Extreme Makeover
By Steven Pigliacelli, CDT
Vice President, Marotta Dental Studio
Catch the wave of cosmetic dentistry

People want change. They want newer, better, younger appearances to match their lifestyles. Television today demonstrates this trend in the everincreasing makeover shows: Whether it’s a car, house or face, the ratings demonstrate society’s need to better itself. Facelifts, plastic surgery and cosmetic dentistry play crucial parts in this equation. It is within our ability to give people the changes they desire.



Modern esthetic cosmetic dentistry is one of the fastest growing trends in our society. Laminates, all-porcelain restorations, invisible braces and implants are all building blocks in the need to perfect oneself. Over the years, we at Marotta Dental Studio have been known for our implant restorations and standard crown and bridge. We have maintained our quality and craftsmanship with time-tested procedures and protocols. Implants were the last wave. Cosmetic dentistry is the new wave. current standards we all must update our systems, protocols, and materia

protocols, and materials. We in the dental industry must choose to ride the next wave or stay planted on the beach.



We have spent the last few years rebuilding the lab from the ground up to reflect the growing needs of the industry—in essence our own Extreme Makeover. Our ceramic department is the best in the industry today, while the gold department has maintained and yet exceeded our expectations for quality artisanship and excellence. Our removable department uses the latest technological equipment for injection and nitrogen processing procedures. Through continuous courses and hands-on training, in conjunction with new innovative technology and new management systems, we have succeeded to a higher level of perfection without any of the usual \ complications. It is with great pride that Marotta Dental Studio invites any doctor to try the premier esthetic department with the most precise fit on the East Coast.

A Plan to Succeed
We have perfected systems and protocols that enable us to ensure maximum esthetics. Through simple steps in case planning, we can achieve truly realistic esthetic results. Diagnostic wax-ups are an integral part of the system. With a diagnostic wax-up on study models, everyone from the technician
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Implants Made Simple Part II
By Steven Pigliacelli, CDT
Vice President, Marotta Dental Studio

Implants have been placed in your patient’s mouth. Healing time has passed and the restoration is ready to be made. What is the next step? How do you proceed? The steps required to complete the restoration are easy and painless if the proper protocol is followed. In Part I, we covered case planning, CT scan stents and surgical stents. If all the steps have been followed, then the next steps are just as simple.

Depending on the type of restoration constructed, procedures may vary. A single tooth implant, for example, is a vastly easier and less time-consuming procedure than a full-mouth reconstruction. For this reason, we will cover the preliminary steps of a more complex, full-mouth reconstruction, whether it is screw-retained, cemented or a patient-removable appliance.
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to the doctor to the patient can see the desired result. We can, and often do, prep the same models to advise how much reduction we will need to achieve the waxed-up restoration. Thus, laminates are not too thin and therefore too opaque.

The Power of New Technology
Using digital electronic communication systems such as Cad Cam technology, internet data transfer, computer simulation and dental engineering sciences has kept Marotta Dental Studio at the forefront of the industry. The systems we carry in the lab are varied. We have Procera, Empress, Captek, Gramm GES, InCeram and Lava. Each one has its own unique qualities and strengths. We have all these systems in production at the lab and we are always experimenting with new systems, some of which are so new and experimental that we can’t even mention them yet. With each new system comes another step toward the desired result of the most esthetic, natural- looking restoration. Some of the new systems we have brought into the lab and perfected are as follows:

The IPS Empress® and IPS Eris™ System, available for crowns, 3-unit bridges, inlays, onlays and laminates, is the closest to gold for fit and function. The IPS Empress® system is a Fluorapatite glass ceramic, which mimics natural translucency, brightness and shades, providing life-like esthetics that duplicate natural dentition. Laminates can have multiple bakes as well as custom staining.

With IPS Eris, dentists will never again have to sacrifice esthetics and fit for the time-saving ease of conventional cementation. IPS Eris layering material offers exceptional shades, ease of handling and optimized compatibility. IPS Eris is indicated for anterior and posterior crowns and 3-unit bridges having one pontic and not extending past the second premolar.

With reduced firing temperatures and a homogeneous composition for easy polishing and finishing, IPS Eris provides outstanding esthetics and simpler processing. Further, the Dentin, Incisal, Impulse, and Transparent materials enable the fabrication of restorations that blend well in the natural oral environment.

Captek is a high-gold, high-strength material with a porcelain bond strength that exceeds that of traditional cast alloys. Captek can be used for both single units and multiple unit bridges. The esthetic benefits are overwhelming. Gold offers superior biocompatibility and prevents the gray margins seen with traditional restorations. Captek's patented advanced gold material produces a crown that will look natural at the gum line, eliminating any unsightly gray or black lines commonly associated with traditional crowns.



The light-dispersion effects of Captek crowns and bridges are designed to mimic those of healthy natural tooth structure. Captek is also ideal for matching natural tooth color following whitening procedures.

Captek crowns and bridges are exceptionally strong and durable. The outstanding physical properties of the advanced gold material come from the

patented reinforcing internal structure of Captek. This structure reduces the stresses between the porcelain and Captek gold.

The Procera® AllCeram Cad Cam System

utilizes extremely dense-sintered aluminum oxide cores ideal for crowns, laminates, bridges and implant abutments. The strength in the core material is such that AllCeram can be used for prosthetic reconstruction anywhere in the mouth. Procera® AllCeram is 99.5 percent pure aluminum oxide and is biocompatible.



We at Marotta Dental Studio have long been involved in the research of Cad Cam technology and alternatives to traditional ceramic-to-metal restorations. We have been involved with the Procera System since its start in the early 1980’s when we constructed the first all-titanium implant bridges. With this experience, we are able to achieve better fits and esthetics with the Procera system since we know how to tweak the system where others do not. The Procera System is not limited to single restorations or limited levels of esthetics or strength. Presently, there is Procera AllCeram 0.4 mm, which allows optimal strength and esthetics and has the ability for white and ultratranslucent shades. The original AllCeram 0.6 mm allows optimal strength and esthetics. The new AllZirkon has much greater strength and yet maintains the esthetics. The AllCeram 0.6 mm is ideal for strong anterior and posterior bridges.

3M™ ESPE™ Lava™ All–Ceramic System is a Cad Cam system for the construction of high-strength, metal-free, allceramic crowns and bridges. The Lava system can be used for a varied range of esthetic restorations for both the anterior and posterior. The milled zirconium oxide base framework has a superior fit with an outstanding marginal fit. Since the tooth requires less preparations and the anterior esthetics are easier to achieve. A basic chamfer margin is all that is required; it needs no special designs. Since it is milled, the one-piece framework is very strong and has a high fractureresistance. Posterior bridges are possible. Furthermore, the color of the Lava framework matches the final overlaying shade and since it is so thin, it guarantees a highly translucent and natural appearance. One can follow standard cementation procedures without the need for any special cement kits.

The Gramm Gold-Electroforming System™ utilizes 24-karat gold, which makes it a better alternative to the customary cast and full-ceramic restorations. 24-karat gold ensures the final crown will be more durable and esthetic, while pure gold is biocompatible to the human body. Gold eliminates sensitivity and allergic reactions. Gold expands and contracts at the same rate as natural teeth, mimicking the natural dentition to the fullest. Gold does not stain or darken with age. Therefore, the shade of the crown will remain constant with the neighboring teeth, especially at the gum line.

InCeram® is a crown made of extremely dense-sintered aluminum oxide. The flexural strength is measured to be in the 350-700 Mpa range while maintaining the highest degree of translucency. There are three variations to the system. InCeram Spinell, InCeram Alumina and now InCeram Zirconia. InCeram Spinell is ideal for inlays and onlays, veneers and single anteriors. If used with the Alpha Porcelain in conjunction

with the 3D shade guide, the superstructure can achieve truly three-dimensional colors and high translucency.

The Shadevision from X-rite has allowed us to get the closest shade to the natural tooth possible. Dentists using the Shade Vision System can take an accurate reading in three simple steps: Attach the disposable tip, calibrate the system and measure the shade of the tooth surface. Once the images are captured, the Shade Vision System uploads the images to the dentist’s personal computer for processing and documentation in the patient’s files. Through an electronic file, disc or printed report of the color map, the dentist communicates accurate shade information to the lab. With this software, we not only get a digital image of the tooth, we get a color map as well. We can see hue, saturations, chroma and many other shade variables needed to match a shade accurately. The Shade Vision System can be changed to match any shade guide by simply pressing a switch. A picture can be printed for additional aid in shade matching. The Shade Vision System has many unique features that other digital shade-matching systems lack, including the “Virtual Try-In Feature,” which allows the completed crown to be scanned back into the computer and compared to the original scan. We have been using this system in-house for all custom shades with incredible results. When the Shade Vision System is used in conjunction with our Ceramic Protocol System, we guarantee the most esthetic cosmetic restorations available, from laminates, Empress and Procera crowns to Captek and Gramm Crowns.

Many dentists are afraid to join the esthetic revolution, just as they were afraid to join the implant revolution. Together we rode the implant wave. We struggled through the screws, custom abutments and continuous new technology and systems that seemed overwhelming and yet became simple. The esthetic wave is more simple. The patient wants it, they see it every day and they are prepared to pay for it. Just follow the proper esthetic protocol and together we can achieve what every person wants. A winning smile and a quick turn around. To quote the father of a young man who had not smiled for years until we and one of our dentists crafted him an esthetic restoration, “Thanks for giving me my son back.” There is no reason not to make the same difference for your patients. Take the plunge; ride the wave.

Implants Made Simple Part II continued

Step I: Case Design

If a full arch is being restored and many implants have been placed, a few questions need to be asked: Are there as many implants as previously planned? Were the implants placed where they were expected to go? What was the desired result and can it still be achieved? Is there enough vertical room? Most of these questions can be answered by sending upper and lower alginate impressions with a quick bite to the lab. Usually the study models will show the healing abutments placed after the implants were uncovered.



The lab will mount the models and trace the line angles of the implants by eye or with a quick mock setup. In most cases, this is enough to determine if the original plan is still feasible.

Step II: Custom Tray

A final impression is required to proceed with the case. The lab will construct one of two styles of custom trays. Either an open-top or closedtop tray will be made. In either style of impression procedure, the first thing to do is remove the healing caps. Place the impression copings on top of the implants, one at a time. Be especially careful not to remove all the healing abutments at one time. In the time it takes to place the individual impression copings, the tissue can start to shrink around the implants. Turn the entire impression coping clockwise on top of the abutment. The impression coping will screw into the abutment. Tighten with finger pressure. If it is too slippery, you can use a dental dam to get a better grip. When

completed, the impression coping will be flush to the base of the abutment. Take an x-ray to confirm that the impression coping is fully seated.

If you are using a closed-top tray, fill the tray with impression material. Use something hard and elastic. Do not use rubber-based impression material. Inject some material around the impression coping. Place the tray into the mouth. After the material hardens, remove the impression from the mouth. Remove the impression coping and replace the healing abutment. Send the impression coping back to the lab with the impression.

With an open-top tray, use patternresin to connect all the impression copings after they are screwed down. When completed, the resin will be around the middle of all the impression copings, joining them all in one piece. This technique may not be possible because of the non-parallelism of the male hex of the implants. You may just want to connect in groups of two. If this looks totally impossible, just leave the individual impression copings.

One obstacle to be aware of is that the guide pins supplied by the manufacturer may be too short. Place the open-opentop

Tray in the mouth to see where the pins come out. If the pins are lower than the tray, place a ball of wax on top of the pins. If the pins are higher than the tray, just leave them as they are. Place wax over the open top of the tray. Fill the tray with impression material. Place the tray into the mouth. Some material will ooze out of the open top. As the material hardens, clear away the material to gain access to the balls of wax. After it is hard, cut away the excess and pluck out the wax. Unscrew the guide pins. Remove the impression from the mouth. Replace the healing abutments. Send the impression and the guide pins to the lab for a master model.



For single-tooth and small bridges a regular stock tray can be used. Follow all the same procedures as previously explained. If the open-top tray technique is used, just cut a hole in the plastic tray above the implant.

Step III: Stabilized Bite Rim

The stabilized bite rim engages one, or occasionally two, abutments. The bite rim is made on the master model. Before proceeding to the mouth, examine the bite rim on the model. An impression coping is cut in half and connected by acrylic to the
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Implants Made Simple Part II continued

connected by acrylic to the tray. Look at which implant the impression coping (or copings) on the bite rim engages. Remove the healing cap that is in the mouth at the same location, using the same technique referred to in the impressiontaking step. No other healing caps need to be removed. Place the bite rim into the mouth. The bite rim is both tissue-supported and implant supported. The cut-down impression coping will lie on top of the abutment. Screw in the enclosed guide pin to hold down the impression coping. Take your bite in the same manner you would a normal bite rim. Mark the mid-line, lip-line etc. as you would a normal bite rim. Unscrew the guide pins. Remove the bite from the mouth. Replace your healing caps. Send the models to the lab for the next step.

Step IV: Set-Up

This is possibly the single most important visit for any fullmouth rehabilitation restoration case. Frames can be reordered and porcelain adjusted, but a wrong bite and incorrect esthetic starting point cannot be reversed.

The set-up for the final case must be tried in before proceeding with the metal framework. The set-up utilizes the stabilized bite rim. The procedure to try in this set-up is the same as the bite rim procedure. An impression coping is cut in half and connected by acrylic to the tray. Look at which implant the impression coping or copings on the set-up engages. Remove the healing cap that is in the mouth at the same location, using the same technique referred to in the impression technique. No other healing caps need to be removed. Place the set-up into the mouth. The set-up is both tissue-

supported and implant-supported. The cut-down impression coping will lie on top of the abutment. Screw in the enclosed guide pin to hold down the impression coping. Try in your set-up in the same manner you would a normal set-up. Check the bite, vertical, lip line, smile line, shade, etc. as you would with a normal set-up.

Show the patient what the esthetics will look like for the final restoration. Whether the final case will be porcelain-fused-tometal or processed denture tooth, this set-up is a good indication of what the final case will look like. If the implants are angled out too buccally or the placement is too far buccal, it will be indicated on this set up, thus enabling the patient to see the shortcomings of the final restoration. It is at this point that the lab can advise on the final restoration and give possible solutions to problems. It is very important for the doctor, patient and the lab to be in agreement on the esthetics and any mechanical concerns before proceeding with the case.

A rubber index or stone index is now made to measure the angles of the implants and the vertical height of the opposing dentition in relation to the implant. By all intents and purposes, if the model is 100% verified, the entire case could be completed at the next visit—though this is not advised. It cannot be stressed enough how important this visit is. In some instances after the set-up has been tried in and verified and the final frame made, a new bite was taken to complete the restoration. The only problem is that the new bite may be many millimeters higher or lower than the original, thus making the frame incorrect and useless. In the case of being a more open bite, there would be three to five millimeters of unsupported porcelain. In the case of closing the bite, there is not enough room between the metal and the porcelain or acrylic.
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Implants Made Simple Part II
continued

Step V: Verification Jig

A final preparation step is the verification jig. Either impression copings or temporary cylinders will be connected with a rigid resin material. The purpose of this jig is to mimic the final frame in fit. The jig is placed on the model and in the mouth to verify the accuracy of the model. If the jig does not fit the mouth, the model is incorrect. The jig must be cut and reconnected in the mouth. The model is then modified, or a second verification model is made. This step guarantees a properly fitting final frame and avoids the expense and time required to take solder pick-up impressions and do solder connections.

Once these steps are performed and proper protocols are followed, we will have all the information necessary to start the final restoration. As mentioned in the previous newsletter, a variation of the old adage MEASURE TWICE AND RESTORE ONCE proves that pre-case planning can truly make implants simple.