Obtaining jaw relation records for full arch implant therapy is nothing more than the usual steps that we do for complete dentures. Ultimately, we have to determine where to arrange the teeth in the oral cavity that would look good aesthetically and function well occlusally for the patient.
What makes this step different from a set of complete dentures is that, technically, you can use the implants to stabilize your recording bases. From the patient’s perspective, this is also the part that the patient can relate the most …because they can actually start to see the final result…They can start the see their face changes with the rims and eventually with teeth…which is really what they want….I find that most patients become more engaged at this stage and they tend to have more input. As Carl Misch would say, people want teeth, not implants!
Over the years, I have changed how I do these steps..…and I want to share the thought process and my logic of why I do them in a certain sequence….Quite simply I just want to make things easier and more predictable for me and the patient.
After taking fixture level impression and verified the master models for the case, I usually ask for a conventional recording base with wax rims. Most labs will ask me if I want to incorporate temporary abutments to stabilize the recording bases. And at the beginning of my career, I would always say yes …but now I would say no….Why? I find the process of tightening the screws and removing the screws to be a very uncomfortable process for the patient. It slows me down significantly as I need the wax rims in and out frequently so I can adjust and contour the wax rim for the best aesthetic and functional outcome. So as much as I don’t like to deal with unstable record bases, I do the first step without any attachments to the implants.
However, once I have developed the occlusal rims to the contour of where I want them to be and registered them the conventional way and sent the case to the lab for mounting, I will do the following:
1/I will ask the lab to convert the recording bases to implant supported ones utilizing two of the available implants for stabilization: At this point, knowing where the occlusal plane is and where the potential teeth may be, I have a better idea where to place the temporary abutments to stabilize the recording bases. Basically, I want to incorporate at least two implants for anti-rotational stabilization and I want to use the two implants that will least interfere with the tooth set up.
2/I will also ask the lab to only arrange the anterior teeth first. With a more stable recording base, this will allow me to evaluate the lip support for aesthetics and to determine how much of a flange I need to incorporate for the final prosthesis. Another advantage of doing just an anterior teeth try in first is I can verify the vertical dimension of occlusion as well as the centric relation with more confidence. Checking phonetics with denture teeth in wax is a lot more natural then to check phonetics with a big chunk of wax.
3/The last thing I do is to start evaluating the patient’s feedback to the anterior set up. This is the part where if you do enough dentures, you will start to identify the different personalities of denture patients. The same principles apply to the implant full arch patients. You can have people who appear to be indifferent…or some people who are very exacting or some who are just very difficult to please. By having just the anterior teeth setup and seeing their response, I know when to continue or when to stop. By having this check point for me, I will apply my patient management strategy differently. Ultimately, I just want to minimize the number of teeth try in appointments.
Full arch implant therapy are big ticket items that patients pay a lot of money for. Most of the appointments for the prosthetic reconstruction are quite straight forward for me. But every now and then, I get burned for having an inaccurate centric record where I have to repeat the jaw relation record….or I get burned by having multiple teeth try in because I didn’t take the time to manage the patient properly.
As a result of my own experience, I tend to plan more time for jaw relation record as well as the teeth try in steps. If the case goes smoothly, I finish earlier than planned. I am happy. But if it took all the planned appointments, I know my fees have covered for these appointments already. But if it took longer than all my planned appointments, you need to evaluate if it is your skills that need to be refined or that you may have a patient with unrealistic expectation.
Full arch implant therapy is very life changing. I enjoy doing these cases…I hope you find the information here useful. Thanks for reading.