Minutes of meeting
05-19-05
Submitted by George F. Green,
D.D.S.
Introduction
Upcoming meetings:
06/16 literature review
09/15 literature review
10/20 Virtual Treatment Planning
Today's speaker: Dr. Sam Strong, private practice in Little Rock, Arkansas, with emphasis on implant prosthetics, esthetic restorations, and sleep apnea treatment. Author, lecturer, adjunct professor University of Oklahoma College of Dentistry.
TAKING YOUR PRACTICE TO THE NEXT LEVEL
WITH IMPLANT PROSTHETICS - DR. SAM STRONG
A nine-page handout accompanied Dr. Strong's presentation.
Little Rock, Arkansas, is a microcosm of the entire United
States.
Most of us make our living treating middle-class patients.
Important to first IDENTIFY the implant patient, don't
treatment plan or quote fees without a prior treatment conference.
1. Diagnostic work-up = "heart and soul" of case
acceptance.
diagnostic casts: Dr. Strong recommends accu-gel
system II (Ivoclar) as impression material
face bow transfer (rare for Arkansas)
dialogue with patient: obtain
patient's goals and expectations; patients usually need to be educated about
papillas
FMX, pano, refer for CT, CBCT
photographs: 9-11 for case analysis
2. Limited work-up
individual P.A.'s, pano (?)
diagnostic casts = important to
determine inter-arch space
3. treatment planning conference = VITAL! with treatment
team, difficult to do in Southern California face-to-face,
use duplicate models, duplicate
radiographs, scheduled phone conference
identify type of surgical template to be used
prognosis, identify limiting factors,
immediate vs. sequential, provisionalization needs, treatment time estimate
treatment options, case limitations,
risk factors, maintanence requirements
(Dr. Strong feels the literature is
ambivalent regarding the effect of smoking on implant treatment outcomes)
fee estimates, financial options,
informed consent
4. Dr. Strong's sample fees:
initial exam: $55
diagnostic work-up: $500
interim appliance: $900
implant treatment: $15000
Implant Considerations Checklist
1. sequencing
2. implant sites
3. fixture data: size, length, spacing, splinting,
cantilever?
Anterior implant selection:
head design (flat?
scalloped?)
subgingival depth
papilla preservation
/ regeneration
provisional (fixed?
removable?)
dual abutments?
spacing/diameter/length
Posterior implant selection
implant length should
be greater than or equal to coronal height of restoration
evaluate bruxism /
heavy wear
when in doubt,
SPLINT!
Nobelbiocare Direct Implant - one piece
implant placed, minimally prepped, temporized
re-prepped after osseointegration
direct vs. fixture-level impression (fixture-level is Dr.
Strong's "work horse")
fixture-level impression requires ridgid tray, Dr. Strong
recommends Axis Dental "Originate"
Question: "Do you ever give a ballpark fee estimate at the initial exam?" - Only in very small cases (single-unit)
Dr. Strong professionally filmed interviews with 30 of his patuients (hand selected, not random), asked patient satisfaction questions. A film vignette of the interviews was presented.
Nobelbiocare is now promoting public education directly to the patient
IMPLANT RESTORATION OF THE FAILING DENTITION
Implant-supported FPD
transfer impression = implant position
transferred to master cast
must confirm seating of impression coping
with X-ray
abutment connection screws protected by
occluding access opening with light-body impression material
Provisionalize 2-3 months to allow maturation
of extraction site
occlusal table narrowed in buccal-lingual
dimension to center occlusal forces over implant
Case Presentation
62 yr old male,
bilateral implant-supported FPD's
knife-edge ridges
were grafted
post-op occlusal splints are recommended for
large cases / bilaminar occlusal splint (soft in the middle)
retrieval of provisionally cemented
restorations:
Improv cement
(urethane-based): breaks away cleanly, 17% teflon - not a tenacious bond
must lubricate (vaseline) casting and abutment
use Richwill Crown Removers with Miltex 72-10C pliers (sometimes works with
permanent crowns)
CURRENT THERAPIES FOR SLEEP DISORDER - SNORING
Currently, dentists may not treat sleep disorder / sleep
apnea - only provide treatment with MD's prescription. Dentists may treat
snoring.
Snoring: can usually be treated more quickly and predictably
than apnea (def. more minimal breathing or stoppage of breathing)
Usually it is the spouse that will force patient to seek
treatment
Treatment usually includes a weight loss program
Mechanical
Constant Positive Airway Pressure (CPAP) very
bulky, commonly prescribed by MD
Positioning devices
Oral appliances (reposition mandible forward,
resulting in tongue being pulled forward)
Snore guard - not
good for bruxers
Silent Night -
breakage problems
*TAP (Thorton
adjustable positioner) - Dr. Strong's favorite
lab cost = $250
ortho changes (posterior open bite) are rare but possible - should include in
informed consent
should include physical therapy / exercises in morning to re-set condyles
locater abutments (Zest) can be added to TAP to fit overdenture abutments
Surgical
several surgical treatments to enlarge airway
opening, including removal of uvula, are available.
DENTAL IMPLANT AND ALTERNATIVE OPTIONS
Dr. Strong has created a patient info DVD
which is available for purchase (www.strongdds.com , 1-866-826-4452)
Exerpts from the DVD were presented
Extract a tooth - walk out with:
1. flipper?
2. provisional crown with Nobelperfect
immediate placement implant ("scalloped" for papilla/bone
preservation)
Scripting For Staff
Staff needs to be reminded daily of
"office mantra" . . . "scripts" should be available at every
telephone so patient inquiries
can be answered accurately
Advise patient that atrophy will proceed if treatment is delayed
10-year survival rate on crowns and FPD on
natural teeth = 75%
10-year survival rate on crowns and FPD on
implants = 95%
Standard of Care for mandibular edentulous patient:
2 implants with attachment overdenture
Locator attachments /
Zest anchors are user-friendly
bar-retained overdenture
outline of
appointments / procedures given in hand-out
Fees for Implant Treatment
An example (4-implant / bar) overdenture was
presented to illustrate a method by which Dr. Strong establishes a fee:
1. Lab fee (surgical template $150, baseplate
135, cast bar 900 (AR) -2000 (CA), process denture with teeth 450, metal
reinforcement casting 150, clips/housings 75, tax, shipping) = $1900
2. implant components (implant copings 200,
analogs 100, abutments 800) = $1100
3. overhead: 4 hours chairside + 1 hr total
for adjustmnents first 6 months = 5 hours X $400/hr = $2000
4. profit: profit/hour for 5 hours =
$500/hour X 5 hours = $2500
5. FEE = lab fee + overhead + profit = $1900
+ $1100 + $2500 = $7500
Use of locater attachments (Zestanchor.com) instead of bar/clip reduces procedure by one appointment (no bar try-in), decreases costs by $1500.
Meeting adjourned at 9:00 PM