Restorative Space


Hey, what's up? I'm trying out a new format. I'm gonna do it this way just to see how you like it. Let me know I feel like it might be a little bit more illustrative. So let me know what you think Okay, but in this one, we're gonna be talking about restorative space. So I choose this cover picture because I feel like we run into a lot of trouble with the all in X treatment Because we try to fit too many things in a space where they really shouldn't be so I'm gonna talk to you a little bit about how to Decide if you have enough space and what to do if you don't. So, let me move forward here All right. So this is a picture from Nobel biocares System so you see right here. We have the implants. I'm going to show you with my mouse here Hopefully you guys can you I'm sure you can see that. So this is where the implant level is. Above the implant level we have the multi-unit abutments. So here's this back multi-unit abutment here are the straight multi-unit abutments in the front This back one is angled. So the purpose of the multi-unit abutment is twofold first you're raising the restorative platform from the implant level to the tissue level and So what that does is it makes it a lot easier to restore? Because you're not going to be pinching the patient's tissues every time you go to take an impression or to try things on. The second thing that a multi-unit abutment does is it changes the angle so you see back here We have a 30 degree angle implant. So this is a an angled implant and this multi-unit abutment corrects the angle. So it's two things it brings it it brings the restorative platform up and it corrects angles when needed but you see we're trying to fit a multi-unit abutment the multi-unit abutment screw and then you're fitting the framework that's inside of this prosthesis and Then you're fitting the the stuff that goes over the framework just to make the make the teeth look pretty and to make the gums Look realistic and then you have these screws inside. So you see there's a lot of things that we're trying to fit into a small space Just to balance it out. I'm going to show you the the neodent Version as well. I'm not like dedicated to any one Company in particular is want to show you the you know how these two compare So with neodent so you have same thing you have the implants up here on top of that you have the multi-unit abutments This is a straight. This is the multi-unit I want to show you and this is the reason why I'm comparing these two these two different systems I want to show you what the Nobel multi-unit looked like and that's that's it right here Remember, we saw it in the previous picture and this is the neodent multi-unit. You see the neodent multi-unit is a lot more slim It doesn't have this corner on it It's got like this more like sleek kind of like wineglass Shape to it and the reason that that's beneficial is because you're less likely to bind on this bone. See, so when this multi-unit abutment goes into that implant one common problem one one thing that you have that takes a little bit of time clinically when you're doing these surgeries is That this multi-unit abutment is gonna bind on this bone. That little angle is gonna push on that bone and you have to get a bone profile burr and then and then adjust that bone Away, that was a problem with multi-unit abutments that are shaped like this, but the neodent design has this kind of like slim Profile to it. So it's a little bit easier to work on that and less likely that you have to adjust away the bone But anyway, I just want to show you all the stuff that fits into that restorative space. This is a picture of a frame that I actually had to cut I was working at a place that was doing a lot of all -in -fours a lot of a lot of implants and They were getting a lot of complications, too. And so this particular case, it's You see these little cylinders. So these cylinders they They were not fully seating on all the implants Well on one implant there was a gap and that doctor kind of like forced the cylinder down with the screw. So ideally what you want is for these frameworks when you go to deliver them That they sit on all of the implant on all the multi-unit abutments that they sit passively so that there's like no gap Between the cylinder the prosthetic cylinder and the multi-unit abutment So there's no gap but what was done in this case was there was a gap But the doctor put the screw on and kind of like forced it down and then so that screw kept breaking and kept breaking even After changing it multiple times so what I did was I just kind of sliced this framework in half and Then I seated both pieces of the of the framework and the patient's mouth I connected them with acrylic then I sent it to the laboratory for laser welding and The patient didn't have that same problem anymore after that But I just show you this basically because I want to show you a cross-section this is the this is actually the only time that I've actually sliced the frame in half and It was cool because I get to see a nice cross -section of what what goes in there So with acrylic frames what what can happen is if you if you try to fit too much stuff in there it makes the acrylic too thin and then the acrylic will will like start crumbling and Once your acrylic breaks and you try to repair it I mean, yeah acrylic is repairable But it is more likely to break again and again and then you kind of like trying to trying to solve you kind of like Chase the the cracks and it's really hard This is a case that I did in my residency So this gentleman had I think he had like three different prostheses made This is his third one and he's just like crumbling it. He's this it's he's just going through it and It's having a really hard time so this is you know, this is what you would call in an acrylic hybrid It's got a titanium frame in the middle and it's got acrylic wrapped around it All right, so I'll show you what it looks like from the front. He's smiling he's actually a really really nice guy and really easygoing, but he's really having a hard time with this and I actually Chose actually requested this case because I want to know how to troubleshoot these things So if you measure so I measured how much space I had there and it looks like I barely had ten millimeters of restorative space So I'm just measuring that from I guess where the incisal edges of the teeth would be all the way down to the implant level In this situation, I did not use there was no multi-unit abutment And so I'm measuring from the incisal edge to the implant platform if there was a multi -unit It would eat up some of the room soThat's one reason why multi-units were not used in this case. So anyhow, these pictures right here. Oops only moved me out of the way and so these pictures right here were published by Lyndon Cooper and they just show what happens when you try to fit too much stuff into too little of a space. All right, so the question you have to ask yourself is, does this patient have 15 millimeters of restorative space? That's after you've already asked if they have enough lip support and if they have a visible transition line. The third thing you're asking is, do they have enough restorative space and with that, what that means for me is, do they have 15 millimeters of restorative space? Now you're probably wondering, like, I was wondering, how do I even know if they have 15 millimeters of restorative space to begin with? All right, so I'm going to tell you. So the only two ways that somebody can have 15 millimeters of restorative space to begin with is, first, if they're a dentalist and they have already had some resorption of their Ridge, right? So if they're missing their teeth and they've already had some resorption. The second way is if they're dentate, so they have their teeth, but they have a lot of perio-related bone loss. If they have a lot of bone loss, they might already have their bone might already be at a level where you don't need an alveoplasty. You just need to remove those teeth. All right, so let me just walk through it with you just real quick. So this is a patient that has just been Indentulated, right? You can see that their teeth were we're just extracted and if this patient was restored with an all-in-four, you won't have that much space. Right, you're gonna try to barely squeeze in their teeth and their gingival Prosthetic in a really small space. So that's not gonna work. But over time, as their bone resorbs and they acquire a composite defect, so these are things that we went over previously, but as they acquire a defect, now you have more space and now you can restore with them with an all-in-x type of prosthesis. Over time, if they continue to resorb, so if they're not restored and they're wearing a denture for a long time and they continue to resorb, then they have a really big composite defect and now it's a little bit of a harder situation you see. This is the scenario that you run into if you try to restore them with a fixed restoration with an all-in-x. You can have this little dip right here. We talked about it previously. That's a nasolabial fold. They'll have this little dip right here, this little stair step, and that could that could lead to an anesthetic result. And in those cases, you might resort to a conventional denture or an implant-supported over denture. So all right. Awesome. So now how do you go about measuring the 15 millimeters? So there's a few different ways to measure it. The easiest way for me and the way that I like to do it is I just take a cone beam and I just look at it in cross-section and I just measure from the incisal edge I started the incisal edge and I carry my little, you know, my little measurement tool apically until I see that it measures 15 and that's and at that 15-millimeter mark, that's where I know that I'm going to be doing my alveoplasty to create that 15 millimeters of space. Now this is an estimation, right? Because like for example, somebody might say in the maxillary arctic the teeth overlap, right? And so even if you measure from incisal edge to the to where you're gonna place your implant, if you measure 15 millimeters, that's not really how much room they're gonna have right because of the overlap. 15 millimeters is an estimation. There's probably other ways to measure too. That's how I do it and it's been a pretty convenient way so far to make it just real easy for me to know how much I have to cut. So after I measure at each individual tooth site or I guess in each quadrant or maybe two sites per quadrant, I reconstruct that cone beam into a panel, right? So I turn my cone beam into a panel, a panel view, and then I mark it up. So that way on surgery day, I have something to refer to and it's really easy for me to know like what I was planning previously, so I just mark my nerve right here. All right, nerves marked in yellow. The implants are marked in red. So I just kind of estimate where I'm putting my implants. It's not super precise. I do change my game plan intraoperatively, but this gives me an idea of where I was planning to put my implants and at what angle. And the purple shows where the big periapical apical infections are. That's important because I'm not trying to place my implant into a big periapical infection, and I want to make sure that I debride that and I remove all that granulation tissue and all that infection from that site. So that just serves as a reminder for me. This green line is the alveoplasty line, and these green numbers are the numbers that I came up with when I look at the cross-section, how much I want to alveoplasty. Another thing you can do is you can mount your models, and then your laboratory can measure 15 millimeters for you, and they can make a bone cutting guide for you. What I like to do is once I've decided how much alveoplasty I'm gonna do, after I pull the teeth, I measure with a periaprobe. You see my periaprobe right here. I measure like if I wanted to do six millimeters of reduction right here. I'll measure it, and then I'll mark it with a burr. I'll mark it with something so that way I know how much I have to reduce, and then I'll go ahead and take that bone down with this rounder. I like to use the round burr. Round burr is safer. If you're just starting out, I know some people use reciprocating saws. Some people use a straight burr and just cut it off. I think that the round burr is the safest. The only thing, the only downside to is you get a lot of bone going everywhere. So be sure to get your face shield to avoid all that bone in your face. All right, the last little tip I'm gonna give you for measuring restorative space is you can get a clear denture or you can even get your regular denture that the regular denture that you're gonna be delivering or converting that day. You can have your laboratory mark it with a permanent marker right here on the side, on the buckle, or you know on the facial aspect where 15 millimeters of space coincides with, or they can make a window. So I'm not talking about this lingual window. I'm talking about a buckle or facial window so they can make a window just to show you how much you have to cut. So with that, I'm gonna leave you with this right here. The last question that you're asking yourself is this, is there 15 millimeters of restorative space? If there is, you can proceed with the treatment. If there's not, you need to do alveoplasty to gain the space, and I hope I described how you can do that. All right, moving on.

Lesson Summary

This text discusses the concept of restorative space in dental procedures. The author explains that restorative space refers to the amount of space needed for a prosthetic restoration on dental implants.

The text mentions that measuring restorative space is crucial before proceeding with treatment. This can be done using methods such as cone beam imaging and measuring from the incisal edge to the implant platform. Additionally, the author suggests using a clear denture or marking a regular denture to visualize the desired space.

The use of multi-unit abutments is also discussed. These abutments can be used to raise the restorative platform and correct angles in dental implants. The text compares two different implant systems, Nobel Biocare and Neodent, that offer multi-unit abutments.

Complications related to lack of restorative space are highlighted, and the importance of alveoplasty (bone reduction) is mentioned as a solution. The author provides examples of complications and emphasizes the need for precision in implant placement to avoid binding on bone.

The text also discusses a case where there was a problem with multi-unit abutments. The doctor had to adjust the bone and force the abutments down with a screw to fix the gap. The use of a neodent design with a slim profile is mentioned as a solution for easier delivery.

Overall, the text provides tips and techniques for measuring restorative space, using multi-unit abutments, and troubleshooting issues in dental implant surgery to ensure successful prosthetic restoration.

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