Implant supported prosthesis steps for the dentist

Implant supported prosthesis steps do not have to be overwhelming for the dentist, just take it step by step. There are many ways to do this and alternatives can be found in each visit.

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Implant supported prosthesis steps – Visit #1 Full arch impression with implant impression copings

This can be done as an abutment level impression or done with multi-unit abutments placed at company recommended torque in Ncm (note on this – multi-unit abutment should be screwed to company recommended torque (usually 30-35Ncm for straight and less for angled) but prosthesis to multi-unit should be 15Ncm – this differs from system to system though). Nobel is 35Ncm for straight and 15Ncm for the 17 and 30. Biohorizons is 30Ncm no matter straight or angled. Shoulder of the multi-unit abutment should be slightly supragingival.  Or may be implant level impression but must consider engaging vs non-engaging and impact that has on future prosthesis options (screwed vs. cemented).  No matter which is used implant should have healing cap or multi-unit abutment should have healing cap if no SR temporary prosthesis.  Ensure opposing arch is level occlusally speaking.  

These implant supported prosthesis steps assume you followed previous page to temporize the area and have fabricated the custom impression copings that will be reluted intra-orally.

If not check at bottom page for the extra steps. If soft tissue esthetics were developed check here for technique on custom impression copings.

1. Check torque is correct on all (multi-unit) abutments
2. Place labeled impression copings back in mouth
3. Confirm seat with xray and at right height (slightly supragingival)

4. Relute jig with Primotech.  Why Primotech? Shrinkage
5. If no jig exists then make one by wrapping floss between the impression copings and lute with Primotech

6. Completely remove jig and let cure in LC machine for 5 minutes
7. Reseat jig and do Sheffield one screw test before screwing down all again
8. Final impression with heavy body (medium on tissue areas under verification jig). Custom tray optional but nice if have pre-model.

9. Patient goes through all border molding procedures
10. Mark midline on tray with black marker
11. Can send approximate horizontal need for lip support (duplicate of what they are wearing or impression of SR prosthesis)
12. Send papillameter measurement for height wax rim at esthetic point A (where want incisal edge) and high lip line measurement (easier to do at wax rim)

13. Get vertical with “mmmm” sound and Ivoclar centric tray -3mm and use of alma gauge
14. Replace provisional prosthesis and cover holes with PTFE and Temp it or PVS
15. Ask for “implant screw retained occlusal rim(s) and verification jig”
16. Lab needs few days to 1 week

Quality stone is Modern Materials Die Keen or Fujirock EP must be Type IV die stone and use double pour technique

Guide pin=chimney screw=Ti cylinder used in verification jig and sits on multi-unit abutment.

Doing a digital impression with fiducial markers like CT-SPOT 120 by Beekley Medical will same a lot of time if a temp already exists. Personally I would not trust this as the model for fabrication as full arch digital scans are almost always found to be inferior to traditional impressions.

Implant supported prosthesis steps – Visit #2 Bite registration and VDO

Returned with verification jig (Sheffield test=one screw test to verify=Replace the cured jig back onto the implants. Tighten a single guide pin into one of the distal cylinders. No lifting of the jig should occur. Check for a passive fit by visually inspecting completely around each cylinder for complete seating. Repeat this process for each implant.) and a screw retained basebar (occlusal wax rim). Lab will use guide pins (chimney screws) to create screw shaft in wax.  As long as 1 temp coping (Ti or plastic) in each quad we are fine (sometimes only 1 per arch).  This cuts down a little on cost (less copings) and on time.

Also, MUST ensure room for multi-unit abutments under screw retained basebar.

1. Ensure multi-unit abutments are torqued down at company recommended torque
2. Place verification jig in mouth and check passive fit with no rocking. Complete a Sheffield screw test and take x-rays to confirm seat if you can not see visually. Stone verification jigs are nice because they do not flex or bend and will just crack if anything is off.
3. If off section and re-lute and back track to steps in visit #1.
4. Screw in wax rim(s) and confirm facial lip support, buccal corridor filled, curve of lower lip follows upper smile arch and esthetic A point (at rest and high smile).
5. Check vertical (lick lips, make “m” sound, and relax then measure point on nose and chin x3 -3mm)  .
6. Once confirm visual aspects confirm “f” sound and “s” sound (2-4mm clearance). Check tight air seal for phonetics (again check “s”)
7. Mark midline, high lip (junction) line, and canine areas.
8. Kois facebow impression IF off.
9. Patient chooses moulds for anteriors and shade
10. Photos of smile, rest, and high lip line to go to lab.  Mark high lip line
11. Bite registration impression
12. Mark on cast where want extent of prosthesis
13. Make sure block out wax placed in undesirable undercuts.  Also for ovate “high-water” lowers, ensure wax block out raises prosthesis 1mm or so off tissue for easier cleansibility.
14. Tell lab “model verified and bite registration taken.  fabricate screw retained base plate with teeth set in wax for try-in for final prosthesis.”  For occlusion check here for recommendations.
15. Lab needs 2+ weeks
16. This is the time to talk about final prosthesis selection and screw vs ti base or ti chimney inside prosthesis. Screw option examples are Rosen screw and Powerball screw.

Implant supported prosthesis steps – Visit #3 Try-in for bite verification and esthetics

Prosthesis is returned set in the same screw retained base bar but with teeth (“Tribos 501 and Mondial 6i/8i which are ceramic reinforced denture teeth which is what Gradia is, ceramic reinforced composite.” Uwe Mohr or Ivoclar Phonares nanohybrid composite or TruBlend=Nader) set in wax to try in.  Another option is to use anaxBLEND for teeth and anaxGUM for gingiva 1. If using all resin gums and teeth need a sealer like Nanovarnish by Dreve.

1. Ensure multi-unit abutments are torqued down at company recommended torque
2. Check phonetics, function, esthetics verified with patient and loved one (Same as step 4-7 above)
3. Check any difficult hygiene areas such as a concave ridge lap.
4. Biting into CR?  Leaf gauge to check   Anterior stop in composite and bite registration if off
5. Very important confirm lip support.  If can’t get and is unacceptable then must go to removable bar prosthesis
6. Check curve of Spee and Wilson
7. Photos of smile, rest, and high lip line to go to lab.
8. Tell lab “Try-in approved.  Please fabricate final prosthesis” or let know about changes needed for another try-in
9. Lab needs about 3 weeks, maybe 4 weeks depending on if do visit #4 or not

Putty matrix made off this wax up at lab prior bar fabrication OR
Silicone matrix of the temporary acrylic denture supported by the temporary metal non-engaging abutments OR
Everything is scanned and then designed virtually June 11

Implant supported prosthesis steps – Visit #4 Final substructure verification

1. Ensure multi-unit abutments are torqued down at company recommended torque
2. Try in of framework (PMMA if Zirconia) without screws for passive fit
3. Evaluate the fit of framework (PMMA if Zirconia) with Sheffield screw Jan 99test again. Tighten one screw and verify a passive fit on all implants (no lifting of the framework). Remove the screw and repeat the process for each implant
4. Teeth will be in wax if using acrylic denture teeth at this point so verify everything from step 4 of visit 2.
5. If individual crowns – dentist can try in and cement on at this point
6. Screwmentable with anterior cementable and posterior screw retained is the choice for larger cases
7. Photos of smile, rest, and high lip line.

Alternative that can save dental visits, allows teeth set in same place, but requires lab work in office. Lambert has very similar but uses Mach3.  Good step by step Sept 06

1. Final impression open tray with temp prosthesis in place and impression material injected in underneath.
2. Pour up in office type IV dental stone with slurry water vacuum mixer needed
3. Seat temp prosthesis on model.  Make 4 notches on the buccal surface of the cast for the purpose of indexing, and fabricate a VPS buccal index with putty extending to the occlusal surfaces of the denture teeth so lab can set teeth in same position

Custom tray does not need to capture all surfaces of teeth because those will be picked up in step 3 above

Charges for just the prosthetic portion

Charges At start 25%=$4069   Final impression 50%=$8916  Delivery 25%=$4096 2012

References

Thomas Wade     His lab
Luke Kahng
Journal of Pros March 11
Glidewell 

1. Quick set PVS open tray impression (with either multi-unit abutment transfer copings or implant impression copings) Closed tray if vertical problems in posterior area
2. Place lab analogs in impression and pour up in quick set stone
3. Removal impression abutments and impression tray
4. If doing this today then decide which angle mutli-unit to use in which implants
5. Seat impression copings (or multi-unit impression copings on abutments and tighten guide pins) on model and lute together with Primotec Metacon LC OR Pi-Ku-Plast by Bredent and bar stock
6. Make custom tray now so is on top of luted areas. Hole in palatal.
7. Section each one .5-1mm (try Serrated Saw 8964 Brasseler) in area that will easily allow intraoral reluting
8. Label the sections R1-2-3-4-x-y-…9L
9. Place impression copings (and multi-unit abutments at 35 Ncm if needed) back in mouth (finger tight) and relute with Primotech
10. Go to step 5 of the Implant supported prosthesis steps – Visit #1 above

Alternative to above implant supported prosthesis steps

Just do open tray impression in custom tray (skip steps 1-10)

Alternative to above implant supported prosthesis steps

Pick up impression in temporary prosthesis with guide pins placed. This is a
Singh (Oak Brook) method and is in his HO. Also similar to Jade technique, but Paul uses the surgical guide. Guide pin=Ti cylinder used in verification jig and sits on multi-unit abutment.