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Implant-supported hybrid dental prostheses have become a popular solution for treating patients with terminal dentitions or who are completely edentulous. Since osseointegrated dental implants were implemented to treat edentulism, multiple prosthetic designs, and materials have been used for full-arch fixed hybrid dental prostheses. The most common restorative failures are attributed to a lack of prosthetic space. This paper reviews clinical and laboratory steps for fabricating definitive implant-supported hybrid prostheses by implementing bone reduction guides, implant osteotomy guides, and immediate provisionals using Hybridge’s digital manufacturing technologies.
Hybridge is a full-solution laboratory service for clinicians handling full-arch implant cases. The four-step clinical workflow provides a straightforward process that enables patients to have the definitive full-arch prosthesis delivered only six weeks after implant surgery.
Figure 1. Hybridge clinical workflow steps
Digital intraoral scans, CBCTs, and portrait photos using the Hybridge Smile Design App are made, and all files are uploaded to “The Digital Box.”
During LAB Phase 1, the laboratory team designs the patient’s ideal smile. Once the new tooth set-up has been confirmed, the prosthetic space is measured, and the bone reduction is determined. Six implants distributed between the maxillary sinuses for the upper arch and five implants between the mental foramen for the mandibular arch are typically planned. This avoids the need for complex bone grafts and multiple surgeries. Once the surgical plan is ready, the lead clinician meets with Hybridge’s team online to review and approve the guided bone reduction, implant positions, and immediate provisional to ensure that everything is ready for the surgery.
Figure 2-4. Hybridge App, surgical plan, and eXact Simply Guided System
The 3D-printed metallic bone reduction guide is screwed to the jawbone once its intended orientation has been ensured by using the occlusal indexing guide. After the bone reduction and extractions are completed, the osteotomy guide is secured onto the metallic reduction guide for exacting fully-guided implant placement. The clinician can do a simple PMMA conversion so the patient leaves with a fixed provisional and a new smile on the day of surgery.
Figure 5-7. Bone reduction guide, osteotomy guide and immediate provisional
The immediately loaded provisional is unscrewed between 2-3 weeks after the surgery for suture removal. Scannable analogs are screwed to the provisional, and the XD scan is made with an intraoral scanner. An intraoral scan of the soft tissues is made to compensate for soft tissue remodeling.
Figure 8-10. XD scan sequence of the immediate provisional restoration
During LAB Phase 2, the laboratory team designs the patient’s definitive prosthesis, which consists of a 3D-printed Cr-Co framework and milled splinted PMMA teeth. After careful inspection, the pink gingival material is applied and finished manually. This assures an intimate adaptation and fusion of the white and pink PMMA surfaces, avoiding delamination and microleakage.
Figure 11-13. XD design and manufacturing process for optimal aesthetics and function
The Hybridge XD definitive prosthesis combines the benefits of an intraoral cemented interface of the Ti-bases to the framework for absolute passivity. The components are cemented with self-curing resin cement for sufficient working time and easy excess removal. With a final photogrammetry impression, the laboratory can fabricate a framework with a milled interface without any cemented components.
Figure 14-16. XD definitive hybrid prosthesis delivery
The flexure-resistant Cr-Co metallic framework permits a longer distal cantilever extension of up to two teeth for improved masticatory function. This allows all implants to be placed between the limiting anatomical structures on the maxillae and mandible. The milled PMMA teeth provide a light natural feel, and the pink acrylic gingiva material can be easily relined chairside if any phonetics challenges or food impaction areas are present through time.
Figure 17-19. XD definitive hybrid prosthesis at follow-up
The Hybridge clinical workflow is a validated treatment modality that allows clinicians to deliver a definitive prosthetic to their patients six weeks after implant placement. The rigidity of the framework and the intraoral cementation technique provide optimal passivity, reducing stress on the surrounding bone, which is crucial during early osseointegration. With the high accuracy of digital photogrammetric impressions, the same concept can be obtained without cemented components.
Dr. Julian Conejo
DDS. MSc.
Malvern, PA
