Dr. Irfan Atcha's article on Inside Dental Technology magazine

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Dr. Irfan Atcha's article get's published in the Inside Dental Technology journal. This is the 3rd article that was published on Dr. Atcha's work on his expertise on the Advanced All-on-4 Dental Implant Concept.

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Dr. Irfan Atcha's article on Inside Dental Technology magazine

  1. 1. 34 inside dental technology November/December 2010 www.insidedentaltech.com eoplearelivinglongeranddemandingmorefunctionalsolutionsformissingdentition.Becausemany patients do not want to deal withthe inconvenience of a conventionaldenture prosthetic, the demand fordental implant-retained prostheticshas increased. Any dental team that in-corporatesalessexpensive,immediate-load product option can offer patientsa great service. However, completerehabilitation of the upper and lowerjaw can be costly and time-consuming.The All-on-4 concept (Nobel Biocare,www.nobelbiocare.com) is an optimalalternative for many patients becauseit utilizes only four implants per archfor an immediate complete full fixed-detachable, screw-retained prosthesis.Thebenefitsarenumerousandexcit-ingforpatientswhohavesufferedwithill-fittingdentures.Dentulouspatientsin need of extractions with terminaldentition can take advantage of thisconcept,whichincreasesstability,evenwithlowbonevolume.Theycanchoosefromseveralprostheticoptions,suchasa fixed, titanium implant bridge withacrylic veneering or individual crownscemented to the bridgework.Thetreatmentprocedureusestiltingposteriorimplantstofacilitateoptimalsupport for an acrylic or compositebridge that can be fabricated and func-tioning just a few hours after surgery.Based on documented measurements,tilted implants have shown good clini-cal results. The system can be used inthe maxilla, allowing the dentist toavoidsinusgrafting,orinthemandible,toavoidhavingtoplaceimplantsposte-riortothesymphysis.1Italsohashigherpatient acceptance rates because of itslower cost and shorter treatment time.Case StudiesThe case study review photos includedinvolve numerous patients who hadMasterClassIrfan Atcha, DDSOwnerNo Dentures Chicago DentalImplant CenterDyer, IndianaLuke Kahng, CDTOwner and FounderLSK121 Oral ProstheticsNaperville, IllinoisImplant-RetainedProstheticsRestoring the orally-handicapped with the All-on-4™technique.By Irfan Atcha, DDS; and Luke Kahng, CDTPGallery / Hands On
  2. 2. www.insidedentaltech.com November/December 2010 inside dental technology 35similar complaints, many of whomwerecompletelyedentulousandtiredofwearingdenturesthatneverfitproperly.Poorly fitting prosthetics limited thepatients’ menu choices at restaurantsand made social gatherings painful be-cause eating or smiling in public oftenmeant dealing with a loose prosthetic.Intheauthors’experience,patientswhoare desperate for a change will eagerlyembraceanimplant-retainedoptioninorder to avoid the embarrassment en-dured with removable prosthetics.Our patient presented with a fully-edentulous maxilla and mandible. Thedentalteamdecidedonatreatmentplanusing the Nobel Biocare All-on-4 im-plant system. The clinician placed eightimplants—fourinthemaxillaandfourinthemandible(Figure1andFigure2).Anopen-trayimpressionwastakenandim-pression copings were placed. The den-tistconfirmedproperseating(Figure3).After taking the impression, the cli-nician sent this case to the laboratorywhere the analogs were placed and thesoft tissue cast was created (Figure 4and Figure 5). The lab received themidline, vertical dimension, high lipline, and lip support from the clinicianin order to set the patient’s tooth posi-tion and facial features (Figure 6).Fig 1. and Fig 2. Retractedview of the patient after implantplacement.Fig 3. The open-tray impres-sion technique was used, andimpression copings were placedafter X-ray confirmation.Fig 4. Soft tissue was addedusing a syringe after the ana-logs were placed.Fig 5. Final working modelwas poured with soft tissue inplace.Fig 6. The clinician verifiedmidline, vertical dimension, highlip line, and lip support.Fig 6.Fig 5.Fig 3.Fig 2.Fig 1.Fig 4.
  3. 3. 36 inside dental technology November/December 2010 www.insidedentaltech.comGalleryAlongwithcreatingthebiteblocks,thelaboratory also fashioned a verificationjig to make sure the master cast modeland the patient’s mouth were mirrorimages. Before creating the verificationindex, the temporary abutments werescrewedintothemodelandabarwasla-seredtocreateindexstability(Figure7).The light-cured wax verification indexwasthenformed(Figure8andFigure9).The next step was the patient try-inat the doctor’s office. The clinician wasaskedtoverifyfitwiththesameverifica-tionindexthatwascreatedbythetechni-cian(Figure10andFigure11)byscrew-ing in each temporary abutment, one ata time. If any problems were to arise atthis try-in checkpoint, the doctor couldcutandreconnectthejigintotheproperposition.Hecouldthenverifytheseatingof the implants with an X-ray and sendthe case back to the lab. Necessary labadjustmentscouldbemadeatthistime.After the lab received the bite blockback from the clinician (Figure 12), atoothwaxtry-inwasfabricatedaccord-ing to the doctor’s bite block markings.Thecasewasthensentbacktothedoc-tor to confirm occlusion and estheticsand verify the phonetic position of theteeth prior to bar fabrication.Oncethedoctorverifiedthetoothset-upinhisoffice,hethensentthecasebackto the laboratory, where a putty matrixwascreatedasarecordoftheteethposi-tioning(Figure13andFigure14).Usingtheputtymatrixrecord,awax-upofthetitanium bar for this case was formedwith the Metacon light-cured wax sys-tem (Primotec, www.primogroup.net)for consistent quality (Figure 15).Using the NobelProcera™ CAD/CAM scanner (Nobel Biocare), thewax bar fabricated from the Metaconlight-cured wax was scanned and sentfor processing (Figure 16). This CAD/CAMtouch-scanningsystemisveryac-curate for designing implant bars, andtakes approximately 2 weeks to com-plete once ordered.Afterthisimplantbarwasmilledandreturned to the lab (Figure 17), the au-thorverifiedthefitwiththeframeworkonthemodel,comparingthemetalandwax framework (Figure 18) and adjust-ing as needed. Next, GC metal primer(Metal Primer II, GC America, www.gcamerica.com) was applied to the bar(Figure 19), followed by the opaquingprocess(Figure20)andapinkcompos-iteapplication(Figure21)beforebeingsenttotheclinicianforapatienttry-in.Thisstepwasthefinalcheckforthepa-tient and clinician to ensure proper fit.Fig 7. The temporary abut-ments were screwed into themodel and a bar was lasered tocreate index stability.Fig 8. and Fig 9. The verifica-tion index was formed usingPrimotec’s Metacon light-curedwax.Fig 10. and Fig 11. The veri-fication index was then sent tothe clinician for him to verify fitby screwing in each temporaryabutment and noting any nec-essary adjustments.Fig 12. After the bite blockwas received back at the labo-ratory, the technician fabricateda wax try-in according to thedoctor’s recorded markings.The more laboratory technicians know about this techniqueand the more they learn to perfect it, the better they will beable to accommodate both the clinicians and their patients.Fig 7. Fig 8.Fig 9.Fig 12.Fig 11.Fig 10.
  4. 4. www.insidedentaltech.com November/December 2010 inside dental technology 37Fig 13. and Fig 14. The puttymatrix was then used for apositioning check and to helpdesign the titanium bar.Fig 15. A wax-up of the tita-nium bar and denture teeth wasplaced over the model prior toscanning.Fig 16. The wax-upwas scanned using theNobelProcera Forte CAD/CAMscanner.Fig 17. and Fig 18. After theimplant bar was milled, the fitwas compared between thewax framework and the metalframework.Fig 19. GC Metal Primer IIwas the first application to theimplant bar and was done priorto opaque.Fig 20. A layer of opaque wasnext applied to the implant bar.Fig 21. A pink composite waslayered over the opaque.Fig 21.Fig 20.Fig 17.Fig 16.Fig 13. Fig 14. Fig 15.Fig 18. Fig 19.
  5. 5. 38 inside dental technology November/December 2010 www.insidedentaltech.comGalleryApprovalforfinallaboratoryprocessingwas given at this time.Aftertheclinicianverifiedthebarandreturnedittothelaboratory,theauthorbegan creating the composite dentureteeth. The first and second steps in-volved the application of GC GradiaOpaque (GC America) (Figure 22) andthenopaciousdentin(Figure23).Aba-sic A2 dentin was applied (Figure 24)beforelayeringpinkporcelainontothegum area (Figure 25). The incisal one-thirdwascutback(Figure26),andbluestainwasapplied.Tomodifyfurther,theauthor applied an orange stain (Figure27 and Figure 28) to reproduce mam-elon effects. To then create a lifelikegradation of color, he applied the stainto the interproximal areas (Figure 29).Thecornerareasofthedentureteethwere covered lightly with a white stainto create a three-dimensional effect(Figure 30) and then layered againwithaclearGCGradiaComposite(GCAmerica) material (Figure 31). Figure32 shows an occlusal view of the man-dibularoverdentureandFigure33dis-playstherightquadrantviewoftheoc-clusalcontour.Themandibularleftsideocclusalview(Figure34)givesaclose-up of the natural, lifelike color the au-thor fashioned with his use of compos-itematerial.ThecurveofSpee,curveofWilson,andtheheightofcontourwerechecked on the cast model (Figure 35)and then again on a mirrored surfaceFig 22. To begin creation ofthe denture teeth, GC GradiaOpaque was layered onto theimplant bar.Fig 23. A layer of opaciousdentin was the next step.Fig 24. The opacious dentinapplication was followed by alayer of A2 dentin.Fig 25. Next, pink compositewas applied to the gum area.Fig 26. The technician cut theincisal one-third back and ap-plied blue stain.Fig 27. and Fig 28. Furthermodification of the dentureteeth was accomplished withorange stain to help createmamelon effects.Fig 29. Stain was applied to theinterproximal contact areas tocreate lifelike gradation of color.Fig 5.(Figure 36). Next, the final restorationwas placed in the mouth (Figure 37).Ifthebarwerefittedwithacrylicteeth,theprocedurewouldbeslightlydifferentfor the final try-in. Instead of buildingthe teeth onto the bar as demonstratedin this case, the acrylic denture wouldbefabricatedandtemporarilyplacedonthebar.Thepatientwouldthenapprovethe shape of the teeth before they werepermanently placed on the bar.ConclusionThemorelaboratorytechniciansknowaboutthistechniqueandthemoretheylearn to perfect it, the better they willbeabletoaccommodateboththeclini-cians and their patients. The All-on-4concept is a perfect alternative formany patients because it utilizes onlyfour implants per arch for an imme-diate complete full fixed-detachable,screw-retained prosthesis.The authors would like to acknowledgeSteve Stevens, CDT, from LakesideDental in Mokena, Illinois.Reference1. Parrish K. Full-arch rehabilitation with theAll-on-4™ technique. Description of lectureto be presented at: the University of TexasHealth Science Center San Antonio DentalSchool; February 18-19, 2011; San Antonio,Texas. Available at: http://cde.uthscsa.edu/coursepages/parrishfeb.php.Fig 22. Fig 23. Fig 24.Fig 26.Fig 27.Fig 28.Fig 29.Fig 25.
  6. 6. Fig 30. The corner areas ofthe denture teeth were paintedwhite to create a three-dimen-sional effect.Fig 31. Clear GC GradiaComposite was applied.Fig 32. Occlusal view of themandibular overdenture.Fig 33. Right quadrant view ofthe occlusal contour.Fig 34. Mandibular left sideview of the overdenture.Fig 35. and Fig 36. The curveof Spee, the curve of Wilson,and the height of contour werechecked on both a cast modeland a mirrored surface.Fig 37. Final restoration inthe mouth.Fig 30.Fig 32.Fig 34.Fig 33.Fig 35. Fig 36.Fig 37.Fig 31.40 inside dental technology November/December 2010 www.insidedentaltech.comGallery

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