Lecture 4 02202024.txt

SPEAKER 0 Noon tomorrow. And for the rest who are with me next week. A lot of what we’re going to be talking about today weather, uh, this morning and then later today in the lab. And for those who have labs tomorrow and next week, we’re going to talk a lot about how to get from where the implant wa...

SPEAKER 0 Noon tomorrow. And for the rest who are with me next week. A lot of what we’re going to be talking about today weather, uh, this morning and then later today in the lab. And for those who have labs tomorrow and next week, we’re going to talk a lot about how to get from where the implant was placed, which ideally, ideally we would have done last week in the lab, but unfortunately we didn’t, um, because of the snowstorm. Um, but at least you have, uh, kind of have an idea about how to place an implant for those who are in. Or if you guys listen to Fleischer’s lecture or you’re there, you would have seen talked a lot about the implant placement itself, the process of the implant placement and everything that comes with it. So today, essentially what we’re going to plan on doing here in the lecture and later in the lab is really talking about, okay, now the implant is placed. How do we take it from here to where we get a crown right. So let’s kind of just this slide is a good reminder. You saw it in the first lecture which kind of talks about there’s. Typically bless you two types of restorations. I mean, there are there are more. Yes. Companies every now and then are going to come up with on one for noble, you know, all these different types of restorations, um, different names. Right. But the concept for the most part is either one of these two, it’s either cement retained or screw retained to review. The cement retained is essentially the implant is already placed right down here. And then what goes inside here is called an abutment. What you see here. Right. This abutment essentially resembles a prep tooth right. It resembles a prep crown. Bless you. Because the restorative crown that is going to go on top of the implant is what you see here. Needs something to connect it to the implant. So you need something that’s typically called an abutment. Right. This abutment is held in by a screw. Right. So this screw is going to hold in this abutment inside the implant. So it’s a screw inside of a screw. Right. And then the crown gets cemented on top of the abutment. And that’s what you see throughout this process here. Right. So the abutment is screwed in and it holds inside the implant typically on top of where the access to the screw is. Right. There’s they usually put cotton Teflon tape, you know something some type of some people even put PVS some type of barrier just so that you don’t want cement to get in here. So that in the future, if for whatever reason, you know, things don’t go so well and you need to retrieve the abutment, it’s easy for you to just, you know, cut the crown off and then just flick whatever is in here and access the screw. Because if you get cement, the chances are if you’re going to try to drill that cement out, you could damage the top of that screw, and it’s going to be very difficult for you then to find something to grab the top of that screw. Does that make sense? All right. So that’s kind of the idea behind a cement routine. A screw routine is essentially the same thing. But the abutment and the crown. Our one piece. The difference is this crown you’ll see here from the side view does not have a hole in it. This one has a hole because the the driver that you have that will tighten this screw will go through the crown. It’s just the longer driver. And this whole assembly is one piece. If you want to think of it in a different way, um, which was the term that came out in the literature maybe ten years ago. Screw mental. Right. The idea is behind this. Essentially it’s a cement retained crown, right. Just with a hole in it. So it’s screw mental, right. The concept essentially is the same. But why we would use one over the other. We’re going to show you we’re going to talk about it in detail why you would choose one over the other. What are the limitations of each one. And. If you look in the literature for 20 plus years worth of data, if you know what you’re doing, there’s essentially zero difference between the two in terms of success and survival. The caveat is if you know what you’re doing, because there is a much higher risk with cement retained restorations because you’re dealing with cement, and if you leave cement behind, you will cause implants. As Doctor Fleisher showed you in those cases yet. No. So you’ll see them in the next lecture. Okay. But in order for us to actually get to the Crown piece of things. Hat like so you prep the tooth, right? Don’t look at the screen. So you prep the tooth with Doctor Brown. How do you get to the crown? Right. You either scan with Saric right. Which is essentially the equivalent of your impression. Or you had to take a physical elastomeric impression. Right. Whether that’s PVS or poly ether you use some type of impression material to impress that tooth. Right, so that you have essentially a positive of what is in the patient’s mouth, and you have a working model that you can design the crown on. Right. You have to do the same for an implant. Right. So. How do I know the position of the implant? How do I know how deep it is in the bone? How do I know the angulation of it? There are so many that parts that go into it. Right? Because if these abutments are just stock, you could just buy them off the shelf. Yeah. This one comes in a size three A size four. Size five. What do you want. Well the implant he plays is different than the implant that she placed because his was maybe more medially tilted. Hers was more distally tilted. Am I going to order the same exact abutment? Probably not. His is a little bit deeper than hers. Should they order the same abutment? Right. So how do I record all of that information? So you need something called an impression coping, which is what you see up here, right? Essentially what it is, it transfers the information from the patient’s mouth onto your working model. Right. So it is a small and you’ll see that at least for noble care, which is the system that we use, it’s color coded. So it’s a lot easier for us. So if you know what color the implant was, then you know what color the impression coping should be. Right. Um, and essentially what it is, is it’s a small analog that you place inside the implant. You make your impression, and after you take the impression out and you have that analog, it transfers all of the information of the implants, depth, angulation and everything, and even the tissue profile around it, so that when you transfer it to the cast, it tells you exactly what the patient has, but you have it in a stone model version. All right. There’s different kinds. There’s something called an open tree and there’s something called a closed tray. Right. Again, for those of you in the lab with me tonight, this afternoon and tomorrow and next week, we’re going to get to do both techniques together. There’s also and I highly recommend it takes maybe five minutes before the lab. I already posted videos on blackboard for both techniques. You could just watch them super quick before you come to the lab. Just familiarize yourself with them. But we’ll talk a lot about them afterwards. Um, but there’s also a digital version, right. So there’s open three closed tray. And that is essentially an elastomeric impression. Right. Meaning that you have a tray, you have impression material. You place this inside the patient’s mouth and you’re taking an actual physical impression. Can you do it digitally like yes. So the way you do it digitally is something called either a scan post or a tie base. And again, I’m going to talk about that in detail during our lab. So we’re not going to spend too much time about that maybe just yet because there’s a little bit of nuances between the two. And you’ll see for different companies right. Like up here. This is Noble Baker down here. This is strawman. The concept is exactly the same. They’re going to look different. They’re going to have different colors. But the concept is exactly the same. Right. So for an elastomeric impression right. As we said there’s there’s an open tray and there’s a closed tray. So what’s the difference between the two. So you’ll see with an open tray the top of it looks like kind of like the letter T. It has these two shoulders. And then it comes down straight right. So you’ll see that here kind of kind of has two shoulders. And then it comes down straight for a closed tray. It has a much smoother profile right. With a little bit of indentations. Same thing here. You’ll see this is the open tray. It has these shoulders in it. I don’t have a closed tray for strongmen in this picture. So you’ll see it right. So talked about these two shoulders that are sticking out. And you see here the invitation on a much smoother profile. If you look at it from the side you can see it even better. Right. It has sort of this shoulder if you will. And this is a lot smoother. So why do we think this has more retentive features than this. It comes from the name right. Open tray. Closed tray. So it really comes down to when you’re recording this impression. As you as you make your impression. Keep in mind these are in the patient’s implants. While you’re taking that impression. When it’s time for you to take the impression out. Right, you’re either going to pull it out and the analogs are going to stay in the patient’s mouth, or you’re going to pull it out and the analogs are going to stay in the impression. Right. So if I have something that has retentive features, you think it’s going to stay in the patient’s mouth or in the impression. And the impression, right, because it’s going to lock into that impression material. But if it has soft sides. When I take it out, it’s going to stay in the patient’s mouth, right? Okay, so if I screw these into the patient’s mouth and I take this out, how is it going to stay in there or how is it going to come out if it’s going to stay in there? It makes sense, because the same way you take an impression for teeth, you just fill the tray, make the impression, and when you pull it out, the teeth don’t come out. They stay in the patient’s mouth, right. And the implant is stuck in the bone. It’s not going to come out of the bone. So I’m not worried about the closed tray. Right. How about the open tray? If I just pull out, won’t it rip the impression? Yeah, right. So then how do we do that? So essentially you’d make a hole at the top of the tray and you see this screw sticking out. So once the impression material sets, you’re going to unscrew it so that when you take it out, it comes out. And again we’re going to do this I know it’s going to sound confusing. Now for the you’re going to do it in the lab. Each and every one of you. We’re going to do an open tray and a closed tray. This is just a very quick overview. And we’re going to get into nitty gritty details this afternoon in the lab right. But they both serve the same purpose. So like with this one. Sounds easier. Why don’t I do this all the time? They obviously have different uses, right? They have different indications. One would you do an open one when you do a closed talk about this, that this afternoon? I just want you to appreciate that there is more than one way. Right. There’s an open trade. There’s a closed trade. There’s digital. Each one sort of has indications and contraindications. But I want you to be familiar with all three techniques so that you have these tools in your arsenal. When a case comes across, you know, based off of the case what to use and when to use. All right. For CAD cam. Okay. And again we’re going to do this in the lab as well. Because we’re using Serac. Serac is very specific about what they call a ty base, which is short for a titanium base, which is the equivalent of a restorative abutment. Right. So remember how we talked about the abutment? Essentially it looks like a prep tooth that fits inside the implant. It’s the exact same thing. But Sirona makes it or Densify Sirona makes it. But it’s specific only for Saric. Every company makes a tie based, no bell makes their own tie basis Strom and makes their own tie bases. Three I Zimmer. Every implant company makes their own tie bases. So why aren’t we using the Nobel typeface for a Nobel implant? But we’re using a Sirona one. Great question. So the problem is, is, um, the scanners we’re using or steric specifically, um, are somewhat of a closed system, so you can’t use a third party, what they would call a third parties component using their system. Right. It’s kind of like you can’t use a Samsung charger on an iPhone. Right. It’s the same thought process. So you have to sort of use their version of Nobel’s invention. So that’s just a brief overview of what you’re going to look at today. But essentially what it is is it’s, it’s it’s the equivalent of, um, what you would consider an abutment. It has like a small plastic cap, um, that you see here in yellow. Oops. Or you see here in gray actually as well. Um, and then that gets scanned and then you can either design a cement retained abutment and then a crown on top, or a screw retained crown with a hole in the middle right. So it gives you both options as well. We’re going to do those in the lab today as well. All right. Um, this on the other hand is very I would say technique sensitive. The quality of the skin really, really matters. Because if you’re off by even five degrees, whatever you’re going to mill won’t fit in the patient’s implant because the angulation is going to be off. Um, additionally, uh, it is not for every case an open tray or close tray. You’re going to do it for almost almost every case. We have seen a lot of restorative complications with these types of restorations, because these are not meant for every single case. All right. SPEAKER 1 Was there? Yeah. SPEAKER 2 So you said it’s a technique sensitive, but it’s a technique sensitive to obtain the scan or when you place the paper. SPEAKER 0 So placing the implant has nothing to do with the scanning portion of things. Technique sensitive in terms of. The quality of the skin really matters. And if you’re missing even you know how in Sarika auto fills a lot of times when you have like a small spot, it just auto fills those spots. If that happens with a digital scan, when you’re doing implants, it won’t fit. It’s very, very finicky. And you have to. It’s not just taking the scan of the tie base. You’re also taking the skin of the typeface or or or even without the healing abutment, you want to get the soft tissue profile. You want to make sure that you’re capturing that properly. Um, like I said, we have enough data, at least from what we do across the street in the dental school to show that these restorations, if not done properly, have a much more higher complication rate than just a regular restoration. SPEAKER 1 Yeah. We still need to cement the crown with the bottom right. SPEAKER 0 Great question. Okay. So if it’s so either way whether it’s screw or cement. And again we’ll talk about this in the lab today. But yes you can see it here. It’s just a piece of metal. So if I’m going to do the cement retained you still need to cement this portion on top of this. And if it’s screw retained you still have to cement this portion on top of this. The difference is once you cement this on top of this, now you’re going to cement the crown on top of this as well. Right. So also keep that in mind. Right. There. The more parts and pieces you add. The higher chance for you to get complications, right? Because now you’re dealing with a screw inside of an abutment and then a cement that’s holding the abutment to the abutment, and then a cement that’s holding the crown to the abutment that’s holding the abutment. Right. You’re just adding layers of complication. So the more you go down that road. Once one part fails, right? You may have to go all the way to the starting and just do it all over. So again, I’m not dissuading you from doing it. It has its uses 100%. It has its uses. But. The challenge we’ve had is typically students like to think, oh, it’s so I could do it in one session. Let me just scan it and get the patient out of my hair. And yes, that’s the beauty of Cedric is that you can do it in a one visit while the patient’s there and finish whatever you need to finish. The challenge is if you, um, if the case isn’t necessarily indicated for this type of restoration, you end up with way more complications. Way more complications. Um. All right. So obviously there’s advantages and disadvantages for taking a traditional impression versus the digital impression. Right. Um you’ll see that right now almost exclusively at orthodontic offices. They don’t take physical impressions anymore. Even the American Board of Orthodontics now accepts digital, uh, casts and printed 3D printed casts for their examinations. Like the shift is going to happen, right? It’s just a matter of time when eventually elastomeric impressions are going to go out. The reason why they haven’t although digital, although circ was invented in 1983 and we still didn’t get rid of elastomeric impression, is there’s still a long way to go, right? There’s still a lot of advancements in technologies that need to happen in order for us to completely eliminate, um, uh, elastomeric compressions. All right. So you heard you. You heard me use the word abutments a lot. So there are obviously different types of abutments. There’s something called the stock abutment and something called a custom abutment. Right. Stock a different word is also called prefabricated means it’s already made, right. So for every implant company, they always give you this beautiful catalog. Looks like the yellow Pages. It’s like this huge book. And they tell you there’s all these different types of prefabricated stock abutments. So let’s say if you’re placing a 4.3 implant it the abutments come in size x, y, z and they’re already zero degrees, meaning they all look straight. But you just buy them and they all look straight. So if the teeth next to them have any modifications, this is how they sell them, right? So they’re prefabricated. Not to say that they don’t come pre plated. You can buy those to either come zero degrees ten degrees 15 degrees 20 degrees. Right. So you can buy those prefabricated ones. Triangulated as well. How much angulation. Right. And does the angulation really matter? The biggest issue with stock abutments. And there was um data published from the LMT which is the lab management today, which is sort of um, they, they collect data from all the labs in the US and just get trends for what’s happening in dentistry. And if you look at what dentists were doing back in. Between 2000 and 8 2013 versus between 2013 to when they collected this data around 2019. The number of stock abutments went from 50% of cases to less than about 12% of cases. Right in the beginning, it was very cost prohibitive to do stuff custom, and you had to do it with stock. So what is what what is what is custom? So I think you’ve seen already when we played enough in um, in Z axis, that bone is never perfectly flat, right? There are parts that are high, parts that are low. And if you remember, I always say bone sets the tone, but the tissue is the issue, right? So if you if your bone is higher on the proximal, the tissue is going to follow it, right. If you have. So if I have tissue that’s higher here. Bless you. But all of my stock abutments come flat like this. Do you see the problem I have? The tissue is going to recede, right? Versus if I have the tissue that’s supported here and I have this custom anatomically shaped abutment. Wouldn’t that be better for an esthetic outcome as well? Right. So the reason why we didn’t do as many um, back in the, in the day is it was much, much more expensive to do these custom abutments. And today the cost difference isn’t, uh, worth the headache isn’t worth you dealing with complications. And obviously we learn right over a period of time, we notice that a lot of these cases that had these prefabricated abutments had restorative, uh, well, not restorative, more esthetic complications than anything. And so we learn from our mistakes. Right. There are different types of abutments, certain abutments that have certain designs that allow them, that are better for screw retention or for cement retention. Like I said, they come and plated, um, they come straight. They also try to sell them anatomical as well. Right. So what they would do is they make the proximal like medial and distal sides higher. And then the buckle has a dip and the lingual is a little bit higher than the buckle. So it looks anatomical. Look like when when a natural tooth would look like. The problem is is you. And it’s not really a problem. But you would essentially have to measure the cuff height right from the free gingival margin to where the platform of the implant is, so that you know how tall this cuff should be one millimeter, two millimeters, three millimeters. You need to know how if you’re going to order something prefabricated, you need to know how tall that cuff is going to be. Right. Because you don’t want to order something that’s too long. Then it’s sticking out of the out of the soft tissue. You don’t want to order something too short, because chances are, if you’re doing that and you’re cementing the crown, you’re going to leave cement behind, right? You’re going to get Perry implant Titus, you’re going to get bone loss. Okay. So the other, uh, the other challenge with ordering something, maybe even anatomical is. It’s a guideline. It’s never perfect. So what we used to do back in the day, and I’m guilty of it myself, is these are titanium, right? You just prep it. So it fits the soft tissue profile better. But then you’re really weakening it, right? Because it’s not solid. It’s somewhat hollow. So you’re trying to prep it to bring maybe the titanium a little bit further down. But the more you do that, the more you’re compromising the the abutment itself. You guys following me? All right. So. This word you’re going to see. For the rest of your time here. I’m telling you right now, you’re welcome. And I know this is being recorded. You’re going to see this on your exam. Emergency profile is an extremely important concept. Okay. As soon as you say that, you see everyone’s emergence profile. So essentially you want what the. Implant restoration. The ear implant supported crown. What it should look like. It’s coming out of the socket, right? You don’t want it to look like a piece of popcorn like you see here, right? Because this becomes extremely difficult for the patient to to clean, because you can see what the contact is like. They would have to go down with floss and go sideways, right. This is going to be very this is this is going to have complications. This is going to have bone loss. But what made this happen? The implant was placed way too high. It should have been placed way more apical, so that it can give us a gradual right transition from where the implant is to where the soft tissue should be. You need at least three millimeters from the implant platform to the gingival margin to allow for that transition. All right. Now this transition should be in this case concave, right. Because your crown is convex. Right. All of our teeth for the most part have the height of contour. That’s convex. Right. So it’s easiest for us to clean. So we don’t get because if it’s concave then this is going to get stuck with plaque and food. Right. So we want the convexity of the tooth. To fit into the concavity of the emergence profile. Does that make sense? All right. So ideally you want all of your implants to be placed parallel to the long axis of the tooth. It makes sense, right? We talked about why it’s important you want to transfer. Remember that that first lecture we talked about the types of forces, whether it’s shear, whether it’s compressive forces and which forces are more favorable. So you don’t get bone loss so you don’t get restorative complications. So yes, ideally. And that’s why when we went into the SLC and we had you guys merge that CAD cam file, right. Not just plan the implant based, one of the bone is we had you merge the CAD cam file first so that when you place your implant, you’re placing it directly underneath that central fossa of that tooth, right? So that you’re directing those forces on your crown when you when it’s time to restore it. Right. Because you can if you just design that implant in bone without knowing where the crown is, you may do it like this, but then your crown ends up like this. Right now we have these forces all the way on the distal side of the tooth that are just unfavorable, that are going to cause restorative complications, screw loosening, bone loss, etc., etc.. All right. Any small degree of deviation could be corrected, right. 1015, 20 degrees. You can. Um, the problem with large degrees of deviation is, like I said, you’re going to get very unfavorable forces. And probably more importantly, is these less restorative material. Uh, so what does that mean? Okay, so you see here where the long axis is, but do you see here on the facial how I have this concavity. Because I need on the facial of an interior tooth that much more ceramic right. For esthetic reasons. So if it’s down the central fossa, do you see I kind of have equal amounts of ceramic here. Right. Or restorative material to withstand forces. Now see, the more the implant is tilted. Do you see? Now I have a larger lingual. Now look here. Right. This is extremely compromised from a material standpoint. Additionally, from a force standpoint. You guys heard the word cantilever at this point, right? Okay. So you know what a cantilever is for those of you who don’t know. Essentially it’s think of a bridge. Right. And if the bridge is going to take you from point A to point B and the basis of the bridge’s A, A, and B, everything in the middle is cantilevered off of A and B because there’s no posts in the middle to to hold it in place. Right. So it’s kind of like me holding the remote like this. And I’m just pushing forces here. Right? All of this is akin to lever off of this. So the problem is, is that all of these forces that are coming to hit here are forces that are not supported. All right. So that’s why it’s important to do along the long axis. Now from in terms of the restorative material, this limits me. This limits me from a material selection standpoint, a for esthetic reasons. Right. Because if I have a very thin amount of ceramic on the facial. Can I use something that has high transparency. Mhm. Because don’t forget that the abutment underneath is titanium. It’s silver and color. Right. So the last thing you want to do is when you’re looking at someone and smiling and see a silver color. I know we all know someone who’s like that. Right. It’s not necessarily because they had an implant, maybe they had an amalgam core, etc., etc. but you see it. So how do I hide that? That limits my options, right? I think I may have shared this with you already, but if I haven’t, I’m sure Doctor Brownell or Doctor Suzuki will next semester. Ceramics are very, very easy science to understand. They really. They truly are. The weaker the ceramic, the more beautiful it is, the stronger the ceramic, the not so beautiful the ceramic. It is right. And it really has to go down to. Biomaterials, and how much particles and how much filler you have in there, right? Because the less particles you have, the more light can transfer through. The more clear, the more transparent, the more esthetic it is, right? The more particles you have, the less light can travel through, the more opaque the material is. Right? And obviously it’s stronger because it’s more packed. So in this case. Right. And I’ll show you a case a little bit later. You may have to use something that’s not as opaque. Now if the adjacent tooth. So let’s say you have to do that in zirconia. So if the adjacent tooth has perfectly healthy enamel that’s transparent when the patient looks sideways. And I’ll show you a picture of a case that I have, you will immediately notice it. So why put yourself in a position like this right. So that’s why I always say like measure two, three, four, five, six times and cut once, right. But you really have to plan your implant because. And if you’re not planning the implant and you’re working with a surgeon, whether a periodontist, oral surgeon, whoever is placing the implant for you. Make sure you’re involved in that planning process. Because yes, while you’re going to be the one restoring it, I can tell you 9/10 at a time. Implants that are placed incorrectly are the implants that are integrate perfectly, because those were placed where there was enough bone for them to integrate, because if they were placed in the area that they needed to be placed in, they either needed a sinus lift or a graft, and the patient didn’t want to go through that. You’re going to have to learn to tell the patient if you want a good outcome. This is what we’re going to have to do. All right, so how do I know which kind of abutment to pick? So for something that is going to be fixed, like a crown, you need about seven millimeters, right? Again different literature. You may read six. You may read things low as five. You may read eight. Seven is kind of a nice average number. Removeable it’s 12. Doctor Chanel will tell you if you’re using microarrays that number could be smaller. Right. Again there is variability in these. These are just guidelines. These are not. You know, uh, absolutes. All right. But why do I have an average of about seven millimeters of minimum? Because you do need to take into consideration resistance and retention form when it comes to that abutment. It doesn’t matter for screw retained right. It matters for cement retained, which is why you can go down to six and even sometimes five millimeters because we’ve screw retained the screws holding it in place. There is no abutment that needs any type of resistance and retention form to hold that crown in place. Right. The amount of taper matters. Right. And so that kind of goes back to this. Right? If I have to taper this so much on the facial to either accommodate for material or because the adjacent tooth is like that, then my abutment itself is so thin. Right. That is compromised. And if I don’t adjust my occlusion properly, I’m going to get problems. All right. SPEAKER 3 Oops. SPEAKER 0 Um, and the surface area. Right. So how much surface area, how big of an area do I have that the crown will get cemented to? Right. And that kind of goes hand in hand. Like if you have a very short prep, do you have a lot of area to bond to? Not really. Right. So just take those same principles of quantum bridge and use that same methodology and apply it here. All right. So what kind of abutments I really wish these companies would just slow down. I mean this slide was maybe 2 or 3 years ago. They just keep coming out with all these different types of abutments. Um, so you’ll have your snaps, your anatomical, your multi units. Um, I’ll talk a little bit about this. This is um, their equivalent of a tie base. That Sirona tie base I showed you. This is their universal base. And these are temporary temporary abutments. So I’m just going to go in order. So we talked about the prefabricated ones. Unless you’re doing multiple implants in the same arch, you’re not going to use these. These are multi units. The reason why they’re very short is because if you have multiple implants, um, let’s say you’re doing a full arch worth of implants. They’re always placed in different locations and different spots. So you don’t want something with a high profile. You want something actually with a short, small profile because your restoration is going to be across the arch. We’re not going to get into details there. This is what is called a gold adapt. Um, which is also very popularly and famously known as a UCLA abutment. You’re going to hear that word a lot. Um, or maybe not as much as we used to. Basically what it is is it is a titanium base you see here, but then the portion on the top is plastic. So why? It is before we used to be able to make custom abutments using CAD cam. We had to wax it up. I’m sure you guys at this point have heard about the lost wax technique. Yes, yes. Okay. For those of you who didn’t say yes or haven’t had their coffee yet, here’s a reminder. Basically, if I want to, um, if I want to replicate exactly this, what I would do is I would take this, I’d cast it in some die with stone around it, and then I take that and put it in an oven, burn it off. So this is burnt off. And now I have essentially a mold of what this looked like. And I pour in whatever material I’m going to make out of, right? Whether it’s gold or silver or whatever. Let it cool down, break it down. And now I created this right, basically by burning whatever it was. Same concept here. So this is plastic. The base is titanium. The heat you use in the oven will not burn. This off will not distort. This will only burn this off. So you can take this, put it on the cast whether you or your lab. And typically it’s your lab technician who’s going to design this beautiful custom abutment. Make it out of wax on this plastic. They take this and they use the last wax technique and whatever metal they’re using. Melts perfectly here and this becomes one piece. So after this is formed, you won’t see this yellow plastic anymore. The reason why it’s called UCLA abutment is because they invented it in UCLA, right? Um. The last two are temporary abutments. Right. So you’ll see there’s a titanium temporary abutment and a plastic temporary abutment. When do we use temporary abutments? So you’re like, don’t we just wait until the implant integrates anyways? And once the implant integrates, then I just restore it. Why would I use a temporary abutment? So great question. Temporary abutments. We really, really utilize them for the most part in anteriores. Right. You’re going to get a lecture not next week the week after, uh, by uh, Doctor Fouad talking specifically about this. Right. Which is anterior restorations. And you’ll see that if you do not use a temporary abutment to shape the soft tissue, you’re going to end with major esthetic failures, right? So really, I mean, can you use them for the posterior. Absolutely. But, you know, is it necessary? It’s kind of overkill, right? Unless you really want to shape the tissue all the way back on a second molar. You know, it depends on how the patient smiles. Right? But you really do want to spend time on shaping that tissue in the interior region. I’ll show you a case. Um, and, like, maybe 15 minutes. I’ll show you a case where this was very important for us to do, because we need it to shape the soft tissue. Right. The reason why it comes in titanium and plastic. Has to go back to esthetics, right? If the implant is related to facial and I’m using something titanium, 80% of these temporary restorations are made out of composite. You will see the titanium through the composite. Right. So then if it’s plastic, you won’t see any gray, right? The problem with the plastic. Yeah. You can see it has some kind of ridges. It’s very it’s it’s not as easy to get composite to stick on there. So what we end up doing is we get like a handpiece and we kind of roughen up that the plastic, like you just get a diamond, then you just kind of roughen up that plastic so that the composite sticks in there. All right. All right. So. Let’s bring it back. So cement retained crowns. Obviously the advantages for it is that it’s familiar. It’s a very familiar concept. I told you, if you just use that same thought process that you had about Crown and Bridge, it’s a very familiar concept to us, right? It’s easier to obtain an esthetic result. So why would I say that? Is because the crown doesn’t have a hole in it. Right and you’ll be able to get this beautiful, esthetically looking crown without having any compromises. There’s going to be fewer porcelain fractures, right? Again, if you have a hole in the middle of the crown, the the areas that are immediately surrounding that hole where the screw is are going to be somewhat compromised, okay, because they’re going to be thin in those areas. So if your occlusion isn’t adjusted properly or if the patient, when they bite down and their cusp is hitting in that spot, you can get some micro fractures which could lead to fractures down the road. All right. Um, you won’t have that with cement. Right. And you’ll have that screw retained. It’s easier to manipulate in the posterior region. I’m going to spend some time explaining this. Why? Why is that important? Okay. You’ve heard me say this before. You’re going to hear me say this while we’re here together. For as long as you’re here and I’m here. The jaw is a class three lever, right? Think of an alligator. When you close your jaw, what’s the first tooth that’s going to hit? Molar, second molar, then first molar, and so on and so forth. That means you have the least amount of room back there and the most amount of room up here. Okay. So if I have this tiny crown that I want to fit back there, I’m already at a disadvantage because at least with my sausage fingers, it’s not that easy. You know, if I have a small patient who you know, and it’s hard for me to get my fingers with a crown that’s full of cement and tried with gloves and things are slippery to try to get everything to fit in there properly. It’s it becomes really challenging. So. With with just a crown. It’s a lot easier because now imagine if this is cemented into it becomes that much longer. It’s becoming that much harder for me to get all the way back there and try to fit this in there. Does that make sense? Right. Because this has a much smaller profile than what a screw routine would have. So it’s easier to manipulate in those regions back there. Okay. Historically, the literature would say it has less screw loosening. I’m here to tell you there is some truth to that, but not necessarily all the time. It really comes down to whether you adjust your occlusion or not. Literature will tell us is that they both have the exact same survival and success rate. You will read some literature out there that says you’ll get less screw loosening with cement retained, which. Could indicate really that before you get a screw loosening failure or any screw or any type of complication from a screw loosening you may have, the crown will show some restorative failure before the abutment shows any restorative failure. Okay. What are the disadvantages of a cement retain ground? They’re not that easy to get out, right? You just use cement to hold this in place. It’s not just going to come off. You’re going to have to cut the crown off. Or, you know, sometimes, even depending on the material, you have to prep that crown off. It really becomes difficult. I can’t stress this enough. And I know Doctor Fleisher is going to talk to you about it next week. Leaving cement behind causes major, major issues. It’s one of the biggest causes of, um, peri implant itis. All right. And have you guys seen x rays before? Yes. No. Okay. X rays are a 2D, right? Unless you’re taking a CT scan. We talked about this. It’s a 2D. So if I’m if you’re taking an x ray of me, what are you seeing? You’re going to see really the proximal. But you won’t see if there’s something in the back. You won’t see it because the front is covering it. Does that make sense? So if you leave cement on the buckle and cement is opaque, but the implant is opaque, you won’t know that you left cement behind. You’ll only see it on the sides, because on the sides there is no implant. So it’s not so easy to identify that you left two men behind. You can think that you cleaned up all the cement, but you haven’t. Um, so it really is a challenge to make sure that you don’t leave too much cement behind. Okay? It’s very difficult to also evaluate how well the implant is doing if you have crowns that are cemented. Doctor Fleisher is going to talk to you next week about recalls and how how to evaluate an implant, but it becomes that much more difficult when you have a cement ground versus screw routine, because if it’s a screw routine, you’re going to unscrew and you can evaluate the implant with cement retained. You’re going to have to either cut off like you’re going to have to do something drastic in order to evaluate whether the implant is good or not. All right. Now this is the key word this. This is essentially an absolute contraindication for cement retained. If you have minimal interaction distance cement retain won’t work. That’s when you automatically have to do square root paint right. Why? Cement retain crowns require a higher profile retention. You have to have an abutment that has resistance and retention. Form an abutment that’s at least 3 to 4mm long, with tapered walls and a crown that’s at least 1 to 2mm thick. That’s going to get cemented on top of it. So if you add two and four, that’s about 6 or 7mm. If you don’t have that distance, what if I only have 5mm or 6mm? What can I do? Am I going to use a very thin crown material and a very compromised abutment? What’s going to happen? Something’s going to fail. No? Then I’ll just use something that doesn’t require such a, um, large retention profile, because essentially, what’s going to hold it in place is just the screw. Right? So that’s that’s basically when you would choose one over the other. It really comes down to how much space you have. I will tell you from a clinician standpoint my preference. 99.999% of the cases that I’ve ever restored were all screw retained. I don’t want to take risks. I don’t if I don’t if I didn’t need to use them and retained, I don’t have to. Right. We’re also by the time you you guys come into clinic, we would have added this. And this is why I’m saying innovation is is a beautiful thing when it comes to these companies. And as we continue to learn so noble by care, which is the company we’re using, they came up with something called ASC. This is not going to be on your exam. This is just me rambling, right? Um, it’s called an angular angular screw channel. So in theory, if you were to think of what a screw routine would look like, right, you have to think that this screw channel that goes through has to be straight, right? Because the screw has to go in straight. Nobel came up with something called an angular screw channel, which essentially is even if your screw channel is like this, they made a screw and driver that you can place sort of at an angle, that you can do things angular without having to use cement either. It’s a little more advanced. We’ll talk about it when we need to, but basically for the most part, you’re also notice that the trends in the market are heading more towards security than they are cement retained specifically so that we don’t leave cement behind. All right. So talking about screw routine obviously is very easy to retrieve. Right. So all any of the disadvantages you saw in the screw routine essentially are the advantages of a cement retained and vice versa. Okay. Right. They’re very easy to retrieve. If we need to retrieve them, the crown won’t fall off because the crown is in the abutment. Essentially our one piece. Um, it has a very because all the profile of retention is just this. Not this and then this, and then the crown that goes on top. This is all that’s holding it in place, which is about a millimeter, maybe. And then obviously the screw that goes into place. Probably the most important thing is that you’re not leaving cement behind. Okay. Disadvantages. The opposite. You’re going to get a little more screw loosening because at least from a that’s going to be your first sign that something is off. If you use a screw routine crown and a patient tighten it. And then a week later the patient comes and says, doctor, my, the implant crown you placed last week is is getting loose. You know that you didn’t adjust the occlusion properly. Okay. Compromise esthetics. Again, if it’s in the middle of a molar, is it compromised? Not really. But if it’s on the palatal of an incisor and I’m like, ah. And I’m laughing like this, you’ll see a spot. Now we don’t leave that hole open. Obviously we put composite, but composite and ceramic are not the same shade. All right. And I’ll show you a case to that effect. Um, you’re going to have a greater chance of porcelain and fracture again depending on where that hole is. In certain cases, sometimes in anterior it actually, that hole could be at the incisal edge based on where the angulation of the implant is if it’s at the incisal edge and that’s where you’re biting into things, chances are that porcelain might fracture. All right. So location is very important when it comes to this. And as I mentioned to you earlier, it’s difficult going all the way back there. Right. Because now you have this whole thing that’s a little bit taller than just the abutment and the crown, and it has to fit in now, not just it has to fit in. You still need the screwdriver that’s going to fit inside of this, and your fingers need to hold that driver to screw this in. Right. So what’s going to screw that screw inside the implant? So do you understand how much of a distance you need? You need a lot of distance. Right now they make many drivers. They make these. They kind of column mini drivers. They’re like drivers that are pretty short. But the problem is, if you have a very long crown, the mini driver won’t engage into the screw. Right. So that is a major limitation when it comes to scrutiny and crowns. All right. So essentially, if you were to look at them side by side, retrieval ability, score retained. And it’s always good to be able to retrieve the crown to evaluate the implant if you ever need to. Hopefully all of your implants go in successful and you never have complications, but in reality, we all hit some type of complication. Whether it’s a restorative, whether it’s a surgical complication, and you want to be able to access that implant if you need to, um, esthetics again, you can get beautiful results in this routine, but it will vary based off of case to case. Again, it’s very easy to correct angulation with cement retained. Right. And I say within limits. But if you know the implant is like this and I want to put a crown on it, I’ll put an abutment that corrects the angulation and then I’ll see the crown on top of it. But screw retained I can’t because it has to go in the same way and it’s going to seat the same way. So I can’t correct that. Does that make sense? Okay. So that’s where it especially when it’s trying to even see two crowns. So let’s say if you have drifting of the teeth right. And let’s say this one drifted a little bit more. And now your crown has to seat. This way you can’t do anything screw routine, because then you’re just going to have this big, huge gap between the teeth here, right? A big, huge black triangle between the teeth. But if it’s cement retained, you’ll get an abutment, right. That is emulated. So what? Fix the fixes the angulation and then a crown. That’s just going to see it normally because the angulation has already been adjusted. Right. So so that plays into it a lot. We talked about the insertion right. It’s very conventional and we’re used to it from crown and bridge in cement retained but a screw retained. It could be a little bit challenging in the posterior region. Um obviously retention at minimal height. It’s excellent with screw retained and passive fit. So the reason why I said questionable again, it really is case. The case how what are the adjacent occlusion look like. Um, you know all that kind of stuff plays into it. Essentially they both have a very passive fit, if you will. The only thing that will make it challenging is essentially the adjacent occlusion that will factor into it. So yes. Sorry, just. SPEAKER 4 A quick question. Sure. Yeah. But the same thing is like this. And you know, if you’re going to play the. SPEAKER 0 The other way around. Let’s say the other way around. Why would I place an. So if the the implant is not straight, the implant is placed at an angle and I will place an angle abutment to correct that angle. SPEAKER 4 Exactly, yes. My question. About this group that is going to be connected and. What will be the font for the screen? I’m just curious. SPEAKER 0 I’ll just go back a couple of pictures. It’s a good question. SPEAKER 4 I’m just curious. SPEAKER 0 Yeah, yeah, yeah. Trying to find a good. Thought I had a picture for this. So. Let’s use this example. If I’m going to use an abutment that’s going to come out like this. Do you see how I had to shave off most of the facial so that I can get access to the screw? All right. Yep. But then that compromises the abutment itself, too, right? All right. So ISDs implant supported fixed partial dentures. Right. So UCLA Crown, could it be both. Yes. Because you can either wax up on abutment or you can even wax up a crown if you want to on that UCLA abutment. So you could do it with both custom abutments. Um. They’re going to be cement and retained. It’s custom. You have to make an abutment that is custom. You’re not making a crown that is custom prefabricated abutment are always going to be cement retained, not scrutin tie bases. You could do either. I showed you in the beginning, you can either design an abutment or you can design a crown and temporary abutments, titanium or plastic. You can do either screw retain cement, and I’ll show you a case in like 3 or 4 slides. And I’ll show you how we use those temporary abutments. All right. Talking. This is an important a very important concept. So. Anytime you tighten two. Uh, pieces together. And in this case, they’re metal, right? Essentially, you create a screw joint. Now, the screw will only loosen if the forces on the outside are larger than or greater than those forces that are keeping them together. Okay. And the forces that are trying to disengage these parts are joint. They’re called joint separating forces. Essentially, think of it of, um. If you’re driving a nail into the wall. Right. And you know, when you get to the end and you’re, like, tightening all the way, and then I get a hammer and hit it. Right. The forces from the hammer, if they’re higher than the forces that it took me to tighten that screw, then this screw is going to come out of the wall. If the forces that I’m hitting with the hammer on that screw aren’t as big enough as the force is generating, tightening these together, then the screw is going to stay in place. Does that make sense? All right. So why is this important? Right. So I want to make sure that that clamping force that I just told you about is higher than the joint separating forces. Right. And the idea is so that whatever two parts I put together in this case, whether it’s the screw routine crown or the custom abutment or the prefab abutment, that it stays inside the implant so that when the patient’s chewing or when the patient’s grinding from side to side, that those forces don’t make that screw come loose. All right. So how do I talk it? We have something called a torque wrench. Okay. Um, you’re going to see a torque wrench when we. You would have seen it last week, but you’re going to see it when we do the surgical in a couple of weeks. Okay. Essentially what you see here forget we’ll talk about this. But what you see here this remember I told you there’s like a driver that you hold in place to drive the screw. This is what the driver looks like. And again, you would have seen it last week had we not canceled for snow. But essentially this driver is what you would fit into the screw to tighten it or to unscrew it. Okay. Now there is a torque wrench that fits on top of said driver. Okay. So in a normal way, when you’re tightening it, you don’t need the torque wrench. You could just hand tighten. But in order to make sure that I’m getting those clamping forces, I’m going to tighten it holding with my index finger on top of the driver. Right. And then the torque wrench at the back here. I have to make sure you know how when we were kids, they say righty tighty, lefty Lucy. Okay. So essentially anything that is clockwise is tightening. So the arrow there’s an arrow there. I want to make sure that the arrow is pointing clockwise. Right. So that means I’m talking in place when it’s doing that. And I hit resistance. And it’s not going to go any further. You see there’s this arm okay. And on here where you see this arm there’s like a gradual and it’s marked by numbers zero new and centimeters, ten new and centimeters, 21cm, 30 Newton centimeters, 40 Newton centimeters. And that’s the amount of torque. Right. So you tie in all the way and then you hit resistance. Once you hit resistance you see there’s like this teardrop shaped thing. And you see your other index finger. And based off of the manufacturer’s instructions they will tell you this screw, tighten it or torque it up to ten Newton centimeters, up to 20 Newton centimeters up to 25 new and centimeters. Every manufacturer is going to tell you based off of their product, right? Only use iPad pros with this or right. So you have to follow what they tell you so that if you don’t get the wrong the right outcome, they’re not responsible. Okay. So once you hit that resistance you’re going to hold this tier and you’re not going to hold the whole thing. You’re just going to use your finger and pull it out to the desired torque. And then you’re done. If I want to undo that. Now, I have to make sure that this arrow was pointing that way. How do you do that? This thing, you pull it out and pull it in, so you just pull it out and turn it the other way. Now it’s unscrewing, and then I just talk if I need to or d talk. Okay. So now let’s talk about it. So to tighten a screw adjust the direction of the indicator so that the arrow is pointing towards the lever arm and rotate clockwise. So that’s if I’m tightening. You want to make sure you’re rotating clockwise. And that this lever the arrow is pointing towards the lever arm okay. Now to loosen it. Adjust the direction of the indicator so that the arrow is pointing away from the lever arm. Does that make sense? Do you want me to go over it again? No. It’s pretty simple. Sure. Clockwise is going like this. This is counterclockwise. Huh? Clockwise is pointing this way. Right. 12. Three. Six. Sorry. This arrow is pointing so that you’re placing the driver inside the implant. Yes. It’s pointing clockwise here. It’s pointing counterclockwise. You see it magnified here. This is pointing towards the lever. Right clockwise is this way. 12 369. So it’s pointing clockwise here it’s pointing counterclockwise. All right, so what do we talk? How much do we talk it? Okay. Plastic temporary abutments. Coping healing abutments. Healing clamp as an impression. Coping. I can’t tell you how many times people don’t pay attention during the lectures. Just like I’m hearing people chit chatting now and make the mistake. And then I go into the clinic and we have to do some type of surgery. You do not use a torque wrench with any of these components. You just hand tighten. Okay. Has there been studies to say how how humanly strong are we possible to and how much new and centimeters can we achieve? Yes. Uh, like at, you know, when they I don’t know, they found the Hulk somewhere and he was able to get somewhere between 8 and 10, which none of us can do, right? On average, we’ll probably getting somewhere between 4 to 6 at maximum. Okay, so you’re not getting that much. Some of the abutments based off of Noble Baker. Right will tell you do not talk it past 15, and especially when you send it to the lab and they send it back, they send you this big red triangle hazard with the case and be like, please do not talk past 15. We are. So, um. Programed that everything has to be talked to 35,000,000cm. Everything because that number is what gets drilled in our head. As students, that number is what we tell you. Make sure it’s not less than 35 and everything gets to 35. The problem is, is that in this case you have a smaller diameter implant. So it has smaller components. So the screw itself is pretty small. It won’t withstand going to 35. The screw is going to snap in half and it happens a lot. Please make sure you are familiar with whatever system you end up using. Whether you use Nobel in your private practice or you’re going to use whatever system, familiarize yourself with the components and what the torque values should be. Any other restorative components will be 3530. I’m going to tell you, I never go to 35 because 35 always you’re at its limit. You’re at its highest limit. You’re going to go into deformation after 35. If you adjust your occlusion properly, you don’t need to go past 20. I don’t think I’ve ever gone past 20 and things have stayed in the patient’s mouth perfectly fine. Okay, you’re putting yourself at risk because don’t forget, you’re just using this with your finger. If you go a little bit past 35, all bets are off. Why risk it? 2025 is more than enough to hold these components in place and withstand the forces that whatever chewing forces, whatever, uh, occlusal forces will come on these teeth. All right, so when would I choose an implant over a fixed partial denture or a bridge or even a removable prosthesis? Well, there’s a couple of things we would take into place, right? What is the rigid relationship look like? How? What is the attached tissue look like? What is the inter occlusal clearance where the nerve is, where all the anatomical, um, landmarks are? Because if the nerve is too close, maybe I won’t be able to place an implant. Whereas the maxillary sinus. Whereas the floor of the nose, what is the neighboring dentition look like? If all the teeth next to it are bombed out already and he needs a crown here or crown there, what I do at Crown, a crown or an implant, or I just do a bridge. What is the periodontal condition of the patient? Right. So a lot of things we have to consider before just saying, oh, there’s an excuse me essential space. Let’s do an implant. Right. I can’t stress this enough. Occlusion is so important. I said this and I will continue to say this occlusion will make or break any of your cases, not just implants. Fixed, removable. Any single case you have in the clinic. As a restorative dentist, the occlusion will either make or break your case. If you don’t understand the occlusion properly and you just think it’s like, hey, just bite on this piece of paper, how does it feel? Good. And you let your patient go. You’re going to end up with with complications. Please spend your time understanding occlusion. I know it’s a very dry and not so sexy subject, but if you do have questions or you do have like you’re not really figuring out because I know in the occlusion course and again, I used to teach it before Doctor Morrow. So I’m very, very familiar with it. I know a lot of the condyle in this and you’re like, oh, just stop already. And I know that that part of it is not. The part that is really as important as what the the relationship of the teeth is, but it is extremely important to understand the nuances of occlusion and exclusive and non and all different types of schemes, whether it’s group function, whether it’s balanced occlusion, whether it’s, uh, canine guidance, mutually protected occlusion, all those types of things are extremely important to make sure that you’re either case is going to succeed or fail. All right. So I’m going to show you a little bit, um, about what we talked about today in a couple of cases so that we have a better understanding. Um, and we can kind of relate what I said in this past hour to some cases. All right. So this was my patient floor. I saw her, I think, in 2012. I want to say, um, um, she was a student. Um, and just upon examination, no, uh, you know, she didn’t have any asymmetry looked pretty straightforward case. She had congenitally missing laterals and she had gone through or she had just finished her ortho, uh, to make both the spaces between, uh, on both sides seven and ten equal. Um, here’s the frontal view of the case after she was disbanded. Right. Looks pretty. Pretty nice. Just on observation when we’re looking like this. What do you guys notice? Hmm? Speak up. SPEAKER 5 How is this going to be? SPEAKER 0 Well the age. No, but I’m just saying on this picture, what do you notice? SPEAKER 4 All right. SPEAKER 0 Yeah, right. So the contacts here. All right. SPEAKER 4 What else are the keys? On the left side is kind of lingual. SPEAKER 0 Okay. SPEAKER 1 Yep. SPEAKER 0 Almost like a Crosby. A little bit. Right. Do you guys see what she’s talking about back here? Level. All right. So. So now we’re getting into the nitty gritty, right? This is the important stuff. So if we’re doing an esthetic evaluation right. So you’re saying that the zenith of a is a little bit higher than nine? Correct. Well well, well you have contact here. You don’t have contact up here. Well, you have contact. You just don’t have. You don’t have tissue all the way in. There is a better way of. I would say you still have contact in the incisal third. What else? Let’s. Why don’t we look at the edentulous spaces themselves? What is is the tissue telling us anything? The level. Right. So you see that the level of tissue on number ten is, is, is we have more tissue essentially than we have on seven. Right. Okay. So don’t you think that that’s going to play a pivotal role when it’s time for us to restore these. Right. Okay. So here’s the maxillary occlusal view. You can see that they had the permanent retainer in eight and nine. Um nothing really significant. Mandibular view again they have their retainer there, a couple of composites, nothing. Nothing too serious. Okay. So again, I, I take this case any day and every day. This is I mean, if you have this much tissue to work with. This is fantastic, right. Okay. So they took out the screws. Okay. This is a panel. Um, and you can see the bone levels. We’re working actually with a decent amount of bone here. Okay. So when, uh, when it was time for the implant placement, um, I had sent it to a periodontist who, when they did the implant placement. We. This is, uh. This is before I started using guided. Right. Um, so my surgical guide was based off of a cast, an x ray, and kind of guesstimating where things would be. So basically, what we ended up doing is, um, you can see that the, the implant and the position of number seven. Just looking here, you can tell it is way to facial. Right. You can see how thin the buckle plate is right. So in order for them to gain width what they do is they use a hammer and a mallet and they split the ridge. Right. So this is called a split ridge technique. And again I’ve done implant surgeries but I I’m not I don’t do that. Um, but if you talk to surgeons and if you maybe if you want to learn more about this, you can ask Doctor Fleisher. But essentially, in order to gain width, if this is all the width I have, if I split it in half, right, I get a mallet and I and a chisel and I split the ridge in half automatically my ridge becomes wider, right? Yes, there’s space in the middle, but it became wider. And when I’m screwing the implant in, it’s still engaging on both sides. It just made my ridge wider. Right. So that’s what you see here in order to gain width. Basically that’s what they did here to fit in the implant. And the position of number seven, number ten was perfectly fine. You see how much bone I have? Way more way more bone. Right. So you can see here and you can really appreciate it in this image. Right. Okay. So right after implant placement, this is the kind of provisional that I like making. I’m not saying this is the only way, but I didn’t want to, especially with number seven because kind of the implant placement didn’t go in with high torque. We said we’re going to do a two stage right, so we’re going to bury these implants, but just put cover screws and then send the patient home. Let them heal completely. And then we’ll, we’ll we’ll deal with them. But I didn’t want the patient to go home without teeth. So what I do is I get the cast, do a quick wax up. If you’re really lazy, you can use denture teeth, right? Do that and then basically make a mold. You can use PVS, you can use putty, whatever. And then you have an idea of where they are. And then you just essentially make composite veneers. Right? Which is what these are. These are composite veneers that are held. By an ortho wire in the back and just with composite to hold it in place. All right. And then the patient can go home. It’s not interfering with the surgical site because you can see where the sutures are. So I just want to put facial veneers that are not going to interrupt with the surgical sites. Right. It’s something strictly cosmetic. It is not functional. The reason why I say that is because I get a phone call, not even a week later, and she said I had corn on the cob and I broke it. And I’m like, well, it will not withstand corn on the cob. Right. You’re going to have to eat corn kernels for a while until we until we do that. The beauty is you already have the silicone. You already have the putty mold. You just need to make another composite veneer and spa and bond. It’s very, very simple. All right. All right. So. We waited about 3 to 4 months and now it’s time to uncover. Okay, so. This. Um, and again, I’m really bummed that we couldn’t do the surgery last week because a lot of what I’m going to say now would have made sense. But, um, when. Okay, so let’s say if you were to scratch somewhere on your body, you’re going to potentially leave a scar, right? You’ll you’ll get a mark. Even with soft tissue, you can get scarring. Right. So typically when you were if you’re going to uncover something you’re going to do a mid crystal incision. But if you want to really reflect it you may want to do like some releases. Right. You’ll do like a buckle release to really flap it open. The problem is if you do those release flaps when it heals, it’s going to leave scars. It’s going to leave these long lines. It’s not going to be discolored, but you’re going to be able to see lines. Right. So we were very intentional when it was time for us to uncover to only do mid crustal incisions. Right. And we’re just going to use a makeup elevator and play around and get the top of those implants. You’re going to see that I use those titanium temporary abutments that I was showing you earlier. Right. And they’re sticking out. All right. What do you see the difference between 7 and 10. Right. Remember how we said seven was a lot more compromised? There was a lot more facial. Now, do you see it? Right. If I were to draw a line in the center of. Of here. Do you see how much more facial that is? Right. So here’s the radiograph with these temporary abutments in place. So. And again, Doctor Fouad will talk to you guys. Doctor Toma will talk to you guys in a couple of weeks about this. But essentially what we made this patient is provisional restorations. Now keep in mind. Right. Look at the tissue. The tissue isn’t molded in any way yet, right? The tissue essentially looks the same the way she came in for surgery and they were uneven. And things don’t look right. So we need to fix that. So how are we going to do that? We’re going to make these the patient provisional restorations. These are made out of composite right. The critical contour. What you see here, that’s convex. And the area that’s going to be under the soft tissue which is here which is called a subcritical contour. This won’t be a question on the exam. Um well it depends on what Doctor Toyama says. But essentially there’s two portions of a provisional. Okay. A critical subcritical critical is what you see is convex. Subcritical is concave. The reason behind that anything that is convex. What does this look like. The gingival margin. Yeah. Right. That convexity will determine the shape the size how steep your gingival margin is. This is concave so that soft tissue fills into it. All right. So we made these provisional for the patient. And this is before they were published. It was just here trying them in to see what does the soft tissue look like? Okay. It looks very squarish and flat here. It doesn’t look so great here. So I know I need to add these are made out of composite. I need to add maybe some flour. All right. I don’t like how this angle is coming steep down this way. So maybe I need to build the composite up here this way so I get a more equal. Right. So you play around with it a little bit. And you see every time you play around you see how the tissue is a little bit white here, a little bit white here. Right. That’s called blanching of the mucosa. If you hold your hand, push your thumb down for a while, take it off, it’ll be white. And then as soon as blood comes back in, it becomes red. It’s exactly the same concept, right? We’re putting pressure here. So it’s going to be white and then it’s going to take its time. And then blood is going to rush back in and it’s going to have a normal shape again. All right. So we didn’t like how this looked. We built up some composite. We got some blanching of the mucosa and wanted to make sure that we got the shape that we’re happy with. All right. Now, I wanted to make sure that these both are completely out of occlusion. I don’t want the patient. These are composite, and I don’t want the patient to keep hitting these and breaking them in place. Okay, this is strictly so that I can mold the soft tissue so I get symmetry across the midline. And so that I build an emergence profile. Remember how we talked about the emergence profile earlier. I want to make sure I build a nice emergence profile so it doesn’t look like a lollipop. So it doesn’t look like an implant with just this bulky thing that’s on top. It looks like it’s actually coming from out of the soft tissue. All right. All right. My. My least favorite picture. But my best picture in order to show you how things. Sometimes can get out of hand and how to go around them, and how every decision that we make has a consequence. Does this look more gray than that? A lot more gray. Do you know why? Do you remember? Do you remember this picture? Right. So these are essentially what we did is we made these composite crowns that you saw here. Right. These are scrutiny. The whole is in the back. Okay. This one. The hole is right here on the front. All right, because I couldn’t get access from the implant from the lingual. So now again. And this is composite. You’re going to see, because I don’t have that much room, that this is more gray than this. Because this the access is from the palatal. This the access is from the facial. Okay. So this is why I’m telling you planning is so important. And now guided placement makes it so much easier for you to get a much more predictable outcome. All right. Okay, so again came in for a follow up a couple of weeks later. Again, we’ll build up there. Okay. We waited about, I want to say a couple of months. Took them out. Now, look what we’re dealing with. Looks beautiful. Right? Looks exactly as if the patient had natural teeth that were extracted. That’s what you want to work with, right? Because that gives you a very predictable esthetic outcome. You’re going to be like Doctor Noah. This looks very red and inflamed. That’s a good sign. It’s not inflamed. Right. These crowns are composite as much as you want to polish them. Even if you put them under a lathe for an hour microscopically, they’re still kind of rough. All right. You heard about the Hemi does muzzle attachments, right? That’s why it’s red. Because the tissue had integrated and attached to that crown. Once you pull the crown out, you took those attachments so the blood rushes to the front. This is a healthy, good sign. Okay. So this is what we want to look like, right? Okay. So. Uh, this is a little advanced. I’ll explain it anyways. It’s a little advanced. Okay. Typically what we talked about the impressions. You’re going to put the impression coatings in the patient’s mouth. You’re going to make your impression. And then the impression coatings are going to be into the impression. So what’s this doctor know at the top. Okay I’m a prosthetist. We like complicating things for no reason. Okay. Um, so essentially what you would do is. Because we worked so, so, so hard. Oops. I’m going too fast because we worked so, so hard on developing this profile, this soft tissue profile. I want to make sure that I am transferring that exact soft tissue profile in my cast. Okay. Do you remember what those impression coatings look like? They look like cylinders, right? Yes. They have some anatomy. The open ones had, like these weird shoulders and the close one had, you know, sort of these smooth sides, but they’re all cylindrical in shape. So if I put something cylindrical in shape here, how about all the space around it. Is that going to get recorded. Right. So how do I record that space? This is one technique by by by doing it this way. Essentially you get the provisional out of the patient’s mouth and then you put some compression material around it. And now you would take your impression coping, put it into that space. And you build a custom impression. Coping. Don’t worry about it. Right? Again, it’s going to make a lot more sense this afternoon in the SLC and tomorrow and next week. But essentially we made these custom impression coatings and now we have these abutments. Now look at the abutments. Do you see how this one is way more facially inclined and how much flatter this is. Again, not by design, by necessity. All right. You’ll notice also that these abutments are in titanium. Ideally, I’d like these abutments to be in zirconia. Why are they in titanium? Well, the implant we placed is a noble biosphere. Active 3.0. It’s a skinny implant. You cannot use a zirconia abutment with a Nobel Biochar 3.0. So you’re already working at a disadvantage. So in order for me to mask titanium, we just talked about the kinds of ceramics I’m going to have to use a much more dense ceramic. So I’m probably going to have to use zirconia, which is way more opaque than something like an Imax or if else pathetic porcelain. Right. So do you understand how every decision has a consequence? Right. That’s why I said in the beginning, measure 18 times before you cut. Because yes, while there is a solution for everything, it’s not the solution that you probably wanted. Okay. Here are the zirconia crowns. Like, actually, that doesn’t look too bad. Doctor know. I’m like. I know, but we, unfortunately, as dentists have very finicky eyes. And we can really tell. Look here, look in the E when they say E, do you see how much more opaque these are? Look at the side view. Then you can really see it right. So lighting matters right? That’s why when you all go to all these conferences and they show you pictures on Instagram. Right. This is what you’ll see on Instagram, right? They won’t show you this on Instagram. Right. So it’s important to understand these nuances. Right. Because lighting of how you take the picture, explaining to the patient what it is that you’re dealing with so that they also understand. Right. Because we also have to use zirconia in this instance also, not just because of the. The material I have. But I also do you see where the facial access here for the abutment. And here it’s a lingual access. I need some thick zirconia so that I don’t see through that. Okay, so all in all. This is one I like. You force her to smile, but with her spontaneous smile. See why it’s important with a spontaneous smile. Because she has an average smile line. You see some pink, right? If you didn’t pay attention to this and you didn’t get symmetry across the midline. Then you’re going to have these crowns. One is tall, one is long. And also I think the next case will will will really show you that. All right. So, um, this case, uh, long story short, she had number eight that needed an implant. Number nine had a failing PFM. You can see it. You can see the metal margin on it. That’s why it looks great. But what do we see in the picture is the biggest thing we see. Hi. Smile line okay. She’s a 28 year old female. So you’re you’re dealing with a high smile line on a young female patient. Which again, if you remember from our my lecture isn’t unusual, but high smile lines are not easy to manage. All right. So you look at the case like okay, everything else you know a couple of fillings here and there, maybe some recession back here, but nothing serious. Okay, look at the FM. What do you see on number eight? Practically zero bone. Right. And again, you see a failing CPC or cast post on corps on tooth number nine, right? Because it’s not fully seated or at least on the distal margin of it. Uh, medial margin. Sorry. Rather. Um, so we’re like, okay, now let’s do a chin graft. Right. So basically what they would do is they would take a block of bone from the patient’s chin and put it in that spot of tooth number eight. So here are the donors. Oops. Here’s the donor sites. Here’s the recipient sites. So you can see where the sutures are on the bottom left corner where they took out the block. Right place the the the bone block up in number eight. Let it heal three months later. Kind of looks like, you know, not much has happened, which is a good sign. So they want what they wanted to do is okay, so the patient’s already getting an implant in eight and nine is failing. Why don’t we redo redo number nine. So the patient leaves the day of the surgery with a provisional right, essentially of a temporary crown on number nine with a cantilever, provisional of number eight. So they wax that up. Right. And then essentially here it is. They took off the failing crown, made a provisional out of PMMa. Right. And this crown is just hanging on. And they just put it that way. Right. So now we kind of have an idea. And this is a good also uh, view for the surgeon periodontist, oral surgeon who’s going to place the implant where the crown ought to be, all that kind of stuff. And they have this provisional they can place at the time of surgery and find out if their angulation is off or not. Okay. So here it is with the Provisionals. This is pre-surgery okay. So. This is what the surgeon did with the implant placement. Okay. So. You as the restorative dentist. Why is a great question. And I and I actually have the answer because I was there when the, uh, uh, the surgeon and this was like, and I and I swear I’m not making this up, and I’m not just trying to to to tell you guys a joke. This is the God honest answer. The, the surgeon at the time said, oh, the implant migrated, which is, by the way, is complete bullshit. That that that that is that you won’t find that anywhere in literature. Okay. So basically what happened is after the graft had healed and they place the implant, they place the implant where there was bone. They didn’t please the implant based off of where it was going to be restored. Right. So that’s why I’m saying it is extremely, extremely, extremely important for you to be involved in the planning process. Because if you’re just sending the cases to a surgeon and then they come back for you to restore from a patient’s perspective. I came to your office. You sent me there. You better fix this. Okay. The surgeon did his job, the implants in there, and it’s solid. You need to restore it. We as a restorative dentist are the end user. We hold all the brunt of the blame. SPEAKER 1 Okay. SPEAKER 0 Choose wisely. So let’s, let’s, let’s think about this. What would you do? Take that implant out. Anyone else? Replace the implant. Do you think we’ll have enough bone after we take the implant out? SPEAKER 4 Maybe. SPEAKER 0 Any any. Any other. Any other. Do we want to try to restore this? No, we don’t think so. SPEAKER 5 All right. SPEAKER 0 So here’s another unnecessary, completely unnecessary prosodic. You know, we have to justify why we get paid what we get paid for. Proceed on it. So we make this. Overly complicated impression. Coping. Ignore the slide. Basically, we wanted to make an impression of it. So here it is on the cast. What you see there is a it’s a it’s a special kind of healing abutment. Temporary abutment. It’s a thermoplastic abutment that you can heat and shape. Okay. Made by strongman. You can see the center of the abutment is past the incisal line. Way past the incisal line. Okay. Yeah, basically. And you can also appreciate where the platform of the implant is. It’s even past the edge of the adjacent teeth. So that means your contact point is. I don’t even know where it’s going to start, right? Okay, so what if we get rid of the facial completely? How much is that going to bring that in from there? We’re still at least 2 to 3mm away. Okay. So here’s here’s the modified healing. Oops. Here is the modified healing abutment in place that we just did. I wanted to see what it looks like clinically. You’re still way off, right? Okay, so let’s do a wax up. So here’s what the tooth would look like. Wax up. But look where the access for the implant is in relation to the crown. Okay. Now again, look really graphically. Look where the cage is and look where the platform of the implant is. Okay. So if you were to restore this simulated, it would look like this. Now the patient has a high smile line. Right. This is why it’s extremely important for taking pictures and documenting, not just to cover your own, you know what? But more so, and more importantly, is that you’re you’re trying to remind yourself and understand if the patient already has a high smile line, what am I doing? Do I need to do a tissue graft prior? Do I need to do a tissue graft before? Do I need to build up tissue so I have more tissue? And then if I need to push it away you can push it away, right? A lot of these things you have to consider and taken to take into mind. Okay. So for the patient, for the student who said, um, we’re not going to restore the implant, that is the correct answer. All right. So essentially what we’re going to do is we’re going to bury this implant. Right. And someone else said take the implant out. You’re always better off if you’re not going to restore an implant for whatever reason. And hopefully you never have to deal with that. Just bury the implant, just put a cover screw in it and just. Ignore. Forget about it. Because if you take it out, you’re going to lose bone, right? Because they don’t just screw out. You have to find the implant out. Essentially, you’d have to remove all the bone around the implant and take the bone with the implant out. So you’re losing a lot of bone. It’s a surgery. It’s unpleasant. It’s unnecessary. Just bury the implant, okay? But in order for us to do that, we still wanted to build the tissue back up. Because you see how facial the tissue is and we want it to build. You kind of have, like, a cleft like defect here, right? So we do something called a tunnel graft. Again, I’m not a periodontist. I won’t spend too much time on this. But essentially they make a tunnel and then they take connective tissue from the palate and pass it through this tunnel so it sutures in place. Right. So here it is. Okay. Here you can see the tissue sticking out through the tunnel. They secure it with sutures okay. And then it heals. So we’re going to do a three minute bridge. So now we have so much soft tissue in that spot that if I need to, I can use an ultrafine diamond with a black strip and create some type of emergence if you don’t want to do that, because that is tricky. Just make an overlay on your provisional. If you use a oh wait on your provisional, you’ll be able to mold and soft the tissue the way you want to. All right. And essentially, here’s the we just made a temporary fixed partial denture for the patient. So that’s, uh, a six, seven, eight. Temporary bridge. And here it is. So you see, when we made that modification use of a Pontiac, how you created sort of an emergence profile, right. So whether you’re doing these provisionals yourself or working with a lab. Spending money on a provisional restoration is not a waste of money. Trust me, you’ll get really, really nice outcomes. Um, one of my mentors, when I was doing process residency, told me something that stuck with me. And. And I always try to imprint this whenever I’m talking about provisional restorations. Don’t think of, oh, it’s just a temporary. Oh. It broke. Don’t worry about it. It’s just a temporary. That is completely the wrong mindset. Your provisional restoration is the blueprint for your final restoration. It is the blueprint for your final restoration. You want to make sure the occlusion is right? It looks exactly. It should be polished because if none of that is right, the tissue is going to come back looking like hamburger. It’s going to stink. If it leaks, then you’re going to get caries. Your provisional restoration should be the exact blueprint for your final restoration. So spend the time. Or the money. If you’re not going to do it yourself and get the provisional right. Okay, so here it is, prepped and everything done. And this is the old ceramic feed in place. And here it is cemented now again. Had to use a zirconia with a cut back on the facial right for it to be as opaque. But you can see here’s the bridge in place with the implant down there. All right. So please, for those of you who have lab with me this afternoon, if you could just take five minutes of your time. Um, and for those tomorrow and next week, just before you come to lab, watch the videos. I’m going to explain everything, and we’re going to do everything. So for those of you, I’m going to see you at 1:00. And if you have any questions, feel free to email me. Thank you. SPEAKER 4 Now.