Masterclass with Ken Hebel
Friday 12 November 2010
Cavendish Conference Centre
22 Duchess Mews
London W1G 9DT
'Treatment Planning Challenges for the Reconstruction of the Partially Dentate Patient using Implants'
Report by David Offord
On Friday 12 November 2010 following our London AGM, Dr Ken Hebel, Canadian prosthodontist, delivered an ADI Masterclass to over 160 delegates entitled “Treatment Planning Challenges for the Reconstruction of the Partially Dentate Patient using Implants.”
Dr Hebel began his lecture explaining the core concepts of treatment planning. He emphasised to ‘do the simple things well’ and that generally not enough time was spent by dentists on treatment planning for straightforward cases.
He believed the use of animated video helped explain the treatment to the patients rather than the traditional form of consultation, as words tended to be ineffective.
Dr Hebel advised to involve the whole of the dental team in the consultation, as enthusiastic reception staff in particular tended to put patients at ease. He deemed it an essential part of the consultation to offer clarity of prognosis of the treatment advised to the patient in terms of expectancy of longevity: less than five years, five to 10 years, or more than 10 years. There was always a ‘gap’ between how the patient presented and the optimum. This was particularly highlighted in a patient’s disease-state – your ability to close this gap determined success or failure in treatment. There were two types of success with treatment planning:
- Patient is happy when they look in a mirror = aesthetic success
- Set the patients’ expectations and manage them downward
Dr Hebel proposed ‘Baby Boomers’ were dentists’ number-one market – they had the need, motivation and money.
Dr Hebel presented his systematic approach to selection of implant diameter and implant positioning, which he developed with Reena Gajjar and the Hands On Training Institute.
Dr Hebel explained four concepts which guided ideal implantpositioning. Concepts 1 & 2 offered a minimum and ideal distance between the centres of two adjacent implants. Concepts 3 & 4 offered a natural and a safe distance for implant placement next to a natural tooth. Critical to adopting this approach was the ability to measure accurately, and he recommended Mitutoyo digital callipers.
He presented three tables. Tables 1 & 2 gave recommendations for implant diameter based on the anatomy of the tooth that was to be replaced, maxilla and mandible. Table 3 gave the standard average distance between the centres of implants as a guide for implant placement. The tables listed the mesial-distal dimensions of each tooth in both jaws at three positions: the crown, the CEJ and the CEJ – 2mm, with the recommended implant diameter for the Nobel Replace system listed for each tooth position.
He explained that it was possible to perform model surgery in advance with this technique to enable an accurate acrylic guide to be made to take to surgery. Before the coffee break, the audience had to engage the brain with a series of exercises, calculating accurately ideal and safe implant positioning from Dr Hebel’s charts.
After the break, Dr Hebel asked the question “What is treatment planning?” He considered it to be the single most important driving force in your practice. He believed all aspects of treatment planning were important. Dr Hebel asked the audience how long they spent on treatment planning and concluded that it wasn’t enough! A great examination led to great planning.
He suggested we stop offering patients options 1, 2, 3 etc, but rather say, “the recommended treatment is...” He advocated custom abutments which are colour-matched to the cement-retained crown, so the abutment becomes part of the restoration. (Incidentally he likes cement in his screw holes!)
Dr Hebel recommended aiming for a mutually protected occlusion:
- When the front teeth touch, back teeth don’t
- When the back teeth touch, front teeth don’t
Dr Hebel then ended the Masterclass with a step-by-step guide to restoring the failed dentition, starting with establishing the occlusal plane, and restoring the lower teeth first.
- Occlusal plane = from a point 2/3 up the retromolar pads on the mounted study casts (does not change through life) to an anterior point on the lower incisors, established clinically.
- The mandibular component of aesthetics is usually with the lower incisor edges 1.5mm above the relaxed lower lip – this is a dynamic relationship. Ask the patient to count 1 – 10.
- Learn to look at the holes between teeth last, sort out the lower jaw, then you will require less preparation of the uppers.
Dr Hebel then fielded a number of questions from the floor before the vote of thanks by Mr Bill Schaeffer.