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Supporting Your Practice

View from the Chairside – The Immediate Bridge

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Dr. Belzycki's Thoughts

The Immediate Bridge is a most useful technique to restore form and function in one appointment. This presentation reviews a recently completed case for an elderly lady that did not desire a long protracted and expensive implant case.  I unabashedly claim that I still prefer conventional tooth supported fixed bridgework over implants where possible. I have experienced long-term success with both approaches, as many of my Oasis posts bear witness. A dentist must be competent with both protocols in order to best serve the individual needs and sentiments of a patient. In a Core 1 presentation, an educator claimed that increasingly dentists may prescribe treatment not based solely on a patient’s needs, but rather on what they themselves might feel most comfortable doing.

Hence I claim…the more tools in the toolbox…the better the clinician.

We hope you you find the conversation helpful. We welcome your thoughts, questions and/or suggestions about this post and other topics. Leave a comment in the box below or send us your feedback by email.

Until next time!
Chiraz Guessaier, CDA Oasis Manager

Oasis Moment (.50")

Full Presentation (40.50")

4 Comments

  1. Vasant Ramlaggan April 14, 2020

    Great presentation. Work looks great. Thanks!

    Reply
    1. Dr Belzycki April 14, 2020

      Dear Vascant

      I remember you from past comments. Many thanks for your support of these presentations.

  2. david melamud April 19, 2020

    Thank you for the great presentation! 3 questions:
    1) With no posterior teeth other than 1st premolars, how is your bite registration accurate…don’t the models rock relative to each other?
    2) Since you indexed the dies, what is the porcelain work done on now, since there’s no opposing occlusion?
    3) After a period of times, you re-prepped the teeth including margins I take it, how does the temp still seat without tipping labially or lingually, and how have you not lost your vertical?
    Thank you,
    Dave

    Reply
    1. Dr. Paul Belzycki April 21, 2020

      David, Thank you for your questions. I believe an attempt was made to describe how the vertical dimension was controlled.
      At minute 12:30, I explained that I initially left the cuspid teeth unprepared in order to index the acetate stent that is used in the fabrication of the provisional bridge. Once the methyl-methacrylate (MMA) acrylic has fully cured, it is hollow-ground (minute 15:40) so that it will go to place and be indexed by the three prepared teeth. Then, the cuspid teeth were prepared and additional MMA acrylic was placed in the stent (minute 17:30) and squashed down on all the prepared teeth.
      The bridge was then refined as best as possible to ensure accurate marginal adaptation and adequate embrasure design to allow for easy homecare, (minute 19:30). At this point, the bridge was placed on the teeth and I decided that the final anatomy, in terms of esthetics and occlusion required further refinement. This is often the case, when so many landmarks are missing…in this case, the posterior teeth. With MMA acrylic, one can add fresh material as I did at minute 19:40, and then ask the patient to bite down and impress the occlusal contacts of the opposing arch into the soft doughy acrylic. Once the acrylic is set, one merely removes the excess and leaves the flat surfaces that were in contact with the opposing teeth. I then “sculpted” the facial surface to mimic individual teeth. This is the artistry we as dentists must master.
      In this case, I did not need to worry about precisely restoring to the initial vertical dimension, as there were no other teeth to worry about in the lower arch. Hence, a tolerance of 1 mm. either way would not affect the health of the masticatory complex. I merely needed to control sufficient space for metal and porcelain, while making the teeth appear “not too long, nor not too short”. This was accomplished and patient remained free of TMJ symptoms during the entire length of treatment. This being the case, I did want to capture the vertical dimension of the provisional bridge as accurately as I could.
      See minute 23:24: After healing, the teeth are reprepared as you asked and the existing provisional bridge was once again hollow-ground and fresh MMA acrylic is placed into the provisional bridge which is squashed onto the teeth and the newly sculpted margins are impressed into the acrylic. The excess is removed. The small amount of tipping buccal or lingual you mentioned is not of consequence as I hollow-grind very little.
      See minute 24:20: To capture the vertical dimension, the retainer 35 was sectioned from the provisional bridge and replace on tooth 35. This severed as an occlusal stop for the bite-registration. After the VPS bite-registration had set, the 35 retainer is removed, and the bite-registration is reinserted on the teeth with a small amount of new VPS material at the site of the 35. I now have a solid bite-registration. And yes, you are correct…some rocking can occur. I expect that, which leads me to your next question, which is very, very good. It lets me know that you were paying attention and thinking.
      2) Since you indexed the dies, what is the porcelain work done on now, since there’s no opposing occlusion?
      See minute 29:00. Two metal stops are designed into the framework at the distal of 35 and 44. These are further evaluated at the metal try-in stage while the bridge is in separate sections. I can try-in the 44 and 35 alone and assess if the stops hit simultaneously and if there is sufficient clearance as the remaining preps are bare. Adjustments can then be made as required. In case you missed it…the solder-jig employs a second set of pinned dies. The dies on the master model are not used. As stated at minute 37:20, often a large framework will not fit accurately on the master model and this was the case here. Hence, the bare framework was returned after soldering and a “pick-up” impression was taken of the finished framework as it sat on the teeth. A new bite-registration was obtained with the framework in place. Unfortunately we ran into editing problems with that video segment and it was lost.
      In addition, I did not take photos of that process.
      I figured no one would notice. You did…good for you…will keep me honest.
      I hope this answers your questions.
      Dr. Paul Belzycki

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