A Progressive Implant
System You Can Bank On
By Steven Pigliacelli, CDT
Vice President, Marotta Dental Studio

Progressive Loading

Progressive loading is a popular concept discussed at many seminars and clinics that has never been fully applied or appreciated, or even completely understood. It is a viable option that lessens the pressure on healing bone and soft tissue while giving implant fixtures additional time to fully osseointegrate. This provides the patient with the convenience of a fixed prosthesis that gradually loads the implants.

Progressive loading with a provisional restoration can be a viable treatment option for many implant cases both clinically and financially. Provisional restorations serve as diagnostic tools for determining final abutment selection and case design. With the provisional prosthesis as a model, a more esthetic and problem free permanent prosthesis can be fabricated.

The main complaint against progressive loading was the expense. In essence, a provisional was a duplicate of a final case requiring all the same steps to complete. The options for a provisional were either all acrylic, which was a short term provisional, or a cast metal provisional, which could last up to two years or more. These provisionals had a cost similar to that of the final case since many of the same steps were applied and materials were used. Most dentists felt they had a hard enough time selling the final case; selling a provisional as well was nearly impossible.

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Implants Made Simple
Part 1
By Steven Pigliacelli, CDT
Vice President, Marotta Dental Studio

Case Planning

At Marotta Dental Studio we have developed lab protocols that make implant restorations easy. In order to achieve the desired goal for any implant restoration we must case-plan from the beginning. It is vital that all factors are taken into consideration and that all roadblocks and obstacles are addressed prior to starting any implant restoration. Only a few simple steps are required. Communication between the patient and the restorative team, which includes the restorative dentist, the periodontist or oral surgeon and the lab, is imperative.

First, a few questions should always be asked. What is the desired result? Why is the patient in need of the implant? Is the patient a bruxer? Can implants even be successfully placed in the patient’s mouth? Is there enough vertical room? Is there enough bone? Many of these questions can be answered with diagnostic wax-ups on duplicated models. The lab can supply varied preliminary wax-ups to show different case designs and options. The restorative doctor must take accurate bites on accurate models. After the lab makes the wax-ups and provides a pre-estimate on varied case designs, the dentist, with the periodontist or surgeon, can agree upon the best direction to go in.

CT Scan Stent

This is where the stent comes into the picture and where the rest of the questions will be answered. We have manufactured many different stent designs that can accommodate every implant company.

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Progressive Loading (continued)

This is a valid argument but very short sighted. Granted, the costs of implant restorations are higher than standard crown and bridge, but the rewards are that much greater. Based on the number of implant restorations completed yearly and the success of all the implant companies in the world it is a safe bet that people are willing to pay for the restorations. How the provisional and final case is presented, however, is a key factor to completing the case as well as getting paid. The progressively loaded implant can and should be a standard to both load the implant and establish a budget for payment for the entire implant process. Patients are more likely to accept the cost of a temporary prosthesis if they know the benefits: It can be worn while the implants heal and the final case is being made. And it can be kept as a spare if a repair is needed. Furthermore, a payment system can be established for the final restorations at the time of the stent fabrication.

Banking

Banking is a common method in which the case is pre-planned and pre-billed from the start. It is very important to case plan and make diagnostic models, setups and surgical stents. After the consultation between the patient, the surgeon or periodontist, the restorative dentist and the lab, the final case design can be presented, a lab fee estimate will be supplied and a payment plan established. The total cost for all procedures will be given to the patient so they can begin paying prior to the surgery and be required to pay until the case is completed. When a payment plan is presented, as in the case of a budget plan for a car payment or a computer payment, the patient is more willing to pay. Companies like Dell Computer have managed to sell millions of computers based on a monthly budget concept of what the customer can afford per month rather than paying outright for their computers “interest free.” Most orthodontists also bill in this manner and have done so for years.

Provisional Restorations

There is more than one way to make a provisional and more than one design. We have different designs at Marotta Dental Studio that can be used for many different time spans and for many different costs. One of the most popular over the years has been the Fiber Mesh or cast metal reinforced processed provisional. This provisional is usually made to cement over a few remaining natural teeth. The Fiber Mesh is as hard as cast metal and is placed on the lingual and interproximial of where the final teeth will be. A few implants are placed and then activated by adding a temporary cylinder to connect to the implant and be cold cured into the provisional. As time goes by, sometimes two years, implants are activated and teeth are slowly removed until finally a fixed screw retained or, if requested, cemented provisional is completed. After all the implants are activated the final case can be completed. In this case scenario one to three years can be planned and budgeted for the final restoration.

Another provisional design utilizes the 3I Locator Abutment. This is very much like the previous provisional in that implants are placed slowly, but not all are activated until the final restoration is made. A denture can be made to attach to a two-locator abutment that is placed on two implants. An existing denture case can also be relined to attach to the locator abutments. The denture can be made as thin as possible with the anterior teeth butted to the ridge to appear as if they are coming out of the gum and, in the case of a maxillary denture, a horseshoe denture case can be made. The patient can wear this denture while the other implants are placed and then after all the implants are placed the final case can be completed.

There are a few alternatives to progressive loading where a provisional restoration is required or requested and the implant is not loaded. The Valplast or Flexite partial is a very popular intermediate provisional. It is inexpensive and easy to make. The patient can wear it prior to implant placement and after. It will not apply any pressure to the implant and will not serve any of the purposes for progressive loading. It only acts as an interim device until the final case is restored.

When planning a single tooth restoration there are two common styles used. In some cases an all-acrylic flipper with Flexite clasps has been worn by the patient up to and just after implant placement. At second stage the implant is exposed and the flipper is modified chairside to become an implant temp by grinding the tooth free of the flipper and hollowing it out to receive a temporary cylinder.

The other is an all-composite lingual Maryland bridge that can be cemented over unprepared teeth. The bridge may be temporary-cemented and again modified to be an implant-born provisional after first stage surgery. For esthetics, a design that has grown dramatically over the years is to place a porcelain laminate over the composite pontic. This gives the best esthetics for the provisional and makes the patient more accepting of the provisional for the months that they have to wear it.

Provisional restorations can be premade to be activated at first stage surgery or made after second stage surgery. They can be made with temporary cylinders that will attach to the implants or over the final abutments (if abutments such as angled abutments are required). Cementable provisionals can be made that can be relined over new custom-made abutments. In most cases these provisional restorations can either be used as spare cases or modified to be spares for future use in the event of any problems or breakage. We have established a system of case planning, stent fabrication and provisional restoration that takes all the pressure off the implants as well as the dentist and patient to make the final restoration
as smooth as possible.

Implants Made Simple Part 1 ( Continued )

CT Scan Stent

The wax-ups can be used as the matrix for the stent. A CT scan stent in conjunction with varied marking systems such as gutta percha, amalgum, barium sulfate or barium denture teeth can be used. The CT scan can be merged with surgical simulation software such as SIM/plant ®. The final case can be simulated on the computer to determine correct abutment choice and angulations of the implants as well as the depth and length of the implants.

At this point the restorative dentist can put all his compiled data together and decide which case design appears to be the best. In some cases, implants are not an option and another restoration is necessary. That is the beauty of pre-case planning. It is so much more desirable to find out prior to placing the implants than to find out after taking the impressions that a case design will be compromised. The patient is then given the restorative options and told upfront if any limitations or exceptions will arise in the final restoration. The lab fee and restorative fee are combined to give the patient the final cost and payment options are presented. (See article on banking.)

Surgical Stent

If implants are the desired option, the CT scan will then be converted to a surgical stent, which will aid the surgeon/periodontist in placing the implants. Since everything was carefully planned and all obstacles addressed, the surgery should be relatively simple. If so desired, the implant can be loaded with temporaries at first stage surgery using a provisional bridge made at the time of the stent fabrication. (See progressive loading and banking article). We also have the ability to make a bio model from the CT scan data.

We have the ability to make a temporary that goes into place either over the implant or pre-picked abutments. We also have the ability to pre-make the framework, thus only requiring solder and porcelain or composite when the implants are fully integrated.

A variation of the old adage MEASURE TWICE AND RESTORE ONCE proves that pre-case planning can truly make implants simple.

Orthodontics
By Steven Pigliacelli, CDT
Vice President, Marotta Dental Studio

We now offer two new Orthodontic services: The Rapid Palatal Expander and the ITI Orthosystem Mid Palatal implant.

The function of the Rapid Palatal Expander is to widen the upper jaw itself. In the field of orthodontics
there is no appliance more effective in expanding the maxillary. A Palate Expander moves the bone and not the teeth. The force of the appliance is transmitted through the teeth to the bone. The appliance consists of a screw that is attached to the teeth with bands. The expander is activated by turning the screw enabling the expansion of the upper as much as 3/4 of an inch! The expansion accomplished with this appliance is very rapid, within a few weeks.

Strauman manufactures an Ortho implant with a diameter of 3.3mm designed to support a transpalatal arch, which ensures maximum anchorage for orthodontic correction. This is ideal for esthetic conscious and adult patients. The Ortho implant is suitable for temporary insertion in the retro molar area of the maxilla and mandible. The implant and restorative components are titanium. The titanium is highly biocompatible. The oxide film in contact with the tissue is practically insoluble and no ions that could react with organic molecules are released. The implant can also be removed when it is no longer required.