TrueTeeth Restorative Reference Guide

TrueTeeth Restorative Reference Guide

GENERAL RESTORATIVE CONSIDERATIONS FOR THE TRUETEETH PATIENT

CASE SELECTION (MOST IDEAL PATIENTS)

Potential patients for TRUETEETH will fall into two categories:

1)The dentate patient which includes the partially edentulous patient with compromised teeth or the “dentally exhausted” (this will be the bulk of the cases) or

2)Fully edentulous patient that cannot “cope and adapt” to a removable format.

PRE-OPERATIVE PLANNING/ PREPARATION

Proper planning and record-keeping cannot be overemphasized. Skipping steps is a formula for unpredictable outcomes. Prosthetics is a summation of countless details.

IMPROVED COMMUNICATION WITH SURGICAL COLLEAGUE

Since the restorative protocol outlines a specific series of clinical steps, there should be an opportunity for improved case discussion, collaboration and communication.

EXPECTATIONS FROM SURGICAL COLLEAGUE

There are a number of mandatory steps, checkpoints, and prosthetic constructs that must be prepared and reviewed in advance of the surgical appointment. Among the goals of this protocol is to provide a seamless integration of restorative and surgical disciplines.

MOST IMPORTANT RESTORATIVE CHALLENGE

The most difficult aspect of treatment for the restorative dentist is to determine optimal 3D artificial replacement and to create a beautiful and natural smile. “Tooth display” is the most common problem meaning the artificial tooth position is either “not enough or too much”. Please note: Literature-based guidelines will significantly lead to more predictable esthetic outcomes and improved patient satisfaction.

IDENTIFICATION OF THE VERTICAL MAXILLARY EXCESS (VME) PATIENT

Clinicians need to understand the difference between those patients with a high smile line and those with VME and the subsequent treatment planning modifications that are needed.

VISIT TWO: INITIAL CONSULTATION WITH RESTORATIVE DENTIST

(Visit One: Surgical consult has taken place)

PRE-OPERATIVE RESTORATIVE DENTIST CHECKLIST FOR DENTATE PATIENTS: ONE VISIT IS NEEDED FOR THE ENTIRE SEQUENCE OF STEPS LEADING TO THE FABRICATION OF IMMEDIATE DENTURE(S). This visit will occur after the initial visit by the surgeon.

STEP ONE: PATIENT INTERVIEW

-Review of questions previously addressed by surgical colleague.

-Confirm chief complaint.

STEP TWO: MANDATORY DIAGNOSTIC DATA COLLECTION

a). Clinical examination intra/extraoral (charting, periodontal probing etc.)

b). Radiographs if necessary understanding a CBCT has already been taken.

c). Photos with the following 8 images: Frontal lips closed rest position, frontal full smile, full frontal smile eyes closed, profile lips closed rest position, profile full smile, profile full smile eyes closed, maxillary and mandibular occlusal). These photos need to be forwarded to the surgeon.

d). Potential location of the prosthetic-gingival junction for those patients seeking treatment in the maxillary arch with a high smile line.

e). Identification of the Vertical Maxillary Excess (VME) which is a subgroup of patients that have an “exceedingly high smile line”. By definition this means those cases with considerable lip mobility that will display at least 5mm or more of gingiva apical to the gingival margin of the remaining teeth. These cases require the most careful discussion with surgeon as the “prosthetic-gingival junction zone” is unavoidable.

f). Preliminary impressions for study casts (elastomeric material or digital scans only) with the need for two casts (one unaltered for recordkeeping and the second casts for treatment. To review, a total of two casts are required. Do not use alginate as an impression material.

g). “Bite” registrations completed ideally with wax materials and not elastomeric.

STEP THREE: DETERMINE IDEAL TOOTH POSITION WITH STARTING POINT ALWAYS BEING THE MAXILLARY CENTRAL INCISOR INCISAL EDGE POSITION

(Without question, the first and most important clinical step is to decide on the vertical position of maxillary central incisor incisal edge position)

a). The clinical starting point is to evaluate how much maxillary central incisor shows IN REST POSITION.

b). Then evaluate the amount of tooth display when the patient smiles.

c). Esthetic guidelines: To increase the vertical length of the maxillary central incisor edge is initially determined by esthetics (showing more teeth) but checkpoints include:

i). Maxillary central incisors and the remaining maxillary anterior teeth need to approximate the contours of the wet-dry border of the lower lip (so using the lower lip is a critical guide) in rest position

ii). Add composite to the maxillary anterior teeth (with bonding agent and no etch) to assess esthetic changes, show patient and take photo for records or lab. A second impression of this mock-up is often helpful.

iii). Increasing the vertical position of the maxillary anterior teeth can often be accomplished without an increase in VDO. This is an important concept to understand.

iv). If overall existing tooth position is correct, it should be unchanged.

d). Phonetic guidelines: Once esthetic parameters are reviewed, one needs to re- assess the tooth position with phonetics as follows:

i). When a patient says words with the letters “F” or “V” or makes a “F” or “V” sound, we are looking for “light contact of the centrals on the wet-dry border of the lower lip.” Trapping the lip would mean the teeth are too long and should be shortened. If there is no contact, the teeth should be lengthened.

ii). When a patient says words the letters “S’, this represents an interaction between the upper and lower incisors. An ideal “S” sound needs about 1mm of space between the mandibular incisor edges and the lingual of the upper anterior teeth. We are looking for “no contact with any teeth,” as the “tongue rests on the palate behind the maxillary central incisors” and the mandible “swings forward.” To achieve a proper “S” sound, the lower incisor edge or the shape of the lingual of the upper teeth may need modification. For example, the “tilt of the maxillary teeth may be altered” to increase the space between the teeth in speech.

e). Midline of central incisors must be aligned with the face. To assess the midline, the patient must sit in an upright position.

f). Determination of proper incisal plane: The anterior incisal plane in a frontal dimension (when looking at the patient) needs to be parallel to the inter-pupillary line. Can use ice cream sticks or fox occlusal plane guide and adjust anterior plane as needed.

g). Overall, the goal is to provide proper tooth display and lip support. The challenge in this endeavor is often “too much tooth or not enough tooth.” Generally, we can make a patient appear younger by increasing the length of the incisal edge position and showing less mandibular anterior teeth. This will have no impact on VDO with proper maxillary tooth angulation.

h). Lab communication: Specific visual and written instructions to the lab are helpful. For example, “please add 2mm of incisal edge length to numbers 7-10,” “please see photos with temporary bondings,” or, more ideally, you may draw with a pencil the new incisal edge position on the facial aspect of the lower anterior teeth.

STEP FOUR: EVALUATE POSTERIOR OCCLUSAL PLANE Use fox occlusal plane guide as the starting point to determine the most ideal posterior occlusal plane. The posterior occlusal surfaces need to be parallel to the ala-tragus line.

STEP FIVE: ASSESS VERTICAL DIMENSION OF OCCLUSION

a). Starting point is extra-oral facial esthetics. Use the patient’s face and lips as your guide and determine whether or not current VDO is acceptable or if an increase in VDO could be esthetically advantageous.

b). Lip competency is the key to evaluate amount of inter-occlusal space or freeway space and to determine if an increase in VDO is possible.

c). Clinical pearl to assess current VDO: 1). Have the patient wet their lips and swallow to determine rest position. 2). Ask the patient to slowly separate their jaws while keeping their lips closed or comfortably together. 3). Ask the patient to “freeze in this position,” separate their lips, and evaluate freeway space. If there is an inter-occlusal space present or freeway space, then an increase in VDO is possible. If their teeth are essentially in contact while their jaws were separated, an increase in VDO is not possible.

d). An increase in VDO will not impact maxillary incisor edge position

e). Nasiolabial angle with proper VDO should be 90-95 degrees

f). “S” sound evaluation: if there is contact with the upper and lower teeth, either the VDO needs to be increased or the tooth position needs to be altered.

g). Increasing the VDO still requires the maintenance of at least 2-3mm of freeway space

h). If VDO is moderately high: Patient will present with a facial grimace. The grimace occurs because they need to use facial muscles to “try and close more.”

i). If VDO is excessively high: Patient will present with a “hyoid jump.” The hyoid bone jumps because the neck musculature is activated in a physiological attempt to increase the biting force.

j). If VDO is excessively high: Patients will not be able to comfortably approximate or close their lips.

k). For recordkeeping, need to document the following “VDO was determined with a combination of esthetics, phonetics, a sufficient amount of freeway space, general comfort and ideal musculature harmony. The patient approves esthetics, tooth shape, tooth shade and tooth position.”

STEP SIX: EVALUATION OF RESTORATIVE SPACE CONSIDERATIONS AND DETERMINATION OF DEFINITIVE PROSTHESIS

a). Each definitive implant restoration is “space specific”.

b). Mandatory measurements include: Periodontal probe measuring the patient’s existing clinical crown and exposed root surface and/or removing the final denture set up in one arch and measuring the distance from opposing inter-arch distance.

c). Determine if additional restorative space is required which can be accomplished surgically (alveolectomy), or prosthetically (increase in VDO), or a combination of both.

e). Assess if an increase in VDO is possible.

f). Correct terminology: Definitive prosthesis not final prosthesis.

f). Minimal space requirements: Hybrid abutment-level 13-15mm

Monolithic Zirconia abutment-level 10-12mm

Note: A hybrid will be defined as CAD/CAM titanium bar with processed denture teeth and will require more restorative space as compared to a monolithic option.

g). Choice of prostheses include other considerations:

i). Hybrid if opposing arch is a completed denture, overdenture or hybrid

ii). Monolithic zirconia if opposing arch natural dentition

iii). Monolithic zirconia in maxilla, hybrid in mandible for full mouth prostheses

iv). Monolithic zirconia for parafunction

v). Monolithic zirconia with layer ceramics for improved esthetics should be avoided with those with parafunction

vi). Milled PFM all metal occlusal/lingual for parafunction with reduced restorative space

h). Decision to choose definitive prosthesis from a “material science perspective” will impact the surgical protocol. This means for a hybrid design, the implant angulation should be altered where the exit point should not be within the confines of a denture tooth (screw-access should be within the denture base). Denture teeth with “holes” drilled in them or those that require considerable alteration will be subject to premature wear and or fracture. For monolithic zirconia options, the screw access can be within the confines of the prosthetic tooth. This distinction has profound prosthetic aftercare considerations.

STEP SEVEN: BASIC RESTORATIVE INFORMATION AND CONSTRUCTS REQUIRED BY SURGICAL COLLEAGUE

In anticipation of surgery, the restorative dentist needs to provide the surgeon with the following:

a). Photographs (eight total).

b). Smile line analysis: Low, High or VME.

c). Three constructs which include a definitive complete denture, a conversion prosthesis (with clear plate for immediate fixed prosthesis), and a clear duplicated denture used as a surgical guide.

d). Space requirements and choice of material for definitive prosthetic design.

STEP EIGHT: RESTORATIVE TREATMENT LETTER TO PATIENT

a). Summation of informed consent options

b). Immediate vs delayed

c). Fixed vs removable

d). Benefits of TRUTEETH with review of fees

b). Advantages/disadvantages of this approach

c). Discussion of phonetic challenges

d). Prosthetic aftercare considerations with regard to definitive prosthesis

e). Time to re-treatment considerations

f). Peri-implant maintenance requirements

g). Occlusal night guard

VISIT THREE: SURGICAL TREATMENT WITH TRUETEETH APPROACH

THIS INCLUDES EXTRACTIONS, IMMEDIATE IMPLANT PLACEMENT, CONVERSION FOR IMMEDIATE FIXED TEMPORIZATION.

Please note: The specific surgical protocol and the 3 dimensional implant placement (defined as position, depth, angulation) will vary with the choice of the definitive prosthesis and an understanding of material science as follows:

a). Monolithic option-Implant placement should support screw access within either the confines of the artificial prosthetic tooth or more lingual/ palatal or,

b). Hybrid option-Implant placement should support screw access within the denture base and not within the confines of the prosthetic denture tooth.

B) EDENTULOUS PATIENTS

PRE-OPERATIVE RESTORATIVE DENTIST CHECKLIST FOR EDENTULOUS PATIENT: FOUR VISITS NEEDED IN PREPRATION FOR THE FABRICATION OF IMMEDIATE DENTURE(S). Please apply protocols and details for dentate patient in previous section.

VISIT ONE: BASIC DIAGNOSTIC CRITERIA

a). Patient interview

b). Radiographs - Not needed since CBCT taken. Again, timing of CBCT may vary.

c). Photos (6 total): Frontal with dentures in and out, profile with dentures in and out, occlusal view mandible, occlusal view maxilla.

d). Preliminary impressions for study casts which can be used for custom trays and record bases with wax rims. If an accurate initial impression is taken, the record bases can be fabricated to avoid another patient visit.

VISIT TWO: FINAL IMPRESSIONS/RECORDS WITH WAX RIMS

a). Always start with maxillary wax rim using lower lip as guide.

b). Properly shaped wax rims for lip and facial support.

c). Ideal VDO and freeway space.

VISIT THREE: TRY-IN TOOTH SET-UP

a). Check esthetics first and phonetics second.

b). Confirm VDO and a sufficient amount of freeway space.

c). Need to document that patient has approved esthetics.

VISIT FOUR: DELIVER PROSTHESIS(optional)

a). Follow classic principles of denture fabrication.

b). Most ideal to deliver new prosthesis prior to surgical session.

A TOTAL OF SIX PATIENT VISITS IS NECESSARY WHICH INCLUDES THE DAY OF SURGERY. Need to supply basic mandatory information to surgical colleague in preparation for day of surgery.