Techniques for implant pick up

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paulg100

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OK have this case at the minute which is proving to be a bit of a challenge for various reasons, so thought id try and get some ideas on this..

1st problem is that to maintain tissue forms, we need to leave the custom abutments and temps in situ during fabrication of the prosthetics, plus its not possible to laser back the tissue to get clear margins to take a conventional imp over the abutments, as again this would disrupt the soft tissue contour.

So the only technique im aware of is to make thimble pick up copings on the abutments before intra oral placement. Then pop the copings on and take an impression over the top.

I then cast resin dies into the copings whilst in the imp, then a conventional stone model around it which ends with this..

aimg834.imageshack.us_img834_8146_img0002ab.jpg

I then recovered the copings from the imp and waxed frames on to these and pressed in MO Emax.



Then finished ceramic work and ended with this:

aimg7.imageshack.us_img7_8862_mg0261.jpg

Now i knew the shade needed to be pretty translucent so i mixed in about 30% Trans Neutral into the dentine, couldn't do to much due to the opaque frames which needed to be opaque to cover the metal abutments. I also had problems getting enough separation between the teeth due to the placement of the connectors, so at try-in..

aimg138.imageshack.us_img138_4361_img8014q.jpg

No where near translucent enough, and needed more separation between the teeth as suspected.

Just look at the damn translucency of those centrals, i hate these cases, how to make teeth look this translucent with an opaque frame underneath !?!

So this is what I'm doing now, managed to get the abutments out to make up some more thimble copings to press. Pressed these in Emax HO which i can stain and then wax frames to go over these and press in LT or even HT.

aimg715.imageshack.us_img715_1734_img0003ya.jpg

This is where the problems are starting, as i do not have an accurate model of the abutments to fit the HO copings to and theres no way i wanna do all the work to go over the top of these if I'm not 100% sure they fully seat and that the margins are correct.

So the questions is.. Anyone know of any other techniques to create an accurate working model of implant abutments when you don't have the abutments?

I thought one way is that maybe i could have adjusted the abutments when i had the analog model at the start, then screwed these in and duped the model in silicone. Although i don't know if this would be accurate enough??

Also maybe someone has some ideas on how to go about making bridge work look this translucent whilst still masking metal abutments?

It would have been allot easier with zirconia abutments as i could have stained these, then just pressed an complete LT or HT frame over the top without worrying about the masking issues, but client did not want to use these due to the bedding in and re-torque issues, and they don't make the two piece ones with metal insert for ankylos yet.

Thanks in advance for any thoughts...
aimg834.imageshack.us_img834_8146_img0002ab.jpg aimg7.imageshack.us_img7_8862_mg0261.jpg aimg138.imageshack.us_img138_4361_img8014q.jpg aimg715.imageshack.us_img715_1734_img0003ya.jpg
 
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Gdentallab

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soz why the pictures appear as a frog in a cube??????
 
rkm rdt

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Could you have opaqued the metal abutments and pressed in LT?
 
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paulg100

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The abutments were modified stock titanium ones, maybe that would be an option for future cases but id have to buy titanium opaques.

Then again, the Ankylos abutments come with the screws fixed into them so i dont think you could run them through a furnace cycle.

Froggs?? images a working fine here.
 
rkm rdt

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OK, stock abutments.

So now you have the temps,ie the first emax bridges.

Can the Dr now take a new impression with the proper imp. copings?

The tissue is now formed to your 1st bridge so it should be fine for the impression and reinserted while you fab #2.

I have not worked with Ankylos, however they should have a castable ucla?
 
JohnWilson

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Nope no UCLA for that system,

Thats another non index internal connection fixture that needs a jig to seat the abutment if the doc takes a fixture level impression.

As far sub g as the margins are on that case the Dr will have more issues cleaning cement than anything else.

Not sure why traditional metal ceramics was not used on this case? Looks like you have the room to get the trans you need, plus it bullet proofs the cant.

If the Dr had jigs to seat the abutments originally you can use them to reverse engineer a tissue/abutment model if they were made well.

From the way the abutments were prepped it appears the doc slammed them in with out a jig and prepped them in the mouth. Why he buried the margin the way he did is beyond me.

I think you are making this case way more difficult than it has to be, Dr appears to be stubborn and not wanting to loose the tissue architecture he created with the temps which is understandable but the plan from the beginning was flawed.

For future use, if the client intends on prepping stock abutments in the mouth and making temps to design tissue architecture then by all means the day he preps the abutment have an analog on hand slide the abutment on a analog, block out the access hole and take an impression for a master die of the abutment. With this information the abutments will never ever have to be removed and tissue information can be transfered much more accurately with this coping.

Just imagine in this particular case with a coping with a loop retention that could be cast out of anything that he can slide over the abutment, inject impression material around it and pic up the entire thing in a master impression. You can then be very certain you have what you need to make a very nice case. The biggest hurdle is when the tissue is very thin and unsupported, this is when the Dr has to take the time to inject in the sulcus immediately after removing the temps to keep the tissue from falling back on the abutment/cope

Anyhow I wish you luck on this case. I would recommend you rethink the material of choice on this.

Good luck
 
dmonwaxa

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Ankylos abutments,,,,,soon, its in the works. And I also echo what John said. As for the case itself; a implant level impression should be provided along with two new abutments, its the only way in my book. Trying to retroengineer the tissue would still require an implant level impression and a complete capture of the engineered tissue. I would suggest using an LT ingot for the framework, stained core and layered. The Ti abutment will help lower the current value issues.
 
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paulg100

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"block out the access hole and take an impression for a master die of the abutment"

Bingo!, now why didnt i thin of that :) thanks John, that will make things much easier in future.

The collar of the abutment is only about 1-1.5mm subgingival so not as deep as it looks. I think because the stock balanced posterior Abutments are not that long, it is making it appear deeper.

I agree about the material choice not being ideal, in hind site zirconia may have been better (dont really use metal anymore),but this still leaves the problem of a very opaque core to make a highly translucent tooth.

Having space to layer a thicker amount of labial ceramic is not going to make the core appear translucent from my experience. I have been playing about with a complex grey stain for masking cores like this, with some success, so maybe this is the trick.

dmon:"I would suggest using an LT ingot for the framework, stained core and layered. The Ti abutment will help lower the current value issues."

Yep i waxed a spare set of thimbles with the intention of waxing into a full LT frame to try. Sadly i blew this set out when i tried to press with a large ingot into in a 100g ring (it was all i had at the time),it cracked the ring! so wont do that again!

Anyway thanks for all your comments, time to see where i go from here :confused:, to move forward, really need the abutments back to duplicate as you have suggested.
 
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paulg100

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OK i just thought id post a little update to this thread to say i got some sorta decent result in the end so thanks for your help. Not perfect but patient was happy which is the main thing i guess.

img8695.jpg


Had to order two new abutments in the end (which the client paid for thankfully, makes a change!),and used LT frames. So good leason i learnt there, LT over metal abutments can work ok if the final shade calls for it. Just hope the emax cantilevers are strong enough to last the test of time, we will see (anterior open bite btw)

Think ive finally found a solution to the custom abutment/ankylos situation by using a combination of stock posterior abutments and emax. Have a few cases in R&D at the min so will post some stuff soon.

Maybe some of you are already playing around with making custom emax abutments??
 
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Bobby Orr ceramics

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Very nice work Paul !! thanks for sharing. Don't beat yourself up over this nice result. No case is ever perfect !! You can't out-create the master Creator !!!

Orr
 
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paulg100

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So this is how i will be doing these ankylos cases in future where i dont have the abutments.

Duplicated resin analogs in gellar syle model:
aimg855.imageshack.us_img855_91_img0001cjq.jpg

Or emax custom abutments, which have a nice aesthetic emergence colar that i can stain etc and also allow the dentist to take a conventional imp without removing the abutments:

aimg10.imageshack.us_img10_2970_img0003wu.jpg

This should solve any future issues i hope :)

Certainly gonna work out nice for these two cases i think.
aimg855.imageshack.us_img855_91_img0001cjq.jpg aimg10.imageshack.us_img10_2970_img0003wu.jpg
 
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dmonwaxa

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Paul, the finals shows a great improvement over the first attempt, what did you do differently? And, are the last two photos of the geller models Ankylos? doesnt look like it but I could be mistaken.
 
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paulg100

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just switched from MO to LT DMON, the extra trans was what i needed but i was afraid it would grey the abutment to much, but it worked out OK.

and yep they are Ankylos, stright stock posterior abutments, modified slightly.
 
dmonwaxa

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Paul; Ok, now you're playing with me.... Are you telling me the last photo is of Ankylos implant abutments? and are you saying you pressed a custom abut using emax? if so how did you address the screw issue?...hmmmmm?
 
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paulg100

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yep the last photo is a stock ankylos posterior abutment with a waxed and pressed emax custom part on top :)

just have to cement it to the abutment with ivoclar multilink implant. The screw is already in the ankylos abutment.

I think Ivoclar are actually bringing out inserts soon for many popular systems, so you will be able to do the same thing with a custom insert.

Its the same as how all the hybrid cad/cam zirconia abutments work. your just doing it manually with emax, not with zirconia.

This technique has been around for a while now, its detailed in here from 2009:

Quintessence Publishing

Just that i only got around to playing about with it and the current limitations of the ankylos system made me get my butt in gear.

EDIT: That is a MO1 (not MO0) ingot btw. I wouldnt use HO i think the collar will be to opaque.

Who needs expensive UCLA parts and Gold huh!

I still need to get a black/uv lamp and check the luminosity in pressed emax. Cant find any info online, maybe someone here knows if emax has much luminosity? it really helps with tissue colour, especially for anterior work where the tissue is thin.
 
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dmonwaxa

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I'm a bit slow,,,:eek: now I get it. I thought you had pressed directly to the modified stock abunments,,,, :confused: :p So the cement is strong enough to be used in this manner? Regarding force and load to the pressed abutment what is the max off axis angle; IYHO?
 
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paulg100

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yes the cement is strong enough (according to ivoclar),its what its made for. Its not regular multilink.

I would not use this technique with unsupported off axis lithium disilicate, it is not strong enough. You need most of the inside to be supported by the metal insert, but ofcourse you can just use an off axis abutment underneath. It just give you control over colour/shape and finish of the emergence, and masking of the abutment to then use a LT or HT over the top.

In otherwords, very handy indeed :)
 
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dmonwaxa

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Paul, great stuff thanks for the info.
 
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Nice one Paul. I'm currently playing around with this technique myself....then comes the next question, where does it fit onto the price scale? Do we charge more (increased asethetics blah blah) or less (much cheaper to produce than outsourcing) than lets say our normal custom Zir abutments? Hmmm
 
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paulg100

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Well as far as i see it, its the same amount of work as waxing and casting a UCLA.

you just don't have the cost of the UCLA or the GOLD.

Instead you have the cost of the stock Abutment and an ingot.

Plus your labour fee which would be the same as you would charge for a gold UCLA/custom abutment.

Not sure on the cost of UCLA's now but there the same if not more than a stock titanium abutment right? so theres a saving there plus the saving on the gold, so they should be a cheaper alternative.

I don't see them comming in cheaper than a custom cad/cam zirconia abutment really. Its just a different technique to achieve the same result, without using cad/cam.

When the inserts are available then these will no doubt be cheaper than buying a stock abutment so more savings there.

But the other thing thats cool about this technique.. The implant companies are starting to get funny with warranties if third party abutments are used with their implants, but with this method your still using there part, but creating your own custom part on top, so that solves that issue also.
 

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