FABRICATE HYBRID DENTURE

Assuming a vertical occlusal dimension has (VOD) been established through a bite block and the relationship of the analogs to each other has been confirmed with a verification index, teeth need to be set up in wax for try in.
1.
Set teeth in wax for try in with a lingualized, lingual contact occlusion (Contemporary Complete Denture Occlusion, Lang, Lauciello et al, Ivoclar Vivadent). Send to Dr.'s office to confirm the bite relationship, esthetics and phonetics. Have Dr. take a new bite with teeth in wax in place.
2.
Remount models with new bite if indicated and reset teeth if necessary. Make a putty matrix of the teeth in wax on the master model.
3.
Remove the matrix and set up from the model and reposition the matrix to verify adequate space for the substructure is present.
4.
Determine AP spread and length of acceptable cantilever.
5.
The substructure can either be a CAD CAM milled bar or waxed and cast with non indexed UCLA's. CAD CAM bars can be outsourced or if in house technology allows, produced on site.
6.
Verify passive fit of the substructure by tightening one screw in a terminal abutment. The bar should seat on all analogs without rocking or lifting.
7.
Reposition soft tissue mulange on master model and seat bar. Ensure adequate room between bar and tissue exist to allow enough acrylic thickness. Adjust if necessary.
8.
Replace the matrix on to the master model with the seated bar substructure to determine sufficient space is available for the denture teeth and acrylic.
9.
Re set teeth in wax on to the bar, utilizing the matrix. Adjust denture teeth and or bar as needed. Drill access holes through teeth and wax to allow access to fixation screws. Send teeth in wax over substructure for final try in to Dr.'s office if requested.
10.
Refine the hybrid wax up. Three options present themselves in regards to the extension of the basal design, option one would be a high water design with 1 to 2mm of space between the acrylic and the tissue, option two no space between the acrylic and the tissue and option three would extend the acrylic slightly (0.5mm) to allow the hybriddenture to displace some tissue once inserted. Keeping in mind all three options require a egg shaped basal profile and some space immediately next to the implant to thread superfloss in between. The basal design is Dr. preference and philosophy dependent.
11.
Remove the wax up from the model and attach a second set of analogs to each "abutment" of the substructure.
12.
Fill the bottom half of the acrylic processing flask with stone and set the wax up in to the soft stone. Obturate each screw access hole with impression material. Apply a plaster separator to the stone and finish investing the wax up in to the flask. Boil out the wax.
13.
After boiling out the wax up, unscrew the substructure and apply a acrylic separator to the stone. Sand blast the framework with Rocatec
14.
Silane the frame and apply opaquer. Stay just shy of the finish line around each abutment. This will prevent a unsightly gap between the acrylic and substructure once the acrylic is processed.
15.
Reattach the opaqued substructure to the analogs in the  flask and obturate the screw access channel with impression material. Process acrylic.
16.
After the acrylic is cured divest the processed hybriddenture and remove the impression material from the screw access holes.
17.
Unscrew the analogs from the hybriddenture used during processing and screw the restoration on to the master model.
18.
Adjust occlusion and lateral contacts according to the lingualised contact occlusion theory..
19.
Finish denture in usual manner, taking care not to damage the abutment/implant interface. Extra analogs can be utilized to protect the interface during finishing.