How did you get started with All-on-4® treatment concept cases?
Steven Pigliacelli: We have been making hybrid cases for over 30 years and receiving milled titanium Procera frames from Nobel Biocare since the early 90s. We were the beta lab for the original Procera implant bridge, which was called the All-in-one Bridge. So for us to make the transition to a milled titanium hybrid solution on four implants was an easy and natural one.
Lenny Marotta: Back in the 1990s, I started doing All-on-4® cases with Nobel Biocare as a continuation of our studies with Drs. Steve Parel and Steve Lewis, and we’ve done the All-on-4® treatment concept ever since.
What do you see as the key benefits of handling All-on-4® treatment concept cases for a lab?
Pigliacelli: For the lab and doctor, a key benefit is having a standard denture and implant protocol. We have a detailed protocol at the lab that has served us well for many years. Every step is discussed with the doctor, supported by instructional memos and chairside consultation, if needed. This ensures that there are no complications, and everything goes smoothly.
You have been working with NobelProcera titanium frameworks for a long time. What are the main advantages of titanium, particularly for substructures for the All-on-4® treatment concept?
Marotta: The NobelProcera Titanium frames always come back with a precise and accurate fit. This is particularly important for All-on-4® cases, since no adjustment is needed and no undue stress is put on the implants.
Pigliacelli: A milled titanium frame avoids distortion issues in the interface that happen during a casting process. Once the gold cylinder is placed in an oven, it distorts, then when the alloy melds to it, it distorts again.
Soldering, when necessary, is another source of distortion and a possible source of breakage and porosity. Because the milled titanium frame is a solid one-piece milled bridge, the need for solder connections is completely eliminated.
And how about zirconia? Is this a material you are working with more frequently? What do you see as its advantages?
Marotta: We have worked with zirconia for crown and bridge restorations for many years. It has very high strength and works well when there is limited occlusal space and esthetics are a concern.
Pigliacelli: Zirconia certainly has its place in the industry. We have done crowns, implant frames and full contour bridges. It is not the savior of the dental industry, however. There are limitations to case design and viability. There are years of research on implant restorations and the All-on-4® treatment concept; yet not on full-contour zirconia restorations.
Nowadays we hear a lot more about the benefits of the team approach—labs, restorative dentists, surgeons and the industry all working together to help ensure the best possible results for patients. Do you see this as an opportunity for labs like yours?
Marotta: The team approach is nothing new for us at Marotta Dental Studio. We have always worked closely with every member of the team, be it the restorative dentist, oral surgeon, orthodontist, periodontist or radiologist. From the very start, we have worked closely to ensure the best possible results for patients.
Pigliacelli: And we have lectured extensively on the team approach for years. Our relationship with our accounts is one of camaraderie and friendship. We stay away from the adversarial relationship that many dentists and labs have. We work side-by-side in fabricating everything from complex implant bridges and all-ceramic esthetic restorations to a simple crown and bridge.
Clinicians are beginning to see the benefits of involving labs earlier in the treatment process. The labs’ value to the clinician often increases when they have knowledge of digital planning software. You use NobelClinician. How has incorporating this digital tool into your offering helped your lab?
Marotta: We have worked with NobelClinician from the start. We have it available at our lab for doctors to use on their own or as part of a digital planning session. Guided surgery is appropriate for a variety of situations. Today we can plan a case with our accounts to ensure that the implants will be placed where they will provide the best support for the restoration.
Pigliacelli: Guided surgery is one of the most important advances in the industry. NobelClinician ensures that the case at hand can be completed as a screw-retained bridge, such as in the All-on-4® protocol. Gone are the days of having a misplaced implant because “that’s where the bone is.”
There are lots of All-on-4® look-alikes out there, what do you believe are the benefits of using the original, proven treatment concept?
Marotta: Nobel Biocare’s All-on-4® research dates back to the 1990s. There are ample clinical studies backed up by years of research and data that support the viability of the system. Look-alikes can’t possibly match that history …
Pigliacelli: … and therefore may not work as well as the original!
The All-on-4® treatment concept comprises several key elements: the implant, the abutment, the restoration and the detailed protocol. How would you summarize the advantages of using components that are engineered to work together as one system?
Pigliacelli: Having a system that works together, backed up by a protocol for all steps, means there are no surprises as you progress with the case. From the start we know exactly what components and parts we need, and can plan for contingencies with a system that is designed to work together. This greatly enhances treatment efficiency, and patient satisfaction.
Marotta: Using components that are all part of a unified system provides the best possible results for our accounts and patients. We know going into a case what will be needed to achieve the desired results. All the years of research support not just one aspect of the system but all the features—as one unified restorative system.
This allows for immediate implant loading, shorter treatment time, enhanced esthetics and function, increased patient satisfaction and reduced overall cost. Nobel Biocare / NobelProcera provides the best and most accurate results when utilizing four implants.