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Inclusive®

Restorative Driven Implant Solutions Vol. 2, Issue 2

A Multimedia Publication of Glidewell Laboratories • www.inclusivemagazine.com

Dr. Lyndon Cooper et al.

Page 38

Immediate

Implant

Loading

Denture Stabilization

Using Mini Implants

Dr. David Cummings and

Dr. Christopher Travis

Page 6

Reinforcing Overdentures

With Cast Frameworks

Jerry Lord, CDT

Page 14

Implant

Restorations:

Cemented or

Screw-Retained?

Dr. William Campbell and

Dr. Marc Herman

Page 20

Tips for Successful Medical Reimbursement

Dr. Olya Zahrebelny

Page 51


On the Web

Visit www.inclusivemagazine.com for

extra content and in-depth coverage.

ONLINE Video Presentations

Preview another Lecture-on-Demand from gIDE and learn from

Dr. Jack Hahn as he discusses the principles to achieve longterm

predictable results when performing tooth extraction and

immediate implant placement.

Watch a video case report presented by Drs. David Cummings and

Christopher Travis in which they place small-diameter implants to

retain a mandibular overdenture.

View the virtual design and fabrication process for cast frameworks

for overdenture cases.

Plus, gain knowledge of a unique alternative to cotton pellets for

covering the heads of abutment screws in a video accompanying

this issue’s Clinical Tip.

Check out the latest online issue of Inclusive

magazine at www.inclusivemagazine.com.

ONLINE CE credit

Get free CE credit for the material you’ve seen in this issue. You will

earn two hours for each test you complete and pass. To get started,

visit our website and look for the articles marked with “CE.”

When you see these icons in the pages that follow, it means we

have even more information on that topic available at

www.inclusivemagazine.com.

– www.inclusivemagazine.com –


Contents

6

Clinical Case Report: 3.0 mm Diameter Mini

Implants for Retention of a Mandibular Overdenture

Providing prosthetic stability is a top concern when treating denture

patients. Drs. David Cummings and Christopher Travis present

a case in which four mini implants placed in a patient’s mandible

provide retention for an overdenture.

ALSO IN THIS ISSUE

29 Clinical Tip: Sealing the Abutment

Screw Access Opening

34 Creating a Culture of Accountability

Within Your Practice

CORRECTION: In the 2011 winter issue

(Vol. 2, Issue 1), on page 13 of the article

titled “Mini Implants: An Interview with

Dr. Gordon Christensen,” Dr. Christensen

refers to a study out of Evolution Lab in

Amherst, N.Y. While the lab is still located

in Amherst, it has since been renamed

Shatkin F.I.R.S.T. Lab.

14

20

38

51

Using CAD-Designed Cast Frameworks to

Reinforce Overdentures

Limited vertical space in overdenture cases can lead to fracture of

the acrylic denture base; however, incorporating a cast framework

into the prosthesis is one way to avoid this problem. In this article,

Glidewell Laboratories’ Combination Crowns & Partials department

general manager Jerry Lord, CDT, explains how cast frameworks

can be virtually designed and fabricated to reinforce three types of

implant-retained overdentures.

Choosing Between Screw-Retained and

Cement-Retained Implant Crowns

There are many factors to consider when deciding whether to use

screw-retained or cement-retained implant crowns. Drs. William

Campbell and Marc Herman discuss the advantages and disadvantages

of each type of restoration. Two case studies illustrate the

decision-making process that’s involved.

The Immediate Loading of Dental Implants

When restoring dental implants, there are many current opportunities

for immediate loading rather than conventional delayed loading.

In their article, Dr. Lyndon Cooper et al. discuss the wide-ranging

applications of the immediate-loading concept and describe the

clinical parameters associated with the success and failure of immediately

loaded implants.

Billing Implants and Related Services to

Medical Plans

Medical billing can be complicated, and understanding the process

is critical to successful medical reimbursement. Dr. Olya Zahrebelny

returns to Inclusive magazine to write about the codes and

documentation requirements needed when billing implant cases to

medical plans.

– Contents – 1


Letter from the Editor

As clinicians, we are faced with many decisions when diagnosing and developing treatment

plans. This issue of Inclusive is dedicated to addressing several of the options that arise when

undertaking dental implant treatment.

One decision we encounter is how best to provide prosthetic stability for our denture patients.

Drs. David Cummings and Christopher Travis present a case report in which they go step-by-step

through the evaluation and work-up leading to the placement of four small-diameter implants in

a mandible, followed by immediate temporization utilizing the patient’s existing denture.

When dealing with full and partial implant overdenture cases, we are often fighting for vertical

space, which can mean the thickness of the acrylic base will be inadequate to resist fracture.

One option to counter this increased fracture risk is to incorporate a cast metal framework into

the denture base. Jerry Lord, general manager of Glidewell Laboratory’s Combination Crowns &

Partials department, demonstrates how CAD/CAM technology can be used to design and fabricate

prosthetic frameworks to provide strength in cases with limited vertical space.

When restoring dental implants, a major decision we face is whether to load them immediately.

Dr. Lyndon Cooper et al. address just that issue and present a clinical checklist for immediate

loading in their article on the subject.

Another choice we confront when treating patients involves the appropriate prosthetic design.

Drs. William Campbell and Marc Herman review the pros and cons of cement-retained versus

screw-retained implant restorations. Their article concludes with case examples that illustrate

the decision-making process.

Due to overwhelming demand, this issue also includes two practice management articles.

Dr. David Schwab focuses on creating a culture of accountability within your practice as a way

of evaluating and motivating your staff, while Dr. Olya Zahrebelny continues her discussion on

successfully billing implant cases and related services to medical plans.

After reading the various articles contained in this issue, check out our expanded online content,

which includes a preview of a gIDE Lecture-on-Demand by Dr. Jack Hahn on immediate implant

placement post extraction. As always, we welcome your feedback.

Dr. Bradley C. Bockhorst

Editor-in-Chief, Clinical Editor

inclusivemagazine@glidewelldental.com

– Letter from the Editor – 3


Publisher

Jim Glidewell, CDT

Editor-in-Chief and clinical editor

Bradley C. Bockhorst, DMD

Managing Editors

Jim Shuck; Mike Cash, CDT

Creative Director

Rachel Pacillas

Contributing editors

David Casper; Dzevad Ceranic, CDT;

Greg Minzenmayer

senior Copy Editor

Jennifer Holstein

copy editors

Melissa Manna, Eldon Thompson

digital marketing manager

Kevin Keithley

Graphic Designers/Web Designers

Jamie Austin, Deb Evans, Joel Guerra,

Lindsey Lauria, Phil Nguyen, Kelley Pelton, Ty Tran

Photographers/Clinical Videographers

Sharon Dowd, James Kwasniewski, Marc Repaire,

Sterling Wright

Illustrator

Phil Nguyen

coordinatorS/AD Representatives

Teri Arthur, Vivian Tsang

If you have questions, comments or suggestions, e-mail us at

inclusivemagazine@glidewelldental.com. Your comments may

be featured in an upcoming issue or on our website.

© 2011 Glidewell Laboratories

Contributors

■ Bradley C. Bockhorst, DMD

After receiving his dental degree from Washington

University School of Dental Medicine,

Dr. Bradley Bockhorst served as a Navy Dental

Officer. Dr. Bockhorst is Director of Clinical

Technologies at Glidewell Laboratories, where

he oversees Inclusive ® Digital Implant Treatment

Planning Services and is editor-in-chief

and clinical editor of Inclusive magazine. A member of the

California Dental Association, American Dental Association,

Academy of Osseointegration, International Congress of Oral

Implantologists and American Academy of Implant Dentistry,

Dr. Bockhorst lectures internationally on an array of dental

implant topics. He maintains a private practice focused on implant

prosthetics in Mission Viejo, Calif. Contact Dr. Bockhorst

at 800-521-0576 or inclusivemagazine@glidewelldental.com.

■ WILLIAM F. CAMPBELL, DDS, FAGD

Dr. William Campbell graduated from SUNY

Stony Brook School of Dental Medicine and

completed a General Practice Residency program

at North Shore University Hospital in

Manhasset, N.Y. He is a graduate of the Misch

International Implant institute and Fellow of

the ICOI and Academy of General Dentistry.

Dr. Campbell maintains a general practice in Malverne, N.Y.,

and is an attending dentist at North Shore University Hospital.

Contact him at wcampbel@optonline.net.

Neither Inclusive magazine nor any employees involved in its publication

(“publisher”) makes any warranty, express or implied, or assumes

any liability or responsibility for the accuracy, completeness, or usefulness

of any information, apparatus, product, or process disclosed, or

represents that its use would not infringe proprietary rights. Reference

herein to any specific commercial products, process, or services by

trade name, trademark, manufacturer or otherwise does not necessarily

constitute or imply its endorsement, recommendation, or favoring

by the publisher. The views and opinions of authors expressed

herein do not necessarily state or reflect those of the publisher and

shall not be used for advertising or product endorsement purposes.

CAUTION: When viewing the techniques, procedures, theories and

materials that are presented, you must make your own decisions

about specific treatment for patients and exercise personal professional

judgment regarding the need for further clinical testing or education

and your own clinical expertise before trying to implement new

procedures.

Inclusive is a registered trademark of Glidewell Laboratories.

■ LYNDON F. COOPER, DDS, Ph.D

Dr. Lyndon Cooper is the Stallings Distinguished

Professor of Dentistry of the Department

of Prosthodontics at University of North

Carolina at Chapel Hill. He is chairman, acting

director of graduate prosthodontics and

director of the Bone Biology and Implant Therapy

Laboratory. Dr. Cooper is a Diplomate of

the American Board of Prosthodontics and is the current president

of the American College of Prosthodontics Board of Directors.

He received the ACP’s 2004 Clinician/Researcher Award

and the IADR’s 2009 Distinguished Scientist Award. His lab’s

research findings have been presented in more than 70 publications.

Contact him at lyndon_cooper@dentistry.unc.edu.

4

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■ David cummings, Dds

Dr. David Cummings received his undergraduate

degree in applied mathematics from University

of California, San Diego. He completed

his dental degree at USC School of Dentistry

and his training in oral and maxillofacial

surgery in 1996, followed by a fellowship in

orthognathic surgery. Dr. Cummings has been

an assistant clinical professor at USC School of Dentistry since

1998, specializing in the field of dental implants. Contact him

at drcummings@mnc.occoxmail.com.

■ Marc w. herman, dds, fagd

Dr. Marc Herman received his dental degree

from University of Maryland School of Dentistry

and attended a General Practice Residency

program at North Shore University

Hospital, where he serves on the faculty and

is chief of three divisions. Dr. Herman belongs

to numerous dental societies, has contributed

to several dental publications and serves on the editorial staff

of the journal of the AGD. Contact him at herm57@aol.com or

516-921-8010.

■ JERRY LORD, CDT

After graduating from the Naval School of Dental

Assisting and Technology, Jerry Lord practiced

dental assisting and lab technology for

10 years while serving aboard the USS John F.

Kennedy. After leaving the Navy, he moved to

San Diego, Calif., where he worked for Grossman

Dental Lab for the next 12 years and

obtained his certification in partials. Jerry joined Glidewell in

1995 and is GM of the Combination Crowns & Partials department.

Contact him at inclusivemagazine@glidewelldental.com.

■ A. Burton Melton, DDS

Dr. Burton Melton received his undergraduate

degree from BYU, his DDS from Baylor College

of Dentistry and his diploma in prosthodontics

from the University of Missouri School of

Dentistry. He has practiced prosthodontics in

Albuquerque and Santa Fe, N.M., since 1972.

Dr. Melton has presented programs to audiences

in the U.S., Japan, Korea, Mexico, Taiwan and England, and

has appeared as a guest lecturer at dental schools across the U.S.

Contact him at abmeltonnm@aol.com or 505-883-7744.

■ DAVID SCHWAB, Ph.D

Dr. David Schwab presents practical, userfriendly

seminars and in-office consulting

sessions for the entire dental team. Fastpaced,

filled with humor and overflowing with

“pearls,” Dr. Schwab’s seminars are as popular

as they are useful. An internationally known

seminar speaker and practice management

consultant who works exclusively with dental professionals,

Dr. Schwab has served as director of marketing for the

ADA and as executive director of the American College of

Prosthodontists. He currently works closely with Straumann to

educate doctors and team members about practice management

trends to help them reach their full potential. Contact him

at www.davidschwab.com or 407-324-1333.

■ CHRISTOPHER P. TRAVIS, DDS

Dr. Christopher Travis received his dental degree

and certificate in prosthodontics from USC

School of Dentistry, where he was an assistant

clinical professor in predoctoral and graduate

prosthodontics. For the past 30 years, he has

maintained a full-time private practice specializing

in prosthodontics in Laguna Hills,

Calif. Dr. Travis is director of the Charles Stuart Study Group

in Laguna Hills, prosthodontic coordinator for the Newport

Harbor Academy of Dentistry and active member of the Pacific

Coast Society for Prosthodontics, American College of Prosthodontists

and AO, as well as a Fellow of the American College of

Dentists. Contact him at surfnswim@fea.net or 949-683-7456.

■ Olya Zahrebelny, DDS

Dr. Olya Zahrebelny graduated in 1978 from

the Faculty of Dentistry at the University of

Toronto, Canada, and completed a general

practice residency focusing on oral surgery,

oral medicine and oral pathology. She has

since practiced in hospital and private practice

environments. A former insurance consultant,

Dr. Zahrebelny taught at Northwestern University Dental

School and was an attending physician at the University of

Illinois Medical Center. She has been a columnist for Dental

Economics and Dental Equipment & Materials, and is a featured

columnist for Insurance Solutions. Named a leader in

continuing education and dental consulting by Dentistry

Today, Dr. Zahrebelny has lectured throughout the U.S. and

internationally. Contact her at drz@thezgroupllc.com.

– Contributors – 5


Using CAD-Designed Cast Frameworks

to Reinforce Overdentures

Go online for

in-depth content

by Jerry Lord, CDT

One of the complications that can occur

with implant-retained or implantsupported

overdentures is fracture of

the acrylic base. This primarily happens

in areas of high stress when

there is lack of vertical space and,

therefore, an inadequate thickness of

acrylic. Fractures commonly occur in

the acrylic on either side of the attachment

or when the metal housing of

the attachment breaks through the

denture base. 1,2

Incorporating a cast framework is one

option for increasing the strength of

the prosthesis. 3–5 Traditionally, these

frameworks are designed and waxed

on the model, then cast and finished.

Today’s CAD/CAM systems, such as

Sensable and 3Shape, allow the technician

to scan the master model and

then virtually design the framework,

including establishing the finish line,

blocking out undercuts and encasing

the attachment housings. Once the

design work is completed, the framework

is printed, cast and finished. The

framework can then be incorporated

into the acrylic base of the bite block

or trial denture and processed into the

definitive prosthesis.

The clinical techniques used in the

overdenture cases that follow demonstrate

how cast frameworks can be

virtually designed and fabricated for

a Locator ® Implant Overdenture (Zest

Anchors; Escondido, Calif.), a Locator

CAD/CAM Milled Bar Overdenture

and a partial overdenture.

Case 1

Locator Implant

Overdenture

For this case, the clinician requested

a palateless overdenture retained by

four Locator Attachments. The cast

framework is designed to have struts

over the tops of the attachment housings

to prevent the housings from

breaking through the acrylic of the

final prosthesis. The framework will

provide strength as well as partial

palatal coverage and support. The thin

palatal apron is designed for patient

comfort, with a smooth transition to

the acrylic. A small bead is incorporated

into the framework design to

provide a palatal seal.

Figure 1: Model with rough framework design with a

groove to create a palatal bead. NOTE: If you select

the Locator Abutments chairside, it is important

that each housing has approximately 2 mm of clearance

above the soft tissue. If you take an implantlevel

impression, the correct abutment heights can

be determined on the model.

Figure 2: The model is optically scanned and the file

is imported into the CAD program.

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Figures 3a, 3b: The framework is designed on a CAD workstation.

Figure 4: After being printed, the framework is verified

on the model.

Figure 5: The framework is cast. Note the metal

struts over the tops of the housings.

Figure 6: The framework is then incorporated

into the acrylic base of the bite block. The Locator

housings are cold cured into the acrylic base.

NOTE: Typically only two black processing caps are

placed into the housings for ease of removal during

the wax stage.

One of the

complications

that can occur

with implantretained

or implantsupported

overdentures is

fracture of the

acrylic base.

Figures 7a, 7b: The case is articulated and denture teeth are added for a trial set-up.

– Using CAD-Designed Cast Frameworks to Reinforce Overdentures – 15


Case 1

Figures 8a, 8b: Once the set-up is approved, the framework is opaqued and processed into the final prosthesis.

NOTE: In this case, the clinician requested that the framework be adjusted to create a more open palate. To

create a seal, the acrylic covers the entire intaglio surface.

Having sufficient space for adequate acrylic thickness

can be even more challenging with bar overdentures.

Case 2

Locator CAD/CAM

Milled Bar Overdenture

Having sufficient space for adequate

acrylic thickness can be even more

challenging with bar overdentures. A

cast framework can provide strength

in cases with limited vertical space.

Figure 1: After the case has been taken through the

trial set-up phase, the bar is CAD/CAM designed

and milled from a solid block of titanium. The Locator

Abutments are threaded into the bar.

Figure 2: The Locator housings are seated on the

abutments.

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Figure 3: The model, with the bar, is optically scanned

and the framework is CAD designed.

Figure 4: After being printed, the framework is verified

on the model.

Figure 5: The framework is cast.

Figure 6: The framework is then incorporated into

the acrylic base of the bite block. The Locator housings

are cold cured into the acrylic base. Note the

two Locator retention caps.

Figures 7a, 7b: The case is articulated and denture teeth are added for a trial set-up.

Figures 8a, 8b: Once the set-up is approved, the denture is processed and finished. NOTE: The mesh section

of the framework is opaqued to prevent the gray color from showing through the acrylic.

Figure 9: An intaglio view of the finished denture.

NOTE: The black processing caps will be replaced

with appropriate retention caps prior to final seating.

– Using CAD-Designed Cast Frameworks to Reinforce Overdentures – 17


Case 3

Partial Overdenture

Implant attachments can also be incorporated

into partial framework designs.

Two Locator Attachments will

be utilized in this case to retain and

stabilize bilateral distal extensions.

Figure 1: A soft tissue model is fabricated. Appropriate

Locator Abutments are threaded into the implant

analogs. An attachment housing is seated on each

abutment.

Figure 2: Note the cingulum rests and distal guide

planes prepared on tooth #22 and #26.

Figure 3: The model is optically scanned and the

partial framework is CAD designed.

Figure 4: The framework is printed and cast.

NOTE: The framework can be designed with a

lingual apron or a lingual bar.

Figure 5: Due to the retention of the Locator

Attachments, clasps can be eliminated.

Figures 6a–6c: The framework and the Locator housings are incorporated into the acrylic base of the bite block.

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Figures 7a–7c: The case is articulated and denture teeth are added for a trial set-up.

Figures 8a, 8b: Once the set-up is approved, the framework is opaqued and processed into the final prosthesis.

Conclusion

Overdenture repairs can be a practice

disruption and a source of frustration

for the patient. For cases with limited

vertical space that would result in

an inadequate thickness of acrylic, a

cast framework can provide the needed

strength. Utilizing Computer-Aided

Design and printing technologies to

fabricate the framework enables a precise

and predictable prosthetic outcome

to be achieved.

References

1. Sposetti VJ, Gibbs CH, Alderson TH, Jaggers JH,

Richmond A, Conlon M, Nickerson DM. Bite force

and muscle activity in overdenture wearers before

and after attachment placement. J Prosthet Dent.

1986;55(2):265–73.

2. Prats LM, Roberson MJ. Preventing fractures

in implant-supported removable dentures. Dent

Today. 2010;29(12):100–02.

3. Finley JM. Restoring the edentulous maxilla using

an implant-supported, matrix-assisted secondary

casting. J Prosthodont. 1998;7(1):35–9.

4. Cheng AC, Wee AG, Maxymiw W, Morrison D.

The management of implant-retained overdenture

treatment with custom-made metallic attachment

housing. J Prosthodont. 1998;7(2):79–83.

5. Rodrigues AH. Metal reinforcement for implantsupported

mandibular overdentures. J Prosthet

Dent. 2000 May;83(5):511–13.

For cases with

limited vertical

space ... a

cast framework

can provide

the needed

strength.

– Using CAD-Designed Cast Frameworks to Reinforce Overdentures – 19


Choosing Between

Screw-Retained and

Cement-Retained Implant Crowns

Go online for

in-depth content

by William F. Campbell, DDS, FAGD

and Marc W. Herman, DDS, FAGD

The choice of a screw-retained versus a

cement-retained crown is a complex and

comprehensive decision involving many

points of consideration. This article reviews

the important components involved in choosing

which crown to use and concludes with

two case studies illustrating the choice

between screw-retained versus cementretained

implant crowns.

RETRIEVABILITY

The screw-retained crown has both benefits and liabilities.

The main advantage is retrievability. The crown

is not only recoverable, but no damage occurs upon

removal of the crown. In the event of loosening or fracture,

the crown can easily be removed. Cleaning, screw

replacement and assessment of surrounding tissue is

also possible. Many dental professionals consider a

yearly cleaning and replacement of screws a prudent

approach. The longer the span, the more important

salvaging becomes. Most dental professionals believe

a long restorative span, cantilever or full arch dictates

screw-retained crowns. To recover a crown or change

a screw for maintenance, the restoration is removed,

the cotton pellet is removed and the screw is accessed.

Once repairs and/or alterations are concluded, the

screw is torqued, a new cotton pellet is placed and

composite or acrylic is used to seal the opening.

For cement-retained crowns, retrievability is not a

major drawback. Cemented crowns may be recovered

if the correct cement is used. Adding a water-soluble

gel to the cement may ease rescue of a crown. Nevertheless,

while the screw-retained crown is certainly retrievable,

removing a cement-retained crown can be a

questionable undertaking if strong cements are used.

PROS AND CONS OF CEMENT

Cement-retained implant-borne restorations offer

several advantages, including the elimination of unesthetic

screw access holes and greater resistance to

porcelain fracture. Standard crown & bridge procedures

can also be used in most situations. However,

excess cement left behind inadvertently is a major

problem and can result in soft tissue damage, bone

loss and/or chronic inflammation. 1 In a 2006 study by

Weber et al., soft tissue surrounding screw-retained

implant crowns was found to be healthier than soft

tissue surrounding cemented restorations. 2 To help

address this issue, custom abutments can now be

designed with supragingival margins that allow for

easy and complete cement removal.

RETENTION AND RESISTANCE

Factors affecting the retention and resistance of

cement-retained crowns on natural tooth abutments

can also be applied to cemented crowns on implant

abutments. Abutment height, degree of taper and surface

area and roughness all affect the retention and

resistance of a cemented crown.

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The ideal taper of opposing surfaces in natural tooth

preparations is reported to be six degrees. 3 Parallelism

of implants has a direct effect on the taper of their

abutments. Implants that are not parallel may require

further preparation and tapering of their abutments

to enable an ideal path of insertion of the prosthesis.

Overtapered abutments may lack adequate retention

for the cemented restoration and may necessitate

a screw-retained prosthesis. To counter this and to

increase retention for a cemented crown, an irregular

abutment surface and/or stronger cement may

be indicated.

Abutment height is an important factor for proper

retention and resistance of cemented crowns. Longer

abutment walls will have more surface area and will

therefore be more retentive. The length of the abutment

wall also plays an important role in the resistance

to tipping forces. To prevent tipping forces from

dislodging the cemented restoration, the length of

the abutment wall must be great enough to interfere

with the arc of the casting, pivoting about a point on

the margin on the opposite side of the restoration. 4

Custom abutments offer an excellent option to correct

the line of draw and provide appropriate resistance

and retention.

At least 5 mm of abutment height is needed for proper

retention and resistance of cement-retained crowns. 5

Therefore, screw-retained crowns are required in situations

when limited interarch space dictates an abutment

that would be shorter than 5 mm.

The primary advantage of a screw-retained superstructure

is the lower profile retention of the abutment

system. 6 These low-profile abutments offer a

significant advantage for bar-retained overdenture

applications. The lower height of the screw-retained

bar offers greater room for denture teeth and greater

thickness of acrylic, which is needed for strength of

the restoration.

REDUCED STRESS TO BONE AND IMPLANT

In implantology, reduced stress to the bone and implant

is a desired feature. This is obtained through

a passive fit of the prosthesis on the implant abutments.

A passive fit is more difficult, if not impossible,

The screw-retained

crown has both

benefits and liabilities.

The main advantage

is retrievability.

to attain for a screw-retained implant restoration with

more than one implant. Distortion of impression

material, dental stone, wax patterns and metal castings

are all contributing factors to this problem. A

passive fit is easier to accomplish in cemented restorations

due to die spacers. The die spacer creates an

approximately 40 µm cement space, which compensates

for laboratory distortions and permits a more

passive casting. If the laboratory is utilizing CAD/

CAM technology, the cement space can be adjusted

based on the substructure.

ESTHETICS

Esthetics is another factor to consider when deciding

between screw-retained and cement-retained crowns.

In anterior screw-retained crowns, the implant is

placed lingually to allow screw emergence through

the cingulum area. The restoration is cantilevered

facially from the implant body, which results in offset

loading of the implant. Lingual implant placement also

results in a porcelain ridge lap, which compromises

hygiene. An implant for an anterior cemented restoration

is placed under the incisal edge. An angulated

abutment is then used, which eliminates the ridge lap

and replicates a more natural emergence profile.

In posterior screw-retained restorations, the access

hole will exit through the central fossa of the prosthetic

tooth. This is not only a cosmetic compromise

but an occlusal one. The cementable crown obviously

has no entrance cavity. Allowing the forces of occlusion

to be distributed along the axial inclination, congruent

with the long axis of the tooth, is easier.

– Choosing Between Screw-Retained and Cement-Retained Implant Crowns – 21


Custom abutments

can now be designed

with supragingival

margins that allow for

easy and complete

cement removal.

with single restorations and in cantilever situations.

Using a ratchet wrench to the recommended torque

has greatly diminished this prosthetic complication.

COST

Cost may be a factor to consider as well. The cemented

implant crown costs considerably less because of

lower laboratory fees and fewer components. Fewer

and shorter appointments are needed to restore a

cement-retained crown, which is more cost-effective

for the prosthetic dentist. Temporary crowns with

cementable implants are far easier to fabricate than

screw-retained provisionals.

Screw apertures may interfere with mutually protected

occlusion, that is, centric occlusion, acquired occlusion,

and lateral and protrusive movements. The

screw opening may account for more than 50 percent

of the crown surface. New modalities to combat the

dilemma of the screw-entry opening being attractive

include the use of lateral set screws and pre-angled

abutments. Gold plating of the inner aspects of the

crown greatly helps with esthetics. All-ceramic screwretained

crowns such as monolithic BruxZir ® Solid

Zirconia and monolithic IPS e.max ® lithium disilicate

(Ivoclar Vivadent; Amherst, N.Y.) eliminate the

challenge of masking underlying discoloration from

showing through the occlusal access opening once it

is sealed.

COMPLICATIONS

Screw-retained restorations are associated with more

complications than cement-retained restorations. Fractures

of the occlusal materials of implant restorations

occur more commonly than in natural teeth due to a

lack of periodontal ligament stress relief and higher

impact forces. Porcelain fracture in screw-retained

restorations is more prevalent due to unsupported

material around the screw access hole. Implant restorations

receive cyclical loading due to the nature

of chewing and, consequently, screw-retained restorations

experience screw loosening and fatigue fractures

of their prosthetic screws. The frequency of

screw loosening is reported to be between 10 percent

and 65 percent. 7 This mainly occurs in posterior areas,

ACCESSIBILITY

Accessibility is another concern. Restoring a screwretained

restoration in a patient with a limited opening

and/or in the posterior of the mouth can be challenging.

The implant-abutment connection must line

up with the interproximal contacts to allow seating of

the one-piece restoration. A cement-retained crown

may be easier to deliver in these situations.

SUCCESS RATES

The success and long-term survival of endosteal dental

implants is largely dependent upon the forces

applied to them and the resultant stress transmitted to

the implant-bone interface. Avoiding even the slightest

movement of the abutment relative to the implant

is the overriding concern for cement-retained crowns

and screw-retained crowns. Most implant architects

have improved abutment screws, torque procedures,

implant size and implant tables, and have enhanced

the match of the implant to the abutment. This has allowed

for less movement and greater stability in both

screw-retained and cemented crowns. Machined abutments

with matching copings have reduced much of

the guesswork in implant prosthetics. With these improvements,

prosthetic and esthetic considerations are

the main determinants as to which crown is utilized.

Implant treatment plans should consider approaches

that eliminate biomechanical overload to the bone supporting

the implant-borne prosthesis. Once a proper

treatment plan is formulated, creating a harmonious

22

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Uses for Screw-Retained Implant Crowns

Uses for Cement-Retained Implant Crowns

Tissue

response

better in

temporary

Need the

crown to be

retrievable

Limited

occlusal

height, less

than 4 mm

Esthetics an

issue

No need for

the crown to

be retrievable

Occlusal

height

greater than

5 mm

No cement

to deal

with

Need for

healthy

tissue

Excess

cement easy

to remove

Need for

healthy

tissue

Esthetics

may be

compromised

Screw-

Retained

Crown

Implant

in ideal

position

Easier

to make

temporary

crown

Cement-

Retained

Crown

Implant

not in ideal

position

Fee not a

factor

Passive

situation

Fee a factor

Passive

situation

questionable

Access

easy

Not a

“power”

chewer

Occlusal

table with

limited

forces

Access

limited

Can be a

“power”

chewer

Occlusal

table can be

adjusted

occlusion in the prosthesis is an important factor in

further controlling excessive forces. 8

APPLYING OCCLUSAL PRINCIPLES

In general, occlusal principles applied to the restoration

of natural dentition should also be applied to

implant prosthetics for partially edentulous cases.

Modifying an occlusion to establish centric relation

coincident with centric occlusion, restoring canine

guidance or group function, or establishing mutually

protected articulation with anterior guidance are all

important guidelines regardless of the type of implant

restoration. Screw-retained dentures should

follow standard denture principles with bilateral

balanced occlusion.

“Implant-protective occlusion” refers to a set of occlusal

principles that are specific to implant-supported

prostheses. 9 These principles are applied regardless of

whether the restoration is cement- or screw-retained.

They also follow a philosophy of “design to the weakest

arch,” in which rigid implant restorations opposing

removable prostheses have occlusal schemes that

favor the tissues supporting the removable prosthesis.

Important considerations in the implant-protective

occlusal scheme are as follows:

• Elimination of premature contacts

• Timing of occlusal contacts

• Surface area over which the occlusal forces

are applied

• Implant angle to occlusal load

• Cuspal inclination

• Cantilevers

• Implant crown contour

• Crown height

• Occlusal contact position

• Occlusal material

One must be especially aware of evaluating all restorative

patients for parafunctional habits. Although

ideal occlusal schemes may exist in the restoration,

excessive forces created by parafunction can overload

supporting bone around implants and result in

failure. If they exist, alterations in the treatment plan

will be needed to compensate for these excessive

forces, and an appliance to control the noxious habit

is recommended.

– Choosing Between Screw-Retained and Cement-Retained Implant Crowns – 23


CASE REPORTS

Case 1 — Replacement of a mandibular

right second premolar

A 4.0 mm x 13 mm NobelSpeedy (Nobel Biocare;

Yorba Linda, Calif.) implant was placed in a longstanding

edentulous area. The implant was placed

directly over the ridge of bone.

Figure 1

Figure 2

Figure 3

Before the restorative procedures were started, a sixmonth

therapeutic interval elapsed. A lab-fabricated,

custom conical abutment with a 20-degree taper was

used to allow for a cemented implant crown (Fig. 1).

Interocclusal space measured 6 mm. The custom abutment

was torqued into place and a custom temporary

was created. A porcelain-fused-to-gold crown was

fabricated with proper contours to allow for healthy

soft tissue and adequate oral hygiene (Figs. 2–5).

A cemented implant crown restoration was used in

this case to maximize esthetics. It also allowed for

porcelain occlusal contacts within the central fossa,

which will not wear over time, and eliminated the risk

of porcelain fracture due to unsupported porcelain

around a screw access hole. Using the principles of

implant-protected occlusion, the crown was adjusted

to have light centric contact along the long axis of

the implant, with the patient in the clenched position.

This took into account compression of the natural

dentition within the alveolar sockets. There were no

contacts on the buccal cusp tips, which would create

off-axis loading of the implant and place it under unfavorable

shearing forces. The crown was cemented

with temporary cement, allowing for retrievability.

Figure 4

Figure 5

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Esthetics is another

factor to consider

when deciding between

screw-retained and

cement-retained

crowns.

Figure 1

Case 2 — Mandibular screw-retained

full-arch FP3 prosthesis

Five 4.0 mm x 13 mm Biomet 3i NanoTite Tapered

Certain ® implants (Biomet 3i OSSEOTITE; Warsaw,

Ind.) were placed directly over the ridge of bone anterior

to the right and left mental foramina. A single

5.0 mm x 10 mm Biomet 3i NanoTite Tapered Certain

implant was placed in each edentulous area of tooth

#19 and #30.

A healing period of four months was allowed before

restorative procedures were started. Biomet 3i Certain

conical abutments were fastened to each implant, at

sizes corresponding to the implant diameter and tissue

height. Plastic non-hexed castable cylinders were

incorporated into the wax pattern for the multi-unit

porcelain-fused-to-metal framework. The framework

was cast and its passive fit was confirmed in the

mouth using the single screw test. Tooth-colored and

pink porcelain were then applied to the framework

to reproduce the teeth and gingival tissues. Biomet

3i Gold-Tite ® retaining screws were placed through

the framework and threaded into the abutments at

10 Ncm. Cotton pellets were placed over the screw

heads, and the access holes were sealed with composite

resin. (Figs. 1–3)

A fixed implant prosthesis was chosen to restore this

case, primarily because the patient did not want a

removable prosthesis. A screw-retained design was

chosen. The implants do not emerge through the clinical

crowns due to resorption of the alveolar ridge

Figure 2

Figure 3

post extractions. The metal framework required a low

profile in this area so as not to interfere with tongue

movement. The shorter profile of the conical abutments

allowed for the reduced height of the metal

framework in this area, but also necessitated screw

fixation of the framework for adequate retention.

– Choosing Between Screw-Retained and Cement-Retained Implant Crowns – 25


“Implant-protective

occlusion” ... principles

are applied regardless

of whether the

restoration is cementor

screw-retained.

CONCLUSION

There are advantages and disadvantages to using a

screw-retained versus a cement-retained crown. 1,2,10

To overcome the pros and cons of each system, newer

implant systems have been developed to include techniques

that increase the link between the implant and

abutment, use larger abutment screws and provide a

geometric lock. 2,11 These advances have decreased the

incidence of screw loosening. 12 Many dental professionals

would conclude that cement-retained crowns

are finer for esthetics and occlusion; similarly, many

would conclude that screw-retained crowns are a

necessity for multiple units requiring retrievability. 13,14

Individual philosophy plays a huge role, however,

and deciding which crown to use is best done on a

case-by-case basis. 15

The aforementioned case studies are representative

of the decision-making process when choosing a

cement- or screw-retained implant prosthesis. The first

case could have been restored either way successfully,

but the ultimate decision for a cement-retained crown

was made due to the patient’s desire to have the most

esthetic crown possible. It was imperative that the

second case be screw-retained for adequate retention

and ease of retrievability.

REFERENCES

1. Goodacre CJ, Bernal GB, Rungcharassaeng K. Clinical complication with

implants and implant prostheses. J Prosthet Dent. 2003;90:121–32.

2. Weber HP, Kim DM, Ng MW, et al. Peri-implant soft-tissue health surrounding

cement- and screw-retained implant restorations: a multi-center, threeyear

prospective study. Clin Oral Implants Res. 2006;17:375–79.

3. Jorgensen KD. The relationship between retention and convergence

angle in cemented veneer crowns. Acta Odontol Scand. 1955;13:35–40.

4. Shillingburg HT, Hobo S, Whitsett LD. “Principles of Preparations.”

Fundamentals of Fixed Prosthodontics. 2nd ed. Chicago: Quintessence

Pub. 1981:79–96.

5. Kaufman EG, Coelho DH, Collin L. Factors influencing the retention of

cemented gold castings. J Prosthet Dent. 1961;11:487–98.

6. Misch CE. “Principles of Cement Retained Fixed Implant Prosthodontics.”

Contemporary Implant Dentistry. 2nd ed. St. Louis: Mosby. 1999:549–73.

7. Hebel KS, Gajjar RC. Cement-retained versus screw-retained implant

restorations: achieving optimal occlusion and esthetics in implant

dentistry. J Prosthet Dent. 1997;77:28–35.

8. Moscovitch M. Molar restorations supported by two implants: an alternative

to wide implants. J Can Dental Assoc. 2001;67(9):535–39.

9. Misch CE, Bidez MW. “Chapter 38: occlusal considerations for implantsupported

prostheses: implant protective occlusion and occlusal materials.”

Contemporary Implant Dentistry. 2nd ed. Missouri: Mosby.

1999:609–28.

10. Sheets JL, Wilcox C, Wilwerding T. Cement selection for cement-retained

crown technique with dental implants. J Prosthodont. 2008;17:92–96.

11. Strong SM. What’s your choice: cement- or screw-retained implant

restorations? Gen Dent. 2008;56:15–18.

12. Guichet DL, Caputo AA, Choi, H, et al. Passivity of fit and marginal opening

in screw- or cement-retained implant fixed partial denture designs.

Int J Oral Maxillofac Implants. 2000;15:239–46.

13. Chee W, Jivraj S. Screw versus cemented implant supported restorations.

Br Dent J. 2006;201:501–07.

14. Lee A, Okayasu K, Wang HL. Screw- versus cement-retained implant

restorations: current concepts. Implant Dent. 2010;19:8–12.

15. Chee W, Felton DA, Johnson PF, et al. Cemented versus screw-retained

implant prostheses: Which is better? Int Journal Oral Maxillofac Implants.

1999;14:1.

Drs. Campbell and Herman receive no remuneration from any dental

company.

26

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Clinical Tip:

Sealing the Abutment

Screw Access Opening

Go online for

in-depth content

by A. Burton Melton, DDS

Clinical dentistry courtesy of Bradley C. Bockhorst, DMD

Numerous materials, such as cotton pellets, polyvinyl siloxane and gutta-percha, have been used in implant dentistry over

the years to cover the heads of abutment screws prior to sealing the access openings. During a recent discussion on the

subject, several of my British colleagues suggested using Teflon tape. This material provides several advantages:

• It can easily be packed.

• It covers and seals the area above the head of the abutment screw.

• It will not act like a sponge, unlike a cotton pellet.

• It can easily be removed if the abutment screw needs to be accessed.

The cases that follow show how Teflon tape can be used to cover and protect the head of an abutment screw under a

cemented crown and a screw-retained crown. Sometimes the simplest ideas are the best!

– Clinical Tip: Sealing the Abutment Screw Access Opening – 29


CASE 1:

Figure 1: The abutment is seated and the abutment screw is tightened to the

recommended torque.

Figure 2: A strip of Teflon tape is packed into the access opening.

Figure 3: The Teflon tape in place over the head of the abutment screw

30

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Cemented Crown

Figure 4: The crown is cemented onto the abutment.

Figure 5: Removal of the excess cement is critical for optimal tissue health.

During a recent

discussion on the

subject, several

of my colleagues

suggested using

Teflon tape.

Figure 6: The final restoration: an IPS e.max ® crown (Ivoclar Vivadent;

Amherst N.Y.) and an Inclusive ® Zirconia Abutment with Titanium Insert

– Clinical Tip: Sealing the Abutment Screw Access Opening – 31


CASE 2:

Figure 1: The restoration is seated and the abutment screw is tightened to

the recommended torque.

Figure 2: A strip of Teflon tape is packed over the head of the abutment screw.

Figure 3: The access opening is sealed with composite.

32

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Screw-Retained Crown

Sometimes the

simplest ideas

are the best!

Figure 4: The final restoration: a one-piece screw-retained BruxZir ® Solid

Zirconia crown with titanium insert

Share your Clinical Tip

Are you an experienced clinician who specializes in implant and restorative dentistry? Would you like to share your expertise

with other clinicians? If you answered yes to both questions, Inclusive magazine wants to hear from you!

Send us a tip based on your clinical experience and it may be selected to appear in the next issue of Inclusive magazine.

Maybe you’ve found a valuable resource you want other clinicians to know about, or a simpler way of performing a difficult

procedure. If your tip is selected for publication in Inclusive magazine, in addition to receiving a contributor credit, you will

also receive $500 in Glidewell credit or a $500 credit toward your account.

Submission is now open, so get your tip ready and send it to the lab via:

WEBSITE

www.inclusivemagazine.com

E-MAIL

inclusivemagazine@glidewelldental.com

MAIL

Glidewell Laboratories

ATTN: Inclusive magazine

4141 MacArthur Blvd.

Newport Beach, CA 92660

Submission deadline:

June 30, 2011

This contest is open to all dentists. Each dentist may submit multiple tips for consideration. All tips should be original content and expressed in your own words. There is no

guarantee that Inclusive magazine will use your tip, and we retain the right to edit your tip for style and accuracy before publishing it. Participants agree that all submissions

will be treated as non-confidential and non-proprietary and deemed the property of and may be used by Inclusive magazine, or its affiliates, for any purpose, including, but not

limited to, reproduction, disclosure, transmission, publication, broadcast and posting. Furthermore, Inclusive magazine is free to use and shall be deemed to own any ideas,

concepts, know-how, or techniques contained in any submission you send for any purpose whatsoever, without compensation to you or any other party.

– Clinical Tip: Sealing the Abutment Screw Access Opening – 33


Creating a Culture of

Accountability Within Your Practice

Go online for

in-depth content

by David Schwab, Ph.D

Most dentists tell me they love their profession,

with one exception: They don’t like being

a cop. The dreaded law enforcement aspect of dentistry

comes into play every time the dentist needs to police the

behavior of his or her dental team. When team members fail

to follow practice policies and protocols, the dentist has to

step in to deal with the offenders. The goal of every practice

should be to create a culture of personal accountability, so

team members will police themselves and the dentist can

devote more time to dentistry. Here are some tips for creating

a culture of accountability.

Practice Vital Behaviors

Change that is intellectually easy can be behaviorally difficult.

A recent search on Amazon.com for books using the

keywords “diet,” “health” and “nutrition” generated nearly

14,000 hits. Add to this the mountain of books, countless

magazine articles, Internet advice, and television and radio

news segments and programs on this topic, and you get the

idea: People have a voracious appetite for information on

how to achieve their desire to be fit and healthy. I will save

you the trouble of trying to read and digest this plethora

of information because it can all be summarized in just four

The goal of every practice

should be to create

a culture of personal

accountability.

34

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words: Eat healthy and exercise. Everyone knows that sticking

to a diet that includes fresh fruits and vegetables and

exercising regularly is preferable to a diet of fast food, ice

cream and sitting on the couch with the remote control in

one hand and a snack in the other.

The problem is not one of comprehending solutions, but

of implementing them. If the policy in the dental office is

that everyone has to answer the phone a certain way, or use

a particular phrase when explaining a procedure, or run

through a checklist to ensure that a task is completed thoroughly,

then these are the vital behaviors. No one learns

how to swim or how to ride a bicycle just by listening and

observing. The behavior has to be tried, mistakes need to be

made, and the person has to practice the behavior repeatedly

until it becomes natural. Encourage team members to spend

less time talking about change and more time practicing

the behavior necessary to create it.

Set Realistic Expectations

Once you decide to focus on performance, not potential,

you are ready to set expectations. Learning new behavioral

skills requires time, fortitude and practice. Suppose a student

wants to learn to play the violin. Even if that student

begins his or her studies with an excellent grasp of music

theory and great motivation, the early days and weeks of

violin practice will result in more squeaks and bum notes

than mellifluous music. Eventually, though, the student

will progress and begin to play increasingly difficult pieces

with aplomb.

When team members in a dental office attempt new behaviors,

recognize their efforts. When they succeed

(only occasionally, at first), offer praise. When they try

and fail, encourage them to try again. For example, you

may want a team member to say, in certain situations:

“Mrs. Jones, we need more patients like you. Please tell

your friends about us.” This behavior will at first be terribly

awkward, just as it was initially hard for the music student

to hold the violin in the proper position. If you expect

behavioral mastery at the outset, you will be disappointed

and your team will be frustrated. If you are willing to coach,

gently correct and beam with approval at every inch of

progress, then goals will be achieved and team members

will enjoy exhibiting their new skills.

Make the Evaluation Process Work

for Everyone

The best evaluation process is one that gives the team

member every chance to excel. Each team member should

have a written job description. These job descriptions

should be organized by major categories. For example,

some categories in a job description for an office manager

might include “front office administration,” “scheduling” and

If you are willing to coach, gently

correct and beam with approval at

every inch of progress, then goals

will be achieved and team members

will enjoy exhibiting their new skills.

– Creating a Culture of Accountability Within Your Practice – 35


“patient communication,” among others. For each of these

broad headings, the job description should include a list of

specific duties.

When team members see a

one-to-one correspondence

between their behavior and their

evaluations, they are motivated

to succeed and proudly hold

themselves accountable.

A job description that is organized in this manner can be

easily modified to create an evaluation form. Simply list all

the major categories (but not the specific duties under each

heading) on a form. Use a scale of 1 to 5 next to each, with

1 indicating poor performance and 5 designating excellent

performance. Be sure to give the team member the job

description and the evaluation form at the beginning of the

year (or when he or she joins the practice). The evaluation

process thus becomes a test for which the employee knows

all the questions in advance and is motivated to try to excel

in the specified categories.

Prior to conducting the evaluation, ask team members to

evaluate themselves. Then fill out your own evaluation and

meet with each team member privately. If you and the team

member concur, for example, that “4” is the proper rating for

a certain line item, this makes the conversation very easy.

If the team member rates himself or herself lower than you

do, then you have the happy task of having your evaluation

(the one that counts, ultimately) trump the lower score the

team member gave himself or herself. When a team member

gives himself or herself a higher score than you feel is

deserved, you can ask for behavioral evidence from that

team member to justify the higher rating. Usually, the dentist

ends up pointing out where the behavior is falling short

and giving the team member specific advice on how to raise

his or her score the next time. In these instances, it is advisable

that the dentist tell the team member that his or her

behavior in this particular category will be reevaluated in,

say, three months, with the expectation that there will be

improvement. Giving team members a chance to pull up

their “grade” is often motivational.

CONCLUSION

By identifying and practicing vital behaviors, setting realistic

expectations and using evaluation forms extrapolated

from job descriptions, you not only help hold team members

accountable, but you also create an environment that

encourages all members of the team to police themselves.

When team members see a one-to-one correspondence

between their behavior and their evaluations, they are motivated

to succeed and proudly hold themselves accountable.

36

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The Immediate Loading

of Dental Implants

by Lyndon F. Cooper, DDS, Ph.D;

Ingeborg J. De Kok, DDS, MS; Fernando Rojas-Vizcaya, DDS, MS;

Preeda Pungpapong, DDS, MS; and Kuang-Han Chang, DDS

Abstract

The aim of this article is to identify current opportunities for the immediate loading of endosseous dental implants.

A biologic basis for the clinical parameters associated with success and failure of immediately loaded implants is

presented, and select clinical situations where immediate loading is presently advocated will be illustrated. The

wide-ranging applications of the immediate-loading concept for endosseous dental implants will be introduced;

however, further experimental validation is necessary before incorporating all of these various expedited therapeutic

approaches into practice.

Evolving Patient Care

Individuals perceive the complete dentition as a state

of good health, and edentulous patients perceive themselves

in a better light when a functional dentition is

established with endo sseous dental implants. 1 This

contrasts with the aversion reported for the use of

removable partial dentures or the frustration reported

for the use of complete dentures for mandibular edentulism.

2,3 Implant success rates for single-tooth replacement

rival or exceed the clinical performance of fixed

partial dentures. 4,5 Implant-supported dental prostheses

offer multiple advantages for patients.

The conventional process of im plant-based dental rehabilitation

was founded on prospective clinical cohort

studies that demonstrated the long-term success of rootform

titanium dental implants. 6,7 High success rates of

dental implant therapy have been repeatedly reported.

The reports were reviewed by Fiorellini and colleagues,

performed according to the established staged pro tocols

with a three- to six-month healing period that avoided

direct masticatory loading from the prosthesis to the

implant. 8 However, the complexities and long duration

of implant therapy may discourage some patients and

clinicians from electing an implant-based strategy for

dental rehabilitation. 9

Nearly a decade ago, some coalescence of opinion regarding

surgical ap proaches to implant therapy was

at tained in light of emerging clinical evidence that

one-stage and two-stage procedures performed using

a diverse array of dental implant products resulted in

high survival rates for endosseous dental implants. 10–13

Osseointegration was reproducibly achieved using both

one- and two-stage approaches, and transmucosal healing

was disregarded as a potential risk factor for most

dental implants. 14

More recently, several clinical investigations reported

similarly high survival rates for endosseous dental

implants placed in the mandibular parasymphysis and

loaded either immediately after implant placement or

within weeks after implant placement (Table 1). 15–49 First

offered as expendable or transitional fixtures, these

reports of immediate loading of dental implants provided

new insight into the biological capacity of the

mandibular parasymphysis to support the process of

osseointegration under diverse clinical conditions. Also,

these successful initiatives suggested that immediate

loading of endosseous dental implants was, in fact, a

feasible clinical enterprise.

As the experience of immediate loading of endo sseous

dental implants has expanded throughout several centers

worldwide, activities have grown to include maxillary

complete arch prostheses, single-tooth implants,

and even posterior fixed partial dentures and single-unit

molar crowns. It remains to be demonstrated if all of

these procedures will achieve high success over long

periods of time.

– www.inclusivemagazine.com –


Author

Table 1 — Examples of Immediate or Early Loading Experience

Number of

Patients

Time of Loading Location Number of Implants

and Prosthesis Type

Implant

Survival, %

Lorenzoni 15 12 At extraction Anterior maxilla Single tooth 100

Buchs 16 93 At extraction Maxilla and mandible Single tooth 93.7

Proussaefs 17 10 At surgery Anterior maxilla Single tooth 100

Kan 18 35 At extraction Anterior maxilla Single tooth 100

Rahman 19 30 At extraction Maxilla Single tooth 100

Andersen 20 8 7 days Anterior maxilla Single tooth 100

Jo 21 75 At surgery/at extraction Maxilla and mandible Single tooth 94.8–96

Cooper 22 48 3 weeks Anterior maxilla Single tooth 96.2

Rocci 23 46 At surgery Maxilla 1 or 2/crown or FPD 91

Degidi 24 152 At surgery Maxilla and mandible Single tooth, FPD, FD >98

Hui 25 13 At extraction Anterior maxilla Single tooth 100

Glauser 26 38 At surgery All locations Single tooth, FPD, 1 FD 97.1

Glauser 27 41 At surgery (up to 11 days) All locations FPDs, single tooth 82.7

Malo 28 73 At extraction; 1–3 days All locations Single tooth, FPD, FD 95.7

Cornelini 29 20 At surgery Posterior mandible FPD 97.5

Grunder 30 10 jaws 1 day Maxilla and mandible 8–10/FD 92.1

Twase-Smith 31 24 At surgery Edentulous mandible 2/OD 95.8/100

Cooper 32 60 At surgery Edentulous mandible 2/OD 96.7

Roynesdal 33 21 3 weeks vs. 3 months Edentulous mandible 2/OD 100

Gatti 34 21 0–20 days Edentulous mandible 4/OD 96

Chiapasco 35 226 0–20 days Edentulous mandible 4/OD 96.9

Colomina 36 13 2 weeks Edentulous mandible 5/FD 96.7

Van Steenberghe 37 8 At surgery Maxilla, Computer-Aided Design FD >99

Brånemark 38 50 At surgery Edentulous mandible 3/FD 98

Horiuchi 39 17 At surgery 12 mandible/5 maxilla 8–10/FD 97.2

Jaffin 40 27 At surgery 21 mandible/6 maxilla 5–6/FD 97 (excluding machined)

Ibanez 41 11 2–3 days Maxilla and mandible FD 100

Randow** 42 16 20 days Edentulous mandible 5–6/FD 100

Collaert and De Bruyn 43 25 30 days Edentulous mandible 5 FD

Tarnow 44 10 At surgery 6 mandible/4 maxilla 5 of 10 loaded/FD 97.1

Balshi 45 10 At surgery Edentulous mandible 3 of 8 loaded/FD 84.7

Wolfinger 46 24 At surgery Edentulous mandible 5–6/FD 97

Schnitman 47 10 At surgery Edentulous mandible 4 of 7 loaded/FD 96

Salama 48 2 At surgery Edentulous mandible 5 95

De Kok 49 28 At surgery Anterior maxilla 43/single tooth 90.6

FPD = fixed partial denture; FD = full denture; OD = overdenture

Defining Immediate Loading

Immediate loading is variably defined, depending on the

restorative protocol used at various investigating centers.

The interval between placement of the implant and the

restoration has varied between 0 and 20 days. However,

from a patient’s perspective, immediate loading should refer

to the placement and restoration of an endosseous dental

implant during the same clinical visit.

Because this procedure often involves the placement of a

provisional restoration, the term “immediate provisionalization”

also was proposed. The speculation that immediate

provisionalization by virtue of provisional materials represented

a reduced loading environment is not fully supported

by existing literature. 50 Immediate provisionalization

of implants also describes the placement of a provisional

restoration that is designed to lack centric and eccentric

contacts to avoid potential risks of loading by function

– The Immediate Loading of Dental Implants – 39


Immediate Loading

Table 2 — Definition of Loading Strategies for

Dental Implants

Enhanced

primary stability

Loading is temporally

irrelevant with respect to

osseointegration

Early Loading Primary stability Loading after onset of

osteogenesis, prior to

attaining osseointegration

Conventional

Loading

Primary stability

Loading after osteogenesis

and woven bone remodeling

to load-bearing

lamellar bone

Delayed Loading Stability limited Loading after protracted

period and process of

bone formation involving

low-density or augmented

bone

Implant placement with primary stability

and prosthetic loading occurs at the

same clinical visit

Implant loading occurs 2–3 weeks*

after implant placement

Implants are loaded 3–6 months

after healing in a submerged or

nonsubmerged mucosal orientation

Loading 6–12 months after implants are

placed without primary stability, when

implants are placed into bone of low

density, when implants are placed into

extraction sockets or concomitant

with bone grafting without significant

primary stability

* Rapid loading should not perturb initial healing (blood clot formation, cellular infiltration, onset of epithelialization; approximately

2–3 weeks of healing).

Provisionalization infers no occlusal contact for restoration of unsplinted implants.

Table 3 — Clinical Assessments

of Primary Stability

Method Parameters References

Tactile Assessment

Sound and

visualization

Adell 62

Reverse Torque* >25 Ncm Sullivan 63

Cutting Resistance >40 Ncm Turkyilmaz 64

Friberg 65

Insertion Torque †

PerioTest -2.5

-3.5

>30 Ncm

>45 Ncm

Malo 28

Horiuchi 39

Olivé 66

Aparicio 67

Hui 25

Resonance Frequency ISQ = 57-82 Balleri 68

Analysis (at placement) ISQ = 60

(maxilla)

* Not relevant to the immediate loading scenario.

Meredith 69

Olsson 73


Evaluation of insertion torque for orthopedic screws suggests damaging

effect of high-insertion torque and cutting resistance was not related to

success or failure of dental implant. 70

(thus alternatively termed nonfunctional immediate

loading). Despite this confusion, it is possible to define

immediate loading in terms that contrast other loading

strategies (Table 2).

A Biological Basis for

Immediate Loading Success

Three predominant biologic factors emerge in consideration

of osseointegration and immediate loading.

They are: 1) factors affecting interfacial bone formation

(osteogenesis); 2) peri-implant bone resorption

(osteolysis); and 3) micromotion effects on peri-implant

osteogenesis. Because of the time-dependent nature of

osteogenesis, success further depends on maintaining

implant stability during healing. As depicted, success

relies on primary stability and achieving abundant interfacial

bone formation to offset cortical bone resorption

that results from implant placement. 51 Strategies for

improving immediate loading success may be directed

at enhancing osteogenesis, limiting functional loads and

micromotion, and controlling the resorption that reduces

stability during the healing period.

A Role for Bone Formation

Osteogenesis must occur at the implant surface in the

immediate loading environment. 52 Both in vitro and

in vivo studies demonstrated that surface topography

enhancement results in increased osteogenic activity of

adherent cells and increased bone-to-implant contact

attributable to this increased osteogenic cellular activity.

53 More recent investigations indicate effects of specific

surface modifications on osteoblastic gene expression

and induction of wound-healing responses. The significance

of contact osteogenesis as described by Davies, 54

the role of surface-dependent gene regulation, and the

demonstration of surface-dependent increases in bone

formation has been reinforced by human clinical histological

demonstration that enhanced surface topography

supports increases in interfacial bone formation

during the first six months after implant placement. 55,56

The early increased rate or extent of osseointegration

may be a central determinant of immediately loaded

implant success.

The early increased rate or extent

of osseointegration may be a

central determinant of immediately

loaded implant success.

Primary stability is the clinical means of controlling

micromotion between the implant and the new, forming

interfacial tissue. 57 This helps to establish the proper

mechanical environment for osteogenesis. Immediate

provisionalization and immediate loading scenarios

superimpose micromotion on interfacial tissue. How

much micromotion is permissible or precisely how

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masticatory function relates to interfacial micromotion

has not been fully addressed. When precursor osteoblastic

cells are exposed to limited physical deformation that

models micromotion in a laboratory setting, differentiation

is enhanced in cell culture experiments. 58 Despite limitations

of interpretation, some range of microstrain is considered

advantageous for osteoblastic differentiation, 59 bone

ingrowth 60 and osseointegration. 61 Current in vivo studies

suggest that micromotion greater than 150 µm (direction

and frequency remain ill-defined) limits osseointegration. 57

Clinical guidelines for gaining and enhancing implant

primary stability include careful evaluation of the recipient

bone site, careful osteotomy preparation, undersized

osteotomy, self-tapping implant insertion, osteotome preparation

of the site, and use of improved implant designs.

It must be acknowledged that little data exists regarding

the relationship of osteotomy dimension, implant placement

and resulting bone formation or resorption. Current

clinical approaches to immediate loading advocate

attaining high levels of primary stability and an array

of methods for assessing implant stability are available

(Table 3). 25,28,29,39,62–70

Initial studies of immediate loading suggested that insertion

torque values of 40 Ncm to 45 Ncm were required; more

recently, values of 30 Ncm to 32 Ncm have been reported.

Additional analytical values of correlation of insertion

torque or stability values with dental implant outcomes

are needed.

In addition to surgical technique, implant design may affect

primary stability. Careful examination of implant stability

by resonance frequency analysis (RFA) after placement of

implants in canine mandibles showed that implants with a

rough surface and retentive elements in the transcortical

region maintained implant stability better than machined

implants of a traditional design. 71 Additional clinical data

provided by RFA of implant stability after immediate loading

further suggests that surface enhancement also contributes

to maintained implant stability during healing. 72 This

maintenance of implant stability has been confirmed, and

implant surface modifications have been implicated in producing

this result. 73

The Role of Bone Resorption

As previously suggested, maintaining implant stability is

a key aspect of immediate loading success and depends

on bone formation and the adaptive bone remodeling that

occurs at dental implants after placement. The complex

nature of the load experienced by dental implant interfacial

tissues is beyond the scope of this report 74 ; however,

accepted generalizations (often cited as Wolff’s law) in clude

concepts of moderate and controlled loading environments

that support or enhance osteogenesis, higher loads that

induce bone resorption, and reduced loading environments

that lead to tissue atrophy. However, intervening resorption

of crestal bone is a consequence of the transcortical implant

placement. 51

It is unlikely that a loading environment associated

with tissue atrophy exists at an unloaded healing dental

implant; continuous bone loss is not revealed at titanium

root-form implants. More importantly, when primary stability

is achieved, it is likely that a loading environment associated

with osteogenesis is present. Preclinical histology from

primate and canine models revealed that immediate loading

of dental implants led to greater bone-to-implant contact,

with incrementally more bone formed at the loaded, relative

to unloaded, endosseous dental implants. 75–77 A possible

conclusion is that the loading environment created by

immediate loading at a primary stable implant is favorable.

Deleterious overloading and high magnitude loads, particularly

in the crestal region of the implant, induces bone

resorption. 78 Proof of reduced stability in the first three to

six weeks after implant placement has been obtained by

measuring implant interfacial stiffness using RFA. 23 Most

immediate load failures occur at three to five weeks after

implant placement.

Bone resorption is the result of cell and molecular regulation

of osteoclasts. 79 At least four key molecular as pects

of osteoclast activation are now well defined: 1) a specific

transmembrane receptor and its ligand (RANK and RANKL)

are essential for osteoclast differentiation; 2) cell adhesion

via a specific transmembrane receptor (ß3 integrin)

are required for osteoclastic activity; 3) a key intracellular

mediator of inflammatory signals (NF-KB) promotes osteoclastogenesis

(lipopolysaccharides from oral bacteria are

powerful inducers of this particular osteoclastic signal); and

4) mechanical strain of bone induces osteoclastogenesis.

A combination of mechanical status and inflammatory

environment at the implant surface determines the extent

of local bone resorption, and thus affects implant stability

during the osseointegration process.

Clinical guidelines for immediate loading success should

also focus on reducing cortical or crestal bone resorption.

Suggestions, in part derived from experience in immediate

placement, 80 include avoiding elevation of mucoperiosteal

flaps when feasible, careful and precise osteotomy

preparation, and avoiding instrumentation of the buccal

plate of the socket. Tooth resorption leads to buccal

alveolar bone resorption that must be anticipated. 81 Engaging

a thin buccal plate with the implant places the implant

at risk of loosening should subsequent resorption occur.

The control of the peri-implant inflammation also necessitates

implant placement at the appropriate axial depth

and the use of components that preclude abutment

loosening or experience retrograde bacterial colonization

at the implant/abutment interface (unitary design,

one-stage or modular, solid, conus design implants and

– The Immediate Loading of Dental Implants – 41


a

b

c

d

e

f

g

Figure 1: a) Initial panoramic radiographic examination. Note the severe resorbed mandible. b) Clinical intraoral

examination of the edentulous mandible reveals a thin atrophic mandibular ridge. c) Complete maxillary

and mandibular dentures are used as guides for surgery at time of delivery. Occlusion and tissue adaptation

are evaluated prior to initiating surgery. d) Two implants and ball abutments were installed; in this case,

ball abutments were connected to the fixtures at time of implant placement and soft tissue was sutured

around them using small full-thickness mucoperiosteal flaps to reveal the local ridge crests and mandibular

anatomy. The soft tissues were carefully closed around the ball abutments in preparation for immediate provisionalization.

e) Intaglio surface of the mandibular complete overdenture at time of placement. Note that

the attachment space was relined with tissue conditioner (GC soft reline) the day of surgery. f) Two preci-clix

attachments were connected to the mandibular overdenture after eight weeks of healing. At this time a clinical

remount was performed. g) Panoramic radiograph taken right after implant placement was completed.

implant-abutment interfaces that lack micromotion).

Extended prescription of antimicrobial rinses can be

valuable in limiting bacteria-associated inflammation at

the healing implant site.

A Role for the Immediate

Provisional Restoration

We have found that using a provisional restoration at the

time of implant placement demands consideration of

three factors: 1) reduction of mechanical challenges to

osseointegration; 2) promotion of peri-implant mucosal

health and control of peri-implant inflammation; and

3) establishment of peri-implant mucosal architecture

(development of transition contour).

The elimination and control of functional contacts is

advocated for unsplinted implants. Eliminating tooth

contacts at the maximum intercuspation position is

possible. Excursive contacts are more difficult to control;

however, development of contacts can be avoided,

delayed or strategically arranged. It is essential to check

the provisional contacts during the first week follow-up

visit and at the three- to four-week visit. This is particularly

important after orthodontic tooth movement,

where minor changes in tooth position can evoke unintended

contacts in centric or eccentric positions.

The nature of the provisional restoration and abutmentprovisional

crown finishing line are important factors

in promoting peri-implant mucosal health and limiting

inflammation. Provisional crown margins should not

approximate the implant-bone interface; therefore,

UCLA-type abutments are not preferred because they

place an interface with potential for micromotion and

bacterial population at the crestal bone. Recommended

are titanium or ceramic abutments placed opposing as

much of the peri-implant mucosa as possible. Dense

acrylic denture teeth provide an ideal starting point

for creating a provisional crown for single-tooth

replacement. The fit of the provisional restoration

should be refined on the abutment or abutment/fixture

analogs using an extraoral step for finishing and refinement

to keep restorative particulate materials from the

healing tissue.

Cementation of the interim prosthesis is an important

step in the immediate loading scenario. Permanent

cements (e.g., glass ionomer and polycarbonate) offer

an additional level of security against debonding and

uncontrolled or unintended loading because of a loose

prosthesis. Careful examination of the peri-implant

sulcus after cementation and at the first recall after

surgery should include the highest suspicion for

retained cement that must be removed at this time by

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a

b

c

d

e

f

g

h

i

j

Figure 2: a) Initial panoramic radiographic examination of the edentulous jaws. b) Initial clinical examination

of the edentulous jaws. c) Surgical guide positioned in the mouth with parallel drill access holes (duplicate

denture). d) A midcrestal incision is made and full-thickness flap is elevated, allowing the alveolectomy needed

to create sufficient occlusogingival clearance for the prosthesis and abutments. e) Four implants and abutments

(Astra Tech 4.0 x 11 mm; 20-degree uniabutments) were placed. Primary stability was assumed.

f) Temporary cylinders were connected to the abutments, for interim acrylic fixed denture fabrication by a

direct technique. g) Interim acrylic fixed completed denture. Temporary cylinders were picked up intraorally

with cold cure resin the day of the surgery by the conversion denture technique. h) The interim acrylic fixed

complete denture was carefully finished before delivery. i) Interim acrylic fixed completed denture delivered

within two hours of surgery. j) Panoramic radiographic examination obtained at time of implant placement.

Four implants were placed in the anterior mandible and abutment connection.

scaling and lavage. At the seven- to 10-day recall, examination

for retained cement and its removal should be repeated.

This complication makes a compelling case for the use

of screw-retained prostheses.

Whether the interim prosthesis is fixed by a screw or cement,

it should be retained for the six- to 12-week healing period.

Excluding the short-term removal of immediately loaded

implant prostheses for implant evaluation led to improved

success rates. 43 Clinical manipulations, such as forming

impressions, provisional restoration delivery or debonding,

could perturb the osseointegration process.

Illustrating Immediate Loading

for Clinically Validated Scenarios

Implants have been either immediately loaded after insertion

(two to three days), loaded early (six weeks), or conventionally

loaded (three to eight months) in edentulous

mandibles of adequate bone quality and shape. The

Cochrane collaboration found three relevant randomized

clinical trials and two trials including 68 patients of high

scientific merit. 15 Statistical evaluation of this data indicated

there were no differences on measures of prosthesis failure,

implant failure and marginal bone loss on intraoral radiographs

when immediately loaded implants were compared

with conventionally loaded implants in the parasymphyseal

mandible. Several additional cohort trials have been published

that suggest high implant and prosthesis short-term

survival. This conclusion supports the immediate provisionalization

of mandibular overdentures (Figs. 1a–1g) and

immediate loading of implant-supported fixed dentures

(Figs. 2a–2j) for comprehensive rehabilitation of mandibular

edentulism.

There also is data to guide the clinical decision for immediate

provisionalization of the single-tooth implant

placed in healed or intact alveolar ridges. Early loading

– The Immediate Loading of Dental Implants – 43


a

b

c

d

e

f

g

h

i

Figure 3: a) Occlusal view of the remaining tooth structure of tooth #8 prior to extraction. The opportunity for endodontic treatment and conventional prosthodontics was

excluded because of a vertical root fracture. b) Osteotomy being prepared with a 2.5 mm drill right after tooth extraction for immediate placement of the fixture in space

of tooth #8. A flapless approach was chosen only after the integrity of an abundant buccal osseous plate was clinically confirmed. c) Implant placed in position of tooth #8,

in an ideal coronal-apical and mesio-distal position. There should be no contact with the buccal plate and primary stability must be achieved at the depth of placement

consistent with an acceptable restoration. d) Direct abutment attached to fixture at time of implant placement. For the immediate provisionalization, an abutment for a

cement-retained crown was selected (Direct Abutment). e) Occlusal view of the abutment placed at the time of implant placement, confirming an ideal facio-lingual position.

f) Immediate loading of the fixture with a provisional restoration in place after immediate placement of the implant. Careful attention to cement removal is required.

g) Periapical radiograph obtained at time of implant placement with a DA 5 medium titanium abutment. h) Postoperative periapical radiograph taken three months after

implant placement. i) Final crown the day of delivery. Note that the gingival levels have been maintained from tooth extraction to crown delivery.

of TiO2-grit-blasted single-tooth implants (Astra Tech

Inc.; Waltham, Mass.) replacing anterior maxillary teeth

(loading at three weeks with provisional crowns in centric

contact) was successful in the short term. 21 Implant

survival and peri-implant bone levels were stable over

a three-year follow-up period. 80 Loading of eight TPScoated

titanium implants (Straumann; Andover, Mass.)

one week after placement was successful; no implants

were lost, and marginal bone levels were increased by

0.53 mm over a five-year period. 20 In a study of immediate

loading in diverse applications, 20 single-tooth oxidationprocessed

titanium implants (Bio-Dent; Toronto, Ontario,

Canada) were successfully loaded. 24 A one-part implant/

abutment was evaluated in 93 subjects. Altiva implants

(Altiva Corp.; Charlotte, N.C.) (n = 142) were immediately

loaded, and the implant survival rate was 93.7 percent. 15

There is a growing database for immediate provisionalization

of unsplinted implants in healed anterior alveolar

ridges to support this procedure. 82

Illustrating Immediate

Loading for the

Yet-to-be-Fully-Validated

Clinical Scenarios

Additional short-term data suggests that immediate

placement and provisionalization of single-tooth implant

may be achieved with success. Thirteen machined

implants (Bio-Dent) were placed immediately after

anterior maxillary tooth extraction and provisionalized

without occlusal contacts. Failures were not detected. 44

A similar result with a similar protocol using Steri-Oss

implants (Nobel Biocare; Yorba Linda, Calif.) was

reported after a 12-month evaluation of 35 patients. 17

Thirty-five SLA surface implants were placed in maxillary

single-tooth extraction sockets and provisional

crowns without occlusal contacts were placed at surgery.

The six- to 12-month evaluation of these implants

indicated no implant failure. 19

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a

b

c

d

e

f

g

h

i

Figure 4: a) Panoramic radiograph at time of initial examination. b) Frontal view of the surgical guide created from the diagnostic waxing in place showing the ideal position

of the cervical contours of each tooth. These contours direct proper implant placement. c) Eight implants were placed into both residual alveolar ridges and immediate

extraction sockets. All implants were placed in relationship to the surgical guide cervical contours. The absence of sufficient buccal cone at the #6 tooth position mandated

the palatal orientation of the implant. d) A cement-retained provisional fixed denture was created on cement-retained abutments and careful adjustments to the cervical

contours were made to guide tissue healing. e) Panoramic radiograph after eight implants were immediately placed and loaded. f) Soft tissue contours after three-month

healing. Direct abutments and a single custom abutment for the #6 implant were used. Note the absence of peri-implant inflammation. g) Occlusal view of the final maxillary

prostheses. h) Facial view immediately after delivery of the all-ceramic prostheses in the maxilla. Note the control of the cervical tissue contours has been maintained

from implant placement through provisionalization to final prosthesis delivery. i) Final panoramic radiograph with the final prosthesis cemented.

Evaluations of single-tooth replacement by immediate

dental implant placement and loading suggest that the expected

success will be defined, and uniform clinical procedures

will be established (Figs. 3a–3i). This procedure

encounters the complexity of diverse tooth socket anatomy

challenging primary stability and implant positioning;

there exists a limited number of short-term reports that

support this approach to tooth replacement with endosseous

implants. 83,84

Several cohort investigations of immediate loading protocols

have included maxillary rehabilitation. 24,27,36–39,42

These limited reports have included the placement of eight

to 12 implants restored using provisional splinted prostheses.

Development of protocols for reproducible management

of the maxilla using immediate loading protocols

is ongoing. One possible approach is the use of six to eight

implants loaded using a cement-retained interim fixed

denture composed of acrylic resin (Figs. 4a–4i). An alternative

approach involves the computer-aided fabrication of a

surgical guide and final prosthesis for delivery immediately

after surgery. 36 The immediate loading of splinted implants

for maxillary rehabilitation has shown great promise. 40 However,

one preliminary report indicated that for the 95 percent

survival recorded at the implant level, nearly one-third of

the patients had experienced an implant failure during the

provisionalization period. 85

There is less clinical information for unilateral fixed partial

dentures. Compelling data have been reported by Glauser

and colleagues that includes implant-supported prostheses

in low-density posterior regions. 26 Histological evidence

for successful osseointegration has been provided. 22 The

potential value of immediate loading of unilateral fixed

partial dentures can be described for the replacement of

failed fixed partial dentures. As illustrated (Figs. 4a–4i),

rapid restoration of function can be achieved by replacement

of failed abutment teeth using dental implants

and immediate loading with a provisional fixed partial

denture. While this has been attempted in select cases with

– The Immediate Loading of Dental Implants – 45


comprehensive informed consent, there remains only

limited published data and experience to support this

procedure in clinical practice.

Conclusion

An understanding of bone physiology dictates the clinical

procedures that lead to success for immediate loading

of endosseous dental implants, and the clinical

checklist for immediate loading is as follows:

• Absence of active disease (e.g., periodontitis,

caries, periapical infection)

• Presence of or ability to establish a stable interocclusal

relationship

• Sufficient bone volume for implant placement

• Implant placement consistent with global treatment

planning goals

• Implant placement occurs with verified primary

stability

• Implant placement does not compromise restoration

(too deep axial placement)

• Buccal bone resorption immediately following

extraction may challenge immediate placement

and loading protocols

• Provisional restoration develops proper transition

contour

• Provisional restoration supports peri-implant

mucosal health and architecture

• Occlusal contacts controlled or avoided

• Control peri-implant inflammation (antimicrobial

mouth rinse)

• Follow-up evaluating soft tissue and occlusal

relationships at one and four weeks

Once primary stability is established, loading environments

and potential inflammatory changes must be controlled

to permit maintained implant stability in support

of osseointegration. Modification of implant surgery

and provisional prosthesis techniques can promote tissue

integration. Improved implant components are one

aspect of clinical success for immediate loading. With

detailed planning and execution, the parasymphyseal

mandible and anterior single-tooth implants placed

into an intact alveolus appear successful in the short

term. The generalized and widespread application

of immediate loading requires additional evaluation

and development.

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cases. Clin Oral Implants Res. 1997;8:48–57.

36. Colomina LE. Immediate loading of implant-fixed mandibular prostheses: a

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37. van Steenberghe D, Naert I, Andersson M, et al. A custom template and definitive

prosthesis allowing immediate implant loading in the maxilla: a clinical

report. Int J Oral Maxillofac Implants. 2002;17:663–70.

38. Brånemark PI, Engstrand P, Ohrnell LO, et al. Brånemark Novum: a new

treatment concept for rehabilitation of the edentulous mandible. Preliminary

results from a prospective clinical follow-up study. Clin Implant Dent Relat Res.

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39. Horiuchi K, Uchida H, Yomamoto K, et al. Immediate loading of Brånemark

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40. Jaffin RA, Kumar A, Berman CL. Immediate loading of implants in partially and

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41. Ibanez JC, Jalbout ZN. Immediate loading of osseotite implants: two-year

results. Implant Dent. 2002;11:128–36.

42. Randow K, Ericsson I, Nilner K, et al. Immediate functional loading of Brånemark

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43. Collaert B, De Bruyn H. Early loading of four or five Astra Tech fixtures with

a fixed cross-arch restoration in the mandible. Clin Implant Dent Relat Res.

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44. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage

1 surgery in edentulous arches: ten consecutive case reports with 1- to 5-year

data. Int J Oral Maxillofac Implants. 1997;12:319 24.

45. Balshi TJ, Wolfinger GJ. Immediate loading of Brånemark implants in edentulous

mandibles: a preliminary report. Implant Dent. 1997;6:83–88.

46. Wolfinger GJ, Balshi TJ, Rangert B Immediate functional loading of Brånemark

system implants in edentulous mandibles: clinical report of the results of developmental

and simplified protocols. Int J Oral Maxillofac Implants. 2003;18:

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47. Schnitman PA, Wohrle PS, Rubenstein JE, et al. Ten-year results for Brånemark

implants immediately loaded with fixed prostheses at implant placement.

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48. Salama H, Rose LF, Salama M, et al. Immediate loading of bilaterally splinted

titanium root-form implants in fixed prosthodontics — a technique reexamined:

two case reports. Int J Perio don tics Restorative Dent. 1995;15:344–61.

49. De Kok IJ, Chang SS, Moriarty JD, et al. A retrospective analysis of peri-implant

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50. Duyck J, Van Oosterwyck H, Vander Sloten J, et al. Influence of prosthesis

material on the loading of implants that support a fixed partial prosthesis: in vivo

study. Clin Implant Dent Relat Res. 2000;2:100–09.

51. Roberts WE. Bone tissue interface. J Dent Educ. 1988;52:804-809.

52. Cooper LF. Biologic determinants of bone formation for osseointegration: clues

for future clinical improvements. J Prosthet Dent. 1998;80:439–49.

53. Masaki C, Schneider GB, Zaharias R, et al. Effects of implant surface microtopography

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54. Davies JE. Mechanisms of endosseous integration. Int J Pro sth o dont.

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55. Ivanoff CJ, Hallgren C, Widmark G, et al. Histologic evaluation of the bone

integration of TiO(2) blasted and turned titanium microimplants in humans.

Clin Oral Implants Res. 2001;12:128–34.

56. Trisi P, Rao W, Rebaudi A. A histometric comparison of smooth and rough

titanium implants in human low-density jawbone. Int J Oral Maxillofac Implants.

1999;14:689–98.

57. Szmukler-Moncler S, Salama H, Reingewirtz Y, et al. Timing of loading and

effect of micromotion on bone-dental implant interface: review of experimental

literature. J Biomed Mater Res. 1998;43:192–203.

58. Hatton JP, Pooran M, Li CF, et al. A short pulse of mechanical force induces

gene expression and growth in MC3T3-E1 osteoblasts via an ERK 1/2 pathway.

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59. Ehrlich PJ, Lanyon LE. Mechanical strain and bone cell function: a review.

Osteoporos Int. 2002;13:688–700.

60. Rubin CT, McLeod KJ. Promotion of bony ingrowth by frequency-specific,

low-amplitude mechanical strain. Clin Orthop Relat Res. 1994;(298):165–74.

61. Qin YX, McLeod KJ, Guilak F, et al. Correlation of bony ingrowth to the distribution

of stress and strain parameters surrounding a porous-coated implant.

J Orthop Res. 1996;14:862–70.

62. Adell R, Lekholm U, Brånemark PI. Surgical procedures. In: Brånemark PI,

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63. Sullivan DY, Sherwood RL, Collins TA et al. The reverse torque test: a clinical

report. Int J Oral Maxillofac Implants. 1996;11:179–85.

64. Turkyilmaz I. A comparison between insertion torque and resonance frequency

in the assessment of torque capacity and primary stability of Brånemark System

implants. J Oral Rehabil. 2006;33:754–59.

65. Friberg B, Sennerby L, Grondahl K, et al. On cutting torque measurements

during implant placement: a 3-year clinical prospective study. Clin Implant Dent

Relat Res. 1999;1:75–83.

66. Olivé J, Aparicio C. Periotest method as a measure of osseointegrated oral

implant stability. Int J Oral Maxillofac Implant. 1990;5:390–400.

67. Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary

sinus grafting: a clinical, radiologic, and periotest study. Clin Implant Dent Relat

Res. 2001;3:39–49.

68. Balleri P, Cozzolino A, Ghelli L, et al. Stability measurements of osseointegrated

implants using Osstell in partially edentulous jaws after 1 year of loading: a pilot

study. Clin Implant Dent Relat Res. 2002;4:128 32.

69. Meredith N, Alleyne D, Cawley P. Quantitative determination of the stability

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– The Immediate Loading of Dental Implants – 47


70. Wöhrle PS. Single-tooth replacement in the aesthetic zone with immediate

provisionalization: fourteen consecutive case reports. Pract Periodontics

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71. Rasmusson L, Kahnberg KE, Tan A. Effects of implant design and surface

on bone regeneration and implant stability: an experimental study in the

dog mandible. Clin Implant Dent Relat Res. 2001;3:2–8.

72. Rocci A, Martignoni M, Gottlow J. Immediate loading of Brånemark

System TiUnite and machined-surface implants in the posterior mandible:

a randomized open-ended clinical trial. Clin Implant Dent Relat Res.

2003;5 Suppl 1:57–63.

73. Olsson M, Urde G, Andersen JB, et al. Early loading of maxillary fixed

cross-arch dental prostheses supported by six or eight oxidized titanium

implants: results after 1 year of loading, case series. Clin Implant Dent

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74. Stanford CM, Brand RA. Toward an understanding of implant occlusion

and strain adaptive bone modeling and remodeling. J Prosthet Dent.

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75. Corso M, Sirota C, Fiorellini J, et al. Clinical and radiographic evaluation of

early loaded free-standing dental implants with various coatings in beagle

dogs. J Prosthet Dent. 1999;82:428–35.

76. Piattelli A, Corigliano M, Scarano A, et al. Immediate loading of titanium

plasma-sprayed implants: an histologic analysis in monkeys. J Periodontol.

1998;69:321–27.

77. Romanos GE, Toh CG, Siar CH, et al. Histologic and histomorphometric

evaluation of peri-implant bone subjected to immediate loading: an

experimental study with Macaca fascicularis. Int J Oral Maxillofac Implants.

2002;17:44–51.

78. Brunski JB. In vivo bone response to biomechanical loading at the bone/

dental-implant interface. Adv Dent Res. 1999;13:99–119.

79. Katagiri T, Takahashi N. Regulatory mechanisms of osteoblast and osteoclast

differentiation. Oral Dis. 2002;8:147–59.

80. Garber DA, Salama MA, Salama H. Immediate total tooth re placement.

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bone walls of fresh extraction sites following implant installation. Clin Oral

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implants for single-tooth and partial-arch applications. Int J Oral Maxillofac

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Originally published in: Cooper L. The immediate loading of dental implants.

Compendium. 2007;28(4):216–25.

Copyright © 2007 to AEGIS Communications. All rights reserved.

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Billing Implants and

Related Services to Medical Plans

Go online for

in-depth content

by Olya Zahrebelny, DDS

Many dentists tell me that they have been billing medical plans for quite some

time but are not getting the results they anticipated. Medical billing has many

nuances to it and understanding the process is critical to successful medical reimbursement.

Knowing what is expected from you in the form of a “clean” claim, documentation requirements

and Letters of Medical Necessity ultimately determines whether payment will be

made or the treatment claim will be rejected as “medically unnecessary.”

CHOOSING THE APPROPRIATE

DIAGNOSIS CODES (ICD-9)

The selection of diagnosis codes pertaining to the presenting symptoms and conditions is

what sets the tone for billing of the procedure. The diagnosis codes should be selected from

both the primary presenting situation(s), as well as from secondary, or supporting, diagnoses

for the treatment to be provided. All surgical claims require pre-authorization from the

medical plans, and this must be done before the procedure is performed. According to the

American Medical Association (AMA), it is also recommended that a Letter of Medical Necessity

be submitted via fax to obtain written verification of coverage and to confirm that the

treatment has undergone medical review and was deemed “medically necessary.”

Medical billing

has many

nuances to it

and understanding

the process

is critical to successful

medical

reimbursement.

The diagnosis codes must be listed in the correct order, both in the Letter of Medical Necessity

and on the claim form. Start the list with the most important presenting condition and

continue in descending order, followed by any V and/or E codes specifying contributing

medical history factors, if present. The lack of a greater medical condition does not negate

the medical necessity of the procedure. In deciding the order, keep in mind that the first

diagnosis listed must relate to the most important or most expensive procedure to be performed

and that only four diagnosis codes are allowed. All medical claims must contain

diagnosis codes or they will not be considered for payment.

– Billing Implants and Related Services to Medical Plans – 51


Primary Diagnosis Codes

520.0*

Anodontia (Partial/Complete/Congenital) Use only if related to a medical issue

(i.e., cleft palate, ectodermal dysplasia, etc.)

525.0* Exfoliation of teeth due to systemic causes

*Requires an additional code to indicate the systemic problem

Codes 525.10–525.19 are only used immediately after tooth loss. They all require a

classification code (only one can be used).

525.10** Acquired absence of teeth, unspecified (i.e., tooth extraction status, NOS)

525.11** Loss of teeth due to trauma

525.12**

Loss of teeth due to periodontal disease (also use V code for medical reasons for

disease, i.e., chronic smoking, diabetes, etc.)

525.13** Loss of teeth due to caries (also code medical reason for caries)

525.19** Loss of teeth, other reasons

**Requires an additional classification code from the list below.

Complete edentulism (4+ contiguous teeth) Partial edentulism (1–3 teeth)

525.41 Class I (one area) 525.51 Class I (one area)

525.42 Class II (two areas) 525.52 Class II (two areas)

525.43 Class III (three areas) 525.53 Class III (three areas)

525.44 Class IV (totally edentulous) 525.54 Class IV (four areas)

All surgical

claims require

pre-authorization

from the

medical plans,

and this must be

done before

the procedure

is performed.

52

Important: Once teeth have been lost/removed for whatever reason, tooth loss codes

cannot be used. Use the codes below.

733.7 Disuse atrophy of bone 526.1

Fissural cyst of the jaw

(globulomaxillary, etc.)

525.21

Minimal atrophy of edentulous

alveolar ridge of the mandible

526.2 Other cyst of the jaw (keratocyst)

525.22

Moderate atrophy of edentulous

alveolar ridge of the mandible

526.3 Central giant cell granuloma

525.23

525.24

525.25

525.26

Severe atrophy of edentulous

alveolar ridge of the mandible

Minimal atrophy of edentulous

alveolar ridge of the maxilla

Moderate atrophy of edentulous

alveolar ridge of the maxilla

Severe atrophy of edentulous

alveolar ridge of the maxilla

526.4

526.5

526.89

905.0

524.73 Maxillary alveolar hypoplasia 906.0

524.74 Mandibular alveolar hypoplasia 909.3

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Inflammation of the jaw (abscess,

osteitis, osteomyelitis, periosteitis,

sequestrum, all of the jaw bone)

Alveolitis of the jaw

(inflammation and/or infection of

the tooth socket)

Other specified disease of the jaw

(i.e., osteoradionecrosis)

Late effect of fractures (closed and

open) of maxilla/mandible

Initially classifiable to 800–804

Late effect of wound or surgery

Initially classifiable to 870–879

Late effect of complications of

previous surgical/medical care

Initially classifiable to 996–999


Secondary Diagnosis Codes

315.39 Speech and articulation disorders

352.1 Glossopharyngeal neuralgia

478.29 Hyperactive gag reflex

527.7 Xerostomia

528.9

Other diseases of the oral soft tissue (i.e., denture sore mouth, denture stomatitis,

ulceration of the mucosa, papillary hyperplasia of the palate, irritative hyperplasia,

pyogenic granuloma, traumatic ulceration, etc.)

710.2 Sjögren’s disease

733.01 Post-menopausal osteoporosis

733.03 Disuse osteoporosis

782.0

Symptoms involving anesthesia (i.e., burning, prickling sensation, paresthesia,

numbness, tingling, etc.)

784.9 Choking sensation

Keep in mind

that the first

diagnosis listed

must relate

to the most

important or

most expensive

procedure to

be performed.

951.2 Pain secondary to nerve compression

Sinus Procedures

473.0 Oro-antral fistula

478.19 Pneumatization of the sinus

733.7 Disuse atrophy of bone

525.24 Minimal atrophy of edentulous alveolar ridge of the maxilla

525.25 Moderate atrophy of edentulous alveolar ridge of the maxilla

525.26 Severe atrophy of edentulous alveolar ridge of the maxilla

Medical History Factors Affecting Treatment

V12.2

V12.4

Endocrine, metabolic and immunity disorders (use for diabetes, immunoglobulin

deficiencies, HIV, etc.)

Disorders of the nervous system (i.e., epilepsy, cannot have a removable appliance

in mouth)

V12.79 Diseases of the digestive system (i.e., GERD, esophagitis, stomach ulcers, etc.)

– Billing Implants and Related Services to Medical Plans – 53


The first

procedure

listed is always

reimbursed at

the highest

surgical benefits

level and each

subsequent

procedure is

paid at a lower

percentage

reimbursement.

CHOOSING THE APPROPRIATE

PROCEDURE CODES (CPT)

Procedure code selection for implants and related procedures are actually very simple and

straightforward. They can be chosen from the following list:

Surgical Placement and Removal

20670 Removal of implant, superficial

20680 Removal of implant, deep

21248 Reconstruction of maxilla/mandible, partial (1–3 per jaw)

21249

21085

Sinus Procedures

Reconstruction of maxilla/mandible, complete (4–6 per jaw)

Add modifier -22 if 7+ are placed in one arch

Diagnostic/surgical stent

Add lab fee on claim form

21210 Bone graft, maxilla, with autogenous harvesting

30580 Repair oromaxillary fistula

30600 Repair oronasal fistula

31020 Sinusotomy, maxilla, intranasal

31237 Removal of foreign body, maxillary sinus

Bone Grafts

21210* Bone graft, maxilla, with autogenous harvesting

21215* Bone graft, mandible, with autogenous harvesting

P9020

Platelet rich plasma

Soft Tissue Surgery

14040

15120

15240

15335

Lateral pedicle graft, mouth


PRE-AUTHORIZATION AND

DOCUMENTATION REQUIREMENTS

All surgical procedures must be pre-authorized by phone. As previously stated, the AMA

also recommends that further verification and coverage determination be obtained by submitting

a Letter of Medical Necessity via fax to Medical Review for written authorization

to perform the procedures and confirmation that they are cleared for “medical necessity”

(Example 1). That being said, medical necessity does not mean that the patient has to have

contributing health issues. It simply means that the anatomical situation and/or presenting

clinical and anatomical picture indicates the patient’s condition necessitates that oral

surgery be performed.

Example 1: Predetermination for Partial Reconstruction of Maxilla

ATTENTION: MEDICAL PREDETERMINATION

Re:_________________________________________________________________

[PATIENT NAME]

Subscriber:__________________________________________________________

[SUBSCRIBER NAME]

Subscriber ID:_______________________________________________________

Group No.:_________________________________________________________

Examining Doctor:___________________________________________________

Date of Examination:_________________________________________________

The following is being provided to predetermine benefits for an outpatient surgical

procedure. Outlined are the diagnostic and procedure codes, description and cost of

the recommended surgery. Copies of applicable medical records to support the procedure’s

medical necessity are attached.

525.25 Moderate atrophy of the maxilla, right side

785.6 Lymphadenopathy

Treatment will be staged and is scheduled to commence within the next three weeks, to

include the following surgical procedures:

21248 Partial reconstruction, right maxilla (three bone stabilizers) $6,000

21210 Debridement, bone graft to the right maxilla $3,000

The patient presented to my office for a consultation on [DATE] on referral from [DOCTOR

NAME]. A review of her medical history included repeated debridement of both the maxilla

and mandible for chronic inflammation. A thorough clinical and radiographic evaluation of

the patient revealed progressive alveolar atrophy and multiple abscesses throughout the

right maxilla.

Please provide us with written notification regarding benefit coverage upon determination

of this case. If we can be of further assistance, or should you have any further questions,

please do not hesitate to contact our office at [PHONE NUMBER].

Sincerely,

[DOCTOR NAME]

Enclosure: Clinical and radiographic evaluation

Cc: Chart

© 2011 by The Z Group LLC

– Billing Implants and Related Services to Medical Plans – 55


SUBMITTING THE CLAIM FOR REIMBURSEMENT

Once the procedure has been performed, the claim can be submitted to the medical plan for payment. Not only must the

claim be completed correctly, but it also must include the appropriate documentation. In the case of Example 1, the Letter

of Medical Necessity is for three implants and bone grafting. The actual claim (Example 2) requires that an operative report

be included with the claim and indicated in Box 19 on the CMS-1500 (08/05) claim form. It also requires that the preauthorization

number be stated in Box 23 of the claim form. An interim prosthesis, although it cannot be pre-authorized, is

also billed with the surgical claim. If the lab is billing your office, the lab charge would also be included on the claim form

in Box 20. Any exam or radiographs (CT scan, orthopantogram and surgical stent) would have been billed following the

diagnostic appointment.

CONCLUSION

Successful medical billing

not only requires knowledge

of the codes, but also knowledge

of the documentation

requirements specific to the

procedures performed. Not

all procedures require the

same supporting documentation.

Examples of supporting

documentation can include:

a radiology report, operative

report, Letter of Medical

Necessity, pre-authorization,

supporting Letter of Medical

Necessity from the patient’s

physician, among others. In

order to obtain successful

reimbursement, it is absolutely

mandatory that those

who handle billing in the

office, as well as the doctor

and surgical assistant(s), take

a comprehensive course in

medical billing.

Medical billing is definitely

not as simple as dental billing

and requires not only

a thorough knowledge of

anatomy, medical terminology

and procedures, but

also familiarity with surgical

modifiers and qualifiers, in

order to correctly complete

the claim form and facilitate

medical reimbursement. The

marketing opportunities this

knowledge provides and the

benefits it affords to your patients,

who may be completely

unaware they even have

these benefits, are priceless!

Example 2: Claim for Three Implants and Bone Graft in the Maxilla

DOE, John

1234 Main Street

Anywhere

90210 987 654-3210 X

90210

987 654-3210

AN905-678

525 25

785 6

JO01

02 21 11

364246789

Signature On File

Op rpt attached

02 21 11

11

02 21 11 02 21 11 11

ZZInterim prosthesis JO01

02 21 11 02 21 11 11

Olya Zahrebelny DDS

02 21 2011

X

CA

21248

21210

21089

06 15 1955

X

99 51 52

1234 X

10200 00 0 00 10200 00

Dr. Olya Zahrebelny

636 North Michigan Avenue 3500

Chicago, IL 60610

8934267812

X

X

X

X

01 21 2011

X 890456732

1 6000 00 3

1

1

X

Humana

PO Box 14610

Lexington KY 40512-4610

DOE, John

1234 Main Street

Anywhere

06 15 1955 X

Universal Studios

Humana

X

3000 00

1200 00

Signature On File

567890456

1

1

CA

250 00 0 00

8934267812

8934267812

8934267812

312 657 3400

Dr. Olya Zahrebelny

636 North Michigan Avenue 3500

Chicago, IL 60610

8934267812

56

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