Full Lower Screw Retained Implant Bridge

[Al.]

I thought Id share this case I have in the works.

Its going in the mail tomorrow for frame try in.

These are a few of the pic's I give the Dr access to, so he can see my progress and request any changes he may want.

He is a prosthodontist and a former tech.
The uppers are to be restored next.

 

[JohnWilson]

Looks great Al

Love the way you sprued it. Did the doc verify the master model prior to you wax and casting?

Or is it metal work try in then cut and solder index if necessary?

Only issue so far I see is that you didn't raise the cylinder on the ling of #21/28 for ling cusp metal support, but it might be the angle of the photo.

Is this nobel or high nobel metal?

Was he concerned with mandible flex and thats why he choose not to cross the midline for a one piece bridge?

Full high water on this one Al or lots of pink porcelain?

Looking forward to see the progression on this one.

 

[Al.]

John he did all the model work. He sent me the case already articulated.

He made a verification jig and tried it on the cast. One implant was not correct so he reset the analog. You can tell which one it is, the one with the stone slurry on it.

I really dont know about the cylinders yet. I am going to open them all up a bit, like the top of a funnel, and opaque and put porc on them so hopefully when he puts his composite on, the access holes will be hidden. I will probably use shoulder porc since it is more stable and wont move later on.

Thank goodness he asked for 2 peices, he said he used to be a tech and knows how difficult splints are when you go around the curve of the arch.

HN 40% au, $1300 my cost for the metal.

Alot of pink porc.

I found those little 18 ga sprues to the gin of the abuttments eliminate the incomplete casting there.

How far off the tissue do you think I need to keep it for cleaning? .5 mm ?

 

[JohnWilson]

How far off the tissue do you think I need to keep it for cleaning? .5 mm ?

Hi Al for these types of cases its client specific. I have made some high water cases that had gobs of room under them and then I have had some clients like the buc aspect to just touch the ridge and wide open ling.

Its best to ask your client what he wants. From what you said his background as a tech will certainly help him communicate with you on a level that most clients can't ever achieve.

Since you know he verified the master model you will most likely not have to deal with any welding, however if he sections that thing and you need it Laser welded let me know and I will take care of it for you.

 

[charles007]

Al, your framework meets, or exceeds your excellence in ceramics..all I can say is wow...and I'm so glad I didn't have to wax/design that case........can't wait to see the finished case...... Hope you have the time to take pics as you progress through this case.

John, I dare say that few techs could EVER come close to designing this case correctly..... Question.... is this a slam dunk designing on your scanner with implant software to print or mill in wax ? Does it make it simple, with some basic implant experience ?

Charles

Edit: Is it easy to design framework with scanner ...not implants on model that Al already received .

 

[JohnWilson]

Truthfully metal ceramic fixed implant restorations of this size have started to go away. Not only because the price is so outrageous but the quality of the restoration and the ease of repairs is making acrylic and denture teeth a more advantageous solution. As to your question Charles,

The software is only as good as the minds eye.

I asuum Al rough waxed this case full contour and cut it back. The scanner can easily handle digitizing the model and has the tools to virtually wax up the case to a scanned counter-bite to design for support. It does not have a virtual articulator that will show function.

At this time a metal ceramic bridge of this caliber in my opinion is better done by hand unless its going to be made out of zirconia.

I have a case coming in after the first of the year that the client is completely insistent to do a full arch based on a Zirconia frame. It will be spilt like this case down the midline. It will be the first full arch case I do on the new system. I am excited to see how it turns out. The scary thing is that the case has about 33mm of inter arch space so the frame is going to be gigantic. Not even sure if the puck can handle this and still give proper glass support. For obvious reason he does not want to do it in Gold, so if the blank can not handle the dimensions I will be forced to do a Ti hybrid.

I will post pics of this and hopefully good pics if santa brings me the new macro lens and dual flash set up I asked for.

 

[paulg100]

"I have a case coming in after the first of the year that the client is completely insistent to do a full arch based on a Zirconia frame. It will be split like this case down the mid line."

The scariest thing about doing large Zirconia frames like this is there ain't no soldering! so its totally reliant on getting an accurate imp from the Dr to start with.

This is something i make a point of warning clients about now and the fact that if it doesn't fit, theres none of this free remake lark on the frame.

I just don't see any way of building a remake factor into costs for zirconia frames of this size.

This is one i finished recently. 2 upper 5 unit frames split down middle on zirconia sub copings.

The sub copings meant there was hardly any room left for the frame and ceramic work so all in all it was an OK end result considering, although not up to presentation standard, which was a shame.

The upper frames were pretty huge and i copy milled all this from a wax up on an inlab MCXL! amazingly enough it all fitted great. One of the few things this system has going for it is that you can scan and design off a solid model which is real handy for bridge work.

One of these a week would be lovely, think the bill came to around $8500k all in (converted from £).

 

[Al.]

Al, your framework meets, or exceeds your excellence in ceramics..all I can say is wow...and I'm so glad I didn't have to wax/design that case........can't wait to see the finished case...... Hope you have the time to take pics as you progress through this case.

John, I dare say that few techs could EVER come close to designing this case correctly..... Question.... is this a slam dunk designing on your scanner with implant software to print or mill in wax ? Does it make it simple, with some basic implant experience ?

Charles

Edit: Is it easy to design framework with scanner ...not implants on model that Al already received .

Charles its really not that difficult to wax.

Take your preformed pontics, starting with the anterior 4.
I heat them and bend them to match the curve of the upper. Then I take a peice/ball of rope wax and position the 4 ant pontics. Then attach them to the ucla abuttments.
Then work my way back attaching sections of pontics. I use the Redi Form Bio Pontics, they are shrunk down crowns. I wax cusp tips where I need them. When the pontics are attached I just fill everything in.

To extend the cylinders I use the metal shank of a lab bur. They fit perfect into the tube. Ill use that to build the porc around also.

As long as the investment expansion is correct I think there is less chances for warpage for screw retained because nothing moves and detaching is simple as unscrewing it vs having to pop dies. I think it is a must to section everyting and reconnect to releave stress.

When you sprue make sure not to block your screw access holes, and you need a longer than normal allen wrench.
Also no bubbles in the cylinders or its a remake.

I think the whole thing took around 5 hours from start to finish.

Long 3 stage burn out.
2 200 gm rings.
Cold furnace 10 F per min to 600F hold 30 min, 10 F to 1200 hold 30, 10 to 1600 hold 1 hr.

I think it would be difficult to design virtualy to get the occ correct, one screw up and your layering is off.

If I had to do it in zir like Paul was talking about I would make the whole thing in a combination of wax and acrylic.
Then I would have a try in of this frame and let the Dr connect this frame in the mouth.

Then I would have it milled off my frame.
Thats where a MAD MAN may come in handy like Zirkon Zahn ?

 

[Al.]

"I have a case coming in after the first of the year that the client is completely insistent to do a full arch based on a Zirconia frame. It will be split like this case down the mid line."

The scariest thing about doing large Zirconia frames like this is there ain't no soldering! so its totally reliant on getting an accurate imp from the Dr to start with.

This is something i make a point of warning clients about now and the fact that if it doesn't fit, theres none of this free remake lark on the frame.

I just don't see any way of building a remake factor into costs for zirconia frames of this size.

This is one i finished recently. 2 upper 5 unit frames split down middle on zirconia sub copings.

The sub copings meant there was hardly any room left for the frame and ceramic work so all in all it was an OK end result considering, although not up to presentation standard, which was a shame.

The upper frames were pretty huge and i copy milled all this from a wax up on an inlab MCXL! amazingly enough it all fitted great. One of the few things this system has going for it is that you can scan and design off a solid model which is real handy for bridge work.

One of these a week would be lovely, think the bill came to around $8500k all in (converted from £).

Yeah everytime I have made pfm bridges over metal copings they have come out huge, and that is with the coping made paper thin where I needed, I can imagine how big it would be with 2 thick zir frames.

 

[Al.]

Truthfully metal ceramic fixed implant restorations of this size have started to go away. Not only because the price is so outrageous but the quality of the restoration and the ease of repairs is making acrylic and denture teeth a more advantageous solution.

Well that sucks.

Cant do anything about the ease of repairs, so to help that it is very important to get support for all the cusps to help prevent fractures.

Using a low gold metal may help a bit with the cost by 3 or 4 hundred dollars.

I think the quality of the restoration is a biggie.

So many ceramists dont know tooth form well enough or how to layer tissue porc and they come out inferior to what the denture dept can make.

Frame design is a big culprit in poor outcome. Connections not rounded and seperated and lingualized make ceramic teeth look opaque and not individual.

Its a problem when a C&B waxer that cant invision the final outcome makes a frame for a ceramist. But that applies to all bridges.

So in order to get more of this type of work I need to attempt to make it look more realistic than acrylic and denture teeth and design it do it dosent break.

 

[TheLabGuy]

Hey Al,
I'm curious, were you just really, really careful not to sandblast the bottom of those implants during devesting or do you have a secret? Great Case!!!!!!!!! and I'm thinking high water on this and I might even suggest using a GC Gradia instead of the pink porcelain, might be something to throw out there to the client........ease of adding/subtracting, cleaning, and should your labor charge drastically

 

[2thm8kr]

@ TheLabGuy


"Hey Al,
I'm curious, were you just really, really careful not to sandblast the bottom of those implants during devesting or do you have a secret?"

I use hydrochloric acid to chemically devest implant cases. Takes a little
time, but the inter phases stay nice and factory finished.

 

[paulg100]

i have problems getting clients to go for pink gum materials.

The thing with it is it looks great if proper gum shades are taken, but sticks out like a sore thumb if the lab is just left to use a stock colour.

This seems to be a common experiance for many of them as they never provide proper gum shades and the resluts have turned them off the idea.

devesting with acid is what Strumann teach for implant stuff.

Also came across this on the GC website some time back which has some good info in:

http://www.gceurope.com/pid/121/manual/en_Manual.pdf

Might be of some use to someone.

 

[Al.]

Hey Al,
I'm curious, were you just really, really careful not to sandblast the bottom of those implants during devesting or do you have a secret? Great Case!!!!!!!!! and I'm thinking high water on this and I might even suggest using a GC Gradia instead of the pink porcelain, might be something to throw out there to the client........ease of adding/subtracting, cleaning, and should your labor charge drastically

Rob I just put my finger tip over the top of the implant abutt then when I get close to it I switch to glass beads at 40 psi. and blast it the same as all ceramic at an angle or with a glancing blow.
You can see in the pic that the top half of the casting is shinny from the glass beads.

What does "high water" mean John said that also ?

What is GC Gradia, light cured composite or is it acrylic?
Its probably too late for that now? I would have to design the frame differently for acrylic? Mabey with some mechanical retention or stippling?

Is that what is considered a hybred, half ceramics and half acrylic?

I should get the tissue porc in 2 seperate bakes, When I do a final bake on the teeth I will also add the tissue I dont count that as a seperate tissue area bake.
Then I will so a seperate bake for the tissue area only and probably one more for character and touch up.

So 3 tissue area bakes 1 incorporated into the final and 3rd body bake and 2 seperate tissue ared only bakes.
It should be 5 or 6 bakes total.
One, body and interproximal bake only to releive stress on the frame and mask the opaqued frame with dentin.
2nd bake of dentin and enamel to full contour.
3rd fill in interproximals and touch ups and 1st tissue build.
4th tissue only.
5 final tissue and other small touch ups.
6th bake is where I missed something I really dont like to add too much during the glaze. The 6th bake may not be necessary but on larger cases when it I think it is done I usually find somthing I missed, or some detail has rounded and I want to sharpen it up.
Usually though Inline holds its shape and detail nicely. Of course I lower my hold time for the later bakes.

 

[TheLabGuy]

That's what I do to currently as well Al during sandblasting, might have to look into the HCL acid though. High water = usually means >2 to 3mm space between the bottom of the bridge to the tissue, leaving a slew way so no food gets trapped, etc.... The GC Gradia is a resin composite in the various pink colors. Lets you focus more on getting the porcelain teeth where you want it and then just add the GC Gradia to where it needs to be and light cure and resulting in a lot less firings.

 

[JohnWilson]

Good morning Al,

I agree in the hands of a master I have seen these cases pop to the point that they are a piece of art. The tough part is when something breaks. Things break even with the most demanding occ planning things break.

In this particular case you mention that the "Upper is next" You will be designing this case ideal or in occ with whats there now? Then Mating up the Upper when it gets restored correct? Full over full Implant retained/supported restorations can generate a tremendous amount of force. Having the ability to unscrew and patch up a porc fracture is great but I don't know a tech on this planet that wants to put something that huge back in the oven after its been in the mouth. No matter how long you dry it its still a huge risk.

The ease/beauty of repairing a fixed hybrid based on denture teeth and acrylic is that any lab across this country can easily repair it in a few hours with consistent results. The quality of the new NFC teeth offer tremendous wear resistance and rival the beauty of a baked restoration. The material gives a bit when the patient functions so that its almost a bit like a shock absorber in my opinion over glass.

Now don't get me wrong I would love to have this type of work every day just based on the fee I charge but I know for the time and mental stress associated with it I can most certainly bang out a fixed hybrid with plastic much more profitably because my labor is more controlled.

Just for fun and to wow the techs that have never done a case like this what did you quote your client on this case. How many single EMAX units would you rather be doing to make up for the stress factor

In any event it is a real pleasure to see you chronicle a big case such as this. It really opens the eyes of many new techs as to what is possible when you communicate, plan, and execute a treatment plan with the team approach to dentistry.

Happy Holidays!

John

 

[Mark Jackson]

@ TheLabGuy


"Hey Al,
I'm curious, were you just really, really careful not to sandblast the bottom of those implants during devesting or do you have a secret?"

I use hydrochloric acid to chemically devest implant cases. Takes a little
time, but the inter phases stay nice and factory finished.

Just a suggestion, you might want to look at the Microclean with Equinox needles. No acid and a super fast way to get a beautiful devested casting. FYI

Nice case Al.

 

[Al.]

Yee Haw, she fit like a Trojan !! By eye and xray.
Shes ready to layer.

I made the connections thin on the occ but beefed them up towards the gin. Like a triangle, or pyramid, that way hopefully I can put some nice seperation between the teeth making them look more individual from the occlusal.

Im going to thin and polish the sub gin areas. And add some wax and remove some stone on the uppers to level out the occ. since they are next.

 

[JohnWilson]

Hey great news, good planning an skill is rewarded at times

 

[Al.]

Opaqued A1, A3, pink/tissue, and dusted with A1 shoulder porc.