Edentulous - Immediate Load - Guided

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® Clinical Protocol for AvaDent® on 4 Fixed-Detachable Dentures

Introduction

This protocol can be used with a variety of prostheses that includes a maxillary conventional complete denture and a mandibular � xed complete denture or other designs such as two opposing � xed complete dentures or an implant overdenture opposing a � xed complete denture. This protocol provides an example of a maxillary complete denture opposing a mandibular � xed complete denture.

Clinical Steps

A. Diagnostic Evaluation: Diagnosis, treatment plan, and gather signed informed consent. This patient is completely edentulous and meets the criteria for a new maxillary complete denture and mandibular � xed complete denture (also known as hybrid, � xed-detachable, and all-on-4 prosthesis amongst other names) (Fig. 1).

B. Appointment #1: Make all records needed by following the conventional AvaDent® process for traditional AvaDent® dentures and send to Global Dental Science (GDS) for fabrication of AvaDent® Provisional Dentures (APD) (Fig. 2-4). Global Dental Science (GDS) will design and provide a set of provisional dentures (APD) (Fig. 5-7) and also an AvaDent® Scanning Guide (ASG) (Fig. 8).

Between Appointment #1 and Appointment #2: Order the required prostheses. Order the required prostheses from Global Dental Science; order an AvaDent® Scanning Guide (ASG) and AvaDent® Provisional Dentures (APD).

C. Appointment # 2: Place and adjust provisional dentures so patient begins to get used to the form of the new dentures (Fig. 9). Insert AvaDent® Scanning Guide and make the same adjustments, which were made in the AvaDent® Provisional Denture.

Place � duciary markers on AvaDent® Scanning Guide (Fig. 8) (after preparing the site with a number 6 or 8 round bur) and then place in patient’s mouth to make CBCT (Fig. 10). Use CBCT in Nobel Clinician software (Fig. 11 & 12) to determine number and location / angulation of implants (the implants can be tilted but they do not have to be tilted unless the angulation is needed to produce a greater AP spread and enhanced biomechanics). It will also be determined as part of this process, whether bone reduction / alveoloplasty will

Edentulous - Immediate Load - Guided

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2 3© 2014 Global Dental Science, LLC. AvaDent® is a registered trademark of Global Dental Science, LLC. Clinical_Protocol_Ao4_EIG_140701

be needed. The implant planning data is sent to Nobel Biocare for fabrication of a Nobel Guide Surgical Template (Fig. 13). The implant planning data and the scanning guide are sent to GDS for fabrication of an AvaDent® Conversion Denture (Fig. 14) and an AvaDent® Bone Reduction Guide when needed.

The required implant components are ordered from Nobel Biocare. When the implants are all aligned parallel with each other, only straight Multi-unit abutments are ordered. When the posterior implants are tilted distally, either 17 or 30 degree angle-correcting Multi-unit abutments will be ordered, depending on the angulation used in the Nobel Clinician planning software. Temporary Copings (Nobel catalog number 29406) for the Multi-Unit abutments are attached to the Multi-Unit abutments

Between Appointment #2 and Appointment #3: Order required implant components from Nobel Biocare and prostheses from Global Dental Science. From Nobel Biocare, order the required number of Multi-unit Abutments (straight and angle-correcting when tilted implants are used). Also, order Temporary Copings for Multi-unit Abutments (catalog number 29406). Nobel Biocare uses the name Temporary Copings in their catalog for what would commonly be called Temporary Abutments. Order an AvaDent® Conversion Denture (ACD) from Global Dental Science. Order an AvaDent® Bone Reduction Guide (ABRG) from Global Dental Science when needed.

D. Appointment #3: (Surgical implant placement & AvaDent® Conversion Denture placement): The Nobel Guide is placed, anchored (Fig. 15), and the implants placed using the guide (Fig. 16-18). The Nobel Multi-unit Abutments are placed (Fig. 19) and only hand tightened at this time.

Temporary Copings (Nobel catalog number 29406) for the Multi-unit Abutments are attached to the Multi-unit Abutments. When tilted implants are used posteriorly, angled abutments (either 17 or 30 degrees, depending on the angulation used in the planning software) are used that correct the posterior inclination of the implants. It is important to recognize that the circumferential positioning of the angle-correcting Multi-unit Abutments within the posterior tilted implants will vary slightly depending on where the implant placement was stopped during the � nal torqueing in the osteotomy. Therefore, the posterior Temporary Copings may not be aligned with the anterior Temporary Copings. When this occurs, the Temporary Coping should be removed so the distal abutment can be loosened and rotated circumferentially so it engages a di� erent location within the internal connection, thereby providing the best possible alignment between the anterior and posterior Temporary Copings. There is no way that Global Dental Science can know the exact positioning of the distal abutments in their implants based upon the implant software planning since that depends on the circumferential orientation of the � nal implant position in the bone. As a result, some adjustment of the posterior channels within the AvaDent® Conversion Denture may be required.

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Temporary Copings (Nobel catalog number 29406)

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circumferential positioning of the angle-correcting Multi-unit Abutments within

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A radiograph is made to assure the Multi-unit Abutments are properly seated and then the abutments are torque tightened as recommended by Nobel Biocare (35 NCm for the anterior straight abutments and 15 NCm for the posterior angle-correcting abutments) and the Temporary Copings attached and hand tightened (Fig. 20).

The AvaDent Conversion Denture (with the channels already created in the denture) is placed over the Temporary Copings (Fig. 21 & 22) and the seating of the AvaDent Conversion Denture on the mucosa veri� ed by checking the occlusion with the opposing maxillary complete denture. It is possible that the height of the Temporary Copings will contact the maxillary denture and prevent closure into the maximum intercuspal position. Therefore, it may be necessary to mark the Temporary Copings and remove them from the mouth for shortening.

Once the AvaDent Conversion Denture is properly seated over the Temporary Copings, � owable composite resin or auto polymerizing resin is placed between the Temporary Copings and the channels in the AvaDent Conversion Denture and polymerized.

All the screws attaching the Temporary Copings to the Multi-Unit abutments are loosened, the denture removed (Fig. 23), and the struts are sectioned that connect the peripheral portion of the denture base to the part of the base that houses the denture teeth, thereby separating the peripheral denture base from the portion of the denture that will a� xed to the implants (Fig. 24).

A� x multi-unit abutment replicas to the AvaDent Conversion Denture before its � nal placement in the mouth and embed the replicas in Whip Mix Snap Stone so a cast is made that can be sent to Global Dental Science to construct the construct the � nal AvaDent Veri� cation Jig. Include a putty matrix of the complete conversion denture on the model.

The borders of the AvaDent Conversion Denture are rounded, the base shaped to the desired form, and the base polished or, alternately, Ultradent’s PermaSeal is applied in two layers with polymerization after each layer (Fig. 25).

The AvaDent Conversion Denture is then placed and the screws torqued to the recommended level of 15 NCm. The occlusal contacts are rechecked and � nal re� nements made, if needed. The occlusal screw access holes are � lled with the clinician’s choice of material (either an impression material so the screw tightness can be re-checked at a post-operative appointment or a de� nitive resin material) (Fig. 26). Eccentric occlusal adjustments are completed as needed (Fig. 27) and the aesthetics of the maxillary provisional denture evaluated (Fig. 28 & 29).

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Optional: It can be useful for the future fabrication of the de� nitive denture to a� x multi-unit abutment replicas to the AvaDent Conversion Denture before its � nal placement in the mouth and embed the replicas in Whip Mix Snap Stone so a cast is made that can be sent to Global Dental Science.

Between Appointment #3 and Appointment #4: Order required implant components from Nobel Biocare and prostheses from Global Dental Science. From Nobel Biocare, order either Impression Copings for Multi-unit Abutments (catalog number 29089) or Temporary Copings for Multi-unit Abutments (catalog number 29406). Order an AvaDent Implant Record Device (AIRD) and AvaDent Veri� cation Jig (AVJ) from Global Dental Science.

E. Appointment #4: (Final impression and records for the de� nitive prosthesis after an appropriate implant healing period)

Prior to this appointment, Global Dental Science will provide an AvaDent Implant Record Device (AIRD) (Fig. 30) and AvaDent Veri� cation Jig (Fig. 31). The resin Veri� cation Jig is designed to � t simultaneously over and around either Impression Copings (Nobel open tray impression copings for Multi-unit Abutments, catalog number 29089) or Temporary Copings (Nobel Temporary Copings for Multi-unit Abutments, catalog number 29406). Either of these copings can be used for the � nal impression.

The previously placed AvaDent Conversion Denture is removed from the abutments (Fig. 32) and the copings attached to the abutments (Fig. 33). The AvaDent Veri� cation Jig is placed around the copings. The AvaDent Veri� cation Jig is held so it is vertically positioned with a 2-3 mm space between the inferior surface of the jig and the mucosa (Fig. 34). It is then secured to the copings by syringing � owable composite resin between the jig and the copings (Fig. 35 & 36). The AvaDent Implant Record Device will have an opening in the denture base that is large enough to � t around the AvaDent Veri� cation Jig that has been connected to the copings while also resting on the posterior edentulous ridge (Fig. 37 & 38).

The � nal impression is then made using the AvaDent Implant Record Device as an impression tray. It is coated with impression adhesive and impression material is placed in the AvaDent Implant Record Device (Fig. 39). Light-body impression material can be expressed around the connected Copings and underneath the AvaDent Veri� cation Jig (Fig. 40). The AvaDent Implant Record Device is then seated over the AvaDent Veri� cation Jig. A � nger or Q-tip is used

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Fig. 30simultaneously over and around either Impression Fig. 30

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to wipe across the occlusal opening in the AvaDent® Implant Record Device to expose the occlusal aspect of the copings so their screws can be located before polymerization of the impression material and subsequently easily accessed for loosening (Fig. 41).

The AvaDent® Implant Record Device is oriented using the occlusion with the existing maxillary provisional denture (Fig. 42). After the impression material is properly polymerized, the screws in the Temporary Copings are loosened and the impression removed (Fig. 43). The impression should have recorded the edentulous ridges and contains the connected Temporary Copings. Excess impression material that interferes with occlusal interdigitation between the teeth of the AvaDent® Implant Record Device with the maxillary denture is removed and the impression reseated and attached with a couple of screws. An interocclusal record is made between the teeth of the AvaDent® Implant Record Device and the maxillary denture (Fig. 44). The � xed AvaDent® Conversion Denture is replaced, the screws tightened, and the access holes sealed with the clinician’s material of choice (typically resin).

The AvaDent® Implant Record Device with its incorporated impression is sent to Global Dental Science along with the interocclusal record for design (Fig. 45-48) and fabrication of the de� nitive maxillary complete denture and the AvaDent® Hybrid Prosthesis (AHP). The AHP is a � xed complete denture with a metal bar, pink acrylic resin and teeth.

Between Appointment #4 and Appointment #5: Order the required prostheses from Global Dental Science. Order an AvaDent® Hybrid Prosthesis (AHP) with incorporated Procera Implant Bar and AvaDent® Maxillary Complete Denture from Global Dental Science.

F. Appointment #5: (Placement of de� nitive AvaDent® maxillary denture and mandibular AvaDent® Hybrid Prosthesis) Prior to this appointment, Global Dental Science will provide a de� nitive maxillary complete denture (Fig. 49) and an AvaDent® Hybrid Prosthesis (� xed complete denture with incorporated Procera bar and new prosthetic screws (Fig. 50 & 51). The AvaDent® Conversion Denture is removed and the AvaDent® Hybrid Prostheses placed. New prosthetic screws are used to attach the AvaDent® Hybrid Prosthesis to the Multi-unit Abutments and torqued to 15 NCm (Fig. 52). The de� nitive maxillary complete denture is seated with pressure-indicating paste (PIP) to re� ne its � t to the mucosa and then the occlusal adjusted. (Fig. 53) and the aesthetic result veri� ed (Fig. 54). The occlusal screw access holes are � lled with the clinician’s choice of material (either an impression material so the screw tightness can be re-checked at a post-operative appointment or a de� nitive resin material).

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complete denture and the AvaDent® Hybrid Prosthesis Fig. 45 Fig. 46

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Edentulous - Immediate Load - Guided