Running Time: 75 min
In this presentation Dr Edmond Bedrossian follows up on his previous lecture ‘A systematic surgical and restorative plan for treatment of the Edentulous Patient with a Fixed Prosthesis’ (catalog #141-00). He will begin by highlighting the differences between the tooth-only defect patient, and the composite defect patient. He will step through 4 different cases, explaining each step that is necessary for a predictable outcome. Dr Bedrossian will discuss the interarch space as well as the indications for alveolaplasty: economic, technical, and esthetic. Release: 11/11/2014 | Expires: 11/11/2017
Release Date: December 13, 2014Subtitle:
Hi. My name is Ed Bedrossian, and I’m going to be speaking with you today on the topic of the edentulous maxilla, treatment planning using the graftless approach. This is a continuum from the earlier video that we did which is on gIDE On Demand series. We’re going to discuss the content of the systematic treatment planning, which was the subject of the first video. But today we’ll expand on it a little bit and show you four different cases and try to apply the systematic treatment planning approach to them. Well, one of the first things I would like to consider is this concept of, do you see the case? Just because we’re all looking at the same patient doesn’t necessarily mean we see the same situation. Hopefully by using the systematic treatment planning approach, when you see a patient with terminal dentition or you see a patient who already is edentulous, you can see the final prosthesis. You can see the final smile line. You can see this final tooth form. You can see where the implants are going to be going. And this is seeing things in your mind’s eye, so that at the time of final prosthesis or at time of surgery, there’s no surprises. So we’re going to be able to analyze the type of prosthesis that’s going to be made as a final prosthesis. We’re going to see or evaluate the transition line, which will then determine the aesthetics, all before we even touch the patient and begin. The edentulous patient has pretty specific needs. And if I can just summarize it into a couple of lines, it’s the fact that the vertical dimension of occlusion needs to be established and the AP tooth position needs to be established in this group of patients, especially if they’re edentulous both in the upper and lower. In order to get the facial support, the lip support, the nasolabial projection, the lower lip contours, and then all of these would then lead into phonetics, it’s important to evaluate preoperatively. And I think that is the part that holds most of us up, in being able to treatment plan these patients quickly. So hopefully, by reviewing this one slide, which we saw at the last video, we can then feel more comfortable in treatment planning these patients. As you see on the screen, the patient on your left and your patient on your right are both edentulous. But they’re completely different types of patients. And if we can start off by imagining a imaginary occlusal plane, you can see clearly the distance between the soft tissue to the occlusal plane on the left hand patient is very different than the distance from the soft tissue to the occlusal plane on the right hand side patient. So how do we describe this to each other? How do we communicate this to our colleagues? Whether you’re the surgeon, how do you communicate it to the [INAUDIBLE]? If you’re the [INAUDIBLE], how do you communicate this to the surgeon, and how does the [INAUDIBLE] and surgeon communicate this to the laboratory technician? Well, this is the content of the first video, the systematic treatment planning article that we wrote at our residency program. And I would like to very quickly highlight some of the components of this article and then apply it to the four patients that we have planned for you. So the first thing, before we can even get started, is to identify whether our patient has a composite defect or not. There are basically two types of patients, one where they’re missing their teeth only and one, the second type is the one who is missing their teeth, bone, and gum. So how can we quickly know this on the existing edentulous patient? If you duplicate their denture– and one assumption that’s made is the denture is in the proper vertical dimension of occlusion and the teeth are set in the proper AP and horizontal dimension. So that’s a good denture. We can’t take something that has a poor vertical dimension or improper tooth positioning and do this evaluation. So the assumption throughout this lecture is that the teeth position and the vertical dimension is correct. So as you see on this particular patient, the see-through denture allows you to evaluate the relationship of the cervical portion of the teeth to the soft issue. As you can see, the soft tissue is blanching. So this patient has no room between this cervical portion of the teeth and their soft tissue, which means they’re missing teeth only. This is somebody like me. I have no periodontal disease. And if you were to extract my teeth, I’ll be missing teeth only. And the only thing that I could have made for me is a PFM, or a ceramometal restoration. If you try to do an overdenture for me, or if you try to do a hybrid prosthesis for me, you would be opening my bite. So it’s very, very important to identify, is your patient tooth-only defect or not. So this is an example of a tooth-only defect. Now here is another patient, duplicated their denture. Go through the same exercise, look at the cervical portion of the teeth as it relates to the soft issue. Now look at the lines. The space between the red line and the yellow line, the green arrows, that is the defect in the gum and the bone. Now if you try to make a PFM restoration on this patient, they will have teeth that will look like a hamster, very long teeth and very inappropriate, especially if the smile line is high. So this kind of patient is missing tooth or teeth, soft and hard tissues. And the type of prosthesis they’re going to be receiving is going to have pink on it. How much pink? It all depends on how much bone and gum they’re missing. The more bone and gum they’re missing, the taller the pink will be. The less bone and gum they’re missing, the shorter the pink will be. Now, tooth, soft and hard tissue defect, that’s a mouthful. Hence the word composite defect. Composite defect is a term that I took from surgery, where we do composite reconstruction, which means you use bone, muscle and soft tissue, so the three different types of tissues. So a denture really is a composite reconstruction appliance. The white part replaces the teeth. The pink parts replaces the gum and the bone. The thicker the denture base, the more vertical resorption, the thicker the flange of the denture, more horizontal resorption. So we have to first identify, does our patient have a composite defect or not? Because once you do that, we can go to step number two. That’s what kind of a prosthesis are we going to make for this patient. A patient who’s missing teeth only, or a tooth-only defect patient can only get a ceramometal prosthesis. And that’s going to be very clear. And if you are trying to– just if you think of this concept from a business point of view, if the patient is ready to commit to the procedure in the surgeon’s office and their only question is, please tell me the restorative cost, how could a restorative doctor be able to give a restorative fee unless they know what kind of a prosthesis they’re making? So not only this is good patient care, giving them the prosthesis they need, but it’s also good management of business, because there’s no way that a patient could be given a fee unless we know what we’re going to be doing. Now, in contrast, here’s the composite defect patient, the patient who needs a hybrid prosthesis. Now hybrid prosthesis is a inappropriate term may not be too exaggerated. It’s not the right term to use. Because the proper term is FICD, fixed implant complete denture. But we all know what that means when we use the word “hybrid.” Basically, a hybrid prosthesis is a hybrid just like in gardening, hybrid between a fixed ceramometal type of framework. But the teeth that are on it are denture teeth. So they are called hybrids. It’s a hybrid of fixed and removable denture. And obviously, the pink and the white could be porcelain also. But acrylic is the most common material that’s used. Now on this patient, if you try to make [? it ?] with ceramometal, as we said earlier, they’re going to have extremely long teeth. And they’re going to look very unaesthetic. So the composite defect patient receives a fixed implant complete denture. So we have two types of patients, a tooth-only defect, a composite defect. We have only two times of prosthesis, a ceramometal or a hybrid or a FICD. Pretty simple, pretty straightforward. So the confusion in treatment planning this patient, I don’t really understand that if we go systematically and identify that there’s only two kinds of patients. And each one receives this specific type of prosthesis. Now to be fair, I will introduce a third type of a prosthesis, which is a variant of the FICD. It’s basically the metal framework of the FICD. But the acrylic teeth, the hybrid portion, the acrylic teeth, are separate. There’s a secondary casting, as you can see. And there is a locking mechanism that allows the secondary casting to be locked into the framework. And once it’s locked into the framework, it becomes one piece. Now it is really nice to make the right diagnosis. It is very nice to pick the right final prosthesis. But the case can be a failure if we haven’t looked at the transitional line. Step number one and two are quite academic– how much bone do we have, where is the gum, are we missing teeth, are we missing bone– and if we are, then we make this kind of a prosthesis. Number three is very practical. If the only thing the patient cares about, how does the prosthesis look, obviously a prosthesis that’s aesthetic or not is probably going to be functional. But the patient’s most important thing is how is it going to look. And you don’t want to find out that the transmission line is inappropriate or the smile line is unaesthetic after the fact, or after the final prosthesis is fabricated. So what are we really talking about when we’re talking about transitional line? Who are we talking about? Which patient? Because remember, there’s only two kinds of patients– tooth-only and composite defect. Well, the transition line being visible or not does not apply to the tooth-only defect patient. So we don’t really care. What do I mean by that? Here’s a patient who is missing their teeth. You’re visualizing the prosthesis, the PFM. Do you see the case? Do you see that the patient’s going to end up with a PFM? And when the implants are placed, are the implants matching up with the do you see the case-type of prosthesis that you had in you mind’s eye. And obviously here, the answer is yes. So if the transition line shows or not, which means if the patient smiles and you can see where the tooth enters the soft tissue, whether you can see that or not, is irrelevant. Because on a tooth-only defect, or a ceramometal prosthesis, the implant must be in the right place. And if they are in the right place, you will look good. If the implants are in a wrong place, the prosthesis will not look good. And whether the patient has a high smile or a low smile line, the case is not done correctly. So if a tooth-only defect done correctly, the smile line is irrelevant, because it should look good. Now the opposite is not true when you have a composite defect. You can do the best surgery for somebody who’s missing teeth, bone, and gum. You can make the most beautiful prosthesis that has pink and white on it. And you can match the pink of the acrylic or the porcelain to the patient’s soft tissue. But where the prosthesis ends and the soft tissue begins, there will always be a fine line. And the light will be transmitted. And you will always see the junction between the prosthesis and the soft tissue. So the transition line not being visible is critical in the hybrid patient or the FICD patient or the composite defect patient. So here’s a case. Patient is smiling. There’s a smile line. The transition line needs to be more apical. So if their lip is retracted, the transition line is apical to the dotted black smile line. In practice, there’s your patient’s smile line. Transition line needs to be apical. We do not want to see where the prosthesis ends and the soft tissue begins. Because if that happens, as you see here, the smile line is more apical than a transition line. The transition line is incisal or more coronal to the smile line. And if you see that, this is what will happen. When the patient smiles, you will see the transition line. You will see where the soft tissue starts and the prosthesis ends and the soft tissue starts and that junction will always be visible and will not be appropriate. So on this group of patients, it is a must to hide the transition line and not to have it visible. So we want to evaluate this preoperatively. And we want to take care of the cases where the transition line is hidden. Obviously, we’re OK with that. But the where the transition line or the soft tissue is evident before we even start the case, maybe an alveoplasty is indicated. And we’ll go through some cases where we actually show the thought process and treatment plan in this patient and why you would do an alveoplasty and how you would do it. Here’s one way. This patient is a terminal dentition patient. Obviously, she is going to lose all their teeth and she’ll become edentulated. Right from the get-go, we can see that the patient has a composite defect. They’re missing teeth, bone, and gum. The soft tissue is retracted. You can see the roots. So the patient is by definition missing their teeth, bone, and gum. Now the transition line is there. And the smile line is there. If we do not work with evaluating where the bone level is, which means where the implant platform is, which means where the junction between the final hybrid prosthesis and the soft tissue will be, if this patient smiles just a little bit larger, we are going to see a transition line. So it’s essential to take a look at the clinical maximum smiling picture– and hopefully the picture on the left hand side is this patient’s maximum smile– and let me tell you, it’s very difficult to get a patient, especially a female, younger, 30, 40, 50-year-old patient, to give you their biggest smile when they are not happy with their dentition. But you must get their confidence and have them give you a smile. And then you have to correlate the clinical smile line to the radiographic findings and try to determine where the alveoplasty will be in this group of patients. Here’s an interesting stent. And here’s an interesting thought process. The smile line stent, a variation of the bone reduction stent. In this particular case, a suck-down stent is made. And where this patient’s smile line is, it’s marked on the stent. This way during surgery, especially if the patient’s sedated, the surgeon can have a stent in the mouth, identify where the smile line is, as you see here in the white line, and then go two or three or whatever millimeters they feel appropriate, more apical in their alveoplasty to make sure that a transition line will be hidden. So where the smile line is here happens to coincide with where the transition line would be. So this would be an unaesthetic case unless an alveoplasty was done apical to where this white line is. So on this particular case, we would go ahead and mark the alveoplasty at the apex. Because you don’t see the apex in the clinical picture. Where the red dotted lines are in a clinical picture happens to correlate where the red dotted lines are on the panoramic cut that you see up there. So that’s our wish list. That would be our transition line. The patient will be a composite defect. The final processes would be a hybrid. Very nice. Now can we actually deliver that? And on the lower right hand side of the screen, the cross-sectional cuts is showing the ability, can we actually duplicate. And as you see in the first cut, this red lines show the buccal and lingual place of the bone. Here is where the crest of the implant will be. So if we were to do an alveolectomy, where the red dotted line is at the apex of those teeth, we’ll be able to place our implants and at the desired level and be able to surgically achieve what the prosthetic desires are, which is a hidden transition line and a base for a hybrid prosthesis. All of this has to be now communicated with a lab. And we take all this information and we go ahead and we draw it on the model. And on many cases, I have a snapshot of this screen, as you see. I will print this out and along with the cast, give it to the laboratory, and make sure that everybody’s on the same page. The alveoplasty that is done is done correctly, so when we are doing the surgery, there’s no extra steps and extra modifications that need to be done intra-op. Now that brings us to the last step, which is what kind of surgery are we going to do. And that’s based on the presence of lack of zones. Zone I is cuspid to cuspid. Zone II is the bicuspid region. And zone III is the molar region. So whether the patient has bone in zone II and III, or they have minimal bone in zone II and III, that determines what kind of surgery we’re going to do. So in somebody who has zone I, II, and III, we do traditional axial implants. Put as many implants as you like in the vertical axial position. And you make your PFM or you make your hybrid or whatever the case might be. These kinds of cases are extremely rare, because most people have pneumatized sinuses or resorbed posterior maxilla. So a lot of our patients have zone I and II. And this is– I don’t really like the all-on-4. But it’s a trademarked term. But I call this a tilted implant. It’s tilted distally, and the only purpose of doing a tilted implant, or an all-on-4, is to reduce the cantilever. Get the biggest AP distribution between anterior implants and the posterior implants for the sake of reducing the cantilever off the final prosthesis. It’s not because it’s the vogue thing to do. It’s to go ahead and reduce the cantilever. And then if we have zone I, bone only, in the cuspid region, no bone in the bicuspid or the molar region, then the zygoma implant comes into play. And that’s how we treatment plan what kind of surgery we’re going to do. What’s interesting is if you took a cast of a zone I, II, and III patient, a cast of a zone I and II patient, and a cast of a patient with zone I who was treated with a zygoma implant, and without radiographs, you should not be able to tell what kind of procedure was done. Because the implant distribution and the location of the implants along the arch should be the same. And hopefully, that’s what the outcome of most of these cases are. So having gone through a review of the first video, like I was saying earlier, let’s go ahead now and apply all of this on a clinical patient. Here’s a patient with relatively large pneumatized sinuses. But as you tell, or as you can see, they have an all-on-4 treatment plan. And as you can see from the Panorex, it’s a PFM. It’s very interesting, right? Don’t judge a book by the cover. Even though this patient looks like they have very large sinuses, the clinical– and they look like they’re composite defect– the clinical presentation and the radiographic presentation have to be amalgamated with each other so you can take a look and figure out what’s going on. He just did not look like a composite defect patient when I saw him. So a very, very quick test to see if he’s a composite defect patient or a tooth-only defect patient is to have a transitional or a diagnostic wax-up. He’s obviously edentulous. So we had a denture made so that the teeth could be held onto something, and cut the flange from cuspid to cuspid. And let’s say if it was only a tooth-only defect, then the cervical portion of the teeth should be sitting on his gum. And lo and behold, the gum and the cervical portion of the teeth are touching each other. So this guy is a tooth-only defect patient. Very, very unusual and tricky presentation of a tooth-only defect. If he was treatment planned for a hybrid prosthesis and the implants were placed not so accurately– because remember, tooth-only defect edentulous patients probably the hardest surgery that can be done, because you have to have all the implants in perfect position. It’s basically multiple single teeth implants. Single tooth implant surgery is the easiest thing to do and the hardest thing to do. And now you got a fully edentulous patient with a PFM bridge, so that’s the most difficult case to do. So if you would plan this thing for a hybrid, you may have not been so accurate on your implant placement, because in a hybrid case, it doesn’t really matter where the implants are. They’re going to come out through the pink portion of the hybrid. And if that’s what you thought was going to happen over here and you made a hybrid for this prosthesis patient, you obviously would be opening up their bite, and then backtracking to make a PFM. And you may or may not have a good outcome. So very important to figure that out. So once we figured out that he is a tooth-only defect patient, then we know what kind of final prosthesis he’s going to get. He’s going to get a PFM. In his case, with a diagnostic wax-up that we had done, we asked him to smile. His transition line doesn’t show. Well, as we said earlier in this lecture, whether the transition line shows or does not show on a PFM, it doesn’t matter. The implants have to be in the perfect position. The PFM has to be in a perfect position. It just so happens in this guy it doesn’t show. But it’s irrelevant. He’s got a smile line. He’s got a low smile line. So the emergence profile of the teeth are not going to show, but still it’s a PFM case. They have to look nice, even though it’s up where the green line is and it’s more apical than where his smile line is. Available zones– he has zone I bone. He has zone II on either side. So he’s going to be an all-on-4 patient. So in our final treatment plan of this patient– remember, we’ve gone through the thought process and we haven’t even touched the patient yet. We know he’s a tooth-only defect patient. We know he’s going to get a ceramometal prosthesis. We know the transition line is hidden. Well, in this case, doesn’t really matter. And we know that he has zone I and II bone, so he’s going to get the tilted concept of the all-on-4 implant. So this is an interesting prosthesis. I immediate load everybody. So this is a concept of what I call a white denture. This is a term that I came up sitting down with my lab technician. I said to her, if you made me a conventional denture for his patient and then I went ahead and I placed the implants, next thing I’m going to do is I’m going to cut out all the pink. And then next thing that will happen is all the teeth will fall out, except the four that I attached to the implants. Why? Because the white teeth on a denture are individual teeth. They’re held together because the pink. So on a tooth-only defect patient, they’re not missing any pink. So once you cut out the pink from their denture, the teeth will fall out. So an immediate load for a PFM case requires a BioTemp type of bridge, where the teeth are all made out of one block. Now if you have a U-shaped BioTemp bridge for this patient, it will be very hard to get the [? yaw and ?] the occlusion correct. So we added a palate to it. And we added some tuberosity coverage and some posterior flanges to it so that the teeth will not rotate as you’re clinically connecting it to the implants after placement of the implants. So we, the lab technician and I, we spoke and we said, why don’t we just call this our little term, a white denture, which means all the teeth are made out of one model block. And therefore, after you cut it out, as shown on the black dotted lines, the teeth don’t fall out. So here is the surgery. We’ll go ahead and we expose the area. I do a lot of inter-op x-rays. And it’s obvious when you perforate into the sinus because you will perforate and you will feel the drop into the sinus. But it’s not so obvious if you are too far forward from the sinus. So you try to be as close to the red line in the sinus as possible. Why? To get the biggest AP distribution. To get the platform of your implant as far away from the anterior platform as possible, so you can reduce the cantilever. And if you are where you are here, which is the right place, then terrific. If you’re a lot more forward or mesial to this, then you will go back and we redo the drilling sequence so you’re further distal than the position you started. And if you’re happy with that, great. The implant goes in. And now the implant is engaging the bone that is in the anterior portion of the maxilla. So you’re engaging the solid bone that is sloping forward towards the anterior portion or the base of the nose. But the implant is now off-axis On these tilted cases, almost always– and I will say almost always, but let’s put a number on it. 95%, if not 97% percent of the time, the implant is going to receive a 30-degree abutment. In few cases where the sinus is not so pneumatized, the implant doesn’t have to be so tilted, and you might end up using a 17 degree. But as a rule of thumb, the posterior tilted implant on all-on-4 always receive 30 degree abutments. And as you can see with the 30 degree abutment photograph there, and that long tool is basically the handle. And what happens is the implant is going in in this trajectory. But the prosthetic screw’s in this trajectory. As you can see over here, the angulated portion of the implant has been corrected by the 30 degree abutment, making the trajectory of the prosthetic working platform in the same occlusal plane as what the anterior implants would be. Now we go to the anterior, two axial implants, do our 2 millimeter drills, take our photographs, our radiographs and see if we’re happy with that. And then we go to our number 14 or the opposite tilted. And again, make sure that we are immediately anterior to the maxillary sinus as we can to get, again, the biggest AP distribution. Once the posterior implants are in place, the 30 degree abutments are placed. They torque down to [? 15 ?] newtons, and the white caps are placed onto the abutments. As you can see from the picture here, the anterior implants have only temporary healing abutments. They don’t have the final abutments. And the reason is the choices for the anterior implants are either a straight multi-unit or 17 degree multi-unit. And which one you choose is based on what the laboratory technician’s needs would be in fabricating these teeth. And this is an extremely important step. And we’re going to go through it using some schematics because it will be easier to follow. But the point here is the implants are placed, the 30 degree abutments are placed on the posterior implants, torqued down. Anterior implants receive temporary healing abutments, and then the case is sutured. Now let’s make our patient, this particular patient, into a model. It will be easy to follow him. So here’s the same patient. Two implants in the back, two 30 degree abutments. The anterior implants are in place, and you’ve got two temporary healing abutments. You suture the case, and now you take the patient’s denture, put Blu-Mousse or Regisil, anything that you like, and then index. Put, in the back of the patient’s mouth– I do all my own conversions. And I do them all directly in the mouth. So I do direct conversions. And now with the Blu-Mousse, you can see that we have identified where the implants are going to be. We carefully drill through the Blu-Mousse, and drill all the way through the denture, picking up the position of the implants in the denture. Where the drill holes or where the implants are in the denture, that’s where the screw access hole is. So if you’re a surgeon, you’re going to call the position identified by the red arrow there. That’s the implant position. If you are a restorative person, you’re going to identify that same position as that’s my screw access hole. So that’s why I want you to think of this as the screw access hole. We’re done with the implants. Where the implants are now is going to determine where the screw access hole, the prosthesis is going to be. The distance from the cingulum of those anterior teeth to the anterior portion of those screw access holes where the red arrow is pointing, the more pink you have between the anterior portion of that hole and the cingulum of the tooth, the more stable that the teeth are going to be in that prosthesis. So if that distance is bigger and you have more pink there, the less chance you have of popping off teeth. But if that distance, as shown by the double headed black arrow, is tiny like you see there, the more chance you have of popping anterior teeth. And the reason is because the pink– the circumferential pink acrylic around those anterior teeth plus the framework underneath it is what keeps it together. So if you have the framework obviously, but you have minimal amount of acrylic, then you can pop off teeth. So if you were to place a multi-unit straight abutment, the relationship between the anterior portion of that hole and the white cingulum is pretty limited, as you can see there. Very minimal amount of pink. But if you were to use a 17 degree abutment, that’s where your subgingival access into the implant would be. But the prosthetic access screw hole is 17 degrees lingualized, if you will– moved to the lingual. And as you can see here, that’s where you still– your trajectory’s still going to be relatively anterior, but that’s subgingival. Once you screw the abutment into the implant, the prosthetic screw access hole is now moved 17 degrees distally or lingually, getting the distance between the screw access hole and the white portion of the teeth bigger, more pink, therefore more stable. Now what’s interesting is the surgeon is talking about laboratory techniques. And this is where I think I want to tie together the fact that a surgeon has to know the process business, has to know the lab’s business. The lab has to know the [? pross ?] and the surgery and the [? pross ?] has to know the surgery [? and pross ?] also. We don’t need to know how to do each other’s work, but we need to understand what each other needs so that they can do their work, and making the laboratory technician’s life easier by picking the 17 degree abutment, making the prosthodontist’s or the restorative doctor’s life easier by already putting on the 17 degree at time of surgery, because it’s much easier to do than afterwards, especially when now the patient is asleep. They’re already numb. These are just– makes for a more elegant procedure as opposed to having to make all these corrections later. Now the abutments are chosen, two anterior 17 degrees, two 30 degrees that are in the back. We put the titanium temporary abutments– sorry, titanium temporary cylinders onto the abutments. Make sure every time you do something, when you connect something to an implant, obviously it has to be verified by an x-ray. So everybody’s seeded. The abutments are seeded onto the implant and the titanium cylinders are seeded onto the abutments. Now we can take our white denture and convert into a hybrid prosthesis and remove the palate and everything else. So the patient leaves with a provisional fixed bridge. They came in with a denture, and they leave in three to four hours, with a fixed bridge. Did we eliminate Stage 2 surgery? Yes, we eliminate the Stage 2 surgery in this group of patients, because they’re immediately loaded, but we did not eliminate the appointment. So six months later for the maxilla, three months later for the mandible, the patient comes back. The prosthesis is removed. The abutment screws are torqued, or re-torqued, confirmed they’re still tight. Because now, the final impression’s going to be taken. And the torquing or the re-torquing of the abutment screws also confirms that the implants are immobile and we have osseointegration. And then when the final PFM or ceramometal prosthesis is made, you can see where the implants are. They have to be in the exactly correct position, because the PFM procedure. And it verifies what we already had planned to do in our white denture pre-operatively. So very interesting case where the patient looks like a composite defect, but it’s a tooth-only defect. And it underscores further the importance of having a systematic evaluation of every patient. Case number two. How do we take a patient with such horrifically jumbled up, [INAUDIBLE] dentition into a practical, interim prosthesis, or an immediate load prosthesis to a final hybrid prosthesis? Here’s the patient with a multitude of problems. This patient has various levels of bone loss. They have supereruption of the upper left quadrant without any bone loss. They have significant bone loss in the mandibles, more in number 29 area than anywhere else. They have a supereruption of the pre-maxilla, a anterior eruption, supereruption of the anterior mandible, a collapsed vertical dimension. There’s a lot going on over here. The sinuses are relatively large, and you got your inferior alveolar nerve, [? foramina. ?] When he smiles, you see his dentition, obviously a terminal dentition. You see some of the gum. When he’s relaxed, you can see the lower soft gingiva. You’re not supposed to see that. Well, you see that because he’s supererupted in his lower bone and teeth. So how do we evaluate this patient? Well, we know he’s a class two, division two malocclusion. We know he has supereruption both in mandibular anterior segment and the maxilla. He has multiple missing teeth. He has loss of vertical dimension. He has loss of facial height, secondary loss of vertical dimension. And he has loss of lip support, because of the collapsing back of his anterior maxillary teeth. So does he have– we still go through the same systematic review. Does he have a presence of composite defect, or is he a tooth-only defect? Well, we have supereruption right there. We have supereruption in the anterior mandible. We have supereruption in the posterior left maxilla. We have occlusal planes. That’s where the soft issue should be, but it is retracted. [? So ?] the smile line and the occlusal plane at three, four different levels. So we need to open this person up, because of the bone loss. The majority of his teeth have vertical bone loss. We are not going to grow this bone back up to make him a tooth-only defect. So he’s an in-between. He’s tooth-only in some segments, such as the upper left quadrant. He’s composite defect in some segments such as the lower right quadrant. So the more practical and predictable procedure is to make an in-between patient a composite defect, rather than trying to do a three-dimensional augmentation of the full maxillary mandibular arches. So in this particular case, we’re going to pick the alveoplasty that we can do on the x-ray and correlate that to the clinical smile line. And as you can see, the alveoplasty, the maximum alveoplasty we could do, because the black dotted lines are sitting at the base of the sinuses. We can’t go any more apical with our alveoplasty. So if that’s where the surgical limitation is, on the clinical picture you can see it is above his smile line. So this is going to end up being a relatively cosmetically acceptable case. This has to be communicated to the lab. We open up this vertical dimension. We’re going to do an alveoplasty, so we marked the alveoplasty lines. We’re going to move that supererupted maxillary posterior quadrant upwards. And we’re going to alveoplasty the entire anterior mandible, because they’re all supererupted. Even though we didn’t open the vertical of the patient, the mandibular anteriors [INAUDIBLE] is supererupted so much that it has to have a significant alveoplasty. class. So obviously, he’s a composite defect. And obviously he’s going to end up with upper lower hybrids. So we know that. So he’s going to end up with an FICD. And then the question now is, is this transition line going to be visible or not? We know it’s not going to be visible because where we decide to do the alveoplasty on the x-ray and we correlated that to the maximum smile photograph, his clinical photograph, and the black dotted line is the transition line. Therefore, it is hidden. Therefore, it will be an aesthetically acceptable outcome. So it’s very, very important to understand that you need– if you’re going to have only two things to evaluate the transition line, is you must have a Panorex to see where the surgical limitation of alveoplasty is going to be. And you must correlate that Panorex to the extreme smile photograph of the patient. So you need to have an extreme smile photograph and a Panorex. And then you can start to manipulate your transition line to see if it’s visible or not. The fourth part, what kind of surgery? Well, he has zone I bone, he has zone II bone. He does not have any zone III, especially after the alveoplasty, as you can see. So therefore he’s again a tilted implant concept. We’re going to go our alveoplasty, and we’re going to place our implants in this position in the maxilla. And we’re going to do an alveoplasty in the mandible. We are not going to augment 29 area. And we’re going to place our implants. So he’ll be an all-on-4 maxilla, and an all-on-4 mandible. So treatment plan of this patient is a composite defect patient who’s going to receive an FICD who will have alveoplasty done as part of treatment– therefore, the transition line will be hidden– with a all-on-4 maxillary and mandibular treatment plan. So a lot of thought went into this patient and we haven’t even started treating him. All of this has to be communicated to the laboratory. And this color photograph of the Panorex, his smile line and his intra-oral picture, is a snapshot, a print screens that I did off my computer and then printed as an 8 by 10 and was sent to the lab so the lab can understand. And we did the drawings on the mounted cast, so the lab can understand exactly where to put the occlusal plane and how much of an alveoplasty to do on the models. If you don’t tell the lab this information, there’s no way they’re going to figure this out. Then you get your maxillary denture and your mandibular denture. Now how can we make a surgical stent? Well obviously, you can have the laboratory make the surgical stent, or you can make your own. A Lang duplicator allows you– it’s basically two maxillary impression trays that on a hinge allows you to fill up one side with alginate, take your denture, and push it in there until you have at the top of the flange. Let it set for five minutes, and you’ve got set alginate. Fill the other side the tray. Fill the inside of the intaglio surface of the denture and now close it. And after another five minutes, you will have duplicated your denture. Wet alginate does not stick to set alginate. So now you gently remove the denture. You got yourself a nice impression of that patient’s denture. Now you can use Ortho acrylic. You can use any acrylic of your choice. It doesn’t really matter. And you pour it into your denture, you close the lid, and after about 40 minutes or 45 minutes, you open the Lang duplicator and you’ve got yourself a duplicated, clear denture. If you were to put this in a pressure pot, the more clear the denture will become, as opposed to hazy or milky, as you see here. You remove it, you cut out all the undercuts, and make sure there’s no undercuts, there’s no sharp edges to it. You Vaseline the intaglio surface and you back pour a model. So now you have a model of your patient, your proposed alveoplasty or your proposed surgery. This is what your patient’s going to look like after you took out the teeth, did an alveoplasty and about to start the implants. And then there is your denture. Now it fits into that model that you just made. Cut out this section of the denture or the duplicated denture. And mark the crest of the ridge. And these are where your implants are going to go. So now– the reason why I like to do this, and there are many times I will do the entire steps. It looks like a lot of steps, but each step takes maybe about one or two minutes to do with a 30 minute or 50 minute wait in between. So this is kind of busy work. And you can do this in between other things. Or if you have an extremely well-trained assistant, you can have them do it. Or if you want your lab to do it, but you have to teach them to do this. Why I like doing it, why I promote that you do it a lot is because you’re basically doing model surgery, or you’re doing a virtual surgery. By doing every one of these steps, you are thinking about where the bone is, where the implant is, where the teeth are, where the crest of the ridge is. So it’s a good exercise for the beginner surgeon to make all their own stents. Because then they’re responsible for the entire steps and you understand it much better. For his mandible, same thing. Put the mandible in the duplicator. Let the sides sit. Take wet– now you’ve got set alginate on that side. The wet alginate on the intaglio surface will not stick. And close the Lang duplicator. After five minutes, open it up. You got yourself a duplicated mandibular denture. Fill that up with Ortho acrylic or Trim or whatever you like, close it. And again, after 30 or 40 minutes, you have your duplicated mandibular denture, which you can take out and cut out all the flash and make sure all on the undercuts are gone. Vaseline it, and back pour. A duplicated denture will not fit an impression of the patient’s mouth. You have to retrofit or retropour a cast. And there you go. You got yourself a master cast of the alveoplasty on this patient. You got your duplicated denture. And now you’re going to cut out the lingual portion and some of the teeth. Because when you’re operating, you will not see above this teeth. You don’t want to cut the whole teeth, because you want to see where the cervical portion of the teeth are. But you want to cut some of the teeth, like maybe two or three millimeters. And what you got is an opportunity to basically do model surgery in your head with your surgical stent, ready to go for the procedure. Now we’re going into the surgery. We’re going in with this 8 by 10. This 8 by 10 is printed and is put on my old x-ray light box, which is never used anymore, because obviously you have everything digital. But it’s sitting there. It’s always– especially when the patients are sedated, especially when you have this kind of a situation– supereruptions, composite defects, tooth-only defects– you start second-guessing yourself. Am I supposed to do alveoplasty here? Am I supposed to do it over there? But when you have these pictures that you are so confident they are correct, when you have these pictures mounted on the wall, it doesn’t matter if your patient is asleep or not asleep, smiling or not smiling. You know exactly from the incisal edge to the yellow dotted lines how much to cut. If you start second-guessing yourself, there’s no reason to panic because you already have the data right there. We know we want to increase the patient’s vertical dimension. And we go ahead. And as I said, must have. That picture on the upper left corner is an 8 by 10 must-have. We take out the teeth and we do our alveoplasty based on the measurements that we have from our clinical evaluation. And you can see the nasopalatine. You don’t want to cut through it, obviously. And you do your two or three [INAUDIBLE] alveolectomy. Now I’m showing you this alveolectomy because they happened to come out nicely in one piece. But it’s exactly what we had planned to do. Not so thick, exactly as the plan was. On the mandible, well, it’s a pretty decent amount of alveoplasty, as you can see. We go ahead and do our alveolectomy in the anterior portion of mandible. And there’s a pretty significant portion that we remove. Now there is a sequence to this surgery. And the way I do it is following this sequence. Everything you saw is done clean. In other words, the instruments are sterile. But everything that you do in dentistry– taking out teeth, doing many other procedures, is not done sterilely. It’s done clean. It’s done with sterile instruments that come out of the autoclave and they’re touched by the assistants using regular gloves and they’re no longer sterile. They’re clean. So we take out the teeth. We do our alveoplasty clean. Because there might be fractured teeth, you want a certain kind of a periotome. If that doesn’t work, you want another periotome. If that doesn’t work, you want certain kind of a hand piece. You don’t want to have to sterilize your entire equipment and have it in sterile pouches sitting there. So if you do it clean, it’s like a regular extraction alveoplasty. Once everything is done, now everything is done sterilely. Patient is gowned up, and you’re gowned up, and the implant surgery must be done sterilely. And then once the implant surgery is done, we de-gown and go back to clean for the direct conversion of the prosthesis. So maybe I can put this into perspective. Why do we gown up and do implant surgery sterilely, if that was a question that was asked on a test? The reason is to protect the implant threads. It’s not for any other reason but to protect the implant threads so that we will have osseointegration occurring. So at this point, we go to the tilted implant. And following the same sequence, we make inter-op x-rays, make sure we are where we need to be. The implants are going in. The first picture is showing the implant going at 20 newton centimeters. And hopefully, you hear the beep and the implant torques out. You increase it to 40 newton centimeters. And hopefully, as you see on the far right picture, about one or two threads before the platform, the 40 newtons torques out. And now you take the hand instrument and you torque in the last millimeter or so, so you’re quite confident this implant is in with primary stability. Anterior implants– two axial implants, as you saw earlier. Same thing, going ahead. That’s 20 newtons. The middle picture is 40 newtons, and the picture on the right hand side is the last one or two millimeters that’ you’re hand-torquing in, being very confident that you have initial stability. Because initial stability and cross [INAUDIBLE] splinting is the two absolute dogmatic musts that are required for success of this immediate load cases. On the anterior ones, sometimes I will use the paralleling pin, the implant insertion tool in number eight to guide me for paralleling number nine. In the hybrid, is it necessary? No. But if you can do it, it’s good form, good surgical form. And we’ve got our two anterior implants in. Again, two healing abutments in the anterior, because we don’t know if we’re going to use 17 degree or straight multi-units. On the back, 30 degree. And as you can see in this radiograph, the 30 degree abutment has a distal hump. That distal hump make get caught on some of the bone. The implant is not going in straight. It’s going in at an angle. So the distal portion of the osteotomy has more bone than the mesial portion. And sometimes the hump of the 30 degree abutments will hang up. You’ll think it’s tight, but it’s not. So check with the x-ray. If it’s not [? seated ?] with a number 15 blade– nothing fancy, nothing rotary so you can ding the implant, just gently carve out the back of the bone. And you’ll be able to fully [? seat it. ?] Once it’s fully [? seated, ?] that’s when it’s torqued down to 50 newton centimeters. Implant number 14– same sequence. Again, as you can see, the abutment was not fully [? seated. ?] We removed it. We removed the interference, torqued that down, and it’s now fully seated. Anterior two implants are healing abutments. Posterior two implants are 30 degree. So we’re now ready to put the lower implants in. Same concept. So, two in the back, 30 degree, two in the front, healing abutments. And we have taken our patient from a [? dentate, ?] terminal dentition patient to an immediate load, fully edentulous patient probably in about four to five hours. The nasolabial angle, the lip support on this particular patient is quite nice. And let me use different schematics to kind of go through the same concept for conversion. Because again, I think that the surgeon’s ability to do direct conversion is one of the easiest ways to overcome the case acceptance in this patient, group of patients. Surgeons know what they’re doing. The restorative doctors are comfortable what they’re doing. It’s that interim, limbo state of the conversion is what’s making things– is the hang-up. And if the surgeon can directly convert the cases, it’s extremely easy to get these patients through the system. So here, the implants are in. 30 degrees in the back. Another way for you to determine whether you’re going to do 17 degree or straight in the anterior is to put your surgical stent. If you put your surgical stent and you see that the implants are butt up against the anterior teeth, you should consider 17 degree. If you put your surgical stent and you see that there’s actually space between the implant and the anterior teeth, then you can consider straight multi-units. You can consider still 17s, but you can certainly do a straight multi-unit there. So once you’ve done that, you put your abutments, you torque them down, suture the patient. Go ahead and do the Blu-Mousse, put it in the patient’s mouth directly. Identify the position of the implants. And then carefully drill through it, so now the holes through the denture correspond to the implant positions in the patient’s mouth. To remove the white caps off the multi-units, remember the white caps on the multi-unit abutments are there just to keep the form of the gum. Unscrew the cap, replace it with the temporary titanium cylinders. And then your denture with the hole should fit passively over those cylinders. Lute it– lute the cylinder through the denture. And now you’ve got all of them luted. You can do this all at one time, you can do one at a time, you can do two at a time. The rate limiting step on this direct conversion is this is the luting of the first implant, or the first titanium cylinder to the denture. Once that is luted, then the yaw, the occlusal plane, the midline, everything is going to be frozen. It’s going to be in the right position, hopefully. And then all the other steps, the 10 other steps, can be done extremely quickly. So it doesn’t really matter if you’re trying to do– having a difficulty. Don’t try to do all four at the same time. It’s one that’s important. If the patient is an easy patient, if your access to the patient is easy, and you have the time to do all four at one time, it’s just more efficient, but it’s not a must. And then you remove the prosthesis out of the mouth, cut off the excess titanium cylinders, cut off the palate and the flange, and you have yourself an all-on-4 or an all-on-6. Whether it’s a zygoma implant doesn’t really matter. All-on-4, it doesn’t really matter. So you take a patient from there, a pre-op to immediate load prosthesis. Six months later, you take off the prosthesis. You torque the abutments to make sure they’re fully [? seated ?]. And then the patient’s ready to go to the restorative dentist to have the final hybrids made. And there’s the final fixed implant completed denture. And there’s this patient’s smile line in relaxed and in smile. And there’s the final prosthesis. And if you compare the patient’s pre-op to the immediate load state to the final prosthesis, I think a tremendous amount of service has been offered to this patient by just making sure he’s got the proper vertical dimension of occlusion and proper AP tooth position, which essentially what we’ve done. Case number three. Here’s a lady who is missing her posterior maxillary teeth and has only the anterior [? sextant. ?] She does not like wearing her maxillary partial denture. She has a tongue thrusting disorder, if you will, or she has tardive dyskinesia, where she constantly bombards the anterior sextant of the maxilla with her tongue, therefore deforming the pre-maxilla over years. The fact that the teeth are so anteriorly deformed, her lip is anteriorly deformed, nasolabial angle is made more acute and she has developed a labial incompetence, so her lips don’t touch. She has, as you can see from the x-ray, zone I bone only. And if we were to take a look at her clinical findings, her diagnosis is she has lost the posterior support. She has primary periodontal disease. She grinds or clenches. Secondary occlusal trauma to a lot of the existing teeth. She has a little slide in her CR-MI position. She has tardive dyskinesia, which has led to labial incompetence and remodeling of her pre-maxilla. So in our planning, we decided to use NobelClinician here. What we did was, we said initially, if we were going to address her labial incompetence, then the support of the lip comes from the incisal anterior– the position of the anterior maxillary incisors. So we have to reposition the maxillary incisors. So to move her lip back, we have to move her crown back. To move her crown back, we have to move the implant back. So the implant cannot go in the trajectory of the extraction site, or where the red extraction site would be. It has to go into yellow trajectory that will allow the crown to be moved back and therefore fix her labial incompetence. So we would like to have that trajectory brought back into more of the yellow trajectory, which means instead of the implant going in the cingulum– because we try to do screw [? retain ?] in these cases, obviously– instead of the implant going in the cingulum, it’s actually going further back. Now that’s the restorative doctor’s wish list. Can we now do this? So one way to do this is using NobelClinician, where we go ahead and put an implant in the trajectory of the extraction site, as if there was no labial incompetence issues we were not going to do any alveoplasty. And then we went ahead and moved the implant into that yellow line, where we moved the further palatal and it’s going to take that new position so the crown can come back. As you can see, from the red to the yellow line, is a tremendous move distally of where the crown position would be. And we looked to see if the implant is still in the housing of the maxilla. And as you can see from here, these yellow zones are the safety zones built in the NobelClinician. So the palatal bone is beyond the yellow zone. And the buccal bone is also beyond the yellow zone. So we actually can do this, can fulfill the restorative doctor’s wish list, which is to move that implant so far back. And one other thing we can do is we can not only position the implant back, but if we were to put a 17 degree abutment on it, we could bring the screw access hole even further back. So we can double distalize the position of the anterior maxillary teeth by physically putting the impact further back and using a 17 degree abutment. We’ll go from there to here and then from there to there. So it makes us feel confident that we can do this. And that’s tooth number eight and that’s tooth number nine. And you can see the difference between the existing trajectory of the natural teeth and then they trajectory of the implants and where the final teeth would be. The blue line following the trajectory of the implant basically represents where the trajectory of the crowns will be. And that’s a tremendous difference from the existing trajectory. And if you want, we can use 17 degree multi-unit abutments to further bring back the position. On the posterior maxilla on this patient, she has no zone II or zone III bone, so she’s a zygoma patient. And in zygoma evaluations, very simple. The submental vertex view, as you see on the right side of the screen, the middle row is a lateral ceph of the left and the right side. And then the left side of the screen is the posterior anterior [? PAVO ?] of the maxilla. And with the PA lateral ceph and the submental vertex, you’ve got the three-dimensional view of this patient’s maxilla. This patient actually does not have a very– this patient’s zygoma. This patient does not really have a very large zygoma. So it’s not the most difficult case, but it’s not the easiest case either. And then if you like, you can go ahead and position your zygoma virtually on the clinician, just to kind of get a feel of where the implant’s going to be. And every zygoma implant receives a straight multi-unit abutment. So in this particular case, we obviously have a composite defect. We’re going to do an alveolectomy to move this patient back. She’s going to receive a hybrid prosthesis. The transition line will be hidden. She will have the zygoma concept as a surgical treatment plan, and we’re going to immediate load her. So, the surgery– we go ahead. We [? flap ?] the teeth. We remove the teeth, flap the soft tissue, and very carefully do the alveoplasty that we had planned in our NobelClinician. We’ll go ahead and remove the bone. And then, as you can see, the drill, the 2.0 drill, is in following the trajectory of the extraction site. This paralleling pin is the more palatal position, the desired position. And I just did this to show that this is not the position we want to go into. This is the position we want to use. So the paralleling pin represents the yellow line. The 2 mm drill represents the red line. And here’s a worm’s eye view of the same thing. The drill on the right hand side represents where the implant would have gone if we did not want to move the tooth position. That paralleling pin represents the more posterior position of our desired implant on our treatment planning. So there it is. The trajectory is pretty good. We match it with the number nine. And it is coming out through the cingulum, so we know we can make a screw retain. And the same concept as in the all-on-4. The only difference is the posterior implants, the zygoma implants, receive multi-unit abutments. The anterior implants still receive the healing abutments until we decide whether we’re going to do a 17 degree or straight. And in this particular case, we knew that we wanted to move these crowns back. So it’s a moot point to try to figure out where the pink is in relationship to the cingulum or the anterior teeth. We are just automatically going to put 17 degrees on it, because the more distal, the more lingual the screw access hole on this particular case is, the more easier it will be for our restorative doctor and our lab to move the position of these teeth back. So there they are. The two 17 degrees are in position. They’ve torqued down after the radiographs have confirmed that they’re [? seated ?], and then the case is converted. So two straight multi-units in the back and two 17 degrees in the front. And this is our virtual planning. This is our immediate post-op x-ray. Accomplish what we wanted to do. Here’s our zygoma, our virtual planning, and our actual zygoma on the other side. The anterior teeth, number eight and nine, in the position that we wanted to do. And one week post-op, patient is quite happy. The transition line is hidden. The prosthesis is stable. And six months later, same protocol. The prosthesis is removed, the abutments are torqued down, and the final steps for making the final prosthesis is followed. And there she is with her final prosthesis. And the tooth position has been moved back. The lip has elongated. The nasolabial angle had become more obtuse and more cosmetically appealing. So we went from there to here, and from there to there. And all of this following basic dental protocol– nothing fancy, nothing unusual. And there’s our outcome. The final case on this video what I want to share with you is another zygoma case. But I want to highlight the bone reduction guide, because you hear a lot about bone reduction guide. One thing I would like to make sure that the message is well-understood in this lecture, is this. If you hear in treatment of the edentulous maxilla, mount the case and look for 18 millimeters of interarch space, be extremely nervous about that information. Because if you mount every case and look for 18 millimeters of space, what are you doing? You’re making everybody a composite defect. And that’s not appropriate thing to do. You have to first identify the composite defect or a tooth-only defect. If they’re tooth-only defect, they’re going to get a PFM. If they’re composite defect, they’re going to get an FICD hybrid. Now, there are people who don’t have enough interarch space for all the components of the hybrid. But they are still a composite defect. So now, you say, OK. I have 12 millimeters of inter-art space. I would rather have 16 or 18. Now I’m going to do an alveoplasty. So do not treatment plan patients based on mounting of the casts and measuring the interarch space. Because if you have a patient who’s been edentulous, but only has 11 millimeters of interarch space, or 10 millimeters of interarch space, you’re going to do an eight millimeter alveoplasty on somebody who should be a PFM case. Did you tell the patient that you were going to do an 8 millimeter alveoplasty? Did you tell the patient that they could have a PFM? So be very, very cautious. So here’s a case– so this bone reduction guide is what you hear about, but remember, before you decide you need a bone reduction guide, you have to identify why you need it. And I’m going to go over the different reasons why. So here’s a patient with a failing dentition, periodontal involved, grossly carious. And her smile line and her transition line are going to be an issue. Her bone level is the slightly resorbed. But the edentulous crest– if you can imagine the edentulous crest, it will be wavy. It would not be straight. There’s some supereruption on the upper right side, making number 10 look like it’s been intruded. So this patient is not going to be a PFM case. This is going to be a hybrid or a FICD case. But you have to be very, very careful that transition line is in a position where it’s acceptable afterwards. So we go through the same exercise. Where’s the smile line, where’s the bone level, and where’s the transition line going to be? And then if the transition line’s going to be visible, we’ll go ahead and mark the red dotted line. We’re going to do an alveoplasty and take everything more apically into that position. So if that’s where your clinical transition line is going to be or bone level is going to be, based on your radiograph, then you’re clinically going to have a successful case. A print screen of that shot, because you want to know what’s going on at all times. You want to communicate this with the laboratory. You want to make sure everybody understands soft tissue line, the bone line. And then, based on that information after you’ve decided to do an alveolectomy for aesthetics in this particular patient, then you measure the height to see, do I have enough room now for components? So in her, we’re going to– is the vertical dimension of occlusion correct? Do we need to open her bite or not? Is the tooth position correct, the [? tooth ?] sides correct? Does the alveoplasty plan address the hardware space needed, the aesthetics, the transition line? And to answer all those questions, we need to understand where did this 18 millimeters come from? This is a photograph I took from my textbook and basically I’ve modified it, kind of going through the anatomy of the hybrid. The tooth position, vertical height of the tooth in most patients is about 10 millimeters. We need two millimeters of acrylic between the cervical portion of the tooth and the top of the framework. A four millimeter tall framework would be appreciated. It would be substantial enough. And then we need two millimeters of acrylic to wrap around it. So if you add these numbers up together, that’s where we come up with 18 millimeters. Now, indications for alveoplasty. You have a patient who comes in and is a tooth-only defect. Needs a ceramometal PFM. But the patient says, I can’t afford it. Remember, the surgical fee for a hybrid or a ceramometal PFM is the same– same number of implants. But the prosthetic fee doubles if it’s a ceramometal. So if the patient says, I cannot afford– let’s pick a number, $40,000 prosthesis– but I could afford a $20,000 prosthesis, then maybe after you have given them the information, informed consent, you can say, you know what? We can re-contour your bone a little bit and give you this. And you show them this prosthesis that has pink and white on it. We call it the hybrid. And therefore, the patient is now going to do the procedure. So in economic considerations, an economic alveoplasty after informed consent, I can understand. To take a tooth-only defect patient and convert them into a hybrid, but not look at every patient and measure for 18. Because then what you’re doing is you’re treating everybody as if they were hybrid. Now the other two reasons or indications for alveoplasty are patients who truly have enough space. They’re missing teeth, bone, and gum. They’re a composite defect patient. They are a hybrid patient. Be careful, because some of them have relatively– they don’t have quite enough space. So you may want to do a alveoplasty on somebody who is a composite defect and has a very low lip line, so there’s not a transition line issue. But the interarch space is only 14 millimeters. So if you had two or three more millimeters of alveoplasty, more space, your lab would have a better time. The framework would be four millimeters. You’ll have two millimeters of acrylic on intaglio, two millimeters on the crestal portion. So it would be a better, stronger prosthesis. So there’s a technical alveoplasty even the transition line aesthetic’s not an issue to obtain the space to do the work. And then the last one is aesthetic alveoplasty. The patient is a composite defect. The patient has 20 millimeters of interarch space. So they don’t need technical alveoplasty, have plenty of space. But for some reason, they have an extremely high smile line. So you’re going to do an alveoplasty making the interarch space 23 millimeters because of the smile line. So those are the three indications to hide the transition line. So how do we communicate this? As we talked earlier, we give the laboratory the print screen. And then we work with them to do the alveoplasty. They take out the teeth. That brings the patient to the yellow line. But we’re going to do an alveoplasty, so we ask them to take the– do an alveoplasty on a [? model to the ?] red line. And we end up with the final proposed case. From that, the denture is made with that position, the red dot showing the alveoplasty that we intend to do during surgery. And then that denture is duplicated into clear acrylic. And with the cut-out, we can see where the alveoplasty is going to be. So during surgery, we go ahead. We have our photographs and we have our bone reduction stent. We take out the teeth carefully. We use the bone reduction stent and we do our alveoplasty. And now you can confirm clinically that you have reduced the bone where you want it to be. Then anterior implants– the bone reduction splint can also act as your surgical stent, obviously. The case has been converted into an immediate load zygoma case, this particular case. She’s a pseudo-class III, so we jump into an edge to edge. And we try to get the horizontal corrected as much as possible. So in one week post-op, the patient goes from the left hand side pre-op to the right hand side post-op. And then, final prosthesis with a final hybrid or FICD made. We have a nasolabial angle that is supported beautifully by her hybrid prosthesis. So you do not need a flange to support the lip. The lip support comes from the AP position of the tooth. And we’ve taken the patient from pre-op to the intermediate stage to the final prosthesis. So by following the composite defect, or tooth-only defect concept, determining the final prosthesis, a tooth-only or a hybrid, looking at the transition length of the aesthetic outcome, and then looking at the zones of the maxilla to decide whether you’re going to do axial implants, tilted implants, or zygoma implants. [INAUDIBLE] the basis for treatment planning these patients. And the reason why I’m not including sinus lift is because of this protocol was written for immediate loading patients. So we don’t like to immediate load [? grafted ?] cases. And each one of these cases are done graftlessly and the patients are loaded whether it’s the maxilla or the mandible immediately following the surgery. I hope this is information that’s useful to you. And I can almost tell you with a high degree of confidence that if you were to follow this systematic protocol, I think you’ll find your cases with positive and very predictable outcomes. Thank you for your time, and I hope you enjoyed this video.