All-on-4 Update, Prosthetic Options, Tips and Procedures
We are excited to be helping more clients than ever before restore screw-retained hybrid dentures popularized by the marketing of the All-on-4 technique. In fact, in 2013 we fabricated more cases with this design than in the previous three years combined. Due to the frequency and volume of this type of casework in the laboratory we have been able to refine our technique to provide an outstanding product at a reasonable flat-rate fee. Our All-in-One fees allow you to quote you
r patient knowing the price will be the same regardless of implant brand (with a few exceptions) or the number of implants placed. Based upon our experience, and the input from customers, we want to share helpful information as we begin the New Year. All of us at ROE thank you for trusting us with these cases and promise to support you in every way we can to help ensure your success and the satisfaction of your patients.
Consider the Need for Multi-unit Abutments (TMA’s)
Multi-unit, or Transmucosal abutments (TMA’s), are permanent fixtures used for three primary reasons. First, they bring the restorative platform of an implant from the bone level to the tissue level which prevents ‘sluffing’ tissue around the implant during restorative and maintenance procedures. Second, they redirect the trajectory of the prosthetic screws to a more esthetic or functional direction preventing access holes from emerging through undesired locations on teeth, especially the facials. Third, they can correct angles of divergently placed implants allowing a common path of insertion.
In our experience, multi-unit abutments are used in 50% of edentulous, fixed cases and are utilized in two common scenarios.
Senario 1 – The treatment plan calls for an immediate provisional appliance. The surgeon or restoring dentist places the implants, aligns the TMA’s to a common path-of-insertion and screw-emergence position to accept the provisional appliance, and torques them in. The TMA’s are the final abutments and will be used for the provisional and final appliance. In other words, there is no need to buy additional abutments for the final restoration in this scenario. It would be prudent to discuss with the placing doctor who will bear the cost of the parts needed for the immediate provisional conversion. The only parts needed for the final definitive restoration of the case are abutment-level impression copings and analogs.
Senario 2 – Implants have been placed as a Two-Stage surgery. The patient will present after successful osseointegration with healing abutments in place. It is important, at this time, that careful analysis is followed to determine the need for TMA’s and the correct angles and cuff heights.
The need for these components should be determined at the very beginning of the process before any final impressions or prosthetic work is done. We suggest the following procedure as the first step in the restoration process:
1. Make a duplicate of the patients existing denture. (http://roedentallab.com/downloads/duplicatetechnique.pdf)
2. Take an accurate alginate impression of the arch making sure that the healing abutments are present and visible on the ridge showing the angles of the implants; or take a reline impression inside the duplicate denture capturing the position of the healing abutments.
3. Provide the deepest probing depth around each implant, or send an implant-level impression.
4. Send this information to the lab. We will determine the abutment angles needed from either one of these procedures by relating the implant position and angle to the position of the teeth on the duplicate denture.
5. The appropriate parts can then be ordered and the final restorative process can begin.
Consider the Cost of Multi-unit Abutments in your fee
The cost of TMA’s can be as much as $345 each, and together with multi-unit impression transfers and healing caps can be $510 per implant. Ordering parts directly or using aftermarket parts can reduce the total. The probability of this cost should be taken into consideration when quoting fees. It is also important to note that ROE does not include multi-unit abutments, impression transfers, cover caps and analogs in our All-in-One fees, since many cases do not require them and often they are provided to us by either the restoring or placing doctor.
TMA Selection & Confirmation Jig
During surgery (as described in Scenario 1 above), once the implants are placed, the doctor must decide which angle and cuff-height is appropriate for each TMA. The angle selected and how they are placed will ensure that the screw trajectory is aiming to the correct location on the prosthesis. One method is for ROE to create a clear duplicate of the immediate denture with troughs cut into areas where the screws should emerge. The abutments are tried-in with the seating handles attached, and maneuvered until the handles protrude passively through the troughs. This will ensure accurate selection and placement.
Avoid a Multi-unit Abutment Puzzle
When multi-unit abutments are required it is always suggested that they are placed clinically and an abutment-level impression is sent to the lab. With the various positions that an angled abutment can be placed, and the very small screw size, our clients have reported difficulty in transferring the abutments from the model to the mouth accurately. Save yourself the challenge and consider the above suggestions and determine the need for these parts at the very beginning of the process.
The TLZ-IB Prettau Bridge Alternative
If you are looking to upgrade a hybrid denture or want to offer an option other than acrylic, look into ROE’s TLZ-IB (Prettau) bridge. This exciting, primarily monolithic zirconia design is much stronger and more esthetic than conventional hybrids. This design comes in a unique two-step process. First, if the patient likes their temporary hybrid, we digitally duplicate it into an acrylic prototype that the patient ‘test-drives’ for a week or two. When the patient gives final approval, it is returned and converted into the final prosthesis which is truly an amazing work of dental technology.
Implant Brand Selection – Critical
When it comes to the restoration of both conventional hybrids and TLZ-IB’s not all implants are created equal. Some implant systems provide better restorative options than others. In fact, some brand selections make it very difficult to complete these case designs. We encourage communicating with us, when possible, about the case design prior to implant selection to ensure your objectives can be met and excess cost is not incurred.
Thank you for taking time to read our update. We welcome your calls on these or any other subject!
The ROE Team