My full arch journey started years ago I suppose and has stair stepped through extraction/ grafting, implant placement, full mouth extractions, over dentures, iv sedation, and was brought all together with 3D dentist courses like Live patient all on x lead by T-bone, scale your full arch, and even onsite mentoring visit with Sully which was a game changer . Not sure if this is the best place to post this but it’s a start. Over the last year we have been averaging 1-4 arches a month and it’s been a fun journey for sure. I just hope to post and share topics that come up in the arena and hope to start some discussions with those who are interested. Also this won’t be about just trying to show how things always go perfect… because basically there is always something to pivot from in full arch. In fact, learning how to PIVOT is probably the most important skill of all.
We had two arches this week here is one of them The full arch journey incredible. Comes with its unique set of challenges and learning curves. Everything from clinical/ sedation/ trouble shooting to the business side and marketing. The team and practice growth that comes with this service is kind of like no other. Literally every case has something to learn, share or teach from. Happy full arching to those already in the mix and to those who are headed that way.. Here are little notes from the cases. Happy to discuss. Basically no matter how well you prepare for these cases things rarely go exactly as planned. It’s those things I hope to share and spur discussion or thoughts on to help level up.
Case 1 BB
Completed upper arch 6 months ago. In temp PMMA. Finishing both in Zr after lower healing.
Quick summary: Original treatment plan to save lower arch and supplement with a handful of single implants. BB is exhausted emotionally and financially at putting $4-5k per single and she also feels down the road her surgical/ sedation complication and healing will only be more challenging. Walked her through the options of keeping what is restorable versus clearly the canvas. She went with the latter.
Risk Factors: low
Arch: did both but this is focused on the mandibular
Stackable: Chrome
Planned: FP3
Photogrammetry: ICAM/ IMETRIC
Designer: ROE Labs
Implant tapered pro
Prosthetic screw: vortex
Obstacles worked through:
Limited opening
Soft bone (mandible slightly unusual)
Hypotension mid surgery
Truncated temp prosthesis
Limited opening: It happens. In this case midway through we removed her upper. Thants not always an option. I think the best way to prepare for this is to quickly look during the consult at MIO and just have an idea what you will do f someone can only open 35-40 mm especially on a lower arch. Being prepared to start an osteotomy with a guide and switch to free hand. Helps a ton on the distal angulated implants to have something started at least.
Soft bone: It happens I think using clues from feel is the best bet here but that does not always work. It’s probably one of the draw back to guided. That being said there are clues. Obviously the mandible usually more dense the the maxilla. Here are three clues I think help: 1) initial pin drills 2) tooth removal 3) Initial osteotomies. On the initial pin drill like to stop 1-2 mm short of the sleeve and run it 1000-1300 rpm. Usually closer to 1300 and go in an out quick. The reason for his is the bur can get stuck in dense bone. When that happens, it sucks balls but you cab get it out with a ronguere or running it in reverse. Leaving 1-2mm short of the sleeve allows you the hammer that thing in and ensure its stable. If these drills have little to no resistance, it’s the first clue to me that it could be soft bone. Tooth removal: kind of obvious here but there are times where tooth removal seems challenging and the bone is not necessarily dense. But it’s another clue. 3) Initial osteotomy: I try to be cognizant of the feel of the first drill in particular. Of course breaking through the cortical plate on an ideal site is going to give some resistance. Yet there are times where the drills feel like they are having any resistance. It’s just another clue. To me why all this matters is it affects your UNDER SIZING PLAN. We typically plan bio 4.2 diameter implants with a preference of 4.2×12 with the intension of placing 4.6. On the new bio kit pro our normal sequence would be 3.2 pre drill, 3.2 x9 drill and then in soft bone go to the 2.8x final and place a 4.6. In dense bone go to 3.2x final and place 4.6. I rarely go to the final 3.7 for a 4.2 era 4.6 apically. Opening the coronal portion of the osteotmy to me is all good but undersizing the apical portion by2-3 burs is standard. In the case I took everything to a 3.2 and had several less than 35 n/cm. The implant in #29 dropped in less than 10n/cm and was removed and placed by hand to a 5.2×9, cover screw and done with it.
Hypotension mid surgery: It happens. Who and how you do the sedations could be anything from oral sedation to iv sedation that you run or having CRNA/ GA. I have done all three. I have kind of prefer doing the IV sedation myself (nurse on the monitor and does veinipuncure 😉 CRNA are awesome but a challenge to schedule, added cost to procedure/ patients and in TN sedates at my level. If they are pretty sick we will do CRNA route. But here just triazolam versed fentanyl and the normal post op stuff dex toreadol and zofran at the start. Anyway….. 1) check cuff this is the first thing recycling it is sometimes all it takes. 2) Open the IV bag line and just take a break for 3-5 minutes. If the BP doesn’t rebound it not uncommon for a patient to start to feel sick during this situation. Sit them up, grab the barf bag, O2 up. Of course if BP does not stabilize and nausea continue, EMS better safe than sorry?
Truncated temp: Best way to handle this… just review at the presedation meeting. Treatment details reviewed after case acceptance idea here. Surprisingly patients are cool with this in my experience. And just better safe than sorry, cut off all the distal cantilevers. Im a self admitted people pleaser. I have done the stupidest things as a result of this at times. Anyway, no negotiable in may opinion here. I also think a good tip is at the pre sedation/ surgical meeting ( for us this is one hour in the assistant chair) and we go over the worst case scenarios including leaving with a denture. Although unlikely, for me it helps just free me upon to make stupid people pleasing decisions. In thins case it was extra truncated because the distal implant #29 had to be buried.. But is what it is. On x tough 2 with vortex.
Happy full arching to all. A rising tide lifts all boats.
