<–Second post  This is the 3rd in a series of 17 posts on this topic  4th post-->

 Basic tips before we begin giving the step by step for a fixed detachable provisional fabrication.

1. Have pre-made and guided surgery.
2. We can convert an existing denture into the fixed detachable provisional.  Several ways we can do this.  From completely guided and pre-made final with Temp Basic and Gradia gum shade (check other PMMA temps) to more rudimentary like the OSU method here.
3. Have lab do it by taking closed tray impression in denture duplicated custom trays

3D guided dental implant surgery and fabrication of a fixed detachable provisional before the surgery

1. Nsequence is one company that works with Pikos.
2. Bonadent is another one that looks nice and has a good thread on dt.

A little tip on something we did improperly was place the rubber dam under not on top of the carrier guide.

Fixed detachable provisional – Dentist does it

2 scenarios when this happens.  I’ve only had to do scenario #2.  General tip for any method is to be ensure the opposing dentition is level!

#1 is when patient has been wearing a full denture already and the implants have integrated. Basically would only wear for few months while final is being fabricated.

#2 is when patient is having any remaining teeth extracted, immediate implants placed, and then going to an immediate full mouth provisional.  Steps to get this ready are same as immediate denture.  For 8 weeks after surgery patient can eat anything as long as they use a spoon.  That means no hands, no forks, and no knives.

Step by step for the fabrication of a fixed detachable provisional.

1. Scenario #1 – Ensure no pressure on healing abutments (check with bite reg).  Relieve where necessary, can be aggressive cause going to relieve quite a bit more for provisional abutments.
2. (Remove healing abutments and) Place multi-unit abutments (screw receiving abutment) at company recommended torque (30-35Ncm usually if straight and less if angled.)  Multi-unit abutments should be slightly above soft tissue.  If this is done guided should have idea of what want to use on each implant. There are custom MUA but that would be a weird situation when you would need one. Truabutment makes them and calls them All on T.
3. X-ray confirm full seating
4. Quick set PVS open or closed or mix tray impression with implant impression copings.  Closed in posterior and whatever easier in anterior (likely closed also).
5. Place lab analogs in impression and pour up with Mach-2 Die-Silicone by Parkell or quick set stone – Save this model will need later!!!
6. Removal impression abutments and impression tray
7. Confirm have correct angle/height mutli-unit abutment chosen.  Multi-unit abutments should be slightly above soft tissue.
8. Mark top of multi-unit abutment to transfer spot to existing denture OR
9. Place bite impression material or fit check in denture and seat to identify location of implants or have a clear retainer over your temp and line that up in the mouth and transfer.

10. Cut holes and trim denture to allow future Ti provisional abutment to easily pass through. Since surgery is usually pretty well planned before can pre cut holes if want and then use a guide of some sort. However, best to have a backup in case things do not work out from some reason.

Avadent make great temps because we mill entire thing together, which means there is no bond that can break between the teeth and pink acrylic.

11. Check occlusion. lip support, incisal edge position, and speech.  This is much more of an issue with scenario #2.
12. Place Ti provisional abutments=non-hexed temp cylinders=screw retained post=interim post hand tight.
13. Re-seat denture and mark Ti abutment at height needed
14. Outside of the mouth, adjust the height of Ti abutment=temp coping multi unti=nobel part 29046 so denture can be in occlusion.
15. Coat with metal primer (Metalprimer II GC) and reseat.
16. Re-verify denture seats properly over abutments.
17. PTFE in access hole abutments
18. Small section rubber dam over implants so acrylic doesn’t pick up sutures Or can use whole rubber dam with punches
19. Posterior implants first.  Using monoject syringe inject pink or white acrylic around abutments and in denture and seat denture and have close without any pressure (have patient feel masseter muscle) Unifast Trad 5 minute total set need compare to others.
20. Allow complete set, spray water as it gets hot.
21. Remove PTFE and unscrew abutments to remove prosthesis
22. Repeat for anterior implants.  Be sure posteriors are screwed back in when pick up anteriors.  Can do all together but gets more complicated
23. When all abutments locked in, unscrew and remove prosthesis
24. Extra-orally fill voids.  Trim excess.  Ensure buccal flange and palatal removed to appropriate level.  Pressure pot, place protection analogs, and final polish

25. Place lab analogs in prosthesis and seat in small amount of quick set stone.  Like photo below.  Redundant to steps 4-6.
26. Re-seat prosthesis in mouth torque abutments 10-20Ncm(hand tight?) PTFE over access, Temp it in access.
27. Verify step 3 again.

 

Preparation for patients first impression visit – Fabricating custom impression copings for splinted impression

1. Take model from step 5 and seat impression copings.
2. Seat impression copings (= multi-unit impression copings on abutments and tighten guide pins) on model.
3. Adjust height impression copings in back if going to be an issue for that patient.
4. Lute together with Primotec Metacon LC OR Pi-Ku-Plast by Bredent and bar stock
5. Section between each one .5-1mm (try Serrated Saw 8964 Brasseler) in area that will easily allow intraoral reluting
6. Cure in LC machine 5 minutes
7. Make custom tray over luted abutments. Hole in palatal.  Could use duplicate denture or surgical guide for this if have
8. Label the sections R1-2-3-4-x-y-…9L
9. Verify sections on model from step 25

 

If all else fails, take an impression and have lab make the fixed detachable provisional

1. Place impression copings
2. Lute together (optional)
3. Ensure lab made surgical guide/custom tray fits over impression copings so surgical guide/custom tray can be in occlusion
4. Section and then relute the small separated areas with Primotec LC (optional)
5. Final impression with heavy body (medium on tissue areas under verification jig) in custom tray
6. Seat custom tray and have patient close without any pressure (have patient feel masseter muscle)
7. Patient goes through all border molding procedures
8. After set.  Take bite.  May need to completely loosen screws before.
9. Remove everything.
10. Healing caps or covers for 2 days while lab finishes temp

May have to do tissue conditioning with these cases with Hydro-cast.

Fixed advantages versus removable temporary

1. Less bulky
2. Fewer phonetic issues
3. Mores stable
4. Soft tissue sculpting
5. Allow undisturbed healing of graft and or implant site (Main advantage)

Disadvantages and how overcome

1. Can break (use metal bar or fiber reinforcing strips inside acrylic)
2. Hygiene challenge (use Waterpik with CHX)

Reference

Implant Direct video Replant teeth in 1 day
Jeff Pennington, DMD; and Sid Parker, DMD