Dr. Balshi's "The Immediate Loading Protocols" Part two

Interview conducted by Gary J. Kaplowitz, DDS, MA, MEd, ABGD
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OsseoNews (ON): In your protocol you connect the provisional fixed partial complete denture to the abutments that have been permanently torqued down into the implant fixtures. What is your technique for accomplishing this?
Dr. Balshi: After the abutments are torque down, we insert a prosthetic cylinder over the abutment. We then screw down the cylinder with guide pins which project well above the height of the cylinders. We relieve the prosthesis in the area of the abutment and cylinder and cover the abutments with rubber dam fragments to block out any undercuts. We then deliver acrylic around the cylinders and insert the prosthesis. The acrylic locks the cylinder into the acrylic veneer. We unscrew the guide pins and then adjust and polish the surface of the prosthesis. The prosthesis is then ready for delivery.
ON: How do you manage a situation where you place an implant and fail to achieve primary mechanical stability? For example, suppose you have a ‘spinner’ (i.e., an implant that rotates in the osteotomy site).
Dr. Balshi: We have experienced this problem on numerous occasions. We have developed two treatment protocols for spinners. One approach is to place a healing cap and to leave the implant undisturbed until osseointegration is complete. Another approach is to unite the spinners with stable implants that have achieved primary mechanical stability by means of a rigid prosthesis, an all acrylic fixed prosthesis or definitive metal reinforced prosthesis both work well. We have found that after uniting the spinner to the secure and stable framework eventually results in the osseointegration of the spinner. Spinners can be encorporated into an immediate load protocol. We are in the process of publishing an article on the clinical management of spinners.
ON: What about situations where you have grafted the implant site and fail to achieve primary mechanical stability?
Dr. Balshi: Again the critical requirement is to provide a stable and secure prosthesis that locks in the implant. Even with a graft, if the implant is locked into a stable and secure prosthesis, it will undergo osseointegration and can be used in an immediate load protocol.
ON: What are you using for graft material?
Dr. Balshi: We use autogenous bone for our grafts. We harvest bone from the extraction sites or osteotomy sites. We have found that this is the most successful graft material. It is readily available at the time of surgery and easy to harvest and place.
ON: Your orientation appears to favor fixed partial or complete dentures and fixed-detachable partial and complete dentures as opposed to overdentures.
Dr. Balshi: We have found over time, and again after decades of collecting data on our completed cases, that the fixed alternative is to be preferred over the removable. In the long term we have found that overdentures require far more maintenance and are prone to many problems. A screw-retained fixed-detachable partial or complete prosthesis is far more stable.
ON: What about the problem of providing support for the lips and cheek?
Dr. Balshi: Placing the teeth in the proper position is the most critical aspect of achieving proper lip and cheek support. We then fill in area between the teeth and the residual ridge using pink acrylic or porcelain. These prostheses can be designed for great esthetics and hygiene access. This should not represent a contraindication to using a fixed prosthesis