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Inclusive

Restorative Driven Implant Solutions Vol. 3, Issue 2

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

I/O Scanning and Model-less

Implant Restorations

Dr. Tarun Agarwal

Page 13

Guided Surgery for

Single Tooth Replacement

Dr. Bradley Bockhorst and Zach Dalmau

Page 19

Soft Tissue Contouring and

Successful Implant Treatment

Dr. Robert Horowitz

Page 50

Immediate Loading or

Provisionalization: Do’s & Don’ts

Dr. Darrin Wiederhold

Page 35

2 NEW COLUMNS!

‘My First Implant’

with Dr. Gordon Christensen

Page 11

Small Diameter Implants

with Dr. Paresh Patel

Page 26

Implant Q&A:

Dr. Perry Jones

Virginia Commonwealth University

Page 42


On the Web

Here’s a sneak peek at additional

Inclusive magazine content available online

ONLINE Video Presentations

■ Dr. Perry Jones talks about the transforming effects of digital

technology on the quality of dentistry, including how it takes

accuracy and predictability to a new level.

■ Dzevad Ceranic, CDT, and Glidewell staff showcase cutting-edge

CAD/CAM processes used to produce a screw-retained crown with

Ivoclar Vivadent’s strong, highly esthetic IPS e.max ® .

Glidewell VP of R&D Robin Carden sheds light on the intrinsic

material properties of monolithic BruxZir ® Solid Zirconia that make

it ideal for implant restorations.

■ Dr. Darrin Wiederhold outlines the Do’s and Don’ts of immediate

loading, providing guidelines for maximizing short- and long-term

restorative success.

■ Inclusive ® Tooth Replacement Solution Tips and Techniques:

• Proper use of the prosthetic guide.

• How the cemented custom temporary abutment and

BioTemps ® provisional crown can easily be converted to a

one-piece, screw-retained prosthesis.

• The simple process of adjusting and relining the patientspecific

temporary components chairside.

Check out the latest issue of Inclusive

magazine online or via your smartphone at

www.inclusivemagazine.com

gIDE LECTURE-ON-DEMAND PREVIEW

■ Dr. Sascha Jovanovic takes viewers through the planning, surgical

procedure, and immediate provisionalization of a maxillary premolar

in this gIDE video lecture, “Single Implant Placement for Missing

Upper Premolar.”

Look for these icons on the pages that follow

for additional content available online

ONLINE CE credit

■ Get free CE credit for the material in this issue with each test you

complete and pass. To get started, visit our website and look for

the articles marked with “CE.”

– www.inclusivemagazine.com –


Contents

13

Intraoral Scanning and Model-less

Implant Restorations

Discover why digital implant restorations make sense in this photo

essay by Dr. Tarun Agarwal. In his first model-less restoration,

Dr. Agarwal shows how going digital not only simplifies the implant

restoration process, making it available at a reduced lab fee within

a quicker turnaround time, but also offers the convenience of an

open platform that works with almost any digital impression system

on the market today.

19

Guided Implant Surgery for Single-Tooth

Restorations: Streamlining the Process

Digital treatment planning and guided surgery can be of significant

aid in the diagnosis and treatment of dental implant cases,

adding a degree of precision and predictability unmatched by

conventional procedures. Addressing common concerns regarding

time and expense, Dr. Bradley Bockhorst and Zach Dalmau,

DTP and guided surgery production manager at Glidewell Laboratories,

provide options for reducing cost and maximizing efficiency

when utilizing this technology, making it feasible even for singletooth

restorations.

35

The Do’s and Don’ts of Immediate Loading or

Provisionalization of Dental Implants

As the cosmetic expectations of implant patients increase, clinicians

are strongly motivated to meet the demand for immediate

loading or provisionalization of freshly placed implants. Bearing in

mind the fundamental importance of unimpeded osseointegration,

Dr. Darrin Wiederhold outlines the Do’s and Don’ts of immediate

loading, providing guidelines for maximizing both short- and longterm

restorative success.

– Contents – 1


Contents

42

50

Implant Q&A: An Interview with Dr. Perry Jones

For some dentists, life after the discovery of technology can

be many things — from fascinating to humbling to confidencebuilding

— all in the same moment. Technology advocate Dr. Perry

Jones explores the transforming effects of digital technology on the

quality of dentistry, including how it takes accuracy and predictability

to a new level.

The Critical Nature of Tissue Contouring from a

Periodontist’s Perspective

Peri-implant health and soft tissue contouring are integral to the

successful implant restoration. Dr. Robert Horowitz’s answer to the

limitations of stock components is patient-specific tissue contouring.

As his article demonstrates, working with Glidewell’s Inclusive

Tooth Replacement Solution custom temporary components saves

chairtime, minimizes typical errors in soft tissue recording sent to

the lab, and helps patients obtain an ideal restorative outcome.

ALSO IN THIS ISSUE

8 Trends in Implant Dentistry:

Custom Abutments

11 My First Implant:

Dr. Gordon Christensen

17 Product Spotlight:

Prismatik PEEK Prosthetics

26 Small Diameter Implants:

Drilling Protocol for Achieving

Primary Stability

28 Clinical Tip: Using the Inclusive

Tooth Replacement Solution

Prosthetic Guide

31 R&D Corner: Strength and Flexibility

of BruxZir Solid Zirconia Implant

Restorations

39 Clinical Tip: Creating a

Screw-Retained Temporary

47 Lab Sense: Back to the Future

The IPS e.max Screw-Retained Crown

56 Clinical Tip: Modifying Inclusive

Custom Temporary Components

2

– www.inclusivemagazine.com –


Publisher

Jim Glidewell, CDT

Editor-in-Chief and clinical editor

Bradley C. Bockhorst, DMD

Managing Editors

David Casper, Barbara Young

Creative Director

Rachel Pacillas

Contributing editors

Greg Minzenmayer; Dzevad Ceranic, CDT

copy editors

Eldon Thompson, Jennifer Holstein,

David Frickman, Megan Strong

digital marketing manager

Kevin Keithley

Graphic Designers/Web Designers

Jamie Austin, Deb Evans, Joel Guerra,

Audrey Kame, Phil Nguyen, Kelley Pelton,

Melanie Solis, Ty Tran, Makara You

Photographers/Videographers

Sharon Dowd, Mariela Lopez,

James Kwasniewski, Andrew Lee,

Marc Repaire, Sterling Wright, Maurice Wyble

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.

© 2012 Glidewell Laboratories

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 Inclusive Dental Solutions.

4

– www.inclusivemagazine.com –


Letter from the Editor

Welcome to the Summer 2012 issue of Inclusive magazine. As technology

continues to grow at a seemingly exponential rate, there is a point when

all things start to come together. And that’s a great place to be. While

the dental field is not completely there yet — new advancements on the

digital front are ever-present — great strides have been made.

Take this issue’s contributors. On the theme of “technology on the verge,”

Drs. Perry Jones and Tarun Agarwal share how intraoral scanning can

significantly improve the quality of dentistry. Another article simplifies

the process for digital treatment planning and guided surgery.

Our last issue coincided with the launch of the Inclusive ® Tooth Replacement

Solution, an exciting, comprehensive approach to tooth replacement

that could just revolutionize implant dentistry. Along those lines,

Dr. Robert Horowitz discusses the importance of soft tissue contouring

and custom abutments in the optimal shaping of the gingiva for successful

implant restorations. Another piece reviews parameters for immediate

temporization. The three Clinical Tips provide suggestions for properly

using the prosthetic guide, prepping and relining provisional restorations,

and converting a cemented temporary to a screw-retained restoration.

We are also pleased to introduce two new columns. In each issue we will

feature a short piece on Small Diameter Implants to keep you aware of

the possibilities with mini implants, starting with Dr. Paresh Patel. We

will also highlight doctors from around the country taking a moment

to recall their first implant case. Sometimes funny, but always meant to

communicate the singular point that everyone has to start somewhere,

My First Implant features leading clinician Dr. Gordon Christensen in

this inaugural installment. Be sure to let us know what you think of our

evolving format.

Ultimately, our goal is to bring you timely, useful topics — both practical

and on the cutting edge — that are insightful about the world of implants,

so you can provide the highest quality of care to your patients. Education

is key in addressing inhibitions about the learning curve involved with

some of these technologies, and that’s one of the things we do best here

at Glidewell Laboratories. To take advantage of the courses offered at our

state-of-the-art technology center, visit www.glidewellce.com.

All the best in your practice,

Dr. Bradley C. Bockhorst

Editor-in-Chief, Clinical Editor

inclusivemagazine@glidewelldental.com

– Letter from the Editor – 5


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

CDA, ADA, AO, ICOI, and the AAID, Dr. Bockhorst lectures internationally

on an array of dental implant topics. Contact him

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

■ ROBIN A. CARDEN

Robin Carden founded Talon Composites, the

manufacturer of Talbor ® — a composite material

that uses advanced ceramics and metals.

He holds more than 30 patents, mostly related

to metal and ceramic composites. In 1998,

Robin won the Design Engineering Award

from Design News. He is also inventor of the

translucent orthodontic braces for 3M ESPE and Ceradyne

Inc., the latter at which he worked for eight years as a senior

engineer. Ceradyne awarded Robin the prestigious President’s

Award for his work with advanced ceramics. Currently, Robin

is vice president of Glidewell Laboratories’ R&D department.

Contact him at inclusivemagazine@glidewelldental.com.

■ TARUN AGARWAL, DDS, PA

Dr. Tarun Agarwal is a 1999 graduate of the

University of Missouri-Kansas City. He maintains

a full-time private practice emphasizing

esthetic, restorative, and implant dentistry

in Raleigh, N.C., and regularly presents programs

to study clubs and dental organizations

nationally. Through his real-world approach to

dentistry, practice enhancement, and life balance, Dr. Agarwal

seeks to motivate dentists and energize team members to increase

productivity and profitability. His work and practice

have been featured in numerous consumer and dental publications.

Contact him at dra@raleighdentalarts.com or visit

www.raleighdentalarts.com.

■ DZEVAD CERANIC, CDT

Dzevad Ceranic began his career at Glidewell

Laboratories while attending Pasadena

City College’s dental laboratory technology

program. In 1999, Dzevad began working at

Glidewell as a waxer and metal finisher, then

as a ceramist. After being promoted to general

manager of the Full-Cast department, he

assisted in facilitating the lab’s transition to CAD/CAM. In

2008, Dzevad took on the company’s rapidly growing Implant

department, and in 2009 completed an eight-month implants

course at UCLA School of Dentistry. Today, Dzevad leads a team

of 170 people at the lab and continues to implement cuttingedge

technology throughout his department. Contact him at

inclusivemagazine@glidewelldental.com.

■ GRANT BULLIS, MBA

Grant Bullis, director of implant R&D

and digital manufacturing at Glidewell

Laboratories, began his dental industry

career at Steri-Oss (now a subsidiary of Nobel

Biocare) in 1997. Since joining the lab in

2007, Grant has been integral in obtaining

FDA 510(k) clearances for the company’s

Inclusive ® Custom Implant Abutments. In 2010, he was

promoted to director and now oversees all aspects of CAD/CAM,

implant product development and manufacturing. Grant has

a degree in mechanical CAD/CAM from Irvine Valley College

and an MBA from Keller Graduate School of Management.

Contact him at inclusivemagazine@glidewelldental.com.

■ GORDON J. CHRISTENSEN, DDS, MSD, Ph.D

Dr. Gordon Christensen is a practicing prosthodontist

in Provo, Utah. His degrees include

DDS, University of Southern California; MSD,

University of Washington; and Ph.D, University

of Denver. He is a Diplomate of the American

Board of Prosthodontics; Fellow and Diplomate

of the ICOI; Fellow of the AO, ACD, ICD, ACP,

and Royal College of Surgeons of England; Honorary Fellow of

the AGD; and an Associate Fellow of the AAID. Dr. Christensen

is CEO of the nonprofit Gordon J. Christensen CLINICIANS

REPORT ® , which he co-founded with his wife Dr. Rella Christensen.

He also serves as director of Practical Clinical Courses.

Contact him at 801-226-6569 or info@pccdental.com.

6

– www.inclusivemagazine.com –


■ ZACH DALMAU

Zach Dalmau began his dental career in 2006

at the nSequence Center for Advanced Dentistry

in Reno, Nev. As the director of guided

implant surgery and 3-D diagnostic imaging,

he played a key role in building the company’s

CT guided implant surgery and 3-D diagnostic

imaging departments from the ground up. In

September 2009, he moved to Baltimore, Md., to work at Materialise

Dental Inc. There, he managed the design and production

of all SimPlant ® SurgiGuides ® for the North American market.

Zach joined the Digital Treatment Planning team at Glidewell

in October 2011 and currently serves as DTP and guided surgery

production manager. Contact him at inclusivemagazine@

glidewelldental.com.

■ PARESH B. PATEL, DDS

Dr. Paresh Patel is a graduate of the University

of North Carolina at Chapel Hill School of Dentistry

and the Medical College of Georgia/AAID

MaxiCourse. He is cofounder of the American

Academy of Small Diameter Implants and a

clinical instructor at the Reconstructive Dentistry

Institute. Dr. Patel has placed more than

2,500 small-diameter implants and has worked as a lecturer

and clinical consultant on mini implants for various companies.

He belongs to numerous dental organizations, including

the ADA, North Carolina Dental Society and AACD. Dr. Patel

is also a member and president of the Iredell County Dental

Society in Mooresville, N.C. Contact him at pareshpateldds2@

gmail.com or www.dentalminiimplant.com.

■ ROBERT A. HOROWITZ, DDS

Dr. Robert Horowitz graduated from Columbia

University School of Dental and Oral Surgery

in 1982. After a one-year general practice

residency, he finished a two-year specialty

training program in periodontics at New York

University and the Manhattan VA Hospital. He

began placing implants in 1985. In 1996, he

completed a two-year fellowship program in implant surgery at

NYU, focusing on bone grafting procedures. Dr. Horowitz is a

clinical assistant professor in the department of periodontology

and implant dentistry at NYU College of Dentistry, where he is

also on faculty and conducts research in the departments of oral

surgery, biomaterials and biomimetics, and oral diagnosis.

Dr. Horowitz has lectured nationally and internationally and

published more than 40 scientific articles and case studies.

Contact him at rahdds@gmail.com.

■ DARRIN M. WIEDERHOLD, DMD, MS

Dr. Darrin Wiederhold received his DMD

in 1997 from Temple University School of

Dentistry and a master’s degree in oral biology

in 2006 from Medical University of Ohio at

Toledo. Before joining Glidewell in August

2011, he worked in several private practices

and as a staff dentist for the U.S. Navy. As staff

dentist in Glidewell’s Implant division, he performs implant

and conventional restorative procedures at the lab’s on-site

training facility and helps support the lab’s digital treatment

planning and guided surgery services. An integral part of the

lab’s Implant Research & Development group, he is also involved

in training and education on implant surgery and prosthetics.

Contact him at inclusivemagazine@glidewelldental.com.

■ Perry E. Jones, DDS, FAGD

Dr. Perry Jones received his DDS from Virginia

Commonwealth University School of Dentistry,

where he has held adjunct faculty positions

since 1976. He maintains a private practice in

Richmond, Va. One of the first GP Invisalign ®

providers, Dr. Jones has been a member of

Align’s Speaker Team since 2002, presenting

more than 250 Invisalign presentations. He has been involved

with Cadent optical scanning technology since its release to the

GP market and is currently beta testing its newest software.

Dr. Jones belongs to numerous dental associations and is a

fellow of the AGD. Contact him at perry@drperryjones.com.

– Contributors – 7


Trends in

Implant Dentistry

Custom Abutments

With the large number of implant-borne cases fabricated

at Glidewell Laboratories, it’s interesting to look at what

types of restorations are being utilized and where.

Which teeth are most

commonly replaced?

Maxilla

l Custom Abutments

Tooth # 1-16

29 %

Mandible

Total Custom Abutments

Tooth # 17-32

are first molars

The many benefits of

custom implant abutments

• Proper support of the soft tissues

• Creation of the emergence profile

• Ideal placement of the margin

• Angle correction as well as retention

• Support of the restoration

8 9 10 11 12 13 14 15

18 19 20 21 22 23 24 25 26 27 28 29 30 31

Total Custom Abutments

(by tooth number in descending order)

Total

Tooth # 1-32

8 7 14 5 12 3 29 20 18 11 31 6 28 21 15 2 23 26 25 24 27 22

Abutment type

by percentage

Titanium is the clear leader with

82% of the total. Zirconia is gaining

popularity with 11%. Currently

representing 7%, gold UCLA-type

abutments are trend ing down.

Abutment Breakdown

Titanium

82%

Maxilla

nium vs. Zirconia

Tooth # 1-16 8

Mandible

Titanium vs. Zirconia

Tooth # 17-32– www.inclusivemagazine.com –


Tooth # 1-16 Tooth # 17-32

Maxilla

Mandible

Custom abutments fabricated by tooth number over a one-year period

Total Custom Abutments

Total Custom Tooth Abutments # 1-16

– Maxilla

Total Custom Abutments

Total Custom Tooth Abutments # 17-32

– Mandible

Tooth #2–#15

Tooth #18–#31

2 3 4 5 6 7 8 9 10 11 12 13 14 15 18 19 20 21 22 23 24 25 26 27 28 29 30 31

2 3 4 5 6 7 8 9 10 11 12 13 14 15

2 3 4 5 6 7 8 9 10 11 12 13 14 15

Total Custom Abutments

(by tooth number in descending order)

Total

Tooth # 1-32

(by tooth number in descending order)

Total Custom Abutments

Total

Tooth # 1-32

Total custom abutments by tooth number in descending order

Total Custom Abutments

(by tooth number in descending order)

Total

Tooth # 1-32

18 19 20 21 22 23 24 25 26 27 28 29 30 31

18 19 20 21 22 23 24 25 26 27 28 29 30 31

19 30 4 10 9 13 8 7 14 5 12 3 29 20 18 11 31 6 28 21 15 2 23 26 25 24 27 22

19 30 4 10 9 13 8 7 14 5 12 3 29 20 18 11 31 6 28 21 15 2 23 26 25 24 27 22

Titanium Maxilla vs. zirconia abutments by tooth Mandible number

Comparing Titanium titanium vs. Zirconia and zirconia abutments by location, the results Titanium are just as you’d vs. Zirconia expect:

zirconia Tooth is used # primarily 1-16 in the anterior maxilla, due to superior esthetic Tooth characteristics. # 17-32

Maxilla

19 30 4 10 9 13 8 7 14 5 12 3 29 20 18 11 31 6 28 21 15 2 23 26 25 24 27 22

Maxilla

Tooth #2–#15

Titanium vs. Zirconia

Tooth # 1-16

Mandible

Mandible

Tooth #18–#31

Titanium vs. Zirconia

Tooth # 17-32

Maxilla

Titanium vs. Zirconia

Tooth # 1-16

Mandible

Titanium vs. Zirconia

Tooth # 17-32

2 3 4 5 6 7 8 9 10 11 12 13 14 15

2 3 4 5 6 7 8 9 10 11 12 13 14 15

Watch here for emerging trends

Titanium Zirconia Titanium Zirconia

The clinical benefits of CAD/CAM technologies are numerous. Based on the number of cases we restore, some clear trends

come to light about your choices in materials. Check back here for more observations in the next issue!

2 3 4 5 6 7 8 9 10 11 12 13 14 15

18 19 20 21 22 23 24 25 26 27 28 29 30 31

Titanium Zirconia Titanium Zirconia

Data Source: Glidewell Laboratories March 2011–March 2012

18 19 20 21 22 23 24 25 26 27 28 29 30 31

18 19 20 21 22 23 24 25 26 27 28 29 30 31

Titanium Zirconia Titanium Zirconia

– Trends in Implant Dentistry: Custom Abutments – 9


my first

implant

with Gordon J. Christensen, DDS, MSD, Ph.D

Inclusive magazine would like to thank Dr. Gordon

Christensen for generously agreeing to appear in our

inaugural My First Implant column, where clinicians

take a moment to recall what it was like to place an

implant for the first time — because everyone has to start

somewhere.

Inclusive magazine: What made you decide to start placing

implants?

Gordon Christensen: I have been placing implants for

about 25 years now. My first course was at Mayo with

[Per-Ingvar] Brånemark himself as the instructor. Then

I went to Sweden for subsequent courses. After working

with oral surgeons and periodontists, some of whom did an

excellent job, I decided that the prosthodontic portion was

often more difficult than the surgical portion, so I started

placing implants myself.

IM: Tell me about your first experience. How did you choose

that first patient, and what was the treatment plan?

GC: The first patient was an elderly edentulous female. I

placed two implants in the mandibular canine areas — an

excellent way to start.

IM: Were you nervous before the procedure?

GC: Of course. Any new procedure causes anxiety.

IM: So, how did that first case go? Did it turn out as you’d

expected?

GC: It went perfectly, just as I had planned.

IM: Any surprises? Looking back, would you have done anything

differently?

GC: I placed implants in animal heads that I obtained from

a local slaughterhouse before placing them in an actual

person. This made the first human placement very easy. I

would do that again. In the hands-on courses I personally

provide in Utah through our organization today, Practical

Clinical Courses, we have participants place implants in

two different simulated mandibles. Then, taking that next

step, placing implants in a human, is relatively easy for

course participants.

IM: What implant system did you use? How did you decide

on this?

GC: My first implants were Brånemarks — which are no

longer made. That particular system was the one on which

I originally was instructed.

IM: How long before the final restoration was delivered? What

was it like?

GC: Twenty-five years ago, we were instructed to cover the

implants with soft tissue and wait at least four months —

preferably six — before loading. The prosthesis was an

overdenture. I have subsequently placed hundreds of these

with success.

IM: Did this first case have any impact on your second case?

How long before the next patient was treated?

GC: My second implant case took place within a few weeks.

The success of that initial case made the next one easy and

eagerly anticipated.

IM: What advice would you give to someone looking to get

started placing implants?

GC: My advice would be:

Take a broad-based, overall implant course.

Decide which brand of implants you want to pursue.

Take a course from that company.

Do your first case on a patient with an edentulous

mandible.

Make an overdenture.

Do your next patient as soon as possible after that first

patient.

Continue to enroll in more complex courses.

Join an implant organization such as the American

Academy of Implant Dentistry, the International

Congress of Oral Implantologists or the Academy of

Osseointegration.

Enjoy this relatively simple and highly successful

procedure. IM

– My First Implant: Dr. Gordon Christensen – 11


Photo Essay

Intraoral Scanning and

Model-less Implant Restorations

by

Tarun Agarwal, DDS, PA

Go online for

in-depth content

Digital Implant Restorations

Are you looking to simplify your

implant restoration process? Imagine

being able to offer custom implant

restorations for a reduced lab fee

within a quicker turnaround time. The

answer is simple: Go digital. In this

article, I’d like to show why digital

implant restorations make sense,

using an example of such a case.

The beauty of this technology is that

it’s not limited to a particular brand of

implants and can be used with nearly

every digital impression system on the

market today.

Nearly all custom abutments, with the

exception of UCLA abutments, are digitally

fabricated using a sophisticated

CAD/CAM process. With the conventional

approach, the laboratory

converts an analog impression to a

digital version. But by taking a digital

implant-level impression in the mouth,

you can go directly to digital software,

bypassing the conversion process and

the errors that come with it.

Case Presentation

Figure 2: After treatment possibilities were discussed,

the patient opted for implant therapy. The

tooth was carefully removed using an atraumatic

technique.

Figure 1: A patient presented with a severely fractured tooth #14 that had a questionable prognosis.

Figure 3: An implant was placed at the time of

extraction.

– Intraoral Scanning and Model-less Implant Restorations – 13


Figure 4: Following a six-month osseointegration

period, the implant was ready for loading.

Figure 5: Second-stage surgery was completed with

the placement of a healing abutment.

Figure 6: Taking a digital implant impression in this

case was the same as taking a digital impression

for a traditional crown, the only difference being the

placement of the Inclusive ® Scanning Abutment.

Figure 7: The CEREC ® AC Bluecam (Sirona; Long

Island City, N.Y.) was used to digitally capture the

implant impression.

Figure 8: Another advantage of the digital process

is that any shade photographs are included with the

digital information.

Figure 9: Following the creation and verification of

a virtually articulated digital model, the case was

securely transmitted to Glidewell Laboratories via

the Sirona Connect portal.

10a

10b

10c

Figures 10a–10c: The case was virtually designed in the laboratory. The flexibility of the digital system allows fabrication of titanium custom abutments, zirconia custom

abutments, lithium disilicate final restorations, BruxZir ® final restorations, and even my preferred favorite, the all-in-one screw-retained abutment and crown — made from

either IPS e.max ® lithium disilicate (Ivoclar Vivadent; Amherst, N.Y.) or BruxZir Solid Zirconia.

14

– www.inclusivemagazine.com –


11a

11b

Figures 11a, 11b: In this case, an all-in-one screw-retained IPS e.max abutment and crown were fabricated.

A screw-retained crown has all the benefits of a custom abutment emergence profile, the convenience of

retrievability, and cost-saving advantages. However, the most important aspect of a screw-retained implant crown

is the lack of intraoral cementation. In fact, cement sepsis — caused by the incomplete removal of cement from

around implants — is the main cause of implant failure. If you haven’t looked at screw-retained implant crowns

recently, be sure to give them another look.

Figure 12: The healing abutment prior to removal.

Figure 14: A radiograph was taken to verify complete

seating.

Figure 13: The restoration was tried in the mouth.

Figure 15: The restoration was torqued according to

manufacturer recommendation.

By taking

a digital

implant-level

impression ...

you can

go directly

to digital

software,

bypassing the

conversion

process — and

the errors

that come

with it.

Figure 16: Teflon tape was used to plug the access

hole over the screw.

Figure 17: A matching composite restoration was

placed over the plugged access hole.

– Intraoral Scanning and Model-less Implant Restorations – 15


18a

18b

18c

Figures 18a–18c: The completed implant restoration

Let Technology Transform Your Practice

In our practice, we’ve gone completely

digital for single-unit implants — both

for posterior and anterior cases. We

enjoy the speed of acquisition thanks

to the power of CEREC with Bluecam

and the predictable results from the

implant department at Glidewell Laboratories.

You owe it to your patients

and your practice to consider moving

toward digital implant impressions. IM

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PRODUCT

SPOT

light

Prismatik PEEK Prosthetics

Intraoral Components with

Radiographic Visibility

by

Grant Bullis

Director of Implant R&D and Digital Manufacturing

Polyether ether ketone (PEEK) is an engineering

thermoplastic that has many applications

in health care. Its stiffness, toughness, durability,

and biocompatibility make it the material of choice

for everything from temporary dental restorations

to femoral implants. PEEK can be repeatedly sterilized

by various methods (e.g., steam, gamma, and ethylene

oxide) without degrading its mechanical properties

or biocompatibility. It is also radiolucent, appearing

only vaguely on X-ray and CT imaging applications.

This presents an obvious difficulty to the clinician or

radiologist looking to verify the complete seating of

PEEK prosthetic components on dental implants.

Advanced formulations enhance the radiopacity of

PEEK prosthetic components by incorporating a radiopaque

filler. Barium sulfate is a widely used,

dense, insoluble material that can be added in varying

concentrations to increase the radiopacity of PEEK.

Prismatik Dentalcraft’s intraoral scanning abutments,

made from barium sulfate-filled PEEK, provide optimal

function and can be easily viewed radiographically.

The custom healing abutment and custom

temporary abutment featured in Glidewell’s Inclusive ®

Tooth Replacement Solution are milled

from the same material, providing

the same high degree of radiographic

visibility. IM

PA demonstrating the visibility of a standard PEEK

component (left) compared to a radiopaque PEEK

component (right)

– Product Spotlight: Prismatik PEEK Prosthetics – 17


Guided Implant Surgery for

Single-Tooth Restorations

Streamlining the Process

Go online for

in-depth content

by

Bradley C. Bockhorst, DMD and

Zach Dalmau, DTP and Guided Surgery Production Manager

T

he use of digital treatment

planning and guided surgery

for the placement of dental

implants entails many benefits, including

the ability to plan cases in

a virtual environment from the surgical

and prosthetic perspectives,

and then to accurately transfer

the plan to the clinical setting. This

technology can be used for essentially

all indications, from single-tooth

to full-arch restorations. There are

certainly specific situations where

the technology is most advantageous,

such as congenitally missing

lateral incisors with narrow interproximal

spaces between adjacent

roots, or mandibular posteriors in

proximity to the inferior alveolar

nerve. However, the additional presurgical

procedures, time, and

expense can often foster a bias

against going guided. Fortunately,

there are now options available that

help streamline the process, provide

enhanced precision, and are

more economical.

– Guided Implant Surgery for Single-Tooth Restorations: Streamlining the Process – 19


Are Scan Appliances Necessary?

While a scan appliance is required for

larger cases such as fully edentulous

arches, they may not be necessary

for single-tooth and short-span cases.

An optical scan of the models can be

performed and the missing tooth virtually

waxed-up in the CAD software.

This provides the prosthetic information

to plan the case without incurring

the cost and time delay of a scan

appliance. It also avoids potential inaccuracy

if the scan appliance is not

fully seated during the CT scan. As

a caveat, if the patient has a large

number of metallic restorations, a

scan appliance may be necessary due

to scatter that may interfere with the

accuracy of merging the patient scan

and model optical scan in the planning

software.

Access and Cost for CT Scans

With the expansion of the CBCT

market, patients can be scanned at a

significantly lower radiation dose and

cost than they can with traditional

spiral beam scanners. If the clinician

does not have a CBCT scanner in their

office, typically a radiology lab can

be found locally. If working with a

radiology lab, make sure the technician

understands the protocol. You may

want to accompany your patients until

you have confidence that the scans are

being performed correctly.

While a

scan appliance

is required for

larger cases such

as fully edentulous

arches, they may

not be necessary

for single-tooth and

short-span cases.

Procedure

Diagnostic Appointment

• Perform a standard diagnostic workup:

review of the patient’s health

and dental history (including the

cause of tooth loss), clinical exam,

periodontal status, and appropriate

radiographs.

• Take very accurate full-arch impressions

(use a custom or metal tray

and VPS final impression material)

and bite registration, and take the

shade (intraoral photos are extremely

helpful).

CT Scan

• The patient should be scanned (at

1 mm or smaller slice intervals/

thickness) with the occlusal surfaces

separated by at least 8 mm. This

may be accomplished with a stack

of tongue depressors (Figs. 1, 2)

or, ideally, with a thick bite registration

fabricated on an articulated

study model (Figs. 3, 4). Whatever

is used must be radiolucent. The

potential problem with using cotton

rolls is that the teeth may overlap if

the patient bites firmly or changes

bite pressure during the scan.

Figure 1: Patient seated in PreXion 3D scanner (PreXion Inc.; San Mateo, Calif.)

20

– www.inclusivemagazine.com –


Figure 2: Tongue depressors used to separate patient’s teeth

• The patient must remain perfectly

still during the scan. One of the

major causes of artifacts and other

quantitative inaccuracies in a CT

scan is patient movement.

Submitting the Case

• Access and fill out your online

digital Rx securely at https://

myaccount.glidewelldental.com (Fig.

5). Note: Quick links are also available

on the Treatment Planning

page of www.inclusivedental.com

under the heading “Submit Digital

Case” (Fig. 6).

• Print out the summary page at the

end of the Rx. Upload the folder

containing the DICOM files of the

patient’s scan.

• Send your impressions and bite registration

with the digital Rx printout

to Glidewell Laboratories.

Figure 3: Pin opened on articulator to separate teeth

Figure 4: Bite registration fabricated on articulated

study model with Capture ® Clear Bite (Glidewell

Direct) for use in CBCT scanning process

Figure 5: Screen capture of the My Account login

page at www.glidewelldental.com

Figure 6: Screen capture of the Treatment Planning

page at www.inclusivedental.com

– Guided Implant Surgery for Single-Tooth Restorations: Streamlining the Process – 21


By eliminating

the need for a

scan appliance,

the cost is

decreased and

treatment time

shortened.

Figure 7: Optical scans of opposing models merged with CT scan in planning software (In2Guide , Cybermed

Inc.; Irvine, Calif.). The mandibular canal has been identified, the missing tooth virtually waxed-up, and the

implant planned.

Digital Treatment Planning and

Surgical Guide Fabrication

• Once your case is received, the

models are poured and optically

scanned. The missing tooth is added

virtually in the CAD program.

• The optical scans of the models and

the patient’s CT scan files (DICOM)

are imported into the implant planning

software (Figs. 7–9).

Digital Plan Review and Acceptance

• A draft of the digital implant plan

is created in the proposed site.

A Web-based teleconference is

conducted with the treating clinician

(or clinicians, if there is a surgicalrestorative

team) to review and

finalize the plan.

Figure 8: The implant is spaced evenly between the adjacent teeth, the trajectory is through the center of the

occlusal table, and there is a good safety margin from the mandibular canal.

• The plan is posted to your online

account. Once you accept the plan,

your surgical guide is fabricated

(Figs. 10a, 10b).

Figure 9: Virtual view of the tooth-borne surgical guide. Inspection windows are added to visualize complete

seating intraorally.

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10a

Summary

Digital treatment planning and guided

surgery provide tremendous tools

to diagnose and treat implant cases

predictably and precisely. This technology

is not just indicated for fully

edentulous arches; it can also be indicated

for short edentulous spans,

including single tooth replacement.

By eliminating the need for a scan

appliance, the cost is decreased and

treatment time shortened. The keys

are to make accurate impressions,

as the surgical guide is based on the

model, and to CT scan the patient

with their teeth separated. Utilizing a

full-arch intraoral scan instead of

impressions is another option, but that

is the subject for a future article. IM

10b

Figures 10a, 10b: Completed tooth-borne surgical guide

– Guided Implant Surgery for Single-Tooth Restorations: Streamlining the Process – 23


SMALL DIAMETER

implants

Drilling Protocol for

Achieving Primary Stability

with Paresh B. Patel, DDS

Choosing the appropriatesized

drill in combination

with the correct drilling

depth is key to ensuring good

primary stability when placing smalldiameter

implants. Dense mandibular

bone may require site preparation to

full length, particularly when using

wider diameters, which comprise a

larger overall surface area. Conversely,

site preparation in the maxillary

arch might necessitate the use of an

undersized osteotomy drill as well as

decreased drilling depth, depending

on the den sity of cortical bone.

Inclusive ®

Mini Implant

Diameters

Ø 2.2 mm

Ø 2.5 mm

Ø 3.0 mm

Corresponding

cortical bone

drill diameters*

Ø 1.5 mm

Ø 1.7 mm

Ø 2.4 mm

*Dependent on bone density

Mandibular Arch

Before beginning the procedure,

determine the quality of bone. It is

important not to over-prepare or

over-drill the initial osteotomy. It is

best to drill halfway first, and then

assess the underlying bone. Try

using the blunt end of an endodontic

explorer to push on the bone and

determine the level of resistance. If

no trabecular bone is found and you

feel ample resistance, then D1 bone

is present. At that point, it may be

prudent to increase the osteotomy to

the full length of the small-diameter

implant. If you encounter D2 or D3

bone, allow the self-tapping design of

the small-diameter implant to thread

its way to full seating depth.

Maxillary Arch

To achieve good primary stability,

assess the bone before starting. Try

26

– www.inclusivemagazine.com –


Type D1

Type D2

Endodontic probe being used to feel density of the

mandibular cortical bone

Pilot drill taken to one-half the length of the smalldiameter

implant

sounding the bone with the sharp end

of an endodontic explorer, even before

using the drill bit, to determine how

much of a cortical plate there is to

work with. If it is nice and thick, you

will get lots of resistance. If it is thin,

you may find your endodontic explorer

has pierced the outer cortical plate

and you are now in the soft trabecular

bone. If the latter is the case, use the

pilot drill to perforate the cortical

plate only. Then, thread the implant

through, allowing it to condense and

compress the bone. Another way to

achieve additional primary stability in

the maxillary arch is to use the smaller

diameter drill.

For example, if you were going to place

a 3.0 mm implant in the maxillary arch

and the bone happened to be very

soft (D3- or D4-type bone), instead of

using a 2.4 mm pilot bit as suggested

in the placement protocol, a 1.5 mm

or 1.7 mm pilot drill may be used to

remove less bone. In essence, this gives

the implant more bone to act upon as

an osteotome. IM

Bone Types

D1

D2

D3

D4

Almost the entire

jaw is composed of

homogenous compact/

cortical bone.

A thick layer of cortical

bone surrounds a core

of dense trabecular

bone.

A thin layer of cortical

bone surrounds a core

of dense trabecular

bone of favorable

strength.

A thin layer of cortical

bone surrounds a

core of low-density

trabecular bone.

Adapted from the Lekholm-Zarb

bone quality classification

Type D3

Type D4

– Small Diameter Implants: Drilling Protocol for Achieving Primary Stability – 27


CLINICAL

TIP

Go online for

in-depth content

Using the Inclusive Tooth Replacement Solution

Prosthetic Guide

by

Darrin M. Wiederhold, DMD, MS

One of the most innovative and useful aspects of the Inclusive ® Tooth Replacement

Solution is that it provides the implant surgeon and restorative dentist with an array

of custom components, each designed to facilitate the placement and temporization

of implants. Among these innovative components is the prosthetic guide, a custom

stent designed to aid the clinician in selecting the location for the planned implant.

Much like the other components of the Inclusive Tooth Replacement Solution, the

prosthetic guide is based on the ideal placement of the final prosthesis. Its design

is driven not by the characteristics of the edentulous space, but rather where the

final crown will be placed.

28

– www.inclusivemagazine.com –


1Prosthetic guide in situ

Because the prosthetic guide is

based on a study model generated

by a diagnostic wax-up of the

planned restoration, it functions

simply as a reference tool — without

consideration of the soft or

hard tissue of the area, anatomical

landmarks or structures, adjacent

roots, or contraindications. Therefore,

it is imperative that the clinician

utilizes the prosthetic guide in

conjunction with appropriate radiography,

CBCT scans, and other

diagnostic information available.

Doing this will enable the surgeon

to optimize the placement of the

implant, as well as the functionality

and esthetics of the other components of the package, including the custom

temporary abutment and BioTemps ® provisional crown. However, because of this

limitation, it is often the case that the prosthetic guide’s proposed location and

angulation of the implant will need to be modified at the discretion of the clinician

who is placing the implant. Consequently, the experience and acumen of the

surgeon must be brought to bear on every case to determine what adjustments,

if any, are required. If changes are made to the prosthetic guide, the additional

Inclusive Tooth Replacement Solution components likely will need to be adjusted

and modified to accommodate the altered implant location or angulation.

2Lance drill through prosthetic

guide

Once the ideal dimensions have been established for implant placement, the

prosthetic guide is seated in the mouth (Fig. 1), and the lance drill is used to drill

through the pilot hole (Fig. 2). The prosthetic guide is then removed, and the

angulation and location of the lance drill verified with a PA. Once any necessary

adjustments are made to the osteotomy pilot hole, the osteotomy is completed

freehand in the usual and customary surgical manner.

The Inclusive Tooth Replacement Solution prosthetic guide can be a useful tool

for selecting the location of a planned implant, but it should not be regarded

as a standalone resource. The suggested osteotomy site of the prosthetic guide

must be viewed within the larger context of the case, taking into consideration

adjacent teeth and root dilacerations, proximity to vital anatomic structures, and

hard and soft tissue contours. When necessary, the prosthetic guide should be

adjusted to secure the ideal surgical and prosthetic outcome. IM

It is imperative that the clinician utilizes the prosthetic

guide in conjunction with appropriate radiography ...

and other diagnostic information available.

– Clinical Tip: Using the Inclusive Tooth Replacement Solution Prosthetic Guide – 29


R&D

CORNER

Go online for

in-depth content

Strength and Flexibility of BruxZir

Solid Zirconia Implant Restorations

by

Robin A. Carden, VP of Research & Development

A

critical consideration with implant-borne restorations

is the distribution of functional stresses. In

the absence of a periodontal ligament to serve as a

natural shock absorber, it is incumbent on the restoration

to withstand the full force of those stresses. BruxZir ® Solid

Zirconia, a monolithic ceramic restoration with no porcelain

overlay, has the ability to meet this demand with a blend

of strength and flexibility, due to a set of intrinsic material

properties that include high flexural strength, high fracture

toughness, low coefficient of friction, and low coefficient of

thermal expansion.

FLEXURAL STRENGTH

Typical zirconia materials demonstrate a flexural strength of

more than 900 MPa. As a result of the proprietary methods

used to process BruxZir milling blanks, BruxZir zirconia

exhibits an even greater strength, measured as high as

1,510 MPa in accordance with the JIS R 1601 standard on

an Instron-5564 electromechanical testing system (Fig. 1).

This standard, established by the Japan Fine Ceramics

Association, specifies the testing method for three-point and

four-point flexural strength of high-performance ceramics

at room temperature. Compared to the flexural strength of

Figure 1: Instron-5564, used to measure BruxZir zirconia’s flexural strength

conventional PFM restorations, measured at roughly 800

MPa or less, monolithic BruxZir zirconia boasts a strength

advantage of nearly twice that of the traditional alternative,

essentially allowing it to bend without breaking (Fig. 2).

R&D Corner: Strength and Flexibility of BruxZir Solid Zirconia Implant Restorations 31


1400

Average Flexural Strength Distribution

1300

Flexural strength (MPa )

1200

1100

1000

900

800

sagemax ht

zirconia

DoCERaM

zirconia

amann Girrbach

zirconia

Zirkonzahn

zirconia

Cercon

zirconia

BruxZir ®

zirconia

Figure 2: Graph showing the average flexural strength distribution of monolithic zirconia products, as tested by Glidewell Laboratories

FRACTURE TOUGHNESS

Fracture toughness (K 1c value) is a quantitative way of

expressing a material’s resistance to brittle fracture when

a crack is present. Materials such as lead or steel, for

example, demonstrate high fracture toughness, whereas

most ceramic and glass-ceramic materials exhibit low and

inconsistent fracture toughness. This means that a crack

can travel through a typical ceramic with little resistance,

resulting in immediate, brittle fracture and catastrophic

failure. Partially stabilized zirconia, however, contains an

internal mechanism that actually inhibits crack propagation.

This “self-healing” event is known as phase transformation

toughening. When faced with a propagating crack tip,

a zirconia grain particle is able to absorb the associated

energy by transforming from its tetragonal phase to the

more stable monoclinic phase. This results in an associated

volumetric expansion, effectively closing the advancing

crack. Transformation toughening gives partially stabilized

zirconia a K 1c value that is three to six times higher than

normal cubic zirconia and most other ceramics, resulting in

tremendous impact resistance.

Figure 3: Spring fabricated from BruxZir zirconia

Figure 4: Compressed BruxZir zirconia spring

32

– www.inclusivemagazine.com –


CONCLUSION

Partially stabilized zirconia …

contains an internal

mechanism that actually

inhibits crack propagation.

The fastest-growing product in the 42-year history of

Glidewell Laboratories, BruxZir Solid Zirconia has quickly

proven itself as a reliable, esthetic alternative to traditional

PFM and full-cast restorations. Manufactured from yttriastabilized

zirconia powder specially processed to achieve a

nanocrystalline particle size as small as 3 nm, BruxZir zirconia

exhibits class-leading strength and flexibility in addition

to its high biocompatibility. These mechanical properties

enable it to absorb high levels of functional stress, making

it an ideal material choice for implant-borne restorations,

whether cement-retained or screw-retained (Figs. 5, 6). IM

As a demonstration of this principle, note the fabrication

of BruxZir zirconia into a spring-shaped coil (Fig. 3). Due

in part to its high K 1c value and ability to transform its

structure, this coil can endure repeated compression cycles

(Fig. 4), returning each time to its original shape without

suffering the fracture damage one might expect of a typically

brittle ceramic.

COEFFICIENT OF FRICTION

Although dependent on system variables such as temperature,

velocity and atmosphere, the coefficient of friction

(COF) is often stated as a material property that describes

the ratio of the force of friction between two bodies and

the force pressing them together. Ice on steel, for example,

would tend to have a low COF, while rubber on pavement

tends to have a high COF. A material with a low COF value,

such as that exhibited by BruxZir zirconia, can be perceived

then as having a greater resistance to frictional wear present

in any nanomechanical system, enabling it to better withstand

the rigors of micromovement.

Figure 5: Cement-retained BruxZir crown with Inclusive ® All-Zirconia Custom

Implant Abutment

COEFFICIENT OF THERMAL EXPANSION

The coefficient of thermal expansion (CTE) describes how

the size of an object changes with a change in temperature.

In general, substances expand or contract when their

temperature changes, with expansion or contraction occurring

in all directions. This causes strain within the material,

which again can introduce the potential for fracture. A

lower CTE number indicates greater resistance to thermal

shock. Because the oral environment is highly susceptible

to rapid temperature changes, a material like BruxZir zirconia,

characterized by a relatively low CTE, is better suited

to withstand the rigors of that environment than a material

with a higher CTE.

Figure 6: Screw-retained BruxZir crown

R&D Corner: Strength and Flexibility of BruxZir Solid Zirconia Implant Restorations 33


The Do’s and Don’ts

of Immediate Loading

or Provisionalization

of Dental Implants

DO’S

Initial stability of 35 Ncm

Go online for

in-depth content

Figure 1: Torque wrench demonstrating 35 Ncm upon

final implant seating

by Darrin M. Wiederhold, DMD, MS

Much like Hamlet’s ageless lament, “To be, or not

to be,” implant surgeons around the world are

plagued daily by the conundrum: “To immediately

load, or not to load?” Is it far better to suffer a patient’s wrath

over a missing maxillary anterior tooth than endanger the

neophyte implant as it osseointegrates? That is the question,

and this, hopefully, is the answer.

An important distinction that must first be made concerns

the terms “immediate loading” versus “immediate nonfunctional

provisionalization” (or “temporization”). From an

academic point of view, “immediate loading” would be any

component that is attached to the implant within zero to

20 days of implant insertion and is placed under occlusal

stress or load. This term is further applied to any situation

where the implant undergoes micromotion and is designed

to be functional rather than just cosmetic. “Immediate nonfunctional

provisionalization” is a generic term denoting the

temporizing — generally for esthetics — of the implant, but

where the provisional component is purposely taken out

of occlusion in an effort to minimize any micromovement

of the implant that might hinder or compromise its

osseointegration. It is important to differentiate the two

terms and recognize that patients are demanding more

and more that we immediately provisionalize their implant,

but are not generally concerned with whether there is true

occlusal loading of the implant.

As with any surgical procedure, there are certain selection

criteria that, if heeded, can help to maximize the chance

of success. Conversely, there are those guidelines that

clinicians ignore at their own peril. The following are the

classic Do’s and Don’ts of immediate provisionalization or

immediate loading.

ISQ score of 50–80, with a higher

score correlating to a greater

degree of initial stability

Figure 2: Osstell ® ISQ implant stability meter (Osstell

USA; Linthicum, Md.)

1 mm–1.5 mm of facial bone

surrounding the implant

Figure 3: CT scan (cross-sectional view) demonstrating

adequate facial bone width

– The Do’s and Don’ts of Immediate Loading or Provisionalization of Dental Implants – 35


DO’S

Healthy, non-infected,

non-compromised bone

DON’TS

Bone that has been compromised,

either through abscess,

periodontal disease, or other

local pathology

Figure 4: Preoperative PA demonstrating healthy bone in

the edentulous space

No history of bruxism or other

parafunctional habits

Figure 7: Large periapical lesion

History of heavy bruxism,

clenching, or other destructive

parafunctional habits

Figure 5: Implant patient with healthy, unworn dentition

DON’TS

Initial stability of less than 35 Ncm

ISQ scores below 50

Deficiency of bone, particularly on

the facial aspect, or where bone

grafting is indicated or performed

Figure 8: Worn dentition suggesting history of heavy

bruxism

An important distinction ...

concerns the terms

“immediate loading” versus

“immediate non-functional

provisionalization” or

“temporization.”

Figure 6: CT (axial slice) showing buccal defect

When deciding whether to immediately provisionalize

or load, it is important to consider the

number of implants being placed and the ability to

splint those implants together. For single implant

36

– www.inclusivemagazine.com –


cases, the caveats noted previously are critical. For multiunit

cases, the ability to splint the implants together via the

provisional prosthesis — be it a complete denture, short- or

long-span bridge, or a hybrid — affords greater flexibility

in the decision to immediately load or provisionalize. There

is greater initial stability, minimization of occlusal stresses

and, therefore, reduced micromovement as a whole when

implants are splinted. As such, the ability of the implant to

integrate successfully into the surrounding osseous matrix

is greatly improved.

Bear in mind that these simple Do’s and Don’ts can help

maximize the odds of success when placing implants.

Patient demand for immediate provisionalization is greater

than ever, and as providers of a service, we are strongly

motivated to meet that demand. But as dental professionals,

we are the final arbiters of what is in the patient’s best

interest. If there is inadequate initial stability, compromised

bone quality or quantity, or if any of the other clinical

parameters are less than ideal, it is imperative that we as

clinicians make the unpopular decision not to immediately

provisionalize or load. It can be difficult to inform a patient

with high esthetic expectations that they will have to

endure a less-than-ideal cosmetic situation for the four to

six months of osseointegration. But, in the long run, what’s

best for the implant is best for the patient.

Custom-fitted components

designed to ... develop soft tissue

architecture, satisfy the patient’s

esthetic demands, and improve

impression quality ... simplify the

implant process.

Once the decision is made to temporize an implant case,

the method must be chosen. There are a variety of materials

and techniques available, but only the Inclusive ® Tooth

Replacement Solution comes packaged with patient-specific

temporary components at the time of surgery, with the

goal of increasing restorative predictability and reducing

chairtime when compared to the use of stock components

or handmade custom components. Additionally, the

Inclusive Tooth Replacement Solution gives the clinician

the flexibility to temporize the case at any point in the

process, be it the day of placement, or at a future date —

whenever it is determined that the implant has achieved

sufficient stability. In those instances where placement of

a custom temporary abutment and BioTemps ® provisional

crown are not immediately indicated, the option exists to

place the custom healing abutment instead. By doing so,

the benefit of immediately beginning to develop the soft

General References

tissue architecture around the implant is achieved

without the worry of any occlusal stress on the

newly placed fixture.

By treatment planning with the end in mind from

the outset, many of the challenges clinicians often

encounter, both surgically and restoratively, can

be minimized. Having custom-fitted components

designed to guide implant placement, develop

soft tissue architecture, satisfy the patient’s

esthetic demands, and improve impression

quality all help to simplify the implant process.

Furthermore, because the process is more

efficient and streamlined, fewer appointments

are required, and there is greater predictability

during those appointments. Greater predictability

means fewer scheduling challenges for the front

office staff, translating to greater profitability for

the practice. IM

• Attard NJ, Zarb GA. Immediate and early implant loading protocols:

a literature review of clinical studies. J Prosthet Dent. 2005

Sep;94(3):242-58.

• Balshi TJ, et al. A prospective analysis of immediate provisionalization

of single implants. J Prosthodont. 2011 Jan;20(1):10-5.

• Block M, et al. Single tooth immediate provisional restoration of

dental implants: technique and early results. J Oral Maxillofac

Surg. 2004 Sep;62(9):1131-8.

• Block MS, et al. Prospective evaluation of immediate and delayed

provisional single tooth restorations. J Oral Maxillofac

Surg. 2009 Nov;67(11 Suppl):89-107.

• Buser D, Martin W, Belser UC. Optimizing esthetics for implant

restorations in the anterior maxilla: anatomic and surgical considerations.

Int J Oral Maxillofac Implants. 2004;19 Suppl:43-61.

• Davidoff SR. Late stage soft tissue modification for anatomically

correct implant-supported restorations. J Prosthet Dent. 1996

Sep;76(3), pp:334-8.

• Degidi M, et al. Five-year outcome of 111 immediate nonfunctional

single restorations. J Oral Implantol. 2006;32(6):277-85.

•Kinsel RP, Lamb RE. Tissue-directed placement of dental implants

in the esthetic zone for long-term biologic synergy: a

clinical report. Int J Oral Maxillofac Implants. 2005 Nov-Dec;

20(6):913-22.

• Kourtis S, et al. Provisional restorations for optimizing esthetics

in anterior maxillary implants: a case report. J Esthetic Restor

Dent. 2007;19(1):6-16.

• Wismeijer D, et al. ITI Treatment Guide, Vol. 4: Loading Protocols

in Implant Dentistry: Edentulous Patients. 2010. Berlin: Quintessence

Publishing Co, Ltd.

– The Do’s and Don’ts of Immediate Loading or Provisionalization of Dental Implants – 37


CLINICAL

TIP

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Creating a Screw-Retained Temporary

by

Bradley C. Bockhorst, DMD

A temporary restoration provides a prosthetic prototype that helps not only

to sculpt the soft tissue contours, but also to simplify the seating of future

components. Think of it as a practice builder: it satisfies the patient because

they get their tooth back more quickly, and clinicians are better able to manage

patient expectations for the final restoration.

The custom temporary abutment and BioTemps ® provisional crown featured

with the Inclusive ® Tooth Replacement Solution from Glidewell Laboratories

are intended to provide a cement-on provisional restoration. However, they can

easily be converted into a one-piece, screw-retained restoration.

As the term implies, a temporary restoration will need to be replaced at a future

date. This is easily accomplished with a screw-retained restoration by uncovering

the access opening and loosening the abutment screw.

Advantages of

screw-retained

provisional restorations:

• Retrievability

• Elimination of potential

excess cement

• Ability to push soft tissues

One of the major challenges with cemented implant restorations is removal of

excess cement. In the procedure outlined here, the components are luted together

extraorally, ensuring complete seating of the crown to the abutment and

facilitating removal of excess cement. Using permanent cement will decrease the

chances of the temporary crown inadvertently coming loose.

To create an ideal emergence profile, you may need to displace or “push” the soft

tissues. This is much easier to do with a screw-retained restoration. If you attempt

to manipulate the tissues with a cemented provisional, you run the risk of having

difficulty seating the crown or the provisional coming loose.

Note: Roughening up the surface or creating grooves in

the abutment with a diamond bur or disc will create a

mechanical retention.

– Clinical Tip: Creating a Screw-Retained Temporary – 39


Step-by-Step

1Seat the temporary abutment and

hand-tighten the abutment screw.

2Seat the BioTemps crown on

the abutment. Check interproximal

and occlusal contacts. Make

adjustments as needed. Note: For

immediate non-functional provisionalization,

the crown should

be well out of occlusion.

Remove the BioTemps crown and

3 temporary abutment. Drill a hole

through the BioTemps crown,

following the trajectory of the

abutment screw.

Roughening up the surface or creating grooves in the abutment

with a diamond bur or disc will create a mechanical retention.

Mount the temporary abutment

4 on an implant analog for ease

of handling. Seat the BioTemps

crown on the abutment and verify

the size and position of the access

opening over the abutment screw.

Cover the head of the screw and

5 block out the screw access opening

with Teflon tape, a cotton

pellet and soft wax, or use a guide

pin. Lute the BioTemps crown

onto the temporary abutment with

permanent cement.

Meticulously remove all excess cement.

Finish and polish the screw-

6

retained temporary as needed.

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Seat the one-piece assembly on the implant and tighten the abutment screw

7 to 15 Ncm. Recheck the contacts.

Cover the head of the screw with Teflon tape or a cotton pellet, and seal the

8 access opening with acrylic or composite.

A key feature of the Inclusive Tooth Replacement Solution’s temporary abutment

and BioTemps crown is versatility. They can be used for cement-on temporary

restorations or easily converted to a screw-retained provisional prosthesis, each

with their own indications and corresponding benefits. IM

– Clinical Tip: Creating a Screw-Retained Temporary – 41


Implant&

Q A:

Go online for

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An Interview with Dr. Perry Jones

Interview of Perry E. Jones, DDS, FAGD

by Bradley C. Bockhorst, DMD

Dr. Perry Jones maintains a private general practice in Richmond, Va.,

and also serves as the director of continuing education and faculty

development at Virginia Commonwealth University School of Dentistry.

One of the first certified Invisalign providers, Dr. Jones has been

involved with Cadent optical scanning technology since its release to

the GP market. He took time to talk about his experience with digital

intraoral scanning technology after attending a recent course at the

Glidewell International Technology Center.

Dr. Bradley Bockhorst: I wanted to

spend some time talking about one of

your passions, digital intraoral scanning.

Can you tell us a little bit about

how long you’ve been involved with

that technology?

Dr. Perry Jones: I have been involved

in optical/digital scanning in my practice

for the purpose of restorations

probably for the last five or so years.

I started when we did our first beta

testing of digital scanning equipment

and was lucky enough to have one of

the first units to be placed in service

in the United States. Coincidentally, it

happened to occur right when my son

joined my practice. It was pretty phenomenal

to have a young kid come in

and learn and see what digital scanning

was all about. He’s lucky enough not

to have lived through the days of VPS

impression taking, when impressions

didn’t come out the way we thought

they would.

BB: Intraoral scanning is obviously

the buzz right now. Every time you go

to any meeting, whether it’s for specialists

or general dentists, that’s one of the

hot topics. What would you consider the

primary benefits of intraoral scanning?

PJ: A digital scanning system has

many benefits. One is that you can do

any type of restoration — it could be

a gold restoration, a PFM, a porcelain

restoration, an intraoral inlay-onlay. It

could even be a provisional restoration,

anything you can think of that

can be made in the restorative world.

And it can be done either model-less

or on models.

Let’s also talk about some of the other

things we can do. We talked about

modeling. We can make polyurethane

models, and use these models for

a plethora of different things. For

example, we might use them for

thermoplastic materials to be made

on the model. The beauty is, when

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we separate the plastic material

from the model, there’s no tooth

breakage, so we can reuse it over and

over again. We might make full-arch

thermoplastic retainers, movement

appliances, canine-to-canine retainers,

occlusal guards, bleaching trays,

athletic guards. All of the different

things you can think of that we make

on conventional models, we can make

on the polyurethane models.

We also have the ability to export files.

So the STL files that we create can be

merged with the DICOM files from

cone-beam CT information, and the

merge allows us to do digital planning

to create surgical guides in a 100 percent

digital environment.

BB: Obviously, digital scanning has

a lot of indications. Do you have any

tips for dentists getting involved with

intraoral scanning, and how to easily

integrate it into their practices?

PJ: Let me make two comments. First,

as with anything, there’s a slight learning

curve. The learning curve is very

small, but like backing up a car with

a trailer behind it, your brain has to

think through exactly the placement

of the camera. I took a two-day inoffice

training and was expected to

bring some cases ready to scan. Honestly,

I went home the first night and

thought, “You know, I’m not sure this

is really for me,” because I didn’t grasp

the concept of simply looking at the

monitor and then relating my camera

position. But once I caught on to

that, the next day, I was a scanning

machine! In fact, my son and I would

fight over who got to scan the case —

and we still do to this day. Who gets to

scan — staff or one of the doctors? It’s

so much fun. The learning curve was

short, but there is a learning curve. I

think that’s probably the first thing I

would say about introducing it into

your practice.

The second thing I think that’s really

important is that doctors have to

understand that there will be a big

reduction in the time they spend

in delivery of the restoration. It’s

significant! Everybody I’ve talked to

who uses intraoral scanning finds

that the time they need for delivery

is radically cut by about half. In my

practice, we used to allow 30 minutes

for each restoration. We’ve gotten so

comfortable with it now, we don’t

even make a delivery appointment. We

simply insert them between the other

patient appointments.

“Hello, Mrs. Smith, we’d like to have

you come in today. We’ll see you at

2:30 p.m. to deliver your crown.” We

have such confidence that in a few

minutes we’ll be able to deliver the

crown with no mesial-distal or very

little, if any, occlusal adjustment, that

we prepare to be able to deliver the

case that way.

BB: So part of that is obviously the accuracy

of the system. Also, because you’re

doing intraoral scanning, you’re seeing

on screen whether you’re capturing the

margin, so you’re actually forced to do

a better job. Can you talk about your

experience along those lines?

PJ: Well, Brad, that is a humbling

experience, to be very honest. Let me

tell you a little anecdotal story. A digital

trainer from the Miami area came to

Doctors have to

understand that

there will be a

big reduction in

the time they

spend in delivery

of the restoration.

– Implant Q&A: An Interview with Dr. Perry Jones – 43


We have

been working

with dedicated

implant scanning

abutments to give

us the information

to create a final

restoration ... in a

100 percent

digital environment.

my office to practice and learn, and

to see a doctor who was recently

introduced to digital scanning. She

said she had a funny story. At first she

couldn’t find the doctor. When she

finally found him sitting in his office,

he had his head in his hands, leaning

on his elbows. He was literally almost

in tears because when he looked at

what was displayed on the screen, he

thought, “I am the worst dentist in the

world. I can’t believe the preps that

I’ve cut.” When you see what’s on the

screen, it makes you become a better

doctor, a better clinician.

I wear four-power loupes when I do

preparations, but to see that on the

screen — if you saw where I started

and where I am today, you would be

able to physically see the difference in

the quality of the preps.

BB: You also get a chance to check that

prep, go back and clean things up, and

scan again.

PJ: That’s right. Absolutely. It greatly

shortens the time it takes to evaluate

your prep and then react to what you

see on screen. For example, you can

outline an area where there is insufficient

occlusal reduction, and then

reduce that area and re-scan only that

area — not the whole prep.

BB: You say you’re going modelless.

Can you tell us a little bit about

articulation?

PJ: I’d love to talk about that because

we’ve done it with Glidewell and have

had fantastic success. In the last year

plus, we have been delivering fullcoverage,

all-zirconia restorations —

your product BruxZir ® Solid Zirconia.

And of the many benefits we’ve

seen, one is a less aggressive prep

than our PFM prep. That is a huge

benefit. Again we have the accuracy

of delivery, so the delivery time is

cut down. And, Brad, at the very

beginning, it was a challenge to look

in the box and go, “Wow, there’s no

model to go with it.” You think, “Is this

really going to work?” And the answer

is, “Yeah, it works. It works with such

accuracy that we’re fully confident

that in both mesial-distal and occlusal

relationships, we’re good to go.”

In recent months, I have started

using semi-adjustable articulators.

However, I will say that even the hinge

articulation is incredibly accurate.

So often it’s the case — especially if

we have mesial and distal full-tooth

contacts, where the prepped tooth

is between an occlusal mesial stop

and an occlusal distal stop — that incredibly

accurate restorations come

back just on that small partial quadrant.

It’s amazing that, universally,

little to no adjustments are necessary

on our restorations.

BB: A lot of our readers may have seen

your article in a recent issue of Inclusive

magazine, the Fall 2011 issue, “From

Intraoral Scan to Final Custom Implant

Restoration,” where you were working

on a BruxZir anterior bridge. Would

you comment on that case?

PJ: That was a huge leap of faith, to

be very honest. That case had two

screw-retained custom zirconia abutments

with a 4-unit bridge attached

to those two abutments. We were restoring

implants in the site of tooth #7

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– www.inclusivemagazine.com –


and tooth #10. And the leap of faith

was that this box shows up, and there

are two screw-retained zirconia abutments

and a 4-unit bridge. I put in the

zirconia abutments and, literally, my

hands were almost shaking to think

what was going to happen when I put

the 4-unit bridge in place. I put it in

place, asked the patient to bite together

— a caveat was that this patient had

such a tight anterior coupling that he

would always break his provisional.

He had a little 4-unit flipper over

the two central incisors that would

break time and time again. This 4-unit

bridge went in place, and he said it

fit perfectly. I said, “OK, let’s check it.”

We checked it with articulating paper,

and I still couldn’t believe it. I called

my son in and asked him to check it,

and he said, “It’s amazing. I can’t believe

it. There are contacts. I can see

coupling marks, and the patient’s

posterior teeth fit together perfectly.”

There was no adjustment on that case,

done 100 percent digital.

BB: In the implant world, not only can

you use the intraoral scanner for scanning

preps, but you can also use it for

scanning the implant. You’ve been involved

with us from the beginning utilizing

the scanning abutment, so can you

comment on your experience so far?

PJ: Well, part of the frustration in getting

started was, there were really just

two big companies: Straumann and 3i,

that were sort of the leaders, the innovators,

having a system to place some

sort of scanning abutment on top of

the implant and get an impression via a

model or via scanning. I’m a big Nobel

guy. I’ve worked with those folks for

years and years and really wanted to

use the Nobel system. I was fortunate,

through a crazy combination of events,

to run into a former Nobel employee

who works here at Glidewell — Grant

Bullis. Grant and I have become collaborators

on working with a system

to be able to use Nobel implants and

be able to scan the information using

digital scanning. We use what we call

dedicated scanning abutments. They’ve

gone through several iterations. Our

first ones were 13 mm in length.

So the concept was: 13 mm implant,

13 mm scanning abutment — it’ll give

us more information. But we found

out that it’s kind of tough to close into

occlusion. So we’ve gone now to a

6.5 mm height scanning abutment,

which seems to work fine. Certainly

for a period over the last six months,

maybe a little longer than that, we have

been working with dedicated implant

scanning abutments for the Nobel

system to give us the information to

create at Glidewell a final restoration

from the information that I send to

you. And that is now done in a 100 percent

digital environment. That’s phenomenal.

Our most current iteration of

that is a custom-milled titanium insert

with an all-zirconia body around it, so

it’s screw-retained. The beauty is that

the interface is titanium-to-titanium

between the implant and the restoration,

so it can be screw-retained. We’re

having phenomenal results with that.

BB: Another benefit of using scanning

abutments is not having to worry about

margins. Do you agree?

PJ: Oh, absolutely. It cannot get more

precise than that. We can take the

analog and reproduce what the scanning

abutment tells us is there. The

phenomenal thing is that it’s done in

a digital environment, as opposed to

modeling. We’ve been very happy with

our results.

BB: Just so our readers understand how

the scanning abutment works, can you

explain the distal impression process?

PJ: Yes. Let’s go through the workflow:

The patient comes in, and let’s say

there’s a healing abutment in place.

We remove the healing abutment and

select the appropriate scanning abutment

for the size of the implant. In

the case of Nobel, it could be a narrow

platform (NP), a regular platform

(RP) or wide body (WP). Then we

place that scanning abutment in place

and digitally scan it. That information

is sent directly to Glidewell Laboratories.

Software at Glidewell allows

us to design what would then be the

final restoration for that case. It could

be many different things — it could

be a cement-retained, or in the cases

that we’re working with mostly now,

a titanium insert with an all-zirconia

body. Where that is derived from is

the scanning abutment that’s screwed

in place, directly to the implant fixture

itself.

BB: Earlier on, we were talking about

the many different indications for

intraoral scanning, and one you

mentioned was guided surgery. Maybe

you can talk a little bit about your

experience with that.

PJ: This is so new to us that we are

just learning all of the nuances. And

some of the workflow has been a little

awkward as we were beginning to try

to make all the parts work. Let’s just

see if we can walk through what we

were actually able to do.

We can create a 3-D rendering of

the information that represents the

patient’s bone and, to some degree,

soft tissue structure, and we can do

that in a 3-D rendering on a computer

screen. That’s derived by way of taking

a cone-beam CT scan and capturing

the information in DICOM files — the

common medical term for passing

that information. The thing that we’re

missing at that point is the accuracy

of the morphology of the occlusion of

the teeth. So if we were to make, let’s

say, a surgical guide, we’d need to have

that accuracy. You don’t get that level

of accuracy from our cone-beam CT.

So the beauty would be, suppose we

– Implant Q&A: An Interview with Dr. Perry Jones – 45


had another way to put the occlusal

accuracy in the very same rendering.

We can do that with the STL files

created by our scan. When the patient

comes in, they’ll have their cone-beam

CT, and they’ll have their scanning

done in the office. Those files, in my

case, are then sent to a third-party

provider. That third-party provider

merges those files together so you

physically can see in the rendering

the accuracy of the STL files and the

morphology of the occlusion of the

teeth and all the bony structures.

Now, in the virtual world, we can

use what I’ll call a “virtual ceramist.”

We can take a software program that

allows us to create a representation

of the crown of the tooth, or multiple

crowns of the teeth, and we can put

that into virtual occlusion and make

sure they are placed where we want

them to be, and then — we’ll call it

a “crown-down” plan — we can go

to the hard tissue. And as you see in

many different implant planning systems,

we can place those implants in

the bone, be sure that the exit hole, or

its relationship to the physical crown,

is proper to that implant, and create a

plan that tells us: this is where we want

the implant to be in terms of the final

restoration. That virtual planning then

can be carried to the next level, which

allows us to send that information to

a computer that can use a milling process

to create a precise surgical guide.

Usually, in the cases we’re doing now,

a little guided cylinder allows you to

place drills sequentially to place the

implant precisely where you planned

it in all dimensions, including depth.

That’s amazing.

BB: We offer a similar service, and we’ve

found that it’s just phenomenal when

you start merging these technologies.

When you merge the cone-beam scan

and the intraoral scan, you’ve got the

soft tissue information, too, which you

really didn’t have before with just the

cone-beam scan. And what we’ve found

through our research is that the fit of a

surgical guide based on an intraoral

scan is superior to other methods.

PJ: That has been my observation,

too. Absolutely. In fact, a case that was

done at Virginia Commonwealth University

in our oral surgery department

comes to mind. One of our residents

actually did the drilling on the case

and he commented, “I think we could

bring the cleaning lady in and she

could do just as well as I can, you’ve

made it so simple with guided surgery.”

They are now strong believers

in the system.

Before I came out to see you guys,

our chairman asked me if the two of

us would collaborate to do a case —

because they believe so much in the

benefit of guided surgery. We’ve done

it with soft tissue; the trick is now

being able to do it with teeth. I think

it’s going to raise the bar in terms of

what doctors can expect, and raise the

bar in terms of what will be expected

of us across the country.

BB: Along those lines of doing toothborne

surgical guides, do you see that

becoming a standard of care for specific

indications, such as single teeth?

PJ: That’s a healthy discussion. A lot

of folks who do surgical placement

feel very comfortable once they’ve

looked at the CT scan that they’re

where they should be. I’ve got to tell

you though, it’s often the case that I’m

disappointed in the placement, and

I think we could do better. I’m not

just talking about not ending up in

the interior alveolar canal; I’m talking

about the relationship to the crown of

the tooth. I think it’s always a help, and

I think where it’s going is getting the

costs to be reasonable. I know there

are many third parties out there who

are doing planning, and I think we

can see that price being driven down.

I know here at Glidewell you have an

awesome deal going. We’re getting

ready to do our first mini implant case

with guided surgery, so I’m looking

forward to seeing how that works. In

fact, I’m here to actually take one of

your courses.

BB: That’s one of our goals, to be

able to provide that service and that

technology at an affordable price, so it

doesn’t become prohibitive. And to let

clinicians know they can use it for other

indications, including single teeth.

PJ: Exactly.

BB: Well, it’s exciting technology, and

it’s obviously the future. I’d like to thank

you for spending time with us today. I’d

also like our readers to know that we’ll

be working with you a lot, and that

there’s going to be a flow of articles like

this in Inclusive magazine.

PJ: I hope to have some articles with

more information about some of the

things that we’re doing. It’s all about

trying to get our family of GPs up to

speed and to understand the things we

can do. I think it’s very exciting. IM

46

– www.inclusivemagazine.com –


LAB

SENSE

Go online for

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by

Back to the Future

The IPS e.max

Screw-Retained Crown

Dzevad Ceranic, CDT

Implant Department General Manager

In processing restorations for more than 160,000 implant

cases, the implant department at Glidewell Laboratories

has accumulated a unique understanding of the industry

as a whole. Among the recent trends observed at Glidewell

Laboratories is the demand for monolithic screw-retained

restorations such as the IPS e.max ® screw-retained crown

(Ivoclar Vivadent; Amherst, N.Y.). While screw-retained

restorations represent a long-accepted prosthetic solution,

the combination of this restorative paradigm with strong,

highly esthetic monolithic materials and cutting-edge

CAD/CAM digital technology has allowed us to produce

an exciting alternative to conventionally processed PFM

implant restorations.

IPS e.max lithium disilicate has already established itself

as a leading ceramic in conventional crown & bridge cases,

highly regarded for its unique blend of flexural strength

(360–400 MPa) and natural esthetics. Available in multiple

translucencies, IPS e.max provides lab technicians with

great flexibility and ease of use when it comes to matching

the warmth and shade of natural dentition. And because

there is no porcelain veneer, there is no risk of porcelain

chipping or fracture.

By affixing IPS e.max to a screw-retained titanium base in

the lab, doctors and their patients receive the full benefits

of both the material and a screw-retained design. There

are additional benefits inherent in the CAD/CAM processes

used to fabricate these restorations. One such benefit is

reduced cost, as an IPS e.max screw-retained crown is less

expensive to produce than a traditional screw-retained PFM

from a UCLA wax-up. A second benefit is reduced lab time,

as the typical turnaround for an IPS e.max screw-retained

crown is typically half of that required for a crown over a

custom abutment.

The combination of … strong, highly esthetic

monolithic materials and cutting-edge CAD/CAM

digital technology has allowed us to produce an

exciting alternative to conventionally processed

PFM implant restorations.

– Lab Sense: The IPS e.max Screw-Retained Crown – 47


PRODUCTION WORKFLOW

The following overview provides a brief, insider’s look at

the state-of-the-art process employed at Glidewell Laboratories

to digitally design and fabricate an IPS e.max

screw-retained crown.

Step 1: Model Scan

For the first optical scan, a soft tissue study model is

created from conventional impressions, and a scanning

abutment is attached to the implant analog, serving to

capture the implant angulation, position, and abutment

connection orientation (Fig. 1). The scanning abutment is

then removed and the arch is scanned a second time, with

the soft tissue mask in place. A scan of the opposing model,

followed by a scan of the fully articulated casts enables the

design software to construct and properly align a complete

3-D model.

Step 2: Digital Design

Once the fully articulated case exists in a virtual environment,

the restoration can be digitally designed using software that

contains a proprietary library of morphology (Figs. 2, 3).

The software enables the technician to exercise

precise control, measured in mere microns.

The technician refines the emergence profile, interproximal

contacts and occlusion — every aspect that would be

estimated and executed by hand if using a conventional

wax-up technique. The software enables the technician to

exercise precise control, measured in mere microns. Such

detailed, comprehensive control is especially critical with

implant restorations, which must be built up subgingivally

from the implant platform, rather than simply dropped onto

a natural tooth prep.

Step 3: Perfactory Crown Printing

Once the digital restoration is complete, the electronic file is

forwarded to a Perfactory ® printer (envisionTEC; Torrance,

Calif.) for three-dimensional printing. The Perfactory system

builds solid 3-D objects by using a DLP ® projector (Texas

Instruments; Dallas, Texas) to project sequential planes of

data into a photoactive liquid resin, causing the affected

resin to cure from liquid to solid. Each data plane is made

Figure 1: Onscreen display showing full-arch model

scan with digital scanning abutment

Figure 2: Computer-aided design of restoration in a

virtual environment

Figure 3: Completed virtual design of screw-retained

implant crown

Figure 4: Plate of printed Perfactory crowns

Figure 5: Individual Perfactory crown and titanium base

48

– www.inclusivemagazine.com –


up of tiny voxels (volume pixels), allowing the printer to

produce, layer by layer, a physical duplicate that precisely

matches the form set by the design pattern (Figs. 4, 5). The

entire printing and curing process takes a little less than

two hours, after which the physical crown can be tested on

the model to ensure proper fit.

Step 4: Ceramic Pressing

Once proper fit is verified, the Perfactory crown is sprued

and invested for ceramic pressing using a traditional lostwax

technique and the appropriate weight and shade of

IPS e.max Press ingots (Figs. 6, 7). After divesting, the IPS

e.max crown has the exact form and shape of the original

printed pattern.

Step 5: Finishing

During finishing, the pressed IPS e.max crown undergoes

a comprehensive quality control inspection to ensure

accurate fit, contacts, and occlusion. After being trimmed

and polished (Fig. 8), the all-ceramic crown is stained and

glazed to match the doctor’s specific instructions concerning

final esthetics (Fig. 9).

Step 6: Cementation and Delivery

Finally, the IPS e.max crown is luted to a premachined

titanium base (Fig. 10). Performing this step in the lab

makes it easy to remove excess cement (Fig. 11). The crown

is then shipped to the prescribing doctor, along with

a positioning index (jig) that can be used at the time of

delivery to ensure and maintain complete, accurate seating

of the restoration while the abutment screw is inserted

and tightened.

SUMMARY

Glidewell Laboratories has long been a proponent of

CAD/CAM technology as a way to produce restorations that

are more precise and less expensive to manufacture, making

them more accessible to a greater number of patients. The

IPS e.max screw-retained crown is another example of this

technology being used to merge proven restorative concepts

with the latest biomimetic materials. For doctors looking

to place a screw-retained restoration that exhibits both

strength and esthetics, IPS e.max represents an advanced

solution at an affordable price. IM

Figure 6: Invested pattern ready for burnout oven

Figure 7: Invested pattern ready for press furnace

Figure 8: Trimming and polishing the all-ceramic

IPS e.max crown

Figure 9: Staining the all-ceramic IPS e.max crown

Figure 10: In-lab cementation of the IPS e.max crown

to its titanium base

Figure 11: Final IPS e.max screw-retained crown

free of excess cement

– Lab Sense: The IPS e.max Screw-Retained Crown – 49


The Critical Nature of Tissue Contouring

from a Periodontist’s Perspective

by Robert A. Horowitz, DDS

■ The Importance of Peri-Implant Health

Most people who need dental implants have lost their

teeth due to restorative or endodontic complications,

or to the ravages of periodontal disease. These conditions

result either from failure of the patient to properly

cleanse, or from iatrogenic dentistry that has left uncleansable

margins.

Once patients lose their teeth, there is often bone loss

as well as a loss of keratinized tissue. This can lead to

black triangle disease, the loss of gingival papillae between

teeth that may result in esthetically compromised

restorations or significant interdental food impaction.

As there is a different attachment apparatus from the

gingiva to implants compared to that of natural teeth,

there is more susceptibility to peri-implant disease from

proximal inflammation. Published periodontal literature

has shown that when periodontal measurements are

taken around implants with inflamed soft tissues, the

endodontic probe tip reaches the alveolar bone. Due to

inflammation, bone loss around implants can be quicker

and more catastrophic than around natural teeth.

An ideal implant-supported restoration, then, should have

the same gingival contours and proximal contacts it would

have were it a natural tooth. It is the goal of the surgeon

to maximize bone and soft tissue preservation at the time

of extraction. If a tooth is not extracted properly, or if the

alveolar bone and keratinized tissue are not preserved at

the time of extraction, multiple surgical procedures may

be required to regenerate or rebuild the alveolar housing,

further lengthening and complicating treatment.

Using properly designed temporary and final restorative

components enables an ideal emergence profile to be

engineered from the shoulder of the implant through the

keratinized tissues to the contact point. When all these

pieces of the restorative puzzle come together properly,

the patient will have an ideal environment for keeping

the area free of inflammation. Minimizing inflammation

increases the longevity of the alveolar bone, keratinized

tissue, and the dental implant.

An ideal implant-supported

restoration should have the

same gingival contours and

proximal contacts it would

have were it a natural tooth.

■ Soft Tissue Contouring and

Successful Implant Restorations

Natural teeth and crowns have certain self-cleansing

contours. Contact points are located at different heights

from the alveolar ridge, depending on the location of the

tooth in the arch. Buccal and lingual contour heights also

vary depending on the tooth. Proper sculpting of the soft

tissues around an implant-supported crown will help keep

the gingiva at a similar height to that of a natural toothsupported

crown. In this manner, the natural actions of

the lips and tongue help move food and plaque away

from the gingival margin, rather than packing it into large

spaces between the contact point and the gingival margin,

or allowing it to build up on the facial or lingual surfaces

in a more receded environment.

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After most extractions, a loss of facial bone occurs in the

vertical and horizontal dimensions. This bone loss can

be regained surgically or prosthetically; however, adding

facial bone around an implant requires the use of grafts,

barriers, and techniques that are often more advanced

than the average practitioner is prepared for. Therefore,

preserving the facial and lingual surfaces with bone at the

time of extraction is a more predictable procedure. If the

surgeon is not familiar with these techniques, however,

and their value is not communicated to the patient, the

patient will likely experience a site collapse (Figs. 1a–1c).

The most ideal time to augment the soft tissue profile is at

the time of conventional implant placement.

Figure 1c: This can give the final crown the appearance of being “stuck” on

the gingiva.

■ Understanding the Limitations of

Stock Components

Stock or standard abutments are designed in the shape

of a perfect circle at the shoulder, or prosthetic base, of

the abutment. The problem with this standard design is

that no naturally occurring tooth is perfectly round at

the alveolar crest or the cementoenamel junction (CEJ).

While flared healing abutments are available, these

stock components still provide only a generic solution,

forming gingival contours that may be less than ideal for a

specific patient.

Figure 1a: After extraction, there is often site collapse necessitating implant

placement further palatally to ensure 2 mm of bone on the facial aspect of

the implant.

To sculpt the soft tissues around an implant, the surgeon

or restorative dentist should mimic the shape of the soft

tissue around the natural tooth in that same area. There are

numerous ways to do this. Many dentists take an implantlevel

impression, insert a round healing abutment, and

let the laboratory do the rest (Fig. 2). But if the laboratory

makes an overly bulky crown or abutment that squeezes,

pushes or compresses the gingival tissues, there is no way

to account for the potential recession that can result. If the

dentist places a stock final abutment on the implant and

Figure 1b: In such cases, to ensure proper occlusion and esthetics, the restoration

requires a facial cantilever of porcelain.

Figure 2: Implant placed properly in center of ridge. Note there is no tissue

sculpting with this conventional, non-contoured healing abutment.

– The Critical Nature of Tissue Contouring from a Periodontist’s Perspective – 51


attempts to shape the tissues with a cementable temporary

crown, there are two potential problems: depending on

the depths of the margin subgingivally, the crown may

not seat fully, leading to a dislodging of the crown and

the gingiva growing over the margins of the abutment. To

avoid this, the dentist may fill the crown with cement and

seat it using excessive pressure; however, this can cause the

cement to be expressed subgingivally around the abutment

or even the implant itself, leading to inflammation and

bone loss.

The optimal treatment for obtaining an esthetic result

around an implant is to place an ideally shaped transitional

restoration (Figs. 3a, 3b). This includes the crown

and — more importantly — the abutment. The abutment

must be shaped in such a way to develop smooth

transitions from the round prosthetic connection of the

implant to the various unique tooth shapes at the CEJ.

The abutment should be at a proper gingival height,

so that any expressed cement can easily be located and

removed. With this accomplished, the transitional crown

will affect the rest of the tissue sculpting.

After soft tissue sculpting has proceeded for one to three

months, the patient is ready for final impressions (Fig. 4).

At this time, the soft tissue dimensions and positions

must be accurately transferred to the laboratory. Using

Figure 3b: Upon insertion of the crown, the gingival tissue is slightly compressed

facially and on the interproximal surfaces. This cannot be accomplished with a

cement-retained restoration without risking residual subgingival cement.

The problem with this

standard design is that no

naturally occurring tooth

is perfectly round.

Figure 3a: Transitional screw-retained crown.

Figure 4: After the tissue has been sculpted with an ideal provisional restoration,

the emergence profile is established 360 degrees around the shoulder of

the implant, up to the contact points.

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computer technology, the ideal emergence profile of the

restoration can then be designed (Fig. 5), and a patientspecific

final restoration created (Figs. 6a–6d).

Figure 6c: Final radiograph shows proximal sculpting of the soft tissues by the

restoration, starting at the abutment-fixture junction.

Figure 5: CAD file showing fabrication of a screw-retained BruxZir ® crown.

This one-piece restoration is designed to the ideal contours and contacts in a

virtual environment.

Figure 6d: Ideal gingival contours one month after insertion of the restoration.

Figure 6a: The lab returns the finished abutment and crown.

Figure 6b: Close inspection of the final restoration shows no cement line, with

smooth contours to maintain the shape of the gingival tissues.

■ Patient-Specific Tissue Contouring:

Working with the Inclusive Tooth

Replacement Solution

Making optimal treatment possible, the Inclusive ® Tooth

Replacement Solution from Glidewell Laboratories gives

the surgeon the ability to place an implant ideally and

begin sculpting the soft tissue on the day of implant

placement. A prosthetic guide fabricated from highly

accurate diagnostic casts is delivered to the surgeon,

enabling ideal implant placement from a prosthetic

perspective that is unique to the patient. Radiography is

then utilized to determine the appropriate implant size.

This would be for conventional placement. There is also a

CT-based option that includes a digital implant plan and

surgical guide.

– The Critical Nature of Tissue Contouring from a Periodontist’s Perspective – 53


As implant dentistry is a restoratively driven surgical

discipline, an ideal crown surrounded and supported

by keratinized tissue should be the ideal end-point of

most implant therapy. The Inclusive Tooth Replacement

Solution helps the surgeon and the restorative dentist

achieve this goal.

With the team approach, the surgeon places the implant

and — in most cases — the custom healing abutment

(Fig. 7a). This will begin to sculpt the soft tissue and

aid in the creation of an ideal emergence profile, all

before the patient returns to the restorative dentist

(Fig. 7b). When ready to proceed, the restorative dentist

temporizes the patient (utilizing the custom temporary

abutment and crown) and then transfers the soft tissue

contour information to the laboratory using the custom

impression coping. The final custom abutment and crown

are delivered to the dentist and ultimately the patient is

definitively restored.

Figure 7b: After removal of the healing abutment, the gingival tissues have

been shaped to the custom-designed configuration.

As implant dentistry is a

restoratively driven surgical

discipline, an ideal crown

surrounded and supported

by keratinized tissue should

be the ideal end-point of

most implant therapy.

From a specialist’s perspective, this is an excellent practice

builder because the restorative dentist does not incur

any laboratory fees or component charges for either the

temporary crown or final restoration. The patient may also

be temporized sooner than they otherwise would, and the

overall restoration provides for better peri-implant health.

Restoring form, function, and esthetics is a given for all

clinicians involved in implant dentistry. It is of course

critical that clinicians understand the importance of periimplant

health from a preventive standpoint and educate

patients along the way. But as we continue to encounter

those who would benefit most from implant therapy, it

is vital that we appreciate the direct correlation between

patient-specific soft tissue contouring and successful implant

restorations, and start to consider the individualized

solutions that are finally at our disposal. Modern dentistry

continues to evolve toward more precision and predictability

when we are able to address the unique needs of

each patient. IM

Figure 7a: The custom healing abutment included with the Inclusive Tooth

Replacement Solution is packaged with a matching impression coping, custom

temporary abutment and provisional crown. From the occlusal view, the shape

of a molar tooth is evident.

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CLINICAL

TIP

Go online for

in-depth content

Modifying Inclusive Custom

Temporary Components

by

Bradley C. Bockhorst, DMD

Temporizing implants can provide multiple benefits, including managing the soft

tissues, preventing the adjacent teeth from shifting, and providing the prosthetic

prototype for the final restorations. The custom temporary abutment and

BioTemps ® provisional crown packaged with the Inclusive ® Tooth Replacement

Solution are fabricated presurgically and will most likely need to be adjusted at

the time of delivery.

Each Inclusive custom temporary abutment is precision-milled from

specifically compounded, medical-grade polyether ether ketone (PEEK), a

thermoplastic material with excellent mechanical and chemical resistance

properties. This advanced biomaterial is used in medical implants and

has a proven long-term track record in dental implantology. These

temporary abutments can easily be adjusted and polished chairside.

BioTemps crowns are milled from poly(methyl methacrylate) (PMMA)

and should be relined with a compatible material (i.e., cold-cured

MMA, Jet Acrylic [Lang Dental; Wheeling, Ill.], ColdPac [Yates Motloid;

Chicago, Ill.] or Palavit ® 55 [Heraeus Kulzer; South Bend, Ind.]). Other

reline materials such as composites and ethyl methacrylate will only

semi-chemically bond to the BioTemps material.

Note: Roughening up the surface or creating grooves

in the abutment with a diamond bur or disc will create

a mechanical retention. This would be done after the

crown is relined, prior to cementation.

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Adjusting the Inclusive Custom Temporary Abutment

1Place the temporary abutment on

the implant and tighten the abutment

screw.

2Seat the BioTemps crown on the

abutment and adjust contacts as

needed.

3Remove the BioTemps crown, and

mark the areas on the abutment to

be adjusted.

4Remove the temporary abutment,

and mount it on an implant analog

for ease of handling. Use a

diamond or acrylic bur to do the

bulk reduction.

5 Smooth and polish the abutment with a polishing wheel and bristle brush.

Reseat the temporary abutment intraorally and tighten the abutment screw. Seat

the BioTemps crown to verify the adjustments. Repeat the process as needed.

Once the adjustments are completed, the BioTemps crown should be relined.

– Clinical Tip: Modifying Inclusive Custom Temporary Components – 57


Relining the BioTemps Crown

If there is marginal fit of the BioTemps crown to the temporary abutment, the

reline can be done extraorally. Otherwise, the BioTemps crown should be relined

on the abutment in the mouth following standard procedure. In this case, the

goal was to lower the buccal margin for esthetic purposes, while leaving the

interproximal and palatal margins supragingival to facilitate hygiene and removal

of excess cement. IM

6Roughen the surface of the Bio-

Temps crown where temporary

acrylic will be added.

7Place the crown on the adjusted

temporary abutment.

Add temporary acrylic to the

8 crown.

The custom temporary abutment and BioTemps provisional crown …

are fabricated presurgically and will most likely need to be adjusted

at the time of delivery.

9 Adjust the crown with an acrylic bur and finish with a polishing wheel. Reglaze the crown. Palaseal®

10 (Heraeus Kulzer) would be a

chairside option.

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Delivering the Provisional Restoration

Seat the abutment on the implant, and ensure the screw is tightened to

11 15 Ncm. Note: If the vertical height is short, you may want to “roughen

up” the coronal section of the abutment to provide additional mechanical

retention for the crown.

Seal the screw access opening

12 with Teflon tape.

Cement the BioTemps crown

13 with a non-eugenol temporary

cement. Important: Ensure all

excess cement is removed.

Recheck the occlusion and

14 schedule the patient for a

follow-up appointment.

– Clinical Tip: Modifying Inclusive Custom Temporary Components – 59


Congratulations, Inclusive Contest Winners!

Thank you to all of the dentists who participated in last issue’s challenge, “How Many Implants?”

Did your estimates come close to the correct answers below?

Length: 13 mm

Diameter: 3.7 mm

Mass: 0.29 g

Surface Area: 319.14 mm 2

Surface Roughness (Ra): 1.5μ

Center of Mass: Y = -6.52 mm

Nitrogen Content (Max.): 0.05%

Oxygen Content (Max.): 0.130%

300

Internal Hex Depth: 2.0 mm

Bonus Question Answer: With these implants inside, this 100 ml beaker would hold 62 ml of water.

To reward your efforts, everyone who participated will receive one free Inclusive ® Custom Abutment

of their choice. The one dentist among you who correctly answered the Bonus Question will also receive

one free BruxZir ® Solid Zirconia crown.

Inclusive Contest entries were individually scored after being sent to the lab via e-mail and standard mail. Prizewinners were notified by standard mail and/or phone.

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