The force of fixed removables

Whether talking about cell phones where something new and improved comes along every other day or cars where the next model comes out next year, the state-of-the-art in any category only remains so until something better comes along.

The concept holds true in dental labs as well, as material options change, fabrication techniques advance and new solutions are discovered. If something was ideal in all cases it might never change, but even something as time-tested as the standard denture can be improved upon. As Preat Corp. founder and CEO Tom Bormes succinctly explained things, “If dentures worked we wouldn’t have implants.”

Improving on the standard

Implants of course are nothing new, but the technology behind the implants themselves and the type of restorations they can support continues to improve, bringing more predictable treatments and improved outcomes to a growing number of patients.

This is especially true for edentulous patients or those with failing teeth, because the ability to create reliable implant-retained overdentures provides them with a new esthetic set of teeth, and probably more importantly, the ability for those teeth to function at a high level. Bormes said this allows patients to eat better, improves their confidence and their appearance, changing “the entire quality of their life.”

“There’s nothing like natural dentition, but once you have implants and secure a denture on top of those implants with a structure, such as a Compartis® ISUS bar, you’ve got the patient back to almost full function,” added Kristi Gregory, CDT, and technical specialist for DENTSPLY Prosthetics who oversees the Company’s Compartis® ISUS services.

Greater predictability and more precise design and fabrication of every aspect of an implant-supported overdenture is bringing down the costs for what is still an expensive procedure for many patients. However, demand for these restorations continues to grow because the outcomes really change patients’ lives, said Chuck Genco, CDT. As General Manager of Van Hook Dental Studio in Tempe, Ariz., Genco specializes in cases where the implants are immediately loaded with a long term provisional, and is trained to be a part of the surgery so he can place the dentures at the appointment when the implants are placed. This is something he said he finds extremely rewarding.

“It’s a phenomenal success for the patient,” he said. “When you talk to the cosmetic doctors, everybody will tell you that the greatest patient satisfaction is not in the final. It’s in the provisionals because that’s where all the changes occur.”

Support for growth

Genco said his lab has seen an increase in immediate load implant-supported cases. While these dentures are a great option for many edentulous patients, the demand is even higher among patients with failing dentition because they now have an option to have their new teeth the same day their bad teeth are removed.

At Collis Prosthodontic Laboratory in Rolling Meadows, Ill., there’s a department dedicated to just producing restorations for all-on-four implant cases, and owner Jim Collis, CDT, said business in this department has steadily increased during the past two years. He attributes this growth to increased patient awareness of their implant options thanks to advertising from dental chains such as ClearChoice and Implant Solutions and the easily accessible health care information on the Internet.

“They’re advertising on TV, that’s bringing to the public information that they’ve never had before,” Collis said. “And because it’s more in the public eye, they can log onto the Internet and everything is at their fingertips now.”

Amos Harting, CDT, owner of Harting Dental Arts Lab in St. Louis agreed that this is an area of growth labs can tap into. He said the CAD/CAM technology such as the NobelProcera system from Nobel Biocare his lab has used for more than 7 years to create restorations built on milled bars makes it easier than ever to offer patients a fixed prosthetic option, and when given the choice between traditional removables and fixed, patients are choosing fixed.

This increasing demand is likely to gain momentum as the economy recovers from the recession that has hit dentists and labs hard during the past several years. Gregory said DENTSPLY is predicting a 15% to 18% growth in the market for milled implant bars this year, with the majority of them being for fixed cases.

“It is a fast growing segment and a value added segment that labs can take advantage of as CAD/CAM technology advances,” she said.

New Markets

The growing demand for implant-retained overdentures is opening up new opportunities for dental labs to work with oral surgeons. Genco said some of his largest accounts are now oral surgeons who come to him for much more than just surgical guide fabrication.

By becoming a part of the surgical procedure to deliver and place the immediate-load prosthesis, Genco said his lab has found a new pool of dentists to bring him cases. His lab is a part of the team restoring dentists get when they want to work with one of Genco’s surgical accounts. The surgeons are proving to be reliable accounts and as an added bonus they help bring the lab’s work to new general practitioners.

“It’s been a great match for us because the surgeon tells the restorative doctor, ‘I do this procedure and I like to use this laboratory,’” Genco said. “On most cases we go in as a partner to the surgeon, rather than as a partner to the restorative doctor unless it was a doctor I was already working with.”

Getting started

Being trained to participate in surgical procedures may not be the best route for every denture technician looking to add immediate load denture cases to their product list. Genco said it requires training, time for the technician to be out of the lab as well as the investment in a mobile lab and an inventory of everything that might be needed during the surgery.

Of course that isn’t a necessary investment for every lab looking to offer implant-retained overdentures. With a range of outsourcing services available, labs of any size and any specialization can find a partner to work with to get started right away. Preat’s President Chris Bormes said any lab can use a service such as his company’s Precision Implant Suprastructure Design and Milling Center and can be up and running without having to learn new skills or even add any software or hardware.

Preat’s service requires the lab to send in an analogue model or cast with soft tissue, a verification jig and a wax set up, and they get back a complete design for a milled bar and restoration via e-mail. The design can be viewed in 3D, shared with the doctor and is only fabricated upon approval. Working with an outsource provider in this way gives labs access to both production capacity and knowledge of the nuances of these restorations.

“The more that you outsource, the shorter the learning curve becomes. You’re benefitting from the additional expertise and experience of the design team. This can be invaluable when designing an implant supported or retained prosthesis,” Tom Bormes added.

Gregory said working with DENTSPLY on these cases is also simple and rewarding. By providing the anatomical details and basic design of the case, a lab can have an ISUS bar produced in around 9 to 10 business days. The service includes a warranty to guarantee the bar will fit to the model, and she often consults with clients to go over the details of the case and the bar design prior to milling. The system is designed to make it easy for a removables or a crown and bridge lab to get into the business.

“That’s the beauty of Compartis® ISUS. It’s a simple, hands-free process, start to finish,” she said. “You can pretty much just send us the model and we make it pain free.”

Technological simplification

Technological advancements are simplifying every aspect of implant-retained restoration design, production and placement. Through digital case design that includes both computer-driven surgical plans based on cone beam scans and CAD/CAM production of surgical guides and the dentures themselves, Tom Bormes said greater, patient-specific precision can be achieved.

The digital components of this process have changed the way Collis approaches these cases, and he likes that they increase success, which means fewer expensive remakes. He insists the doctors he works with use guided surgery for the implant placement, and because he is able to convince them of this greater chance for success, few balk at this requirement.

“I tell them exactly what we need to do to make this case successful on my end and I tell them why they need to give me these things, and most of the time they agree,” he said.

Genco said the predictability of working with digital case planning software and CAD/CAM production allow his lab to charge a flat fee for his immediate load cases. With cone beam data used to plan implant placement and milled components used in the dentures, he has few cases that fail, and thus is confident the fee he charges will be profitable for the lab. Having a set lab fee also helps dentists price the procedure to make it attractive to patients.

“I think by having predictable fees the doctors are more confident going in to the procedure,” Genco said.

Milled Vs. cast bars

That predictability continues over to Genco’s material of choice for his substructures. He prefers a milled titanium bar for support because they are proving to be reliable over the long expected life of these restorations and provide this support without adding unnecessary weight to the restoration.

Not only are these bars stronger and lighter, but because of the precision possible through digital designs and computer-driven milling, they are more accurate, Chris Bormes added. Designing and fabricating these bars is easier, especially when it comes to critical details such as placing the bar beneath the denture teeth for support and properly locating attachments. Also, the costs to produce them are less volatile when compared with what it takes to cast an implant bar.

“Milling produces accurate, tension free, one-piece bars that just drop into place,” he said. “When you compare the cost of gold, implant components, and labor needed for casting a bar, milling provides a more economical, simpler, and better final product for the lab.”

That cost savings is one of the reasons Harting likes using NobelProcera bars. It takes far less time for his lab to design a bar and send it off for production than it would to design and cast the bar, but the real cost savings come from the materials.

When casting a bar for an implant-retained overdenture, castable abutments need to be purchased. Harting said the cost of a milled bar isn’t much more than just the cost of the four abutments needed for an all-on-four restoration, but casting the bar also includes cost of the metal being used, and with high alloy prices, that cost can be significant. Some labs might be making money doing these cases with cast bars, but Harting said they could be making even more money if they were using milled.

“Just in materials alone, you’re saving money, that’s without any labor being involved,” he said. “That’s good business. That’s smart business.”

Then of course there are those times when the casting process doesn’t work out. The abutments in the cast are often a victim of the mishap. Gregory said labs can save themselves the hassle of the sensitive casting process by choosing an outsourced milled bar service. This process means labs have predictable expenses for implant-retained cases, need to carry less on-hand inventory for casting bars, and most importantly, receive a more accurate appliance that provides a truly passive fit.

“It’s difficult to get an accurate fit the first time with casting,” she said. “With milled bar options, the CAD software provides precision in design.”

Education and communication

But long before a technician should be learning about what type of bar will provide the best results in specific situations, it is critical to understand the principles of designing dentures for these cases. Collis said continuing education in this area is a never ending process, and one that should be started long before the first case.

The two main areas of knowledge a technician needs to complete an implant-retained overdenture are case design and how implants work. Learning the later is simple, but when it comes to case design there are many details for a technician to understand to create a restoration that will work for the case at hand.

“Case design is a big thing. You need to know the dynamics behind the curtain. How is this case going to function in the mouth,” he said.

Gregory added that there are too many implant options out there for a technician to be an expert on all of them. However, with systems like Compartis® ISUS, compatible with over 250 implant systems, the manufacturer assumes the responsibility of interacting with the platforms, making it possible for a technician to be comfortable working with just about any system.

Another key to learn before tackling an implant-retained overdenture is the critical details the lab will need from the dentist. Tom Bormes said it is important to know not just what information is needed, but why it’s needed so the technician can explain this to the dentist when necessary.

That communication and teamwork between the lab, the restoring dentist and the surgeon is critical to the success of these cases. Chris Bormes said having the case start at the removable lab with a diagnostic waxup prior to surgery can help get the process started and provide a guide to keep everyone involved on the same page.

When implants are involved in the case, work at the lab can start months ahead of time, Collis said. He likes for his dentists to send him a PowerPoint featuring specific patient images and information so everyone can review the same documentation while planning the case.

In many cases, the patient will transition from a traditional denture, to a provisional on the implants to the final restoration, and a lot can go wrong as the case transitions from one phase to the next if everyone involved isn’t on the same page along the way.

“We all need to know what’s going on with this case from the very start. From the very start there’s an awful lot of communication,” Collis said.

Harting values this communication because it gives everyone confidence in the outcome of the case, and Gregory said working as a part of the team, planning the case design from the beginning, puts the lab technician in an important position for success of the restoration and overall patient satisfaction.

“It gives the entire team an opportunity to visualize the case and plan the restorative with the end in mind,” she said. “With better planning, laboratories aren’t just dealing with what they are given, but are now true partners in the restorative scheme.”

A new role

Being a part of this communication is important to the success of these cases, but it also can be important to the future of dental technicians. Tom Bormes said lab technicians have the knowledge and skills to serve as valuable members of the dental team, and these communication and teamwork intensive implant-retained cases are a great way for a technician to show how important they can be to successful outcomes.

“It’s an exciting time to be a dental technician. The dental technician’s knowledge and skills are an invaluable resource to the restorative team when fabricating removable prosthetics,” Chris Bormes added.

That value can be especially apparent when working on an implant-retained overdenture case with a dentist who mostly does crown and bridge work. Because those clinicians are not used to working on designing smiles for edentulous patients, Genco said they rely even more heavily on the skills and advice of their technician.

In fact when the restoring dentist will not be involved in the implant placement and not as experienced designing restorations for these types of cases, Genco said the technician and the surgeon are really driving the case.

“The surgeon’s role is key and the laboratory’s role is key. The restorative doctor, their biggest role is working with the patients,” he said. “The restorative doctors rely heavily on every word that we say.”

Collis said he experiences a similar sense that his role in these cases has been elevated. Still, that role is just as an advisor to provide input based on expertise in the nuances of these cases. The final decisions must always be left to the dentist, but the best outcomes are achieved when everyone involved is working together, and this is actually a big step up from the traditional dentist, lab technician hierarchy.

“We decide together what type of restoration is best for this patient. More and more doctors are coming to the laboratory for advice,” Collis said. “We are no longer dental technologists. What we are or what we’re becoming are oral designers.”