DENTAL TECHNIQUE

A technique to guide replacement of multiunit abutments

supporting an existing implant-supported fixed complete
denture
Timothy A. Hess, DDS,a Van Ramos, Jr, DDS,b and Dana Buglione, DDSc

Patients who are edentulous ABSTRACT

or in a terminal dentition state
This article describes a technique for replacing a fractured multiunit abutment (MUA) supporting an
are increasingly restored with existing implant-supported fixed complete denture (ISFCD) with a custom-fabricated abutment
an implant-supported fixed alignment device. The angulated MUA threads that receive the prosthetic screw to secure the
complete denture (ISFCD). ISFCD can become stripped, cross-threaded, or, in some patients, the thin metal in this region
The ISFCD consists of dental may fracture. These conditions necessitate the removal and replacement of the angulated MUA.
implants, transdermal abut- For many clinicians, replacement of the angulated MUA will be a rare and unfamiliar procedure.
ments, a supporting metal One of the biggest challenges is to achieve the correct orientation of the replacement angulated
substructure, and denture MUA hexagon to the supporting implant’s internal hexagon. This technique aids the accurate
indexing of the current angulated MUA position and replacement with a new angulated MUA
teeth with pink veneering without a trial-and-error approach involving multiple insertions and tightening of the abutment
acrylic resin. Various systems screw. (J Prosthet Dent 2019;-:---)
have been marketed, including
the All-on-4 (Nobel Biocare), Uni-for-Fixed (Dentsply prostheses. Framework fractures (5% of complications),
Sirona), and Pro-Arch Fixed Solutions (Straumann). abutment screw fracture (2%), and prosthetic screw
This technique article focuses on complications asso- loosening (1%) were reported. Abutment fractures did
ciated with the All-on-4 angulated MUA (Nobel Biocare). not appear as a separate complication.1,2
Occasionally, when attempting to tighten the prosthetic For the experienced clinician, replacing the MUA is a
screw, the clinician will feel the screw engage, but, as 15 straightforward procedure. However, for a less
Ncm is applied, the screw slips and adequate torque is experienced clinician, replacing an angulated MUA may
not achieved. Often it is simply that the prosthetic screw offer challenges such as achieving correct orientation of the
is worn and needs to be replaced. However, the angu- replacement angulated MUA hexagon to the supporting
lated MUA threads can be stripped or cross-threaded, or implant’s internal hexagon, difficulty attaching the delivery
the angulated MUA may be fractured. If replacing the handle to the MUA, and trouble holding the angulated
prosthetic screw still does not achieve the manufacturer’s MUA in the correct position while tightening the prosthetic
recommended torque value, replacement of the angu- screw to the manufacturer’s recommendation. These chal-
lated MUA must be considered. lenges can be overcome by indexing the failed angulated
Unfortunately, intraoral inspection with loupes does MUA to an adjacent MUA. The use of autopolymerizing
not always allow for observation of the fracture line in the and light-activated resins to index dental implants and
abutment (Fig. 1). Recently, Goodacre et al1 published a abutments during impression making is well documented,
review of prosthetic complications with implant and the following technique uses these concepts.3-11

a
Affiliate Assistant Professor, Department of Restorative Dentistry, University of Washington, Seattle, Wash and Affiliate Assistant Faculty, Department of Oral Medicine,
University of Washington, Seattle, Wash.
b
Program Director Graduate Prosthodontics, Department of Restorative Dentistry, University of Washington, Seattle, Wash.
c
Graduate Prosthodontics Resident, Department of Restorative Dentistry, University of Washington, Seattle, Wash.

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Figure 1. Fractured angulated MUA. MUA, multiunit abutment.
Figure 3. Attachment of multiunit delivery handle and open tray
impression coping to abutment analogs on definitive cast.
TECHNIQUE
1. Retrieve the definitive cast containing the abut-
ment analogs and soft-tissue moulage (Fig. 2).
2. Attach a multiunit delivery handle (Nobel Biocare)
to the laboratory analog compatible with the
damaged angulated MUA to be replaced. Attach
an open tray impression coping (Nobel Biocare) to
an adjacent laboratory analog (Fig. 3).
3. Paint the model and moulage with separating
medium. Add light-activated polymerization gel
resin (Triad Gel; Dentsply Sirona) to connect the
MUA delivery handle to the angulated MUA
impression coping. Create an extension to the
palate to aid positioning of the index intraorally
(Fig. 4).
4. Polymerize in a unit (Triad 2000; Dentsply
Sirona) for 4 minutes. Then, remove the index
from the model and confirm that the MUA de-
livery handle will turn freely in the polymerized
gel (Fig. 5).
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Figure 2. Definitive cast with abutment analogs.
Figure 4. MUA index created with light-polymerized gel to connect
multiunit delivery handle to open tray impression coping. MUA,
multiunit abutment.
5. Clinically, remove the existing ISFCD to expose
multiunit analogs and verify that the abutments
are tightened to the manufacturer’s recommen-
dations. If necessary, place healing caps (Healing
cap small NP/RP; Nobel Biocare) on the MUAs not
associated with the index. Place a small pellet of
cotton over the angulated MUA abutment screw
such that it will not prevent the delivery handle
from engaging the angulated MUA threads for the
prosthetic screw.
6. Attach the index loosely at first with the impres-
sion coping and then rotate the index until the
palatal extension is in contact with tissue. Turn the
delivery handle to engage the angulated MUA and
tighten the impression coping (Fig. 6).
7. Use a high-speed handpiece to access the abut-
ment screw through the index. Remove the cotton
pellet and use a torque wrench (Salvin AccessTorq;
Salvin Dental Specialties Inc) and driver (Unigrip
Hess et al
- 2019
Figure 5. MUA index removed from definitive cast analogs. MUA,
multiunit abutment.
Figure 7. Torque wrench engaging angulated MUA screw. MUA,
multiunit abutment.
driver; Nobel Biocare) to remove the angulated
MUA abutment screw (Fig. 7).
8. Remove the damaged angulated MUA from the
index delivery handle. Position a new angulated
MUA into the index by using the delivery handle
such that the driver can engage the angulated
MUA abutment screw (Fig. 8).
9. Guide the indexed angulated MUA into the
implant and attach the index loosely at first with
the impression coping by slowly inserting the
angulated MUA into the implant. The palatal
extension of the index in contact with tissue con-
firms correct orientation of the angulated MUA.
Hand tighten the impression coping. Use the tor-
que wrench and Unigrip driver to tighten the
angulated MUA abutment screw to 15 Ncm.
10. Remove the index and position the ISFCD on
the MUA. Tighten the prosthetic screws to 15
Ncm. Verify seating of the ISFCD by using
radiographs. Cover the prosthetic screws with
polytetrafluorethylene (PTFE) tape (Oatey Co), seal
Hess et al
3
Figure 6. MUA index attached to MUAs intraorally. MUA, multiunit
abutment.
Figure 8. MUA index with angulated MUA attached. MUA, multiunit
abutment.
the access with composite resin (Filtek Z250; 3M),
and polymerize for 20 seconds (Parkell Curing
Light; Parkell). Confirm the occlusion and dismiss
the patient.
DISCUSSION
Although not a commonly documented complication of
ISFCD, fracture or damage to the MUA requires
replacement, and as more clinicians provide or maintain
ISFCDs, this complication will need to be addressed
more frequently. Removing and repositioning an angu-
lated MUA correctly into an implant while negotiating a
soft-tissue depth of 4.5 mm or more can be particularly
difficult, especially with a posterior or angled implant.
The gauze throat pack recommended when removing
prosthetic screws and abutments will also hamper the
ability of the clinician to manipulate the angulated MUA.
A right-angled torque wrench that allows the clinician to
tighten or loosen the angulated MUA and prosthetic
screws is strongly recommended as opposed to a manual
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torque wrench that requires a wide arc that is difficult to dimensional accuracy of multiple implant impressions: an in vitro study.
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This article describes a straightforward technique for in- Bottino MA, et al. A strain gauge analysis of microstrain induced by various
dexing the position of a multiunit abutment requiring splinting methods and acrylic resin types for implant impressions. Int J Oral
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Corresponding author:
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with implants and implant prostheses. J Prosthet Dent 2003;90:121-32. Dr Timothy A. Hess
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4. Lee SJ, Cho SB. Accuracy of five implant impression technique: effect of Email: drhess@tahessdds.com
splinting materials and methods. J Adv Prosthodont 2011;3:177-85.
5. Saini HS, Jain S, Kumar S, Aggarwal R, Choudhary S, Reddy NK. Evaluating Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry.
the effect of different impression techniques and splinting methods on the https://doi.org/10.1016/j.prosdent.2019.07.016

THE JOURNAL OF PROSTHETIC DENTISTRY Hess et al