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ePaper created 2017-08-16, 11:36:35 | version 1.38.0
2017(cid:9) Pakistan Edition(cid:9)DENTAL TRIBUNE(cid:9) 15 March Training for medical teachers ... Continued from page 02 Earlier Prof Lehri while addressing the gathering said that such conferences are good for exchange of knowledge. PM&DC is the sole regulatory body in Pakistan and it is its mission to build institution of standard and improve the existing ones. After taking over the reins “We completed all pending certificates and registrations of 20000 within 3 weeks and centralized the induction system for UG medical graduates” he added.(cid:9) PM&DC is committed to improve the quality of doctors nationally and bring them at par with international standards. Soon PM&DC will become part of World Federation of Medical Education (WFME).(cid:9) He said that doctors have the biggest representation outside Pakistan after the labour class. He warned the sub-standard colleges that PM&DC will go after them and it will be either the colleges of the PM&DC, our job is to ensure good medical education and healthcare system.(cid:9) Dr Gordon, President World Federation of Medical Education in his address said that WFME is based in Voltaire France and works through regional associations and also with WHO’s regional office in Cairo. WFME is an organization concerned with the standard of medical education supporting accreditation of schools. Soon PM&DC will be fully recognized by it, he concluded. (cid:9) Dr Rukhsana Zuberi was given life time achievement award in recognition of her services to the profession. Prof Tariq Rafi VC JSMU, Dr Nazeer and Dr Rukhsana of AKU also spoke on the occasion and the ceremony was conducted by PVC Prof Lubna Baig. An indirect method for ... Continued from page 06 PIEZOSURGERY (tip: OT4) and irrigated thoroughly with sterile water.(cid:9) With the anatomically correct surgical guide in position and firmly held in place by the surgical assistant, measurements were made from the midbuccal of each tooth. Surgical cuts were made going from the anticipated cantilever of site #3 (FDI: #16) to site #14 (FDI: #26) using the PIEZOSURGERY saw (tip: OT7). Our team goal was to create the prosthetic room necessary for a hybrid restoration i.e. 10–12 mm. The cuts were intentionally extended beyond the anticipated cantilever length to create adequate strength and thickness of the final prosthesis in these unsupported cantilever areas. The mandibular arch was treated in a similar manner. Additionally, bilateral mandibular tori reduction was accomplished with the aid of the PIEZOSURGERY saw (tip: OT7) after the extractions and prior to the vertical bone reduction of the mandibular ridge. Subsequently, the implants were placed.(cid:9) The implant sites were prepared per the manufacturer’s protocol (except for bone tapping) for the Straumann BLT implant. The implants were placed using the surgical guide template with the following insertion torques measured: site: FDI: #15, #12, #11, #21, #23, #25, #34, #32,#42/US: #4, #7, #8-9, #11, #13, #21, #23, #26. All torques were >35 Ncm with #28 (FDI: #44) recording 20 Ncm insertion torque values. All implants were 4.1 mm in diameter and 14 mm in length except FDI: #12, #11, #21, and #23/US: #7, #8–9, and #11, which were 12 mm in length. All 17 and 30 degree angled implants were bone profiled prior to SRA abutment placement. This allowed the complete seating of the SRA abutment at the recommended 35 Ncm torque. Using the available Straumann bone profilers with the appropriate Narrow Connection (NC) or Regular Connection (RC) inserts was a critical step for an abutment to fit correctly. The following SRA abutments (all were 2.5 mm gingival heights) were then chosen: straight: FDI: #32, #42/US: #23, #26; 17 degrees: FDI: #15, #12, #11, #21/US: #4, #7, #8–9; and 30 degrees: FDI: #23, #25, #34, and #44/US: #11, #13, #21, and #28. Tall protective healing caps were then placed, and the dentures were checked to evaluate that there was adequate space for the pink acrylic to allow for bite registration material thickness. All sockets and buccal gaps to the immediately placed implants were bone grafted. Prior to suturing, the tissue flaps were scalloped with 15c blades to reduce overlap of the flaps over the protective caps. This not only aided in post-operative healing, but also aided in the visualisation of the abutments by the restorative dentist for the provisional insertion. The patient was sutured with resorbable 4-0 chromic gut and 5-0 Vicryl sutures (Ethicon: Johnson & Johnson) and was released to be seen immediately by Dr Randel for the coordinated restorative visit.(cid:9) As discussed below, his responsibilities included: bite registration, impressions, and the dental lab conversion of the complete denture to a metalreinforced fixed transitional prosthesis (indirect provisionalisation technique). Our team of restorative dentists have been treating full-arch immediately loaded cases on 5–8 implants (depending if restoration is a hybrid or C&B) since 1994. Our earlier experiences, for approximately the first two years (1994–1996), have resulted in us all presently using the indirect technique, which in our hands is easier for everyone involved (especially the patient). We handle these coordinated visits between offices, the dental lab, and our Straumann representative weeks in advance so we are all on the same page with timing. These coordinated efforts could be compared to a symphony orchestra, where each musician knows their specific part and when and where they are expected to be. Many of our patients have described this fluidity as a seamless experience that they witness first hand and greatly appreciate.(cid:9) Same-day restorative appointment: The patient was seen in Dr Robert Levine’s office for restorative records with Dr Randel (prosthodontist) in preparation for immediate load protocol. The previously processed dentures were first checked with pressure paste to ensure the absence of contact between the intaglio surface and the tall healing caps. Bite registration material was then used to confirm there was no contact, and later will be used by the lab to articulate the models. Efforts were made to confirm the OVD (with the marked tongue depressor provided by Dr Levine), incisal position, midline, plane of occlusion, and centric position with the prosthesis in place. Adjustments were made as needed. Photographs were acquired to document and relay information via e- mail to the lab technician. The lab will use the registration material left in the intaglio surface of the prostheses, as healing caps will be placed on the newly fabricated models. This allows the index to transfer the OVD and centric relationships with contact just on the healing caps. The soft tissue plays no role in this relationship. A bite registration was made to confirm centric relation. Healing caps were then removed and open tray impression copings were placed. If the connection between the implant abutments and the impression copings are not visualised, then X-ray confirmation of the connection is needed. Transfer impressions were made using a custom tray and rigid impression material of choice, in this case polyether was used.(cid:9) Our lab courier delivered the dentures and impressions to the lab for the conversion to metalreinforced, screw-retained provisionals, which were delivered back to the restorative office within 24 hours. The next afternoon, the prostheses were inserted and panoramic radiographic confirmation of proper seating was obtained. Any necessary occlusal adjustments were then completed. The patient was then seen every two to three weeks for deplaquing and plaque control review per our earlier discussed protocol. The occlusion was also refined as needed. The patient’s TMJ symptoms were significantly reduced within the first three weeks. A water irrigation device was given and reviewed at six weeks post- surgery. As the patient was in Florida for the winter, and unable to come in after the typical three-month protocol, she was seen 4 1/2 months after the surgery. At that time, periapical X-rays of each implant were done to confirm bone healing. The prostheses were removed and cleaned. GC verification jigs, made on the original models and fabricated prior to the appointment, were tried in. If passivity is not confirmed, then the GC jig can be cut and re-indexed.(cid:9) Once the fit of the verification jigs was confirmed, custom trays were used to transfer the relationships. During the following appointments, OVD and centric relations were obtained, and the waxtry-ins were confirmed for aesthetics, phonetics, and occlusion prior to the milling of the framework. It is important to confirm tooth location prior to milling the framework so that the framework was designed within the parameters of the acrylic/tooth borders. At the insertion appointment, the healing caps were removed and cleaned with chlorhexidine. The healing of the soft tissue was demonstrably excellent prior to insertion of the prosthesis. Once inserted, aesthetics, phonetics, and OVD of the prosthesis were confirmed. The occlusion was adjusted as needed. Screws were tightened to 15 Ncm, screw access openings were filled with Teflon tape to within 2 mm of the surface, and a soft material such as Telio or Fermit was used to seal the access. A maxillary acrylic nightguard was fabricated to help protect the occlusal surfaces from wear and reduce any parafunctional habits. At subsequent appointments, the prostheses were evaluated to determine if they needed to be removed to assess the soft tissue or if any contouring of the acrylic was necessary. Eventually, the soft material used to close the access can be replaced with a hard composite material.(cid:9) A Complex-SAC Straumann Pro Arch Case was presented. Management of this treatment utilised the advantages of the team approach for maximising our combined knowledge to benefit the patient, consistent with ITI doctrine. The use of the BLT implants, due to excellent initial stability, gave us the confidence in our ability to not only use immediate extraction sites (Type 1 implant placement), but also to increase avoidance of anatomic structures. In this case, the structures include the maxillary sinuses, nasopalatine and mental foramina, as well as the inferior alveolar nerve canals. In addition, with the tapered design of the BLT implant, maxillary anterior areas could be utilised by the surgeon to avoid apical fenestrations where undercuts could become problematic using straight-walled bone level implants. The coordinated appointments, along with the symphony-like steps in the procedure, created a positive, “seamless” experience for the patient.-(cid:9) DT, Implantology USA TMDT 2017 Continued from page 04 be found about as often as in telescopic prostheses of metal—that is, rather seldom. PEEK is extremely resistant to plaque and inert to acids and chemicals; therefore, the denture can be cleaned with a chemical dental cleaner. F riction is one of the most critical characteristics of telescopic prostheses. The friction of PEEK is very good and can be controlled ex cellently with expansion plaster. However, most important is that friction is permanent. We made our first telescopic prostheses of PEEK about five years ago and we have not observed any loss of friction in that time. Our laboratory has the experience of having made over 300 non-metal telescopic prostheses over the course of 11 years. After initial problems and several tests, PEEK has finally proven a suitable material for telescopic dentures in the long term. Non-metal telescopic prostheses are in no way inferior to metal telescopic dentures, provided they are made professionally. On the contrary, the light weight, the high wear comfort and the absence of metal, in particular, are compelling arguments for dental technicians and patients alike. - DT, General Dentistry Germany