Strategic Planning for Implant Cases.
Ray LeGendre, part of Arrowhead Dental Laboratory’s technical support team, recently talked with Aesthetic Dentistry about communication between dental labs and dentists—particularly with regards to implant cases. Ray emphasized the importance of effective communication for the overall success of implant cases and gave several tips for doctors when submitting them. Here are highlights of that conversation:
AD: How can effective communication with a dental lab contribute to implant success?
RL: To ensure that each implant case is successful, communication between the doctor and the dental laboratory is key. When the doctor makes plans for a case from the beginning with an overall case plan in mind, a more predictable result can be achieved.
With this article, my goal is to address a few items that are sometimes overlooked, forgotten, or otherwise not always considered when a doctor submits an implant case to a dental laboratory. A solid plan leaves little open to interpretation.
AD: What do you need from the doctor when you receive a new implant case?
RL: The most important thing is to have the proper information. This includes six key pieces of information, which are:
1. Aesthetic level of the restoration—Elite, Bella, or Traditional.
2. Crown material—E.max Press, Zir-MAX®, PFM, Zircrown.
3. Implant information—surgeon’s report, X-rays.
4. Custom abutment milling—in-house options, abutment emergence.
5. Shade photos, stick bite, study model.
6. Case plan—future treatment that may impact the current plan.
When a case arrives at the lab, the doctor can finalize all details with a member of the technical support team. This ensures that the case moves forward quickly and smoothly. When questions inevitably arise, technical support representatives are available to answer them—everything from questions about filling out the prescription to questions about full mouth reconstructions.
Years ago, only a few implant systems were on the market. Today, we work with numerous implant systems and we continually evolve and adapt to these new innovations. As technical support representatives at Arrowhead Dental Lab, our goal is to guide dentists through all the changes in the industry.
AD: Is all the information that you need listed on the prescription form?
RL: It is helpful if the prescription includes a few notes about the doctor’s and patient’s expectations. A section is provided on the prescription form for the doctor’s case plan. That’s a great place to put notes about the case, including any plans for future treatment.
Sometimes we receive cases in which the doctor is only planning on restoring the upper arch, but the dentition is broken down on the patient’s lower arch. If we build the upper restorations based on a broken-down lower arch, then the opposing dentition can be problematic.
In each case, lab technicians ask what the plan is for the lower arch, because instead of a doctor placing restorations against opposing dentition, we can offer alternatives. Such alternatives may include a White Wax-Up, to show what’s possible with a full mouth restoration.
If a patient needs to segment out treatment due to financial or other concerns, we can suggest Snowcaps (long-term Radica® temporaries) that a patient can wear for up to two years. That way, patients are set up for success.
AD: What is typically missing when doctors send their forms to you?
RL: When a case is submitted, the items that are most often missing include photos, X-rays, brand of implant to be used, and size of the implant. When we don’t have all the information that we need, we call the doctor and ask him or her for it. We realize that some things may not be available, but the more complete the prescription, the smoother the process for both the doctor and the lab.
AD: Can the surgeon’s report be attached to the prescription?
RL: Yes, a copy of the report is usually mailed with the prescription. This information will help identify the implant so we can mill the correct abutment. Attaching a surgeon’s report is helpful because it is information from the placing surgeon to the dentist. It outlines the results of the surgery and if the patient is ready for the implant.
It also includes implant information and any recommendations or concerns the surgeon may have. This is valuable information to keep in the patient’s chart for future reference.
AD: What else can doctors do to ensure their case has the best possible outcome?
RL: Today’s dental practices are very busy and patients’ expectations are high. A complete case plan will increase success and invite patient referrals.
AD: When doctors submit photos with a case, what do you recommend to ensure that the photos meet your specifications?
RL: Taking photos correctly makes a big difference in the success of the case. The “Social Six” (tooth numbers 6 through 11) can be the most challenging (for more information, see my story in Aesthetic Dentistry magazine, November 2015, “Q and A on the Social Six”). Tooth characterization is unique to every patient due to hypo-calcification, striation marks, and halos. When we receive photos with shade tabs and proper lighting, it helps lab technicians achieve the requested shade.
For example, if there is fluorescent lighting in the office, the shade tab may come across a little more yellow. Color-corrective lighting makes all the difference when taking a case photo. Predetermine an area in your office for photography. Send photos with the following angles: non-retracted, retracted, frontal, and lateral.
Focus on the specific tooth or shade tab you would like to match. Using a shade tab in the photos helps to compensate for the surrounding light in the dental office. When a crown shade needs to be adjusted, take a photo with the crown in place or at least next to a tooth the doctor is trying to match.
Photos can be used as a reference for horizontal plane. It is imperative that the patient is standing up with his or her head and shoulders leveled. I recommend having a Symmetrigraf® posture grid in the background or a solid horizontal reference.
If an office can designate one operatory to have proper lighting for photography, it can save a lot of time in capturing accurate shades for the restorations.
AD: When you have a large case, what are the most important things for dentists to communicate?
RL: The first step is to take a great impression. When taking an impression, the phrase “quality in, quality out” is apropos. Good margins that are clear in the impression or scan lead to good results with the implant case.
The horizontal plane is also key. Mounting the models to the correct plane of occlusion is important because it determines long-centric, cant, curve of Spee/Wilson, etc. A facebow sent on a transfer table and or a stick bite helps with proper mounting. Most popular articulator brands offer a transfer table for lab use.
Impression copings or transfer copings are used for implant-level impressions. When the impression coping is placed chairside over the implant, tissue and bone must be evaluated to ensure a flush seat. It is important for the doctor to X-ray verify to make sure that the impression is not being held up by bone or surrounding tissue. When the impression coping is not fully seated, it can result in height differences and rotational discrepancies.
Using closed tray impression copings as the manufacturer suggests means not using it as an open tray. Depending on the system used, this can greatly affect the working model pour-up. Open tray impression copings are great for implants that are at a severe angle. They disengage at the interface facilitating a smooth removal of the impression tray. Taking the time to make sure an accurate impression of a correctly placed impression coping will be time well spent.
AD: What are other ways the lab can help doctors with implant success?
RL: At Arrowhead, we offer surgical guides for implant placement. If a doctor uses guided surgery to help place an implant, it becomes more predictable. A CBCT scan and models can start the process of planning for guided surgery. We work directly with doctors to help dial-in each case using TeamViewer screen-sharing software, so that doctors can easily see what’s going on with their case.
Additionally, doctors may not be aware of all the possibilities that the lab can create. For example, in-house abutments can be customized with a gold hue to add more warmth through the tissue in areas where the patient may have thin bio-type. When there’s thin tissue, there’s a tendency for the color of the titanium to shine through and cause a gray halo. When a gold hue is added to an abutment, it creates warmth through the tissue. It’s just one of many possibilities!
Implant case success is a joint effort between the lab and doctor. The greater the communication, the greater the success.
