Custom healing caps

[rkm rdt]

I would like to make custom healing caps that would provide a better emergence contour for the implant abutment and crown.

I find bone level implants to be most problematic when restoring to a stock cap cylindrical shape.

How could I make a properly contored cap from a study model prior to surgery? We don't have the luxury of CBCT or CT scans for every case especially singles.

Could I design one with my 3 Shape?

 

[PCDL]

The biggest problem would be thread timing, depth of the implant, and how you would index the rotation of the implant vs. the healing cap.

Years ago (90's) 3i made a line of tooth specific healing caps, called Sculpture Caps or something, that were just what you were speaking of. It flopped due to surgical unpredictability of depth/rotation.

You would be better served by indexing the implant at time of surgery, and having a custom made PMMA/Composite abutment and temp at time of uncovering (Second stage). This will still accomplish what you are looking for and allow for primary integration to occur. Or you can immediately load your cases; but thats based on your comfort level and that of your GP/Specialist.

 

[rkm rdt]

How do provide a temp abutment and crown for immediate loading?

 

[PCDL]

Well, the easiest way would be a Stock PMMA abutment (plastic, most companies have them. With a study model, wax your ideal temp unit, and provide the Dr. a clear plastic suck-down shell of it.

At the time of surgery, the implant is placed (or within the first two hours of placement),the Surgeon or GP will screw down the temp abutment, adjust the vertical height to fit under the Clear Matrix, and then reline the space with a Bis-Acryl material (i.e. Luxatemp.) After the reline, you will have a screw retained, one piece temp. The Dr. can then reline and contour the gingival portion as needed, and proceed with primary closure once the temp is contoured, polished and screwed back down.

Let it heal for 4 weeks, keep it out of function (a debatable concept, I know) and you are on your way to a great sulcus.

 

[CB93]

How do provide a temp abutment and crown for immediate loading?

One way to do this is using Guided surgery. You will know the position of the implant before surgery because you have digitally planned it. Yes you need a ct scan, planning software, a surgical guide and a fully guided surgical kit.

Once you have the surgical guide, you basically do the surgery on the stone model and place the analog. You don't drill into the stone, but you cut away enough stone to be able to lute the analog into place. Form there you create the abutment and temp crown. The advantage is, this is now ready to be delivered at the time of implant placement.

This technique is accurate enough to make the final abutment but not the final crown.

Cary

Edit, As far as indexing, the surgeon just needs to make sure the flat of the hex, the lobe of the tri-lobe or whatever reference is oriented to the buccal.

 

[rkm rdt]

Well, the easiest way would be a Stock PMMA abutment (plastic, most companies have them. With a study model, wax your ideal temp unit, and provide the Dr. a clear plastic suck-down shell of it.

At the time of surgery, the implant is placed (or within the first two hours of placement),the Surgeon or GP will screw down the temp abutment, adjust the vertical height to fit under the Clear Matrix, and then reline the space with a Bis-Acryl material (i.e. Luxatemp.) After the reline, you will have a screw retained, one piece temp. The Dr. can then reline and contour the gingival portion as needed, and proceed with primary closure once the temp is contoured, polished and screwed back down.

Let it heal for 4 weeks, keep it out of function (a debatable concept, I know) and you are on your way to a great sulcus.

That seems simple enough ! Thanks PCDL for your explanation.
The funny thing is that I make the vac forms from a diagnostic wax up all the time for the surgeons. I guess that is more proof that they don't use the guides let alone use them for custom temps.

 

[rkm rdt]

One way to do this is using Guided surgery. You will know the position of the implant before surgery because you have digitally planned it. Yes you need a ct scan, planning software, a surgical guide and a fully guided surgical kit.

Once you have the surgical guide, you basically do the surgery on the stone model and place the analog. You don't drill into the stone, but you cut away enough stone to be able to lute the analog into place. Form there you create the abutment and temp crown. The advantage is, this is now ready to be delivered at the time of implant placement.

This technique is accurate enough to make the final abutment but not the final crown.

Cary

I would love to work with guided surgery but unfortunately our surgeons are not quite there yet.

 

[PCDL]

Edit, As far as indexing, the surgeon just needs to make sure the flat of the hex, the lobe of the tri-lobe or whatever reference is oriented to the buccal.

Actually, I was referring to the older technique of indexing. For an accurate index, the specialist will place an impression coping on the implant, and then, using flowable composite, create wings onto the adjacent dentition. Once cured and removed, this will act as a guide you can use to do some model surgery with in the lab. Attach an analog, ream out the model, place the index in place, reline, and voila! Working model to create your abutment and temp.

This process is for a temp to be delivered at second stage.

 

[JohnWilson]

I make contoured healing abutments with my nobel scanner, essentially they are abutments that have no margin.

At time of surgery dr makes a index jig that I will use to make an altered cast impression from a preop model. This model allows me to contour the stone to my ideal emergence and allows me to scan and design my healing abutment.

I make it conical with no margin and cut the chimney off so that the abutment is just supra gingival.

We also can make a screw retained temp from this index as well,

Recently I have been milling them out of PMMA Cheap, Fast and better than any prefabbed healing abutment.

 

[rkm rdt]

I make contoured healing abutments with my nobel scanner, essentially they are abutments that have no margin.

At time of surgery dr makes a index jig that I will use to make an altered cast impression from a preop model. This model allows me to contour the stone to my ideal emergence and allows me to scan and design my healing abutment.

I make it conical with no margin and cut the chimney off so that the abutment is just supra gingival.

We also can make a screw retained temp from this index as well,

Recently I have been milling them out of PMMA Cheap, Fast and better than any prefabbed healing abutment.

Thanks John, any pics?

 

[PCDL]

John, what do you find to be more common, the Dr. going for the healing abutment option, or just loading the case with the temp?

 

[lcmlabforum]

I would like to make custom healing caps that would provide a better emergence contour for the implant abutment and crown.

I find bone level implants to be most problematic when restoring to a stock cap cylindrical shape.

How could I make a properly contored cap from a study model prior to surgery? We don't have the luxury of CBCT or CT scans for every case especially singles.

Could I design one with my 3 Shape?

WE just attended a combo seminar with Straumann and iTero about this - the Surgeon a OMFS Finerman or something like
that works with CDT Grady Crosslin in Florida to have him make the temp in advance that he would insert at the day of surgery.
There was alot of management strategies, etc that went with the talk but also lots touting the iTero and the CoDiagnostix/
and you can talk to Grady about it. My point is that he would use a non-engaging temp abutment and bypass the timinig
all together and apparently they do not loosen as often as you think. I would use acrylic to engage the adjacent
teeth if I were to do that although I don't tell patients to temporarize on the same day . . .
LCM

 

[rkm rdt]

WE just attended a combo seminar with Straumann and iTero about this - the Surgeon a OMFS Finerman or something like
that works with CDT Grady Crosslin in Florida to have him make the temp in advance that he would insert at the day of surgery.
There was alot of management strategies, etc that went with the talk but also lots touting the iTero and the CoDiagnostix/
and you can talk to Grady about it. My point is that he would use a non-engaging temp abutment and bypass the timinig
all together and apparently they do not loosen as often as you think. I would use acrylic to engage the adjacent
teeth if I were to do that although I don't tell patients to temporarize on the same day . . .
LCM

Not sure I follow you. Use a non-engaging and contour the temp freehand from the study model? How do you know where the implant will be prior to surgery ( other than from a CT scan)?

What is " bypass the timinig" ?

 

[JohnWilson]

John, what do you find to be more common, the Dr. going for the healing abutment option, or just loading the case with the temp?

Depends on 3 things really

1) the surgeon,
2) the implant zone
3) which fixture is being used

If in the esthetic zone and we can eliminate/min load we will do a temp. Bi's or back rarely ever make a temp

% of treatment that use either of these options is less than 25%

 

[CB93]

WE just attended a combo seminar with Straumann and iTero about this - the Surgeon a OMFS Finerman or something like
that works with CDT Grady Crosslin in Florida to have him make the temp in advance that he would insert at the day of surgery.
There was alot of management strategies, etc that went with the talk but also lots touting the iTero and the CoDiagnostix/
and you can talk to Grady about it. My point is that he would use a non-engaging temp abutment and bypass the timinig
all together and apparently they do not loosen as often as you think. I would use acrylic to engage the adjacent
teeth if I were to do that although I don't tell patients to temporarize on the same day . . .
LCM

I was looking into the iTero/CoDiagnostix setup for my self. My rep wanted me to wait until next year to demo the system. Then, just last week she told me Strauman is no longer offering the iTero and CoDiagnostix guided surgery system. I'm not sure why.

And, you guys will like this. She, my rep, told me I will be just sending my impressions straight to Strauman for the fabrication of the custom abutments.

 

[shane williams]

I would like to make custom healing caps that would provide a better emergence contour for the implant abutment and crown.

I find bone level implants to be most problematic when restoring to a stock cap cylindrical shape.

How could I make a properly contored cap from a study model prior to surgery? We don't have the luxury of CBCT or CT scans for every case especially singles.

Could I design one with my 3 Shape?

I actually use to produce these years ago. I was supplied wax-ups of what the emergence profile wanted.(basically what they are is temp abutments waxed up). I took small cups(like medicine size cups) drilled a hole put in an analog, screw the wax up onto it, duplicate the wax up. Then all you do is unscrew the wax up prep another temp abutment and apply composite. Polish and you have a custom made gingival former. We made them in three sizes one for each of the implant sizes. Very easy to make.

 

[lcmlabforum]

My bad - but they had CBCT and CAD-CAM guide with Gonyx/CoDiagnostix so they knew
exactly, as good as the situation allowed, where the implant platform was.
The news that they will not offering the iTero Co-Diagnostix is brand new news to me -
something might have happened between the corporate backroom deals.
I had questioned the whole process altogether - with all that information, it would
not take much for Straumann or any vender with the library to fabricate the
temp digitally and bypass the lab altogether . . .
Apparently in Florida, the patients do not like/tolerate removable temporaries
and it is a big deal to be able to have patients leave office with a temporary
at the day of surgery. He went as far as to tell the patients his referring DDS
made and supplied the temp - and Grady would basically visit them to establish
communications that way. A lot of work to go to nothing once Straumann
starts to do this digitally for the surgeon . . . I can imagine this happening
in the board room discussions already . . .
LCM

 

[lcmlabforum]

Bypass the timing - I meant ignoring any engaging feature of the implant by using
basically the 'brdige' version of the implant temporary abutments. Good luck if you
are using the Astra 3.0 . . .
LCM

 

[rkm rdt]

So what I have learned is that the surgeon must provide some type of transfer jig to allow me to translate the abutment and analog to a diagnostic cast.

There is no way to make a custom healing cap/temp prior to surgery?

 

[PCDL]

Well, as was mentioned above, you could use a non engaging abutment for the procedure, but my only beef with that is you are relying on the Specialist to place it properly, and hope it doesn't come loose. If I were you, I would try to foster a few of your better clients into using temps in the esthetic zone in order to shape your sulcus and papilla. I think its more predictable that way. But thats just my take.