Place and Restore Dental Implants Economically

INTRODUCTION
Let’s face it: in today’s economy, dentists are seeing more and more patients who have put off treatment for several years; however, it’s not all gloom and doom. Implant dentistry is becoming more accepted and desired by patients. This growing population now actively seeks to replace their missing teeth with implants. New technologies are emerging that make implant placement a reality for well-trained general practitioners. The need for cost-effective implants, and associated restorative components, is in great demand.
In the latest ADA survey, it was noted that around 45 million teeth are extracted on an annual basis.¹ Only 2 million of those teeth will get replaced with implant therapy. The need to increase the penetration of dental implant therapy is greatly needed.
As a general dentist who practices in a small, blue collar town where unemployment is higher than 10%, one of the challenges that I face is how to price my implant restorations. With the growing number of new implants entering the marketplace, it can be difficult to know what laboratory components will cost when restoring a case. Some cases have 300% variability in cost for just a single unit; this is due mostly to the implant restorative component pricing.
One solution to this dilemma is to use a dental laboratory that can offer the entire restorative and/or surgical process for one flat fee. A simple flat fee provides a straight-forward approach to treatment planning, helps with making appropriate clinical decisions, and helps in the financial planning process involved in restoring the patient’s implant from start-to-finish. It embodies the philosophy of beginning the surgical process with the end restorative goal in mind.
This article will present a case example in which a missing premolar is replaced with this philosophy (Figure 1). A new service, called Inclusive Tooth Replacement System (TRS) (Glidewell Laboratories), where everything is included for one fixed price, was utilized. This inclusive laboratory service includes:

• Prosthetic guide or surgical guide
• Implant(s)
• Custom healing abutment
• Custom temporary abutment
• Matching custom impression post
• Provisional crown
• Final restoration (delivered at a later date).

If the clinician prefers to use the implant of his or her own choice, the system is available for most major brands.

Figure 1. Inclusive Tooth Replacement Solution (Glidewell Laboratories) components.	Figure 2. Preoperative periapical radiograph, showing the missing upper left second bicuspid (tooth No. 13).
Figure 3a. Prosthetic guide for pilot bit on study model.	Figure 3b. Prosthetic guide with ideal tooth wax-up.

CASE REPORT
Diagnosis and Treatment Planning
A 50-year-old woman presented with an unremarkable medical and dental history. Her chief complaint was the missing upper left premolar No. 13 (Figure 2). Her dental history questionnaire revealed the tooth had been removed 2 years ago because of a vertical fracture. The patient did not wish to consider a partial denture or bridge to replace the missing tooth, and had been saving money to restore the area with an implant.
Clinical examination utilizing the bone sounding technique, stone study models, and a panoramic radiograph revealed adequate width and height of bone. There was a noted decrease in the buccal-lingual dimension of bone, but it was determined that sufficient volume was present to proceed with implant therapy. Adequate attached gingival was present and the surrounding tissue was in good health. The adjacent teeth would eventually require new cast restorations, but they did not pose any immediate risk/complications for the proposed implant treatment.

Laboratory Phase was Initiated
To accurately begin the laboratory phase of the case, full-arch vinyl polysiloxane (VPS) impressions (Capture VPS [Glidewell Laboratories]) were taken and sent to Glidewell Laboratories to start the TRS process. Shade and clinical photos were taken to help facilitate fabrication of the components.

Figure 4. Custom healing cap, temporary abutment, impression post and BioTemp (Glidewell Laboratories).	Figure 5. Tissue punch to allow for flapless implant placement.

It was determined that a prosthetic placement guide would be adequate for this case (Figures 3a and 3b). The prosthetic guide, based on the diagnostic wax-up, was fabricated to show the ideal position of the implant platform. If the dentist creates the osteotomy with this guide, the implant can be inserted in the proper trajectory to utilize the custom temporary abutment and crown. All contraindications, such as anatomy and bone contour, that cannot be determined from a stone model and panoramic radiograph, must be accounted for by the treating dentist. In this clinical case, these factors were taken into consideration at the treatment planning phase with bone sounding.
Prior to the surgery date, all the necessary components were received and inspected (Figure 4). These components included:

• One 3.7 mm x 13 mm inclusive internal hex implant
• Custom healing cap
• Custom temporary abutment
• Custom impression post
• Custom temporary (BioTemps [Glidewell Laboratories]).

(The final crown was included in the fixed price, but delivered at a later date.)

Clinical Treatment Protocol
The implant was placed without a flap utilizing a tissue punch (OCO Biomedical) to expose the bone crest (Figure 5). A parallel pin (ACE Surgical) was placed to verify the correct angulation based off of the prosthetic guide (Figures 6a and 6b). The final insertion of the implant was done with the implant motor (Aseptico AEU-7000) set to 40 rpm and 40 ncm (Figure 7). Although the implant felt stable, 35 ncm was not achieved; the number accepted to consider immediate loading.^2,3 As a result, it was decided not to temporize the implant, and the custom healing cap was placed to sculpt the tissue. Close inspection of the custom healing cap shows that it was contoured in shape much like a natural tooth and not round like a stock healing cap (Figure 8). This allowed the soft tissue to be “trained” (formed) for optimal aesthetics.
Eight weeks later, the custom healing cap was removed. The tissue was evaluated, as well as the stability of the implant. Greater than 45 ncm of torque and an implant stability quotient of 72 was registered on the Ostell unit. The custom impression post was placed, and a VPS impression was taken to exactly communicate to the lab our hard work sculpting the soft tissue. The patient was sent home with a custom temporary abutment and custom temporary crown (BioTemp) (Figure 9).
From the impression, a final titanium custom abutment was milled and a zirconia crown was fabricated (Figures 10 and 11).

Figure 7. Size 3.7-mm inclusive implant placed.	Figure 8. Custom healing cap to train tissue.
Figure 9. BioTemp over custom temporary abutment.	Figure 10. Custom titanium abutment.

Figure 11. Full-contour zirconia crown (BruxZir [Glidewell Laboratories]).	Figure 12. Abutment seating jig.
Figure 13. Final crown in place.	Figure 14. Final periapical radiograph.

At the seat appointment, the included abutment positioning jig helped to ensure the correct placement of the titanium abutment (Figure 12). The abutment was screwed to the recommended torque and a radiograph was taken to confirm proper fit. The monolithic zirconia crown (BruxZir [Glidewell Laboratories]) was tried-in, and then the interproximal and occlusal contacts were adjusted as needed. The crown was left out of occlusion by approximately 30 µm to allow for equal dissipation of biting forces during clenching. Next, the abutment screw hole was covered with Teflon tape, and then the crown was cemented with resin cement (MaxCem Elite [Kerr]) by only applying a thin layer to the inside of the crown. All excess cement was carefully removed and a final radiograph was taken to verify exact final fit and that no excess cement had been left behind (Figures 13 and 14).

IN SUMMARY
With laboratory solutions, such as the TRS package described herein, clinicians can now remove much of the anxiety often associated with placing and restoring implants. To summarize, this laboratory solution offers: a prosthetic/surgical guide with the end result in mind; simple implant placement and temporization; custom healing caps providing emergence profile sculpting of the soft tissue for optimal aesthetics; extremely accurate soft-tissue impression with a custom impression post; custom titanium or zirconia abutment for optimal crown strength and emergence considerations; any final cement or type of screw-retained crown desired; and, a simple fixed flat fee that includes consultations and planning assistance for the clinician during any phase of treatment.
In the author’s opinion, this is a welcome solution to complex and time consuming challenges that dental practioners face in today’s market.

References

1. American Dental Association, 1999 Survey of Dental Services Rendered; estimates from Nobel Biocare, Zurich, Switzerland, September 2002.
2. Flanagan D. Fixed partial dentures and crowns supported by very small diameter dental implants in compromised sites. Implant Dent. 2008;17:182-191.
3. Uribe R, Peñarrocha M, Balaguer J, et al. Immediate loading in oral implants. Present situation. Med Oral Patol Oral Cir Bucal. 2005;10(suppl 2):E143-E153.

Dr. Patel is a graduate of University of North Carolina at Chapel Hill School of Dentistry and the Medical College of Georgia/American Academy of Implant Dentistry Maxi Course. He is the cofounder of the American Academy of Small Diameter Implants and is a clinical instructor at the Reconstructive Dentistry Institute. Dr. Patel has placed more than 2,500 mini-implants and has worked as a lecturer and clinical consultant on mini-implants for various companies. He can be reached at pareshpateldds2@gmail.com or at dentalminiimplant.com.

Disclosure: Dr. Patel reports no disclosures.