetic smile line good lip support and good occlusion one of the things that's also attractive about the all-on-four procedure is any items that we see that are not acceptable in the temporary allem for service very good references for us to change those items when we go into the final all-on-four of course these temporary on floors do not have a metal or a bar reinforcement so the patient is advised to stay on a very soft diet for at least two months or more and is strongly urged to use their mouth guard every night or every time during sleeping periods to minimize any damage to the temporary acrylic all-important so we've Illustrated the conversion process of the follow for now let's look at how we make the final appliances I want to illustrate two workflows here one on the left being the traditional workflow and the one on the right will illustrate it an expedited workflow also using digital technology but I want to illustrate the traditional workflow first with this case and this is the beginning condition prior to doing the all-on-four procedure for this patient patient was already a and I'm actually overdenture that was unacceptable and she had not been restored on the mandibular arch so as in as always after a thorough conversation with her options that being dentures over dentures or hybrids facially ultimately agreed or stated that she wanted to proceed with a maxillary and mandibular all-on-four format the black circles here indicating where she had fractured denture T out of her over denture previously she had these four implants in place by the time she came to our office he had already lost one of them and those implants were severely angulated so for to complete the treatment plan of a maxillary and mandibular all-on-four all the teeth were removed and those three remaining implants were removed we went through the same procedure we just illustrated to convert dentures to temporary all on floors including maxillary and mandibular mouth guards so the patient is in these temporary all on fours our provisional appliances for approximately four months and at the conclusion of that time the implants are torque tested and deemed ready to go through the procedures for the final all on for prosthetic appliance again we're going to illustrate a traditional workflow here with five appointments to go from an abutment level impression the multi-unit abutment level two delivery first of all the temporary all on Ford's are removed and we expose the multi-unit abutments so therefore we're going to make level impression this will be done by connecting long open open tray impression copings to the multi-unit abutments excuse me and as you see in the in the photo here those long pins and impression copings have also been strutted together with meta struts and then what you see here is Auto curing GC pattern resident connected around those of metal struts we will take make an open tray impression using light and heavy viscosity honeycomb fast said final poly select slots a material so with one assistant using retractors to open the filled up for me I'm injecting lightness cos of the honeycomb material if that's that around all of the impression copings and also getting that up underneath of the struts as much as possible those tractors will stay in place while I then insert my tray that has already had holes cut through it so that I can have the long pins extrude through the impression tray as soon as I get that in place you see the second assistant coming in and quickly cleaning away the trade material so that we can visualize all those long pins before the impression material is set the fresh material is allowed to go to full set and of course I said we should be able to visualize all of the pins to remove the impression for an elfin tray impression we have to unscrew all of him using the novela you Negril hand wrench but then reverting to my contract old wrench which is really essential in many of these types of cases for me to be able to get access to particularly the posterior areas but once we remove all of those long pen screws we can now remove the impression which has embedded in it all the open trade in question tokens and the struts we can then poor master cast into this impression either send that to your lab or pour it in your own lab today what you're looking at is an example of the strutted open tray impression copings but today I like to use light cured flowable composite because it's so much more user-friendly quicker and it actually distorts less than the cold cure acrylics that we use in the past so here we have our maxillary and mandibular impressions from which we pour our master casts so all that occurred at the first appointment and then the lab work to construct the master cast our next appointment will be involved in our records appointment to get our centric relation our insides of ledges ition and also to confirm the accuracy of our cast so at the second appointment I'm you're typically going to do the face bow and a jaw relation record and also try in an abj an acrylic verification jig the acrylic verification jig allows us to confirm the accuracy of our master cast which is very important since we're going to make a milled titanium bar eventually in the mouth the acrylic verification jig is placed with one screw on one end and we confirm by pushing down throughout the length of the acrylic jig or bar that there's no movement of that jig if we do that from one end to the other then reversed screw to the other side and confirm that there's no movement and we can confirm that there is that that we do have accurate master cast and we should be able to build our bar accurately as well for a passive fit of the titanium milled bar now many of you many of us will get our centric relation records with the traditional wax rimmed base plates and you may manipulate those base plates into position which I will do for the maxillary in order to get incisal edge positioning and lip support what you're looking at here is a gothic arch tracing and that allows me to get centric relation at the correct occlusal vertical dimension cursor here is showing the tip of an arrow or a gothic arch tracing and the tip of that arrow now isolated with this plate with a hole in it the tip of that arrow illustrate constitutes centric relation for that patient and at our next webinar which will be focusing on over dentures I will go into more detail about the use of the Gothic arch tracing how we do that and how we obtain centric relation at the correct vertical dimension in the lab we've now mounted our master casts with our records and we now have our maxillary and mandibular master cast illustrated here one item that is important at the surgical procedure theater is to determine that we will have at least 17 millimeters from the incisal edge position to the residual our newly-created alveolus if we have much less than that enter arch space it becomes very difficult to have an adequate thickness of acrylic for our denture base wrapped around our titanium bar I hope to be able to have time to show you an example of that later on moving on now at this point is this the laboratory will have set denture teeth and wax as we would for any type of denture construction and we will have that returned back to us we will try those setups in the mouth before we fabricate the titanium bar we want to make sure that all these items on the right occlusion etc are satisfied by us and the patient before we move on to construct the bar here we have an example to retract it occlusion once we've approved the setup then we can go and make our titanium bar now theoretically because you have vented the master cast with your acrylic verification jig perhaps we don't have to have a verification or a tri end of the bar but particularly in your early uses or early cases of all on floors I would strongly suggest that you have the barmaid and this tribe you have to make sure that it is a passive fit the correct fit not only my digital one screw test as we did with the adj but also with a radiograph one item of note to determine how far we can cantilever the bar posteriorly is the AP spread so if the distance between the anterior and posterior implants is measured we can cantilever the bar 1.5 times that distance so if the red arrow happens to be six millimeters of measurement we can cantilever the bar back to as much as nine millimeters here you also see radiographic confirmation with a panoramic x-ray of the bars before we go ahead and finish the case and you're also looking at Nobel bowel care speedy and active implants and combination once we've approved our setups then we've confirmed that our bars fit we can have the laboratory process the standard denture acrylic around the titanium we call it a wraparound procedure in addition new mouth guards were made and here we have the wraparound all on four hybrids ready for insertion and so what you're looking at here is conventional process to acrylic and denture teeth wrapped around the titanium bar insertion day of delivery and retracted view of the column force in occlusion now our second case is a little different we're still going to go to final all-on-four prosthetics after conversion of dentures into the temporary all fours but we're going to use quite a different with different procedure we're going to do what we call the expedited digital workflow and in this workflow we will be able to reduce the number of appointments from five to three essentially we're going to be combining the first two appointments from the traditional workflow our master impression and our records into one appointment this appointment will take longer for you to accomplish in your operatory and perhaps you will want to share that with or have some of that done with you with a lab technician we're also going to ultimately use fully milled acrylic so we're not actually going to have denture teeth anymore everything that you're going to look at in the final appliance is completely milled and I'll speak to that more as we go through it here we have the preoperative condition of the patient lots of where lots of cervical as well as interproximal caries patient has an extremely dry mouth due to medications as well as hepatitis C survive that problem and once again became able to move forward with addressing his dental condition so as I've stated previously we went through all the options for the patient extraction of teeth dentures over dentures or all four type hydrants all those red arrows that you're looking at indicate recurrent decay in and around existing crowns or existing restorations as well as we have decay in the incisal areas of all the maxillary and mandibular anterior teeth here we are preoperatively before teeth are removed and so as we've seen in the previous cases maxillary and mandibular teeth will all be removed for implants placed on each arch and the dentures that we will construct prior to extraction of the teeth will then be converted to the provisional or temporary all of fours so we've gone from the preoperative case to completion of the provisional all on fours a very nice pleasing look we've got very good lip support a good incisal edge position and good occlusion at a very comfortable occlusal vertical dimension and so in many of these cases when everything looks good or for the most part looks good with our Provisionals our task is simply to copy that those contours those the occlusion the buccal corridor and the lips aboard and our final appliance closer look at the Provisionals and smile as well as in retracted view and we also are able to confirm from the patient if the shade of the denture teeth themselves is acceptable or whether they would like for them to be darker lighter or have some arrangement changed in the setups so let's look at the first appointment for this digital expedited workflow I'm going to ask you to really focus with me for a minute because that first appointment is fairly laborious and time consuming so first of all the first requirement to be able to do this expediting technique is to confirm that the temporary all on Thor's and their titanium cylinders that are contained within them are fully seated because we're actually going to be making an open tray impression of the temporary all on Thor's and that's going to form our master caste as opposed to taking those out and putting in open tray impression copings with long pins the only thing we're going to change about the temporaries is we're going to substitute one by one on the retaining screws for each titanium cylinder and placed in a long impression pin that will allow that pen to extrude through our open tray impression tray again you're looking at noble speedy and active implants now at the first thing I will do at this first appointment is make two of four impressions ultimately I'll be making four impressions for this appointment what I've done here is to make standard impressions either alginate or VPS impressions of the existing temporary all on fours I haven't put in my open trade pins at this point I will take those impressions to the lab along with the face bow and a bike registration that I've made and mount the maxillary of for those two before those impressions and then once those impressions are set I will mount the maxillary cast using the face Bowl to a semi jet semi adjustable articulator and once that mounting stone is set using the bike registration that I've made I will mount the lower stone cast of the temporary all-on-four to the just recently mounted upper caste so I wind up with stone casts of the temporary all on fours at the correct vertical dimension that has been approved by me and the patient and I want then use that to cross Mount my next step of models while all of that is setting I will go back to the lab excuse me I will go back to the operatory and I will complete open tray impressions on both the maxillary and the mandibular temporary all on fours I'm going to show you this on the lab [ __ ] so to speak I'm going to ask you to imagine that the cast you're looking at is actually the mouth because videoing this impression is somewhat difficult and laborious so I will illustrate this on the lab page once again if you envision that the cast is the mouth we've now substituted long pins into the titanium cylinders I've cut holes through my impression tray and then I will make a dual and viscosity impression we will put heavy or rigid DPS material once again this is Hana come from dmg we'll put that into the impression tray and then first in the mouth I will inject like viscosity all around the temporary all on for being very conscientious to try to get that impression material squirted or injected up under the tissue side as much as possible because I want to pick up that area in my final impression once the like viscosity is in place the impression tray is inserted and as you saw in the previous impression very quickly we want to dig down through the impression material and expose or visualize the tips of those long compression pins once the impression is set we unscrew the long pins and remove the impression from the mouth and we will have picked up in the impression patients temporary all-on-four we have already know face boat and a bike registration as well to allow us to mount all of this on our semi adjustable articulator now either I in this case I will do this or you could hire a laboratory technician to come in and do this part of the lab procedure I won't connect multi unit analogs or replicas to the titanium cylinders in preparation for pouring the master cast I'll lubricate this impression material and first I will inject soft tissue material all around these analogs and let that set not only takes a few minutes and then I will pour impression material dye stone over that well all of this is going on the technician will be basically alone with under supervision in the operatory you want to make sure that you place these white healing caps onto these multi unit abutments because the patient will be in the operatory with no temporary but in place for at least an hour perhaps more and if you don't put those white caps in place the tissue will collapse over those multi unit abutments and it will greatly impede your ability to reseat the temporary all for now with my previously mounted models once my soft tissue and stone cast has said I will then remove the upper stone cast from the articulator with the bike registration I will mount the new maxillary master cast with the temporary all-on-four in place once that mounting stone is set I will mount the mandibular master cast with the temporary all-on-four to the newly mounted maxillary cast with a temporary om4 and I wind up with both temporary all on floors mounted at the patients correct vertical dimension dr. strong dr. strong can you hear me dr. strong can you pause please your mic I believe is muted ok yes sorry can you repeat that one more time my starting from about a minute ago sure sorry about that okay thank you this point now can you hear me yes okay thank you sorry about that so I'm reverting back to a previous point I hope I'm picking up where I left off so I'm one by one I have I'll come back one more slide I will take the maxillary stone cast off put on the newly poured and set master cast with the temporary on foreign place and mount that against the stone cast of the lower once that is set I will mount the mandibular master cast to the just now mounted maxillary cast and I'll lined up with the two temporary all on Ford's mounted on the semi adjustable articulator at the approved vertical dimension at this point we can remove the temporary all on floors and go back to the operatory and reinsert those back into the mouth as I previously mentioned you will need to place white healing caps on those multi-unit abutments while all of your lab work is completed to keep the gingival tissue from collapsing over the multi-unit abutments so you're looking at the master cast soft tissue and die stone material now with the temporary all on fours removed and placed back in the mouth and here we have the mounting of the maxillary cast showing the inter arch space available for us to build our final appliances and generally speaking we want at least 17 millimeters per arch from the incisal edge position to the residual and as measured here you can see we've got just about that about thirty four millimeters of inter art space for the double jaw case now at this point the patient goes home with their temporary all on fours back in place a lot of lab work goes on at this point in this particular case we won't be doing base plates and wax rims or denture teeth setups we'll send that to our lab partner who will scan our master casts and our bike registration and they will bring back to me online what we call a preview as I will illustrate the preview is a virtual set up on the computer I will approve that preview or make changes to it and once I have finalized and approved the preview I will get back what we call the hybrid Tryon which is a milled try and appliance we will not be trying and denture teeth in wax we will have a solid try and that we will be able to use at the second appointment so following all of that lab work scanning virtual set up and the milling of the Tryon we will have the HTI's the hybrid Trion's returned to us these will be substituted for the temporary all on fours and evaluated just as you would for everything that you do or a wax triad so here you see an all white solid milled trying we evaluate everything that we would normally do for dentures for example we look at midline buckle ves vestibule lip support and incisal edge position etc as well as phonetics and so we're looking in the lower left at the patient's beginning smile and more animated smile and we can evaluate how much actual pink acrylic will be exposed when we go into the final appliance another very nice feature of the solid triad is what we call a to test so in this paint in this case the patient actually was able to eat an apple or any other type of food that you would like to let them road-test so to speak so patient actually gets a preview for what it's going to be like with the final appliance in place generally speaking the final column for will extend at least one tooth farther posteriorly in the temporary all-on-four if we once we approved the triumph that is returned to the lab we'll usually get a new bike registration photos of that and then the lab goes back to work on the computer the lab scans the any adjustments to the hybrid try and scans the new bike registration if there is one and I will receive once again a new preview in order to evaluate the design for the final bar and the final setup here we're looking at the design on the computer from Novell Biocare of the bar design I want to pay a lot of attention to how much acrylic I think we'll be able to wrap both above and below the bar because thickness of the acrylic is an important aspect to preventing breakage in a different case we're looking at the virtual set up from evident the blue translucent material represents the bar and then you also see just the denture teeth where they fit in proximity to the bar keep in mind in this particular case we will not have individual denture teeth everything will be milled from a solid acrylic puck and here we have after approval of all the bar and setup if we have the fully milled maxillary and mandibular all-on-four hybrids just a moment about positions these three positions on the upper are excellent one here gives us a little concern about possible breakage of that pin area adjacent to that mesial portion of the tooth so we want to evaluate as much as possible where we can get our screw holes to come through to minimize the chances for breakage another nice thing that the evident technology allows us to do is to custom colorize the final denture base so this is a GC grandia type staining material that gives us a much more lifelike appearance to the denture base once again just to repeat you're not looking at denture teeth these are completely fully milled out so you're looking at one solid piece of acrylic from the incisal edge to the flange of the appliance and the patient with the completed maxillary and mandibular all-on-four some place a look at where we started before so all on four as literally a transformative appliance for patients who have failing dentition and it allows them to walk out even with their temporary with a greatly improved degree of stability and aesthetics we've also developed a storage system so we retain all of the temporary all fours as well as the hybrids in case we ever have to return to those now we're beginning to run out of time but I certainly want to get in this one case because in some cases you will line up with less than ideal inter arch space you'll wind up with less than that 17 millimeters so I want to look at this case the patient was a previous maxillary conventional denture where we're going to treatment plan our options once again and she agreed to a maxillary for however we wound up with far less than their ideal 17 millimeters of inter art space and so we're going to utilize a concept called the Montreal bar and you can look at that on the website for various from various entities including Nobel and others to illustrate what the Montreal bar the advantages of that feature here we are with the page we're going to pick up the patient with her temporary home for in place and she is now opposing an over denture but our focus right now is going to be on the final all on for procedure we're going to use the expedited technique once again so we've confirmed with our panoramic x-ray that the titanium cylinders in her temporary all-on-four are fully connected into the multi-unit abutments it's a critical part for successful completion of getting a master active inaccurate master cast patient did have three implants previously we had one more implant placed so that we could better stabilize her existing lower over denture patient is 92 years old and so for that and other reasons I elected to use an alginate material for my first appointment procedure so I made an open tray impression with alginate and unscrew those open trade impression pens and removed her temporary all and floors you see here connected the multi-unit replicas to the titanium cylinders and poured my soft tissue and stone cast and unfortunately we wind up with significantly minima deficient into art space about 11 millimeters versus 17 so we get this preview from avid ed showing where denture teeth can go we can rotate that preview and look at our inter art space here or how much room we have to build acrylic and titanium bar as you can see with the cursor it's very very limited I can put a grid on this preview and also very accurately determine how much space in millimeters we have each one of those little square boxes is one millimeter so we're going to utilize the Montreal bar because of this issue but first at our second appointment as part of the expedited procedure we get a milled Hybrid trying solid trying back and back to us after previewing an approval of the virtual setup so here we have the patient with her milled try and in place and we can adjust that solid trying as needed we did determine that we wanted to move the midline to millimeters to the patient right which we were able to do with the software involved in this without having to do another trying so that goes back to the lab and now we're ready to design the bar the next two or three slides are going to illustrate in gold what the Montreal bar does so instead of a wraparound concept the tissue side of the bar will actually contact the tissue or almost contact of whereas in the previous cases we would wrap up acrylic around the bar and we would have the tissue side to be all acrylic everything you see in gold there will be the Montreal bar in this case the bar is a t-shaped bar with a flange on the facial and the lingual and again the tissue side will be completely milled titanium this look will also illustrate how little acrylic thickness we would have we wrapped completely around the bar you blow that up this allows us to maximize the amount of acrylic that we can have over the titanium bar so the completed compliance here illustrates the tissue sign of the Montreal bar and all of its connections into the multi-unit abutments by designing that you also get a very nice emergence profile from the top of the multi-unit divided Mint which would be particularly important if you have a sub gently a position a multi-unit above radiograph of the completed Montreal bar within the appliance and also over denture connection and a couple of more shots here of the Montreal bar so if you wind up with an inadequate inter art space but strongly recommend that you explore the possibility with your lab of the Montreal bar other options could include going to a zirconia perhaps you can make the zirconia still strong and a kind of thinner dimension although there's a limit to that as well and another option is for you to open the vertical dimension of occlusion hours in some cases you can only do that so much owing without lining up with difficulties in comfort to the patient as well as aesthetics in this case we we're looking at the upper-left the patient's previous overdenture with three implants in place we put in 1/4 implant and connected that with the new RT X attachments from zest dental and we'll be illustrating those RT x locator attachments along with several other items in our next webinar which will focus on over dentures as well as centric relation and I'm going to zip to one more thing now do want to show the patient's final final view really a sweet patient 92 years old world war ii veteran and when they're actually one of the heroes of world war ii and we were thrilled and honored to be able to so provide this type of appliance successfully for the patient i do want to look at two more items before we take questions cleaning is often a question how do we clean underneath all of them floors and we rely heavily on an irrigation device we like the hydro floss which allows us to generate a pulsing but gentle stream of water plain water around the appliance and underneath the appliance in the intaglio to flush out if you will any food or debride it might be collected we have the patient's start using the hydro floss two weeks after the surgery so they are acquainted with this appliance while they're in their temporary appliance as well as the final and then just a preview for our next webinar you know one of our difficult things in prosthetics is gaining a good centric relation for the initials patient here we have a patient triad you know when a patient opens and then closes again my heart rate is typically going up and up and up is I'm hoping that they're able to go close back together in a good occlusion and that's where the gothy cards tracing I think really helps us out because we can accurately complete [Music] [Music] and so that pretty much fills up our time for the webinar we want to leave a little time for questions and answers so at this point I'll turn the program back to ten and entertain any questions that you may have all right thank you so much dr. strong and yes we will turn it now over to the Q&A portion of this program I will start with the first question is there a torque requirement for being able to provide the patient with a temporary what are the contraindications for a temporary yes that's a great question so at the time of surgery it's important that the implants themselves torque in to the manufacturers directions in the no bowel bowel care family the implant needs to be torqued at at minimum of 35 newton centimeters anything less than that would give us a reservation about movie Gone with the boat down temporary appliance now very seldom is that the case I have had that happen in a couple of instances and if the implants do not torque in then we have to just put the patient into the temporary denture until the implants are stable enough I would want to mention one thing I just want to on a different note I've shown you or illustrated the avidin technology for scanning and mailing and digital technology so this is one of your choices for digital scanning and milling you would want to consult with any of the modern dental laboratories including micro dental about any options you for engaging in digital scanning and milling technology I just want to get that in all right next question can you repeat your comments per cantilever design please sure that that cantilever requirement is called ap spread the anterior-posterior spread so if we simply measure from the anterior implants the two anterior vertical implants we may take a measurement from those implants to the posterior implants whatever that measurement is we can safely cantilever 1.5 times that measurement so if the measurement between the anterior to posterior implants is six millimeters we can cantilever the bar nine millimeters posteriorly all right next question what is your technique worked work testing the implants okay there's two aspects there at the time of surgery prior to placement of the multi-unit abutments in most cases we're going to torque test the implants themselves so the driver can be placed into the implant the torque wrench applied to it and confirm that we can apply the required 35 Newton centimeters of force generally speaking when we get to making the final four we will simply remove the temporary all of four and torque test the multi-unit abutments and I would caution you that in the Nobel family those screws are much smaller than the screws for the titanium cylinders so those crews torque in at 15 Newton centimeters so once again just confirm that we can put 15 Newton centimeters of force on those multi-unit abutments without any movement of the implants any sensation to the patient alright next question if a patient comes in with implants previously placed how do you deal with the liability of one or more of the of those implants failing after you have worked on the patient that's an excellent question and it will happen from time to time so first of all radiographically we're going to have to confirm that at least there appears to be good Accio integration in addition to a panoramic x-ray if you have the capability it would be strongly recommended that you get a CBC t done a cone beam CT done to confirm that there's good bone integration around the implant of course that can be a little misleading but at least you want to cover that base and then you certainly want to get down to the implant if there's some sort of temporary appliance or crown on the implant I would want to remove those and subject the implant to a new torque test and confirm that it is that it is integrated that it can absorb the required amount of force and then just another item that you would probably want to concern can make sure that you do is that you get a good consent form from the patient acknowledging that the implant was placed by another clinician and that you're not liable for any problems resulting from the surgery it's a tricky question and I think we need to in those types of instances we have to do everything we possibly can to minimize the amount of liability to yourself all right we will answer three more questions sorry our time is limited but it doesn't mention if you have any questions after the conclusion of this program you can always email dr. Strawn directly all right next one how long to schedule scheduled for your first restorative appointment in the expo didn't work flow the amount of time scheduled for that first appointment and I think the the condition is very acute there and realizing that's going to be a lengthy appointment so in in my hands that is at least a two hour appointment for some patients who you may have difficulty getting in and out you may want to schedule even more than that may be an all afternoon or all morning appointment but in general you want to get in and out in about two hours now recognizing that your lab work itself will probably constitute an hour or more by the time you've poured models allowed stone to set and mounting those models on your articulator as an alternative option you might find it more productive to hire a laboratory technician once you've removed the temporary all fours with the appropriate face bow and bike registrations and place the flight healing caps in place then you can have the laboratory technician take on all those procedures perhaps you could move on to another procedure that's productive in my hands I typically do all of that myself in my own laboratory all right next question how often do you remove the all-on-four for professional cleaning yeah another very good question so that the answer to that varies quite a bit from clinician to clinician or in various authorities I've certainly seen it recommended that the temperature that the final all enforce should be removed annually I typically do not do that because I wouldn't want to point out that it is a laborious procedure and time-consuming by the time you unscrew them for clean it evaluate it and certainly x-ray it and then get it back in place you probably going to pregnant spend at least an hour so it's difficult to make a fee that's commensurate with therefore I typically remove these only when there's evidence of some bone loss occurring or visually if we're able to see some stripping of the tissue if the patient notes quite a bit more food collection underneath the appliance that could indicate a problem or if there's any evidence of inflammation I certainly don't oppose removing the appliances whenever one suspects the need to do so and get under and clean it one final thing I'd like to know there's kind of there's pretty much what is called the 5:00 appointment rule so a screw can be safely removed and retort in up to five times perhaps not that many but no more than five times before the screw head itself is weakened and remember the multi-unit abutment screw Torx head only had 15 Newton centimeters and the cost of those screws is significant so if you're going to have to remove an appliance and replace screws the cost of that gets fairly large and you need to factor that into your feet all right well answer the last question I see that we do have many questions so unless our time is limited so our last question is do you ever have anterior teeth 8 & 9 break off from upper all-on-four how do you fix if this happens well breakage of acrylic is something that's part of your life if you're dealing with that I don't have experience with zirconium but that might be an option for you to consider if you're having a lot of that yes and with conventional acrylics I have certainly had a fracture of both denture acrylic base and denture teeth I've had far less than that once I have embraced digital milling technology so the fully milled acrylic is at least 8 times stronger 8 times breakage resistant than conventional acrylics that doesn't mean that even the milled acrylics can't break my inclusive scheme also in that anterior region is to not allow coupling of the anterior for teeth as I was taught previously I should do so I do not want those interior for teeth touching and centric relation and I would like to have no overbite if at all possible so when the patient moves anteriorly I want them to barely touch the incisal edges of a t9 with the lower incisors or not at all and then one final item is I would like to build the denture teeth to have a fairly good thickness from facial to lingual if you wind up having ground a lot of the lingual portion as well as the incisal edge portion to adjust occlusion even with any kind of acrylic you're going to be more subject to breakage there from the repair for that with conventional acrylics is you have to replace the entire denture tooth you might do that with milled acrylic might grind out the tooth and then bond in acrylic denture tooth or in some cases you can repair that with composite all right okay I like to squeeze one last question in what happens if one of the four implants fells three years later are there any guarantees warranties on the work rendered generally speaking as I understand it warranties are in about a year from most manufacturers beyond that there there may not be any and you would want to consult with whatever manufacturer of the implants as well as the laboratory about warranties and that's vary widely from lab to lab as far as the prosthetics what I generally see is the labs warranty items anywhere from one year to five years I don't think you're going to find anything greater than five years out there so you in our hands we typically fix most anything that happens within the first year of them beyond that there has to be some sort of prorated charge all right everyone we will do a hard stop here on the Q & A and I just want to say thank you everyone for attending my crudo dental C II webinar we look forward to your participation and our upcoming webinars and thank you dr. strong for your partnership partnership on this speaking engagement if you have any follow-up questions it feel free to reach out to dr. strong directly and today's webinar with dr. strong is part of a series of three total this being the second the third part will be next Friday May 15th at 11:00 a.m. PST is title new normal prosthetics for implant over dentures dr. strong would you like to briefly elaborate on this next course yes I will illustrate again traditional technique or denture construction and over denture construction versus the fully mill construction and a really nice expediting technique or your over denture construction using scanning and milling technology as well as I want to illustrate the method of technique for gaining centric relation at the correct vertical dimension using a gothic arch tracing device which actually is very simple and can be relied upon with a lot of accuracy and probably solve a lot of our problems and we may have had in the past and gaining an accurate century relation so I look forward to the next you