Fixed Full Arch Workflows – 5 Options to Attain a NobelProcera Bridge

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To make a bridge without copings means a lot. It’s a tremendous shift in the industry because we have customers who ask us all the time, how do you make one of these things without copings for all the reasons that Travis said, but one of the main ones is just hygiene, right? And delamination. I’ll get into it. I’ll get into a little bit of that, not too much, but I’m going to get into a little bit of the reasons we love it. So I’m going to go through a few more slides before I get to this, but this is the outline of the program and I’m, I’m going to go through these as quickly as possible. It’s going to be recorded and it will be shared on our website. It’ll be broken down by whether you’re digital, whether you’re analog, whether you’re doing this through surgery or whether you have an iOS scanner or just want to use stone.

We have a method for each one of those protocols to send us to simple records to order a Procera bridge. So what I have seen, what we have seen and in the many cases over the years and working with our doctors, what are the issues with full arch? And they can all be solved with our techniques for records. And with this Procera bridge, lack of passivity, that’s going to be the number one reason that a zirconia breaks. I mean, sometimes it’s material failure, but let’s face it, usually the model is not perfect or perhaps the manufacturing process or the inserting the coping process is not perfect and the product’s not passive. And if it’s zirconia, it’ll break. So has to be passive. A screw access position. I mean, who has not had a problem with screws, facially, lingually, any number of reasons. So this built-in screw channel certainly helps with the positions of the positions of the screws.

So much better hygiene. I mean, my goodness, if you don’t have copings, you don’t have cement, then you don’t have all the issues on the intaglio. You don’t have as many. You have to design the prosthetic, obviously concave, convex, and it has to be polished and it has to be cleansible. But if you turn over a full arch you know what’s underneath it, and it’s usually mostly around those areas, a copings and then of course fracture. If we don’t have to manually put in the copings on a model with cement space, cement gap, then you’re going to have less fracture. It’s going to be a more secure prosthetic direct to the  MUAs or direct to implants and ti-base to bonding. We’ve talked about that. You’re not going to have that. They don’t exist. Travis went through most of this, certainly more hygienic, it’s more dependable. The zirconia around the prosthetic adapter, and certainly that’s on the direct implant.

But most of the cases we work on are MUA level. And if you don’t have a coping inside, you have more material. Everybody wants a procera. Everybody wants a zirconia bridge. Procera bridge to be narrower, buccal lingual, labial lingual, but you can’t sacrifice it because of strength. Well, if you don’t have a coping inside, then you add another millimeter, at least with cement and material space. So it’s much stronger. And then today, really not doing any layered ceramics on these. It’s all surface fired stain with MiYo, which is beautiful, but you won’t have chipping. So this product is very strong and we went through the angle screw channel part, but because we’re so involved with guided surgery and these full arch cases, the answer always is we’ll use a shorter collar height and then the metal will be hidden. We’re working sub-gingivaly instead of super gingival or at the gingiva, especially in the anterior on the maxilla.

So if you can take out or not use in the first place a 15 or a 30 degree abutment because you can use a zero degree with an angled screw channel with a 1.5 millimeter collar height, problem solved. And so that you can solve that problem on so many cases, especially a case that’s been around for a while. You have tissue die back, bone loss, that kind of thing, and now you have some exposure and you’re thinking about making a labial flange of zirconia, which you don’t want to do. So instead use something else to remove the metal as opposed to mask it.

If you speak with a Nobel rep, they are going to tell you that these are compatible with Nobel implants, Nobel MUAs, and that is true. But if you work through us, through ROE and obviously other laboratories too, you have the ability to order a Procera bridge on these different systems, doing a little testing with Straumann. We do a lot of Straumann work, but with Nobel obviously it’s a perfect marriage. But with these compatible MUAs, not implant level, but MUA level, these companies have mimicked the conical shape of the MUA and therefore we can order Procera bridges for all these other systems, which is a really nice advantage.

Let’s get into how to order attain a Procera bridge. So let’s go into the first one, which is surgical, a little bit more of an analog technique after surgery. But if you’ve seen this product around the world, maybe you’re involved in it. It’s a brilliant way to go to final after surgery directly. This is Dr. Jacob Keefer. He’s one of our serious Chrome users, is up in the northeast and heck of a nice guy with a lot of experience. He’s a heck of a photographer. So I put this slide up on here because he’s just getting into these final restorations. We’re talking about these Procera bridges. Well anyway, if you’re involved in Chrome, if you’re not, this is a process. Sorry for the lunchtime gore here. But the process is, and this is just real quick in a nutshell, guided surgery where we are controlling the bone reduction, the implant placement, the temporary cylinder pickup and prosthetic delivery all in a few hours.

But what happens is on the day of surgery, you do two pickups. The top one is the patient’s take home prosthetic that they’re going to wear, and the bottom is called the rapid appliance. It’s a second pickup. And traditionally that RAPID appliance is held at the office and in six months the patient comes in and let me stay on this slide. The patient will come in and the long-term prosthetic is taken out. The rapid appliance is seated, its equilibrated, and you could do a reline impression, take a bite and an opposing, and you could go right to final. You could send that into us and we would order a Procera bridge for final. And it cannot get any simpler than that. Now the top prosthetic the patient’s been wearing for the past six months can also be relined.

If the equilibration the tooth position, everything is already accepted, approved or we can make adjustments to it here in the laboratory. But the point is that you can send the patient home in something they’ve been wearing, they approved, send the patient home that day in the RAPID appliance, the bottom one and the top one comes to us, physically comes to us in the mail reline impression bite opposing, we scan it, we make some tweaks, some design changes if needed, add the molars and we return a Nobel Procera bridge and that could not be simpler. So here’s the first appointment. This is at the restorative part. First appointment, seat the rapids or realign the long, the long-term prosthetic bite registration, equilibration bite registration and send this to us. We do. Second appointment is a try-in, so Dr. Keifer adds a little bit of pink to these try-ins.

So they’re just beautiful. Patient even wore this for a couple of weeks. Test drive, comes back in. We made the Procera bridges. Very simple process. And actually forgive me, I believe the image on the right is actually still the temp. I should have put his final picture in there. But Procera bridges, so very simple process to acquiring a final. There he is start to finish. And the middle one’s a smile simulation, which is also available through us. Patients have an old worn down prosthetic. I’m going to show a bunch of ’em here in a minute. But what are the possibilities of turning over their long-term prosthetic into something more aesthetic, beautiful, something that really fits their face. Do a smile simulation. We do ’em all with PreVu. It’s a powerful software to recommend anybody doing smile simulations to la go to PreVu and you basically rent their software and do this, do the smile simulations in your office in about five minutes.

They’re second to none best in the world. So we, we’ve made thousands of smiles with them. There’s nothing like it. The middle appointment where we did a printed try-in, generally they’re monochromatic. We charge a little more. You can add pink to it, the patient can wear it home. This is a printed Lucitone material, but you try it in. And this is a test drive for the final, either just clinically real quick or test drive, but you would try it in. Do a one screw passivity test, X-ray to make sure it’s seating. Go through the normal protocols, maybe you can visually seat, and then if there’s any gaps in the tissue, do a reline impression equilibrate and if there’s aesthetic changes, contouring, that kind of thing, do it then physically send it back to us. And then we go to final. So that was a chrome surgical process, kind of a neat process that we have done just about 9,000 times in the past five years that Chrome product has become an international sensation.

And one of the reasons is it’s so easy to order a final convert to final as opposed to traditional denture conversion processes. So the last, I’m sorry, the one the next, forgive me shrink that. The next one is a RAPID, RAPID and existing prosthetic. So the RAPID appliance is kind of a different thing either from the surgical or we do a RAPID, like a delayed method or a patient walks in with a prosthetic that needs to be redone. You can see these images here. Look how far the midline is off. Patient has a gummy smile on the lower one. It’s an FP1 on the upper. It works best if it’s an MUA level implant level of work. But MUA level is what we generally work with. Patient comes in with really just about any situation that you come across. And I took all these pictures, full disclosure, most almost all these from the internet.

But just to give an idea of what comes in the office and what you can do with it. And why did we develop the RAPID appliance technique? Because the traditional methods are tedious to say the least. You have an appointment for a stock tray, impression comes back for a custom tray. Impression, second appointment. The third appointment is a fit verification jig and maybe a screw down bite block probably with us, a screw down bite block, maybe not. Try-in on the bottom left. So now we’re at four appointments on the fifth appointment. If you’re doing a traditional bar with Overton, we don’t do many of those anymore, but traditionally that’s what it would’ve been. So fifth appointment, six appointments, probably a reset, which could be even with some of these more digital processes. And then seventh appointment of final seating. So three and a half to four months depending on the patient’s schedule.

And what a hassle. I mean I’ve seen spreadsheets on the math of these, the cost of chair time, materials, doctor’s time, it’s incredible. It’s barely profitable at seven appointments. So instead do something else. We’re suggesting do something else that’s quite simple. And this is one of the processes. But think about this with almost all of our processes that we’re going to show today, the patient is provided a final restoration prototype on the second appointment with all these protocols, the implant model, bite fit, aesthetics, tooth position, all are confirmed on that second appointment. The team saves lots of time, appointments, expenses, you can do other things on that schedule. And then of course the patient gets to test drive the prosthetic. To make a RAPID appliance, the materials are very simple. Some type of flask, it can even be a denture cup, doesn’t have to be an official flask, something that’ll hold stone.

You’ll need some stone that did not add that here. You’ll need multi-unit abutment analogs, some lab putty, an opposing model of bite, and then an impression of the tissue and the MUAs. And I’ll explain it all. So I went through the whole process of recording what you do. So let’s just say patient comes in, it’s a lower, I think I kind of added upper and lower images into this full rapid slide deck here just for the most effective pictures. Patient comes in with a six unit lower prosthetic and needs a new one. It’s fracture, the teeth are worn down, whatever the reason is. Of course this one looks nice for our demonstration here. But what you’ll do is you’ll order either from us, from the lab or from your rep, order the multi-unit abutment analogs, screw them into the prosthetic. Then once you have the prosthetic in hand with the analogs, take your flask, fill it with stone, right till it’s till it’s maybe three quarters full.

Set the multi buttons in stone and you can see don’t let the prosthetic touch stone. We’re not trying to capture an taglio, the prosthetic because it’s probably a gap anyway, so it won’t tell us anything. So let it set. And then once it’s set, what we want to do is take some lab putty, I believe this is kittenbach material, an accelerant and a putty and just knead them together till they’re one color. And then flask over the prosthetic. Put a little dimple in the middle that helps to make sure you capture the intaglio, the lingual, sorry, not the intaglio. Capture the lingual, once it’s set about 20 minutes, take the flask off of the model. Whichever one comes easier, usually the flask comes out easier. You can leave it in the in the denture cup too and ship it to us. Take the flask off.

Now we have a negative of the prosthetic, but look what we really have. We have implant position, we have tooth position. We have a means of mounting the case because you’re going to send a bite and an opposing. We have everything we need to make a prototype. The only thing we don’t have is the tissue. So what you’ll do is you’ll just, while the prosthetic is out, you’ll take a polyvinyl or an alginate impression of the tissue and the multi-unit apartments just like that. No scan bodies, no analog, nothing, no impression posts, nothing. Just that. Because we will digitally bring that into the case. And what we’ll do with this is we will bring this into the software, hole there. This was actually from an intraoral scan. This is where I wanted to show really how it looks in software. So we will take the prototype and we will articulate it, the opposing the digital, and then we will make a proposal for the final, which is the dark green here.

We will email this to the doctor and you’ll approve it. Is that overjet? Okay, is the overbite okay? And you’ll sign off on it. And from that point, we make the middle one, we make a printed try in it’s monochromatic. Again, we can add pink. It’s a lower paging and wear at home if you want them to. Otherwise you’re just going to do a clinical test and then simply physically send it back to us with the model work and we’ll order you a procera bridge just like that. And you’re going to critique these and say, wait a minute. These cases aren’t the same. They’re not. And I kind of warned that at the beginning. To get the work to get the full workflow is always kind of tricky with pictures. But the idea is that you make a simple flask, a RAPID appliance flask, we make you a prototype and then we make you a final. And it’s very efficient. It’s only three appointments, very accurate. And you don’t have to start a bite block.

Another protocol, which is digital. So went through surgical, went through analog, just simply analog, analog procedure. And then we’re going to go through a digital procedure. And this is a fascinating product that we have worked with for a number of years. Now this is a patent pending process and the iJig is a prototype for the final. In other words, we’ve made all of the aesthetic functional changes in software, but we made it from a digital impression. And I’ll show you how that works. And this does require digital impressions. We really work with all the systems. If I’m missing any here, we probably work with it. The trick with all these systems is that you have the ability to scan the prosthetic in your fingers and roll over to the intaglio and capture these special iJig analogs.

And actually they’re a little bit different now than the ones in this picture. We use a little different one. But these still work in case you do have them already. So these are the tools, obviously an existing prosthetic, a driver for multi-unit abutment screws and prosthetic screws. And iJig scan analogs, which you can buy from roe. I think they’re only $25 a piece. And they’re reusable. You’d reuse them for every time you scan or you can use existing prosthetic screws, that’s fine too. So what you’ll do, and I don’t want to go through the whole process, it takes a while to show the scanning of one of these prosthetics. But essentially you take the prosthetic out of the mouth and you scan the mouth. That’s the first step to do. The bottom is an image. You just scan the tissue and you send it off to the lab.

Okay? That’s the first event if you will, on the iOS scanner. Then open up a new event, unless you’re working with Cerac or maybe one other ones where you can actually stack multiple scans, but sometimes they’ll get lost. The scanners look for working, opposing, bite send. And this is a little bit different. So send the bottom, bottom right off. Then you’ll hold the iJig prosthetic in your fingers and you’ll scan it 360 degrees. So it looks like the top right, every part of it is scanned. You’ll screw the prosthetic back in the mouth and you’ll scan the bite and the opposing. The next case I’m going to show you is double arch. So it’s a little bit different, but single arch, this is it and we will fabricate this. Now the neat thing about this is it’s sectioned so that that’s because we don’t have an analog model to put those copings in.

These are not coping free yet. But what you’ll do with this is you’ll just simply seat this in the mouth. You’ll make sure that those sections are passive, that each section has some passive passivity between them. You can put some dental and then you’ll do an injection procedure to lute them all together. And then you’ll do a reline impression with a little bit of trait adhesive to give us any gaps of tissue, equilibrate and return to us physically. So I’ll just go through the process real quick. This will just take a second. So here’s an iJig comes to the mouth, put some trade adhesive on the intaglio seat it screw it down, right? There’s a little delivery device you can see in the top right there’s a tray that delivers it. Remove the tray, run some floss through each section and then inject, right? We use Stellar. You can use Voco, you can use Duralay.

A near zero shrinkage factor is very important. And then cure it. If it’s a dual or cure, fully equilibrate, then capture a bite because it’s equilibrated, remove the iJig and then just inspect the integrity. I’ll make sure it looks good, but there was a reline impression that everything is intact and then send it off to us. And from that, this is what we receive. This is what they look like. And you look at the screen, you go, what a mess. Right? What are you going to do with that mess? Well, what do we have here? We have teeth just like before, we have tooth position, implant position, bite registration, opposing. We have a reline impression. So now we got an adequate perfect soft tissue model. What do we do with this? We make a printed try-in and we go to final or we go directly to final because the iJig was really a prototype, totally up to you, but very, very efficient method. And that’s four appointments. Digital impression, iJig seating, prototype final. And the second, the third appointment, the prototype could be skipped.

So let’s go to the next one. This one’s very quick. iJig. It’s all the same protocols you saw for capturing all the digital records. With a twist, you can skip the iJig appointment. So it’s still an iJig protocol because of the scan, but you don’t have to have the iJig seating appointment because on the top right you did what we did in the rapid appliance. While the prosthetic is out of the mouth, you made an analog model, just set it in stone and stick it in the mail. Because what we’ll do is instead of making a sectioned prototype for final, we make one that’s un-sectioned and we loot the copings in on these models and then you verify it, it physically send this printed trying back to us. We make a final very simple process again and it really helps to make the analog models because you could skip that other appointment.

The fifth and last method, which is bleeding edge, as they say, technology. I only say that because what we’re doing with it, I believe is bleeding edge. The PIC and the iCAM have been around for a number of years. We saw them in at IDS in Germany five years ago. They were around a little bit before that. Their technology is incredible for making a passive digital file. And the reason we held off on getting involved is because we found that their acquisition of multi-unit abutment or implant position is more accurate than the model we would print to reproduce it. And we didn’t trust a resin printed model to go to make a restoration. So instead we decided to stay fully digital, which is where Nobel Procera bridge came in when they walked in our door months ago and put that coping free Procera bridge in our hands, the light bulb went off.

Now we get involved with iCAM and maybe PIC some time, but right now iCAM and make a prosthetic simply from digital records, in my opinion unattainable before, a hundred percent digital. So watch this cool process. This is Dr. Hansen. He and I have worked together an awful lot in the past five months, completing several cases all from his digital records. Dr. Hansen is great to talk to and great to troubleshoot problems with, but very good at what he does clinically with the records, exceptional. And it made our job easier for really for R and Ding this process. So what he had, this is a, I’m going to show two cases. So this case is he had a patient come in today with a completely demolished upper temporary hybrid. So patient already had, even though this doctor does surgery, he had a patient who already had a hybrid, needed a new one.

So he uploaded the scans, he took the iCAM scans, you saw that with the dominoes. He takes DESS scan bodies, that’s accompanied DESS. They sell scan bodies that are specifically made for the iCAM registration. He scanned the prosthetic, he scanned the opposing and scanned the bite and he sent that to us. Here are the records, I’ll turn this down. It just makes that little beeping noise. That’s just registering. But the dominoes are in the mouth and the doctor takes his iCAM scan, he hovers it over the mouth and he is capturing the positions of the four in this case, four multi-unit abutment positions, i.e. implant positions. And it takes, I think it’s a minute or two depending on how many implants there are there. These are really spread out through the mouth so it’s easy for the camera to capture them, but it registers.

You can see green, green, red, red. So he’ll keep going until they’re all green. And then once that’s finished, he’ll take those scan flags out the dominoes. He’ll do another scan with these DESS analogs and then he’ll seat the prosthetics and he’ll do intraoral scans of the prosthetics seated. Those are the scans. And then what we receive, you see on the left is we have tissue, we have scan bodies, we have a prosthetic seated that can be registered back to the original scan. And we have tissue. So we have intaglio, this is what it looks like in color. This is black and white. And what do we do with this? We bring this into our software. We have what the patient’s wearing. We have implant positions. I think I’ll turn on the little, yep, yep. So we, those are not copings, those are screw channels. Those are just screw channels. This is a coping free try-in and a coping free Nobel Procera Bridge.

Make a proposal, right here. That’s what we’re proposing as a new final. We print it in, we printed it, we send that off to the doctor as a preview. And sometimes it’s just screenshots with the DTX software, Nobel’s software. And sometimes it’s a video plan for a prototype. Doctor signs off on it, we fabricate. This is a printed try-in for trial and we use these special screws and these screws contact the resin only, no copings. So now we’re really test driving the coping free prosthetic, doctor will receive this. And then you can see here, printed trying with pink went perfectly. No adjustment order to the Procera bridge. So he screwed this in. Oh is we put pink on this cause we wanted the patient to wear this one home, come with it, screwed it in. He had no adjustment, zero and he did not have to send the prosthetic back.

There’s no model, there’s nothing to articulate or ship, nothing. He just calls us and says, make a final. So with that, we just simply uploaded our file to Nobel. They milled this bridge, we shipped it back to him, screwed it down away. The patient went. It was brilliant. And you can see his quote here, final zirconia seated with no adjustment. I can’t think of a better, more efficient way to do it now you have to buy a scanner. You have to buy an iCAM scan. We’re working with, we’re working on PIC. Maybe someday we’ll be compatible with a pick scanner. Right now it’s iCAM. It’s pretty affordable I think for what you get, especially if you have a lot of full arch cases in your practice that need turned over in the coming years. Let’s look at one more. This is a dual arch. This one’s pretty creative, but don’t focus on the complexity of the workup to get to scanning. In other words that that’s going to be kind of intimidating because what he did with this case was he sent us, these are just photographs on the left. He sent us a digital impression of the patient. So this was pre-surgical and from this we did a diagnostic, a digital diagnostic workup, made a matrix. And from this he went to surgery and it was a free hand surgery and sent the patient home for just a few days over a weekend in this prosthetic.

And the bite is was right on for him. He had to do a little bit of equilibration, but it’s based on the pre-operative records. So he converted this and on the day of surgery he scanned it. So 96 hours later we sent him a prosthetic. These are the files that he sends us on the day of surgery though, that same protocol we went through, just like what I’ve been showing all along here. We make them a prototype. We emailed this over, within 24 hours there is the tissue. And this is a temporary, we’re going to go to a final down the road there’s going to be changes in the tissue, yes. But we have the records here to make a Procera bridge. In the end, all the doctor has to do is scan the tissue uploaded to us. We bring it into the plan and we order a bridge, coping free, model free, a hundred percent digital.

You cannot do that with any other zirconia. Not possible, that I know of. You can chat in the end if you like and we can talk about it or you can give me a call if there’s some other option. We’ve been looking into this for a long time. And Procera bridge seems to be the only method of doing this that I’ve seen. Model free, coping free, a hundred percent digital. Here’s a try-in patient. Patient went home in the other prosthetic, the not so hot prosthetic, but had this by believe Tuesday after a Thursday surgery. Very efficient, nice work.

And so just a little recap. There’s surgical, there is digital, there’s analog. However your office is set up to take records for full arch. I think this presentation kind of answered any of those methods with simple to use techniques and I thank everyone for joining us. We’re going to have a little chat here at the end. I do want to mention we have two courses coming up. One is on the 18th, surgical guides from simple guides to full arch. I’ll give that presentation. I enjoy that one. We make a lot of surgical guides here, so hope you join us for that. And then we are changing the whole industry. This will be a full arch guided surgery program with Dr. Grant Olson. That’s not Gant, it’s Grant. Sorry about that. Dr. Olson, where he is going to demonstrate full arch immediate load chrome surgery using zero holes. You can see that prosthetic, there’s no holes in it. The patient went home with that on the day of surgery. Using energy, not screws, no screws. Fascinating technology.

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