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What are the most important considerations for effective collaboration among the dental team on implant cases?
Lee Ann Brady, DMD
One of the most important considerations is providing the laboratory with the most accurate information for custom anterior implant provisionals to allow alteration of the emergence profile of the abutment from the top of the fixture to the free gingival margin and to optimize the pink esthetics during tissue maturation. It is imperative to capture the shape of the model and the customized emergence profile so the laboratory has an identical soft-tissue model on which to create the emergence profile of the final abutment/crown. The instant the temporary restoration/abutment is unscrewed, the tissue shape begins to slump. We use a specific technique to fabricate a custom impression coping quickly and simply.
First, remove the implant provisional and inject die silicone to create a silicone plug to help hold the tissue shape. Then, screw the implant provisional onto an analog. Mix snap set stone and fill a medicine cup to approximately ¼ inch, place the analog/provisional into stone, and allow it to set for 4 minutes. Inject die silicone onto the snap set stone, around the remainder of the exposed analog and several millimeters up onto the provisional to capture the emergence profile. Allow it to set for 45 seconds.
Mark the facial with a marker on the stone and outside of the cup. Unscrew the provisional and replace it with an impression coping. Inject dual-cure resin cement around the impression coping into the soft-tissue impression, and allow it to cure fully. Mark the facial of the impression coping with a marker. Unscrew the custom impression coping, wipe it with alcohol to remove any air-inhibited layer, and place it in chlorhexidine. Remove the plug from the fixture with an explorer and seat the custom impression coping.
The final impression, customized impression coping, and medicine cup impression are all sent to the laboratory for use fabricating the final abutment and crown. This is a variation on an older technique; filling the medicine cup with a combination of stone and silicone and marking the facial with a marker were suggestions from Gold Dust Dental Lab.
Rob Maatta, CDT
Several factors contribute to successful implant cases from a laboratory standpoint, the most critical being great communication during the diagnostic phase. The ability to predictably drive prosthetic success is contingent on collaboration with the laboratory and surgical team before the placement of the fixtures. Technology has evolved, and fabrication of surgical stents based on cone-beam images has been a game-changer in the planning process, providing an accurate blueprint for case design.
At Gold Dust Dental Lab, we are committed to incredible esthetics coupled with longevity. Elements such as tissue symmetry, ideal emergence profile, and screw hole placement are too fundamental to leave to chance, so they must be designed ahead of time. Most surgeons seem to be concerned primarily with placing implants in locations where the greatest surgical success is likely, and they may not consider restorative materials, abutment design, access hole placement, substructure design, and other such considerations.
Laboratories also must recognize that dentists manage up to three conversations while serving as the “quarterback” of the treatment plan. The laboratory is just one facet; discussions with a specialist also are necessary if the restorative dentist is not placing the implants, and the third conversation is with the patient. Dentists have an incredibly difficult job in managing expectations before, during, and after treatment, so the laboratory can make important contributions to the patient’s outcome by assisting with digital designs, images of similar treatments, and even virtual consultations. Still, dentists sometimes inherit fixtures already placed in less than ideal locations. Material suggestions such as pink porcelain to hide tissue defects, creative abutment designs, and ceramic artistry can contribute to a more successful result but require ongoing connection with the dentist and patient.
We are privileged to work with some phenomenal educators, and as a result we have created strategies to improve our processes and outcomes, all resulting from ongoing effective communication.The speed and effectiveness of this technological evolution depends on our commitment to cross that chasm.