FAQ's - Frequently ask Questions   Dr. Scott MacLean (Implant Lecturer)      902 229 4567 smaclean@trimacdental.com  youtube.com "smmaclean" www.trimacdental.com Common FAQ's on NobelActive Prosthetics  Question #1- Should I always use a transfer jig to deliver final abutments to the correct position?  Scott MacLean... Yes. This greatly makes the handling of the abutment easier. (Makes you dental team happier as well!)  It is important to seat the abutment in the correct position to allow finger torquing of abutment prior to the "confirmation of seating" xray. After position of the abutment is confirmed then the abutment is ready to torque. If you torque the abutment and it is not seated in the hex then this "can" create major stress on the abutment since all the forces are then on the angles of the hex of the abutment.  It makes the process easier to use a transfer jig! This saves time and that is a good thing!   Question #2 - How can I tell what size of healing abutment was used as it is hidden under the tissue much of the time?  Scott MacLean...  "The healing around the NobelActive tissue is amazing!" There are a few tips to help you tell the size the healing abutment.  a. The size of the healing abutment ideally should be communicated by the surgeon placing the implant.  If this is not happening then a quick phone call can sometimes help the surgeon realize this makes your practice run smoother.  It is important for the prosthetic dentist to realize the are only...  * 2 NobelActive Platforms - NP and RP  (No WP - The 4.3mm and 5.0mm both have a RP connection!)  * 3 width with NobelActive Healing Abutments - Straight 3.6, Flared 5mm and flared 6mm The NP parts are pink and the RP parts are silver. b, Ask your surgeon to place flared healing abutments. The flared healing abutments can shape the profiles of the tissues for excellent tissue outcomes.  The length of the healing abutment does not matter to choice of transfer copings. It is chosen subsequent to how much soft tissue is in the area to allow the abutment to be 1 mm above the tissue. If less then 1 mm the tissues may start to heal over the healing abutment. An xray can be taken to see the width of the healing abutment. The widths are 3.6 mm, 5 mm, or 6 mm at the top of the healing abutment. ***Choose Flared Healing abutments to make the process more esthetic and easier for the prosthetic surgeon. Choice of impression transfer coping should be the same width as the healing abutment. Choose length of the impression copings to allow the wings to be completely engulfed in a firm impression material - (Polyether or PVS) c. Choice of Healing abutment is based on width and height. Width is more important to the prosthetic dentist, Narrow Platform Healing abutments NP - straight 3.6 mm - used for laterals and lower centrals (pink) - to grow tissue NP - flared to 5 mm - used for lateral and lower centrals of space issues (pink) Regular  Platform  Healing Abutments RP - straight - Used to develope tissue in thin situations or if bone is limiting placement of a flared healing abutment at surgery. Might have to do small incision at insert of the abutment to push the papila forward. (flared abutment might not be able to be placed because hits the bone when screwing it in.) RP - flared to 5 mm - used for centrals, premolars, some molars - Adapts the tissues well! RP - flared to 6 mm - molar situation - emergence profile NOTE : If you have a flared to 5 mm healing abutment then order the flared to 5 mm impression coping (open or closed tray - you decide) If you have a straight healing abutment use a straight transfer coping.  Coverscrew NP and Healing Abutment Flared to 5mm (NobelBiocare code 34214 - see form below))  Abutment and Transfer Coping match the Healing abutment shape!  for a copy of form below with your office name email me! smaclean@trimacdental.com   Question #3 - Should I be recommending a flared healing abutment to my surgeon and why?  Scott MacLean... Yes...Yes...and Yes!  - 98% of the time i.. shapes the emergence profile from the time of surgery ii. makes the impression a lot easier for prosthetic dentist.  iii. less pain for the patient during impression. iv. less inflammation since bone platform shift is enhance and protected by the flared abutment.  v. very little tissue collapse vi. ***Cool Surgical Tip! On a flapless surgery the surgeon can use a 5mm access hole to see the top of the ridge then place the 4.3 body or 5 mm implant.  Since the coronal portion of the implant is narrower then you can see that the implant is at bone height on insertion. The access hole is larger then the top of the implant however the flared healing abutment will completely seal the surgical site! This allows for excellent vision of the top of the ridge for nerve reference point. The flared healing abutment then seals the area for excellent healing. No Pain!!! No incision!!! Minimal inflammation!!! No sutures!!!  Question #4 - How do I know what impression coping to order? Shouldn’t my surgeon be including this in his/her letter to the restoring doctor? Scott MacLean... Email me for a form - smaclean@trimacdental.com *The impression coping width should match the healing abutment width. That said... You must choose the length. It makes it easier for the surgeon to write the codes down about what they placed. You should have both impression coping  lengths available in case you want to increase or decrease the length at time of impression. Remember...90% of the impression coping should be in the impression material on an open tray impression. (see photo below) If the impression coping sticks too far out the hole of the tray then the impression material will not secure the impression coping during removal. Tray design is essential  Open tray Impression coping must be 90% in impression material  Material around impression coping stabilizes impression. Wings should be ideally between the adjacent teeth if possible On closed tray place wax in the unigrip screw hole of impression coping to aid in replacement of the coping prior to surgery.at the lab. After you pick the width of the impression coping as discussed in question #1... The impression copings come in 2 lengths Open Tray impressions NP straight - 14 mm long only RP flared to 5 - 10 mm or 14 mm long Closed Tray impressions NP straight - 13 mm long only RP flared to 5 -  9 mm or 13 mm long Remember to use bridge impression coping   if you are connecting/splintting implant together. Surgeon must also use bridge healing abutments.  Impression "Coping Crown engaging" and "Bridge non-engaging" See form below...   Question #5- Seating of impression coping and abutment is causing lots of confusion. Conical seating is different and many have been confused. How can I tell when the abutment and or impression coping is seated?  Scott MacLean Answer - The seating of the impression coping and abutments reminds me of the accuracy needed when seating a 3 unit bridge.  It is precise but easy if you follow the steps. This implant system is very accurate with the fitting of components. This makes it an excellent system. The photo above show the hex and the conical seal. The hex is anti-rotation and the seal provides a tight barrier to bacteria and an accurate tight prosthetic fit. The conical seal minimizes inflammation and abutment pumping. The interface between in abutment and the implant is one of the key prosthetic features that make this implant successful by strength esthetics and minimal crestal boneloss. Sometimes the more precise the fit is then it makes following the step even more important. In the implant world there are good better and best designs. The more precise a system is makes it best. This is a best implant in my opinion.  The NobelActive manual online listed below shows the seating of impression copings quite well.   page 28 and 29 of manual below http://www1.nobelbiocare.com/Images/22324_NobelActive_Product_and_Procedures_GB_tcm57-13044.pdf    NobelActive Impression Coping Seating Tips 1. Use correct width to match healing abutment 2. Use proper length of impression copings so that impression coping wings will be supported by an impression tray that extends up around the coping when it is in place on the implant.  3. Consider using a stiff impression material. (Polyether or med PVS) No need to use low viscosity impression to pick up margins of  crown. You need to pick up lateral teeth , occlusion, and implant position. If you need anterior soft tissues then use lower viscosities in these areas only. (or resin pickup technique) 4. Tray should be designed to fit the height of the transfer coping. Only 1-2 mm of the transfer coping should stick out on a open tray impression. Build the tray up with tray material (not wax). Use perforated tray with adhesive. 90% of the impression coping should be in the impression material supported by a proper tray. 5. Xray to confirm seating - should be parallel fitting into the implant, should be seated with lines at the top of implant head (need proper xray to see this (see diagram), should be 1 mm under the screw like diagram below. 6. Make sure impression coping is dry 7. **Use the thumb screw on the impression copings to tighten the impression coping but also use the unigrip driver (no wrench) to do final finger tightening before the impression  Seating FAQ's - Page 30 NobelActive Manual There should be 1 mm under the implant screw and the occlusion should be very near correct. The impression copings have a line on the base of the structure that can be seen on an xray to show proper seating during impression. Also make sure this look parallel prior to final torquing. You can deform or break components if you torque abutments that are not lined up. After initial toque of 35 cm. Wait 5 minutes then do it again to check seating.   Question #6 - The tissue management when placing final abutment is a concern to me. Is this affected by the choice of healing abutment due to platform switch? Scott MacLean's Answer... Tissue management is always a concern with implants since the gingival fibers react differently to titanium then they do to cementum. The choice of healing abutments wil improve the healing since the tisue will be properly vascularized and shaped to accept the implant supported crown. The platform shift occurs at the top of the abutment to implant interface.  The shift is a .25 mm reduction in size from the implant head. This is thought to reduce or eliminate crestal boneloss. The choice of healing abutments will all encourage the platform shift to occur except for the bridge healing abutments which sit on top of the implant and they are non engaging (no hex). The straight and flared engaging abutment (hexed for single crown anti-rotation) all have the platform shift. Thus there is a size reduction in the implant to abutment with a platform shift. Thus all show excellent results if the implant is place properly. The platorm shift act to seal the top of the implant interface like a biologic width of a natural tooth. Regardless of the exact mechanism researchers are finding that the interface has less inflammation due to this design. Less inflammation lead to less boneloss. The conical seal and hex of the implant also enhance this phenomenon. I have been using this implant for more then 2 years now and the boneloss has been minimal to none. Not only will the abutment fit precisely but you can also have the abutment made in a shade that will minimize tissue show through. The share of the abutment can be matched to the shade of the coping for the crown. If you are concerned about abutment and tissues responses then it would be best to have the lab fabricate a customized abutment and crown fabricated using "NobelProcra" technology to make the final outcome meet the anatomy of the patient. I routinely use customized abutments. This is one of the beautiful features of the NobelBiocare system.  Bridges with NobelActive - Implant Level Zirconia and Titanium (Dual Functional Connection stuff!) The really cool thing about this implant is the ability to do an implant level screw retained bridge. This implant  has a dual functional connection to allow screw retained bridges to seat without a platform shift. If you want to do a screw retained bridge with the platform shift then you can use multiunit abutments to create this design. Place the multiunit  abutment on and then take an impression with the multiunit impression coping.  Regarding tissue management... a. Tissue management begins at extraction of the tooth. If you are worried about tissue loss following extraction then consider using an immediate temporary abutment and immediate temporization. Need 40 Ncm torque with "non functional loading". No force contacts on implant temporary crown in centric, working and non working occlusal movements. The bolus of food will cause contact. There should be no contact in parafunctional or functional movements.  b. Or... straight healing abutment - used to grow tissue. Latter you use a immediate temporary abutment to shape the extra tissue.  c. Or... Use the final abutment  crown to push the tissue to lift it. Might have to have a releasing inciision to help keep the tissue vascularized. (Blanching) d. Or... flared to 5 mm abutments are fantastic in the anterior. The tissue emergence works well and is easily picked up with the transfer coping that is also flared. For example use a 34218 flared to 5 mm healing abutment with a 35350 flared to 5 mm transfer coping. The tissues will be replicated how there are healing. You can do this at either stage one or stage 2 surgery. e. Or... chairside customized abutment - using immediate temporary abutments - any contours can be picked up with light body PVS -(very little) or using resin on the transfer coping. The wings of the transfer coping should be in a more rigid impression material for stabilization. The immediate temporary abutments also have a platform shift. (see youtube.com video about NobelActive Temporary Crowns - search "smmaclean") f. lab fabricated temporary. Be careful not to wait too long after placement of implant. The osseointegration of the implant begins once the implant is placed. Placing an lab fabricated crown should occur in the first 24-48 hours after placement of the implant. At stage 2 this is not a problem since the implant is already osseointegrated.  Question #7- Screw-retained posterior crowns end up being very expensive for most docs.  Often the only option is a GoldAdapt Crown. You can't use Zirconia in the posterior and labs generally don’t have Ti porcelain. With the price of gold ($60 per gram for high), a casted abutment can end up adding an unexpected $250 to $350 to the lab fee.  What does MacLean do in this situation? Dr. MacLean - The cost of dentistry is always a concern for patients and dentists. Communication of the costs is the key. Up front talking about fees after he value has been instilled. You can get fooled with a large lab bill by using a lot of gold. You will be out of pocket if you have quoted an "all in lab included price". This is an experience thing to deal with. Once you have a few crowns done you with be able to judge cost. Break it down into anterior, premolar and molar pricing. The amount of gold used can vary greatly on boneloss issues in the posterior. If the crown height space is large (ridge to occlusal plane) then the gold costs can be higher. Keep a list of the crowns you place you  can take the highest one to do your estimate. Don't use the average or you will get hit 1/2 of the time! Remember Zirconia is not billed on weight.  Some Options a. You can use a cemented abutment made of titanium with a zirconia crown or gold crown - take pictures of the position of the screw - if it ever needs to be removed...make it into a screw retained crown by making a suck down guide over the crown then place it back on the original model with the transfer screw only in place. This will guide you to the exact position of the screw chamber. Take cotton out, remove crown at will. Fill access with cotton and composite resin after you are re-torqued.  b. Use screw retained zirconia. Very strong. This is very successful if you have proper thickness of zirconia.  c. Charge for gold adapt lab fees on top of your professional fee. If they know the concerns they will pay. Need to tell them up front. d. Have lab make a titanium abutment and cement a Procera Zirconia or PFM crown on with a screw hole access. The cost of  Zirconia is not an issue with the fluctuations in the stock market. Gold as you know is sensitive to the fluctuations in market price. Zirconia actually has a Tensile strength higher then gold.   Question #8 - What steps can be done to minimize zirconia abutment fractures upon insertion or try in? Dr MacLean - I do not see this much in my practice. a. Use insertion jigs to make the forces on the abutment axial. b. lab needs to use water cooling when adjusting - very important c. Do not toque the abutment with the torque wrench till the seating id verified with an xray   Question #9 - If a zirconia abutment gets stuck, how is it best removed? Dr. MacLean - THe abutment fits very tight. Do now tighten it to 35 Ncm till you are ready for final seating. To remove zirconia or titanium abutment... Try this! a. Make sure the abutment screw is out ;) .  b. Place an impression coping screw in the access an very slightly apply lateral force.  c. Place the crown on the abutment and slightly move it back and forth.  d. Gently tug with cotton pliers Question #10 - Do I need a new prosthetic kits for the NobelActive? Dr. MacLean - No. The NobelBiocare prosthetic kit can be used for NobelActive, NobelReplace, and Branemark prosthetic connection Best luck with your cases. The NobelActive implant is an excellent implant for both surgery and prosthetics. I have enjoyed the features of this system and hope these tips will help you as well. best regards Scott MacLean youtube - "smmaclean" 902 229 4567 smaclean@trimacdental.com www.trimacdental.com Note: Dr. Scott MacLean was evaluated for a NobelSpeaker training program. He placed first in this program out of 40 North American speakers. His lectures are visually stimulating using a treament planning approach. http://www.youtube.com/watch?v=MwlEAMXw_Xo  NobelActive Inventors Ophir Fromovich and Bennie Karmon in Mahwah NJ -  Dr. Scott MacLean is in the Middle - Happy user of NobelActive!        mailto:smaclean@trimacdental.comhttp://www.trimacdental.com/mailto:smaclean@trimacdental.commailto:smaclean@trimacdental.comhttp://www1.nobelbiocare.com/Images/22324_NobelActive_Product_and_Procedures_GB_tcm57-13044.pdfmailto:smaclean@trimacdental.comhttp://www.trimacdental.com/http://www.youtube.com/watch?v=MwlEAMXw_Xoshapeimage_2_link_0shapeimage_2_link_1shapeimage_2_link_2shapeimage_2_link_3shapeimage_2_link_4shapeimage_2_link_5shapeimage_2_link_6shapeimage_2_link_7