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Inclusive
Restorative Driven Implant Solutions Vol. 4, Issue 2
A Multimedia Publication of Glidewell Laboratories • www.inclusivemagazine.com
Mini Implants and the General Dentist
Dr. Gordon Christensen
Page 20
Clinical Advantages of Custom Abutments
Dr. Jack Hahn
Page 29
Reducing Treatment Time with
Digital Dentistry
Dr. Dean Saiki and Grant Bullis
Page 36
Optical Impressions and Full-Arch
Implant Restorations
Drs. Guy Rosenstiel and Michael McCracken
Page 67
COLUMNS
‘My First Implant’
gIDE Institute’s
Dr. Sascha Jovanovic
Recounts His Path
to Implantology
Page 25
Implant Q&A:
Dr. Dennis Tarnow
Clinical Professor of Periodontology and
Director of Implant Education
Columbia University College of Dental Medicine
New York, N.Y.
Page 9
For more exclusive content, visit www.inclusivemagazine.com
Watch Video Presentations • View Clinical Case Photos • Earn CE Credit

On the Web
Here’s a sneak peek at additional
Inclusive magazine content available online
ONLINE Video Presentations
■ Dr. Dennis Tarnow reflects on the changing world of implant dentistry,
exploring dental education, implant spacing, the international
implant marketplace and more.
■ Dr. Gordon Christensen offers his thoughts on the growing role of
general practitioners in placing implants, the benefits of mini implants
and the ongoing debate over restorative materials.
■ Dr. Timothy Kosinski illustrates the clinical flexibility of the Inclusive
® Tooth Replacement System by summarizing the restoration of
an edentulous anterior maxilla with an implant-retained bridge.
■ Dr. Perry Jones discusses how digital scanning, CBCT, guided surgery
and treatment planning software are improving the predictability of
restorative outcomes.
■ Dzevad Ceranic, CDT, details the laboratory production of a
Screw-Retained Hybrid Denture, demonstrating the efficiency of an
all-in-one approach to implant therapy.
■ Two-Day Custom Abutments and Crowns: Learn about taking advantage
of the latest digital impression systems and CAD/CAM technology
with digitally produced custom abutments and crowns from
Glidewell Laboratories.
Inclusive Magazine Digital Edition
Inclusive magazine is now optimized for all
popular desktop, tablet and smartphone
platforms. To try out the new digital edition from
your computer or favorite mobile device, visit
www.inclusivemagazine.com.
Look for these icons on the pages that follow
for additional content available online
■ R&D Corner: Catch a glimpse of digital implant restorations from taking
and submitting the digital impression through CAD/CAM design
and fabrication of the abutment and crown in “Digital in a Day.”
gide lecture-on-demand preview
■ Dr. Egon Euwe presents key considerations involved in effectively
managing soft tissue when treatment planning and completing an
implant restoration in this excerpt from the gIDE video lecture “Soft
Tissue Management Around Implants.”
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
9
20
29
36
Implant Q&A: An Interview with Dr. Dennis Tarnow
Dr. Dennis Tarnow — In this exclusive interview, Dr. Dennis
Tarnow, clinical professor of periodontology and director of implant
education at Columbia University College of Dental Medicine
in New York, shares his experience as a clinician, researcher and
educator. Discover what this expert thinks on topics ranging from
the relationship between endodontics and implantology, to training
the general dentist to place implants, to immediate loading, biologic
width, guided surgery and digital scanning.
Mini Implants: Insight from Dr. Gordon Christensen
Dr. Gordon Christensen — Dr. Gordon Christensen, director of
Practical Clinical Courses and CEO of CLINICIANS REPORT, has
shared his knowledge and experience with Glidewell Laboratories
on numerous occasions. This article recounts his recent insights on
the current and future state of implants, detailing his thoughts on
mini implants as a permanent solution, the advantages of mini implants
for both patients and clinicians, and the factors that can lead
to their failure or success.
The Clinical Advantages of Custom Abutments
Dr. Jack Hahn — Custom abutments are an excellent option for
implant treatment, with advantages including patient-specific soft
tissue management during the healing phase and final restorations
that adhere precisely to the patient’s gingival architecture. Even so,
many doctors are hesitant to make the switch from stock abutments.
Dr. Jack Hahn discusses his conversion to custom abutments,
highlighting the efficiency, precision, cost-effectiveness, and optimal
functional and esthetic outcomes these customized, digitally produced
components provide over their generic counterparts.
Reducing Treatment Time with Digital Dentistry
Dr. Dean Saiki and Grant Bullis — For edentulous patients with
ill-fitting lower dentures, persistent soreness can make wearing
their denture difficult, even with periodic relines. Screw-retained
fixed implant restorations can greatly improve comfort and chewing
function for these patients. Dr. Dean Saiki and Glidewell Laboratories
Director of Implant R&D and Digital Manufacturing Grant
Bullis use a case example to explain how advanced treatment protocols
that leverage digital impressions, treatment planning, guided
surgery and dental CAD/CAM technology can transform implant
therapy, shorten treatment times and improve prosthetic outcomes.
– Contents – 1

Contents
49
55
Bridging the Gap: Restoring Partially Edentulous
Spaces and Maximizing Treatment Options with the
Inclusive ® Tooth Replacement System
Dr. Timothy Kosinski — Continual improvements in surgical and
restorative technology, materials and methodology are allowing
clinicians to approach implant cases with more certainty and
predictability than ever before. Dr. Timothy Kosinski explores
how these advances in implantology are maximizing the range of
treatment options available to patients, presenting an edentulous
maxillary anterior case that illustrates how a comprehensive
approach to implant dentistry that uses patient-specific components
and CAD/CAM technology can help to guide any case toward
predictable success.
Clinical Case Report: iTero ® Digital Scanning
Technology and Tooth-Supported Surgical Guides
Dr. Perry Jones and Zach Dalmau — Digital scanning technology
used in conjunction with CBCT scanning can offer a high level of
confidence to practitioners both in terms of implant placement and
implant restoration. With a clinical case report involving the replacement
of two missing maxillary left bicuspids, Dr. Perry Jones
and Zach Dalmau show how digital technology can be used to capture
data and design and fabricate tooth-supported surgical guides,
temporary abutments, cement-retained provisional crowns and final
zirconia restorations with the highest level of accuracy.
ALSO IN THIS ISSUE
8 Trends in Implant Dentistry
Model-Less Restorations
25 My First Implant
gIDE Institute’s
Dr. Sascha Jovanovic
46 Product Spotlight
Two-Day Custom Abutments and
Crowns from Intraoral Scans
73 Lab Sense
All Together Now: Inclusive ® Tooth
Replacement System Removables
79 Clinical Tip
Managing Implants in
Patients with Bruxism
83 Small Diameter Implants
Benefits of CBCT-Assisted
Guided Surgery
67
Optical Impressions and
Full-Arch Implant Restorations: A Case Study
Drs. Guy Rosenstiel and Michael McCracken — When restoring
implant cases, clinicians strive for accurate impressions and wellfitting
restorations, yet highly accurate implant impressions can
be difficult to achieve using conventional methods. In a case
study involving a full-arch maxillary implant restoration, Drs. Guy
Rosenstiel and Michael McCracken detail a cutting-edge impression
technique that utilizes scanning abutments and an optical scanner,
demonstrating how this all-digital process can increase impression
accuracy and improve the fit of the final restoration, while saving
the clinician time and money.
2
– www.inclusivemagazine.com –

Letter from the Editor
This issue of Inclusive magazine showcases some of the leaders in the
field of implant dentistry. Implant dentistry is in a state of constant
evolution, with breakthroughs in digital and CAD/CAM technologies
at the forefront. Coupled with practice decisions relying on evidencebased
dentistry, strong scientific research and a focus on improved dental
materials, these technologies position implantology at the leading edge
of dentistry.
An exclusive interview with Dr. Dennis Tarnow of Columbia University
College of Dental Medicine touches on his journey in implant dentistry,
offering a historical perspective, current trends and what he believes
the future holds. Continuing education is the basis for personal growth
for clinicians and desired outcomes for patients. As one of the most wellrespected
practitioners and educators in our field, Dr. Tarnow speaks to this
importance and other implant-related topics that are well worth the read.
As clinicians, we’re constantly looking for ways to improve quality of life
for our patients. Providing solutions to patients with moderate to severe
bone loss who are not candidates for bone grafting procedures and face
socioeconomic challenges has always been difficult. The validation of
the use of small-diameter implants for the retention of tissue-supported
removable prostheses allows practitioners to address these patients’
concerns. Drawing from his years of experience as a prosthodontist and
educator, Dr. Gordon Christensen discusses his experience with smalldiameter
implants and current trends in patient treatment.
Several articles highlight the use of intraoral scans to initiate a completely
digital workflow, from the diagnostic phase through delivery of the
temporary and final restorations. Complemented with the merging of
intraoral scan data and DICOM data from CBCT scans, precision in
treatment planning and implant placement has reached a new level.
Take note of the digital workflow incorporated at the laboratory level to
fabricate case-specific custom temporary components and final abutments,
allowing for efficiency in tissue contouring.
As you’ll discover in this issue, the combination of esthetics, science,
materials and technology makes for an interesting and exciting future for
implant dentistry.
With kind regards,
Dr. Siamak Abai
Editor-in-Chief, Clinical Editor
inclusivemagazine@glidewelldental.com
– Letter from the Editor – 3

Contributors
■ SIAMAK ABAI, DDS, MMedSc
Dr. Siamak Abai earned his DDS degree from
Columbia University in 2004, followed by
two years of residency in general dentistry.
After two years of general private practice
in Huntington Beach, Calif., he returned to
academia and received an MMedSc degree
and a certificate in prosthodontics from
Harvard University. Dr. Abai brings nearly 10 years of clinical,
research and lecturing experience to his role as director of
clinical research and development for the Implant division
of Glidewell Laboratories. He is also editor-in-chief and
clinical editor of Inclusive magazine. Before joining Glidewell
in January 2012, Dr. Abai practiced at the Wöhrle Dental
Implant Clinic in Newport Beach, Calif. Contact him at
inclusivemagazine@glidewelldental.com.
■ DZEVAD CERANIC, CDT
Dzevad began his career at Glidewell Laboratories
in 1999 as a waxer and metal finisher,
working his way up to ceramist. In 2007, he was
promoted to general manager of the Full-Cast
department, successfully conducting a complete
turnaround of that business in 18 months.
Dzevad completed the eight-month “Implants
A to Z” course at UCLA School of Dentistry in 2009, while
assuming a new role as general manager of the Glidewell Laboratories
Implant department. Dzevad has spearheaded an annual
department growth of more than 38 percent for four consecutive
years, leading to his 2013 promotion to vice president of lab
operations. Dzevad has a certificate in dental technology from
Pasadena City College and recently completed a management
development program at the USC Marshall School of Business.
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 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 ® Mini Implants, Tapered Implant
System and Custom Implant Abutments. In 2010, he was
promoted to director and now oversees all aspects of CAD/CAM,
implant product development and manufacturing for more
than 1,000 implant and prosthetic components at the lab. He
has an MBA from the Keller Graduate School of Management.
Contact him at inclusivemagazine@glidewelldental.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 at
nSequence, he played a key role in building the
CT guided implant surgery and 3-D diagnostic
imaging departments there 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 Glidewell Laboratories in October 2011
and plays a key role in the company’s R&D efforts for digital
treatment planning and implant manufacturing. Contact him
at inclusivemagazine@glidewelldental.com.
■ David Casper, MBA
David Casper is president of San Diegobased
IOS Technologies Inc., a wholly owned
subsidiary of Glidewell Laboratories and
manufacturer of the IOS FastDesign System.
After beginning his dental industry career
at CeraMed in 1990, David went on to hold
various positions in sales and global marketing
for Nobel Biocare, GE and Sybron Implant Solutions. He joined
Glidewell in 2011 as vice president of implant sales & business
development, contributing significantly to the lab’s growth
through his business development efforts. David assumed his
current role as president of IOS Technologies in June 2012.
He has an MBA from LaSalle University. Contact him at
inclusivemagazine@glidewelldental.com.
■ GORDON J. CHRISTENSEN, DDS, MSD, Ph.D.
Dr. Gordon Christensen is a practicing
prosthodontist in Provo, Utah. He is director
of Practical Clinical Courses and CEO of
CLINICIANS REPORT ® . He is also 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 and his wife
Rella are co-founders of the nonprofit Gordon J. Christensen
CLINICIANS REPORT (formerly CRA Newsletter). Contact him
at 801-226-6569 or info@pccdental.com.
4
– www.inclusivemagazine.com –

■ JACK A. HAHN, DDS
Dr. Jack Hahn earned his DDS from The Ohio
State University College of Dentistry, and
completed postgraduate coursework at Boston
University, New York University, the University
of Michigan and the University of Kentucky.
A pioneer in the field of implant dentistry,
Dr. Hahn developed the NobelReplace dental
implant system for Nobel Biocare and has been actively involved
in placing and restoring implants for 40 years. In addition
to lecturing to dentists around the world, he maintains a
private practice in Cincinnati, Ohio, focused on placing and
restoring implants. He received the Aaron Gershkoff Lifetime
Achievement Award in implant dentistry in 2004. Contact him
at replace7@mac.com.
■ TIMOTHY F. KOSINSKI, DDS, MAGD
Dr. Timothy Kosinski graduated from the University
of Detroit Mercy School of Dentistry
and received a Master of Science degree in biochemistry
from Wayne State University School
of Medicine. An adjunct assistant professor
at UDM School of Dentistry, he serves on the
editorial review board of numerous dental
journals and is a Diplomate of the ABOI/ID, ICOI and AO.
Dr. Kosinski is a Fellow of the AAID and received his Mastership
in the AGD, from which he received the 2009 Lifelong Learning
and Service Recognition award. Contact him at 248 -646 -8651,
drkosin@aol.com or www.smilecreator.net.
■ PERRY E. JONES, DDS, MAGD
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.
■ SASCHA A. JOVANOVIC, DDS, MS
Dr. Sascha Jovanovic received his training in
periodontics, implant dentistry and prosthodontics
at UCLA School of Dentistry, Loma
Linda University and University of Aachen in
Germany, respectively, and holds a Master of
Science degree in oral biology from UCLA. He
maintains a private practice in Los Angeles,
specializing in dental implants and periodontics, and is academic
chairman of the Global Institute for Dental Education
(gIDE) and course director of implant dentistry for UCLA Continuing
Dental Education. Dr. Jovanovic lectures worldwide
and has published numerous materials on implant dentistry.
Contact him at 310-820-9641 or sascha@jovanoviconline.com.
■ MICHAEL McCRACKEN, DDS, Ph.D.
Dr. Michael McCracken is co-director of the
Comprehensive Implant Residency Program
(CIRP), a yearlong comprehensive implant
education institute in Birmingham, Ala. After
completing dental school at University of
North Carolina at Chapel Hill and a prosthodontic
residency at University of Alabama
at Birmingham, he received a Ph.D. in biomedical engineering.
Dr. McCracken is a part-time professor at UAB, where
he has served as associate dean for education, director of
graduate prosthodontics and director of the implant training
program. He maintains an active research program within
the university and a private practice focused on implant dentistry.
He lectures internationally on dental implants and
complex oral rehabilitation. Contact him at 256-797-1964 or
inclusivemagazine@glidewelldental.com.
– Contributors – 5

Contributors
■ Guy Rosenstiel, DMD, MAGD
Dr. Guy Rosenstiel received his dental degree
from the University of Alabama School of
Dentistry and completed a general practice
residency at the Birmingham VA Medical
Center. He teaches continuing dental education
involving implant surgery and implant prosthodontics
to private practitioners and AEGD
residents through CIRP in Bessemer, Ala. His interests in IV
sedation, surgery and all aspects of general dental practice
enable him to continually enjoy his career as a dentist, both as
a faculty member and as a private practitioner. Contact him at
205-979-8655 or drguy@agd.org.
■ Dean H. Saiki, DDS
Dr. Dean Saiki graduated from the USC
School of Dentistry in 1988. He maintains a
private practice in North County San Diego,
Calif., specializing in cosmetic, laser, implant
and digital dentistry. He has been a member
of the ADA, CDA and San Diego County
Dental Society since 1989, as well as other
advanced study clubs including the Trojan Dental Study Club.
Dr. Saiki is trained and certified in dental soft tissue lasers
and CAD/CAM technology. Contact him at 760-732-3456 or
dentist@deansaiki.com.
■ Dennis P. Tarnow, DDS
Dr. Dennis Tarnow is currently clinical
professor of periodontology and director of
implant education at Columbia University
College of Dental Medicine. Formerly, he was
a professor and chairman of the Department
of Periodontology and Implant Dentistry
at New York University College of Dentistry
(NYUCD). Dr. Tarnow has certificates in periodontics and
prosthodontics from NYUCD and is a Diplomate of the American
Board of Periodontology. He also has a private practice in
New York City. Dr. Tarnow has published more than
100 articles on perio-prosthodontics and implant dentistry,
co-authored several textbooks and lectured extensively in the
U.S. and internationally. Contact him at 212-752-7937 or
www.nycsdonline.com.
Publisher
Jim Glidewell, CDT
Editor-in-Chief, clinical editor
Siamak Abai, DDS, MMedSc
Inclusive Marketing & Education Manager
Jennifer Archer
Managing Editors
Grant Bullis; David Casper;
Dzevad Ceranic, CDT; Greg Minzenmayer
Creative Director
Rachel Pacillas
Copywriters/copy editors
David Frickman, Jennifer Holstein,
Chris Newcomb, Keith Peters, Tina Quan,
Megan Strong, Eldon Thompson
digital marketing manager
Kevin Keithley
Graphic Designers/Web Designers
Emily Arata, Jamie Austin, Deb Evans,
Juan Gallardo, Kevin Greene, Joel Guerra,
Tony Hsiao, Audrey Kame, Allison Newell,
Phil Nguyen, Ty Tran, Makara You
Photographers/Videographers
Sharon Dowd, Mariela Lopez;
James Kwasniewski, Andrew Lee,
Marc Repaire, Stanford Southall, Sterling Wright,
Maurice Wyble, Peter Yun
Illustrator
Phil Nguyen
coordinatorS/AD Representatives
Teri Arthur, Suzeanne Harms, 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.
© 2013 Glidewell Laboratories
Neither Inclusive magazine nor any employees involved in its publication
(“publisher”) make any warranty, expressed 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.
6
– www.inclusivemagazine.com –

Online Exclusive
R&D
CORNER
“Digital in a Day”
See how your implant case can be turned around in a single day!
View the video “Digital in a Day” as we follow an implant
restoration in real time from scanning in the doctor’s
office to receipt in the laboratory, design, manufacture and
shipping back to the doctor. Every step of the process will
have a time stamp in the upper right-hand corner of the
screen showing the elapsed time since the start. This video
presents a convincing argument for the adoption of digital
dentistry into your practice.
You can view “Digital in a Day” and other Inclusive
magazine videos on your computer or favorite mobile
device. To watch these videos anytime, anywhere, visit
www.inclusivemagazine.com.
www.inclusivemagazine.com

Trends in
Implant Dentistry
Model-Less Restorations
70 %
Year-Over-Year Growth Rate
for Model-Less Crowns
March 2012–March 2013
Growing ranks of clinicians are using chairside digital impression
systems to save money and time on their restorations. They benefit
from working with a fully integrated digital dental lab that can
produce restorations entirely from a digital impression — without a
physical model. Ease of use and accuracy make digital impressions
a superior option for a wide range of restorations. In addition to
crowns, bridges and veneers, custom implant abutments can be
produced directly from a digital impression. Model-less restorations
are priced lower, exhibit a better fit and cut the in-lab working time
in half. They deliver more benefits for less money, and the dental
community is taking notice.
4000
Total Model-Less Restorations — June 2010–March 2013
3500
3000
2500
2000
1500
1000
500
0
879 934 942 958
817 787
729
85 115 131 212 309
1171
995
1644
1520
1278 1276 1355
3241
2897 2937
2713
2665
2492
2369
2272 2314
2178 2145
1863 1923 1964 1971
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
2010 2011
2012 2013
Source: Glidewell Laboratories internal data
Watch here for emerging trends
Check back here for more observations in the next issue.
8
– www.inclusivemagazine.com –

Implant&
Q A:
Go online for
in-depth content
An Interview with Dr. Dennis Tarnow
Interview of Dennis P. Tarnow, DDS
by Managing Editor David Casper
Photo courtesy of Columbia University
Dr. Dennis Tarnow, expert in the field of implantology and leader
in dental implant continuing education, is currently clinical
professor of periodontology and director of implant education
at Columbia University College of Dental Medicine in New York.
Here, the seasoned practitioner shares his experience on
topics ranging from the relationship between endodontics and
implantology, to training the general dentist to place implants,
to immediate loading, biologic width around implants, guided
surgery and digital scanning.
David Casper: Dr. Tarnow, you’re known
around the world as the leader in dental
implant continuing education. Everywhere
we go, whether it’s undergraduate
or postgraduate, it’s clear you’ve touched
the lives of so many dentists around the
world. Tell us about this journey. How
did it start, and what ignited this passion
for continuing education?
Dr. Dennis Tarnow: Well, I graduated
in 1972 and went for a general practice
residency at Brookdale University
Hospital in Brooklyn. There I realized I
was being trained beautifully as an intern
and as a general practitioner, but
I wanted to do a lot more. So I wound
up pursuing a double specialty in
both periodontology and prosthodontics.
And I loved education, which
stimulated my entire way of thinking.
– Implant Q&A: An Interview with Dr. Dennis Tarnow – 9

I knew I was very fortunate to be exposed
to some of the world’s greatest
teachers who also had great dedication,
and I learned to see their passion,
and what their teaching did for me
and for my fellow students. So I think
what gave me my own passion for
education was seeing how many people
you can impact as a teacher.
I have a very active group practice
in New York City, and when I teach,
whether I lecture to 10 people or
2,000, I think of how many people I
may indirectly touch — to me, that is
the beauty of being an educator. If they
can learn even one thing in an hour
lecture and take it home, they will do
it for the rest of their lives. Hopefully,
they will not only propagate better
dentistry, but they will also feel better
about themselves. So, education was
really inspired in me by my teachers
— people like Dr. Sigmund Stahl
in periodontology, and Drs. Harold
Litvak, Frank Celenza Sr. and Sidney
Silverman in prosthodontics — these
people were great mentors to me.
Today, I think of doing their quality
of work and continuing that thought
process.
DC: When did you first start the emphasis
in dental implants as part of your
curriculum in the universities?
DT: I completed my internship — we
called it an internship then, what is
now a general practice residency or
GPR — at Brookdale Hospital under
Dr. Norman Cranin. Unfortunately,
Norman passed away last year. But
Norman was one of the pioneers in
implant dentistry, particularly in subperiosteal
and blade implants. He was
the first to develop what was called an
“anchor implant,” which was a modification
of the blade. During that year,
we worked with him and did some
subperiosteals and some blades. So
my first implant was with Norman
Cranin and it was quite an interesting
thing — we were placing blade
implants into edentulous ridges. That
was in 1972 or ’73. It wasn’t until 1982
that I was exposed to them again in
Toronto at a continuing education
course given by Drs. Per-Ingvar Brånemark
and George Zarb.
DC: You were at that original Toronto
conference on tissue-integrated prostheses?
DT: I was at that original conference.
I was being trained as a periodontist
and a prosthodontist, but what was
always interesting to me was that, at
the time, no periodontist was allowed
to take the course. So I actually took
it legally as a prosthodontist! It was
quite a learning experience. I knew
that this was a paradigm shift. And
when I saw what George Zarb was
showing, which was a duplicate of
what the Brånemark group had done
in Sweden, I realized that this was
something totally different.
As a periodontist and prosthodontist I
was saving root tips. I was doing hemisections
and root resections, and these
teeth were holding fine for a few years
— five years, seven years, even 10
years. But in attending this conference
I realized there was another world out
there. To me, this was the next step
in perio and prosthetics. We now had
something that looked amazing and
was different from what I saw with the
blades. These were being what was
termed “osseointegrated” — and we
never looked back. We learned what it
was that Brånemark did that allowed
integration, and of course since then
we have modified it from there, along
with the rest of the world. Everybody
has improved on what was there, from
that fantastic work and great thinking
of Brånemark.
DC: A paradigm shift, for sure.
DT: It was a paradigm shift. Recently, I
was lecturing on when to save a tooth,
and when I went back and looked
at the post-ops from some of my old
cases from 20 to 30 years ago, I realized
that there are not many of the rootresected
teeth around anymore. But
the implants that I did in 1982, 1984,
1985 — most of them are still in and
functioning well. And so, especially
with the original machined implant,
once it took, there were very minimal
periodontal problems. With many of
the teeth that we were holding on to,
in addition to periodontal disease, the
people also had problems with decay.
So how nice it is to give somebody
a new root that doesn’t decay — it’s
called an implant. Whatever implant
you choose, there’s still no decay. So, in
most people, the crown on an implant
definitely lasts longer than the crown
on a tooth, especially if the patient is
prone to decay or periodontal disease.
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DC: We often hear that endodontics is
pre-implant therapy. Do you share that
view?
DT: [Laughing] Not quite, no. As a
matter of fact, the person I lectured
with today is a great endodontist —
Dr. John West. We supposedly had a
head-to-head debate on endo versus
implants, but it’s not that way. Endo
is just one aspect of treating a tooth.
Great endodontists today have a 95 to
97 percent success rate. So, that’s not
the question. It’s not about the apex
— that’s about a 3 to 5 percent failure
rate — it’s about what’s left of the
natural tooth that becomes the real
treatment planning problem. You can
seal an apex, but what does the rest
of the tooth look like? Is the patient
prone to decay? Is the patient prone to
periodontal issues? Is the patient still
susceptible even though the apex was
sealed beautifully? Is the tooth strong
enough to withstand the occlusion?
What’s the fracture rate of posts in
general and the fracture rate of teeth?
So, I see it as what they call the “etiological
pile.” The pile builds up on
a given patient. If you have a patient
sitting in your chair, and the patient
is prone to periodontal disease, prone
to tooth decay, and they’re in your
chair because they have lost teeth and
are having problems in their mouth,
it’s not just whether the apex can
be sealed. Decay rate in five years
might cause a problem, certainly in
10 years. Post fractures, post loosenings,
debonding of teeth — all of these
things become an additional pile. And
if the patient has a few of these things
on their list, not just the apex of a
tooth being the problem, the pile suddenly
can become overwhelming and
you’re leaning toward an implant. So
it’s not endo versus implants. Some of
my best friends are endodontists!
DC: [Laughing] And your best referring
doctors, too?
DT: And my best referring doctors,
yes. We work very closely together.
But if they can’t save a tooth, we go to
an implant. But, clearly, for a lot of the
teeth that I used to treat endodontically
— hemisections and things like
that — I don’t need it anymore, other
than to hold a temporary while I
transition these patients out of those
teeth and put in implants. Long-term,
an implant is a far superior restoration
in our hands, and I’ve been doing
both. Being a periodontist and a
prosthodontist, I saved all those teeth
for so many years. I built my practice
on that originally. And if you ever
want a great lecture on furcations, I’ll
be glad to give it to you. But the reality
is that nobody wants to listen to that.
If I did a lecture today on furcations,
nobody would show up. Or if I did a
lecture today on implant esthetics versus
teeth — forget it.
In most people,
the crown on an
implant definitely
lasts longer than
the crown on a
tooth, especially
if the patient is
prone to decay
or periodontal
disease.
DC: How would you assess the state of
dental education on implants at the
university level today?
DT: I think it’s gotten a lot better.
When we first started with implants,
we realized this needed to be taught
more universally because the students
were not getting the right kind of
information. Some of them were just
getting lectures. There were six or
eight lectures they used to get back in
the 1980s, but nothing that was handson.
That was only for the grad students
— the prosthodontists, periodontists
and oral surgeons. So the general
dentists who were coming out of school
were totally untrained. And I really
mean untrained. They didn’t know
how to do it. So if a patient came to
one of these former students missing a
tooth and needing it replaced, and the
patient was their first since graduating
from dental school and opening their
own office, what was the new dentist
going to tell them?
DC: A bridge?
DT: If you’ve never even done one implant
restoration, then you’re going
to do a 3-unit bridge. Because that is
what you were trained to do in school.
But this has finally changed. Now it’s
a requirement to restore some missing
teeth with implants while in dental
school. Even if you’re not doing the
surgery, you should at least be able to
do the restoration. So it’s still minimal
compared to the number of patients,
and it’s more costly in general, although
not much more costly than a
three-unit bridge. Dental insurance is
just starting to cover implants, as you
know. But before that, people would
say, “Well, it’s the same price for a
3-unit bridge or a single implant.” But
the insurance didn’t cover the implant
part. They’d think, “Well, my insurance
will give me some money for the
3-unit bridge, so I’m going to have
to go that route.” So, they were still
cutting down perfectly good virgin
teeth to put 3-unit bridges on.
DC: What are your thoughts on training
general dentists at the undergraduate
level to place implants?
DT: This is a politically charged question
in some respects because it takes
the place of what an oral surgeon and
a periodontist want to do. Today, even
prosthodontists are being cross-trained
for certain easier cases. It is ethical
now in their code of responsibility to
get trained in simpler cases of placing
implants. Right now, many schools
– Implant Q&A: An Interview with Dr. Dennis Tarnow – 11

are struggling just to get the implant
cases restored by the undergraduates,
believe it or not. But you probably see
it routinely in a laboratory the size
of Glidewell, that everybody is doing
prosthetics on implants. But that’s not
so easy yet. The young practitioners
are still gun-shy and still feel a little
overwhelmed by it. This is also true for
many of the older practitioners, who
were never exposed to implants during
their training. So it’s more like the
practitioners who are five to 10 years
out of school who are into the new
technology. They have learned about it
and know they have a whole career to
expose themselves to it, so they’re the
ones doing most of the work now. But
to go back to your original question, as
far as training people in school, I think
we’re just doing a very limited amount
when someone has to have the training.
We don’t want anybody to take a
two-day course and then think they’re
an implantologist.
DC: Right.
DT: That’s where we see the mistakes.
Sixty percent of my new cases in my
private office today are redoing other
people’s work. This is an absolutely
frightening scenario. And it’s gotten
worse since a few of the companies
started offering a weekend course.
One company in particular was
just into sales, and so they said,
essentially, “Come to us to take the
course for two days, and we’ll sell
you all the equipment, we’ll give you
some implants, you give us a whole
bunch of money — and then you’re
an implantologist.” And the reality is
these people didn’t know what they
were doing. They had no surgical
knowledge; they had no background
in biology and wound healing. They
were just mechanics. And many of
them were bad mechanics. What we
saw was just a horror show. It keeps
me busy, but believe me, it’s almost
like gut money. It’s hard because the
patients are unhappy. They’re angry.
And that’s not good for dentistry, and
it’s certainly not good for the patient,
which is really the main story.
But I think that the proper training
is now available. I started a program
at Columbia to train general dentists
who want to learn how to do implant
procedures properly.
DC: Is it a four-year or a two-year program?
DT: We do both. We do it with the
undergrads if they’re in an honors
program for placing implants. For
restorative, they always should restore
and do clip-ons and attachments,
things of that sort. But for the surgical
part, we are just doing a pilot program.
Those with the desire to learn more
and who want to do the surgery go
through courses, and during their
senior year they take an elective in
implants and implant surgery. By the
end of the year we involve them in the
placement of implants for some simple
cases. But they have to take more than
just their regular courses.
DC: Are they partnered with a mentor
— maybe one of the post-graduate residents?
DT: They partner with the faculty.
Columbia is a small enough school that
we have that personal touch. We get
to know the students, we work with
them, and they come up and watch the
periodontists and the surgeons and
eventually do the procedures themselves.
But they need the didactics, too.
So they are allowed to join the elective
courses and get more education.
I started a program at Columbia in
2010 for the general dentist to learn
how to place implants. It’s either one
weekend a month for six months,
which is a 12-day program; or two
one-week programs, the first of which
is six days, and then they come back
about eight weeks later for another six
days. That’s 12 days of didactics. So
it’s definitely not a two-day course. It
teaches the biology of implants, wound
healing around implants, anatomy and
the entry-level basics to get you feeling
comfortable with incision designs.
These are the things people need to be
comfortable, to know what they should
and shouldn’t do. So, as important as
knowing which cases to take on, they
need to learn when to say, “OK, this is
for the periodontist, and this is for the
oral surgeon — or someone trained
with appropriate skills.” So they know
how not to get into trouble.
There is no reason why a general dentist
can’t learn how to place implants.
If they can prep a tooth, and they are
good at that, then there’s no reason
why they can’t angulate an implant.
But they must know the biology; they
must know the diagnosis and treatment
planning of the case. And therein
lies the difference. I could teach a
high school student how to place an
implant. If they have any kind of manual
dexterity, give me a week or so
and I can teach them how to place an
implant. But they wouldn’t know what
they’re doing. They would be like a little
monkey: monkey see, monkey do.
If you say, “Now go do this,” the monkey
goes and does it. But he won’t
know what he’s doing. He just knows
that he is supposed to do it. You can
train someone to carve anatomy into
an amalgam, and to carve an occlusal
surface; they can be an artist and
carve it, but they have no idea what
amalgam is, or what composite is, or
what zirconium is, and which material
should be used and why. That’s the
doctor. Otherwise, they’re just doing it
because they were told to do it, and
they become like a carpenter. That’s
the level we want to try to avoid by
offering proper education. But do I see
people doing it in the future in undergrad?
Yes. Do I think it’s tomorrow? No.
It’s just because of the lack of patients
available. But they will just do the simple
cases, and they will know when to
refer. This is very important. The periodontist
and the oral surgeon should
not feel threatened. If you become the
teacher, you will be busy — busier
than you can imagine.
As you know, we’ve only penetrated
about 8 percent of the market in the
U.S. today — 10 percent at best. And it’s
been that way for a while. The expansion
is not there, but it could be. Other
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markets have been highly penetrated,
such as Korea and Japan. Statistically
speaking, per 10,000 people, they have
more people who need and are getting
implants. So why are we behind? Part
of it is the general dentist population,
who patients go to and trust —
DC: The quarterback.
DT: More like the gatekeeper. The guy
you trust, who does not feel comfortable
doing an implant, so he does a
bridge. And the patient doesn’t question
it, unless the patient is well educated
and realizes there is another
possible route. Today, the Internet is
helping. I’ve said this to my own academy
in periodontology: “Don’t hesitate
to train the general dentist now.”
They’ve been fighting general dentists,
and I’m on record now saying this, as
a teacher: “If people want to learn
something, they’re going to learn it.”
When I at first was not allowed to take
the course that Brånemark gave, I had
to take it as a prosthodontist, not as
a periodontist. But we periodontists
had a will. This was something that
we wanted, and we found a way to
learn. The general dentist who wants
to learn is going to do the same thing.
So why don’t we be the ones to teach
them in a way that is accepted, so they
can decide whether they want to do
implants? They’ll still come to us for
referrals in the more difficult cases,
and even in some regular cases — and
for their mother and their father. What
I’m saying is, if we had penetrated the
market by 50, 60, 70 percent, everybody
would be looking at each other’s
cases, and stealing each other’s cases.
But here’s the key: Because we’ve
only penetrated the market by about 8
percent, there’s such room for expansion,
for the whole pie to grow. And
that’s when everybody will be happy,
including the general dentists who
may want to do something different,
as well as the periodontists, the oral
surgeons and the prosthodontists. The
market will expand for everybody.
The key is to get the word out to the
general dentist and to the patient that
Because we’ve only penetrated the market
by about 8 percent, there’s such room for
expansion … And that’s when everybody
will be happy, including the general
dentists who may want to do something
different, as well as the periodontists, the
oral surgeons and the prosthodontists.
implants are safe and reliable when
done properly. The periodontists,
prosthodontists and oral surgeons can
all do their part, and everybody should
be happy because the pie will grow.
DC: We’ve seen that the metric you mentioned
— the number of implants placed
per 10,000 inhabitants — is pretty common
within the industry. One thing
we’ve noticed is that those countries
with the highest level of penetration are
also the countries where the cost is the
lowest — not only the treatment cost to
the patient, but also the cost of the components,
the materials, the implants. Do
you think there is a direct correlation,
or is this a coincidence?
DT: Well, I think it may be part
coincidence, due to some of these
countries tending to be more
nationalistic from a business standpoint.
Whereas the big companies had market
share in many parts of the world —
often total market share — some places
like Korea, to give an example, began
to develop their own industry, and
they began making their own implants.
So there were Korean companies
making their own implants, and they
were moderately priced — not even
inexpensively priced. Some people in
these countries said, “OK, the quality is
there, I’m Korean, and I prefer to buy a
Korean implant.” So the big companies
lost some of their market share there.
The same thing is happening in Brazil.
Part of that is because it’s inexpensive,
but part of that is a feeling of national
pride in being able to place a Korean or
a Brazilian implant, for example. If you
look at the implant marketplace around
the world, let’s say in Germany — which
is a big implant market, as you know
— one of the German-made implants
is always one of the biggest sellers,
certainly one of the top two or three.
In Switzerland, it’s Swiss implants. In
Sweden, the Swedish implant is number
one. So there’s a bit of a nationalistic
flavor to the implant world.
DC: It’s the World Cup of dental implants.
DT: That’s about right. In the U.S. for
a while, it was that way, too. We were
certainly strong contenders. Americanmade
implants just felt comfortable.
That’s what I think was going on. Of
course the economy today is so difficult,
certainly in Europe. There are
ups and downs in Asia. And in America
now, we are just slowly starting to
come out of the recession. But we’re
getting there. I certainly see that in
my practice. Three years ago, when
we were all about to go over the cliff,
almost literally, people just stopped
spending. You couldn’t tell patients
they needed a full-mouth rehabilitation.
The words just wouldn’t come
out of your mouth. The question was
more, “What do I need now to hold
me off?” They weren’t ready to spend.
– Implant Q&A: An Interview with Dr. Dennis Tarnow – 13

The same thing is happening in Europe
right now. Some of my graduate students
who are in top practices in
Spain, for example, are in such tough
situations because people are just not
spending. They don’t know what’s happening
to the euro; they don’t know
what’s happening to the economy.
Patients are not coming in except for
the most critical needs — and I’m talking
about really established practices,
not clinicians who are just starting out.
So, clearly, if the economy is affected,
people are going to say: “Hey, can I
get the same quality for less money?
And if it happens to be a company in
my own nation, even better.”
DC: That’s an interesting take on things.
If we look at research for a second, and
the library’s worth of articles you’ve
written over the last several years, we see
that many of the papers you’ve authored
have changed the way doctors treat patients
when it comes to dental implants.
DT: Hopefully, for the better [laughs].
DC: Well, we all think so. One of the
articles that comes to mind for me is
that first paper in 1997 that refers to
immediate loading. 1 It was the first paper
that had good long-term data showing
pretty good results with immediate
loading and immediate function given
the right parameters. What’s your take
on immediate loading now, immediate
provisionalization? Has it changed?
DT: Dr. Paul Schnitman was the first
to do something like that for implants.
He did seven cases and published an
article — in 1990. 2 He published that
article with seven cases with three
implants: one in the midline and
two small ones in the back. And he
buried the other five in the front. So
if the three failed, the patient would
still have five implants to finish that
case — a regular hybrid case. So 21
implants were loaded. And when I read
that, I nearly fell off my chair. Why?
Because this was 1990, and we were
all doing Brånemark-style implants
and we submerged everything. Here
he took three implants and an old
denture — the previous denture —
and just secured it like a tripod, with
one implant in the front and two in
the back. And we assumed that all
of those implants would fail because
it went against every principle that
Brånemark had taught us: no loading,
submergence — all of the things that
Brånemark taught us were being
violated for those three implants.
Immediate loading. Non-submerged.
Everything was wrong. And yet the
three implants took. Everybody said,
“Overall, three out of 21 have failed,
so it wasn’t a high success rate.” But
I was amazed that 18 survived! I’m a
glass-half-full kind of guy. For me the
amazing thing was that 18 survived.
They were not supposed to survive.
In fact, Dr. Leonard Linkow was teaching
with me at New York University
when I inherited the job as director
of implantology. Lenny is one of the
fathers, or pioneers, of implants. He
was involved with blades and screws
— many people don’t know he had
patents on screws. Anyway, I was so
amazed that 18 of the implants hadn’t
failed, that they osseointegrated — not
fibrous encapsulation. So I said to Lenny,
“Look at what Schnitman is doing.”
And he said, “Yeah, well, that works.”
“Really?” I asked. And he went on to
say: “I’ve been doing it for years. I may
have more failures than anybody else,
but I also have more successes than
anybody else.” When I asked him why
it worked, he said: “It went around
the turn of the arch. As long as you
go around the turn of the arch, you’ll
have a high success rate. It doesn’t
matter. Just don’t move or take off the
temporary and everything will be fine.
Wait three or four months, and then,
even if you have to drill the temporary
off, the implants are going to be tight.”
And I said, “Tight, like osseointegrated
tight?” He said: “Yeah, osseointegrated
tight. No problem.”
So right after this, I started the process
of looking at a very standardized
way of going about this. The biggest
problem that Schnitman said he had
on these three was that they were
short implants. The extra ones he put
posteriorly behind the mental foramen
were short, and in softer bone. So I
said: “What if we loaded four or
five? Let’s pick mandibles that have
plenty of bone.” So as a process at
the school, we picked mandibles that
we could put lots of implants in, 8 or
10 — more than we would normally
need — but we would load half of
them and submerge the other half. So,
medical-legally, the patient would be
good either way. So we loaded four to
six implants on these 10 consecutive
cases over five years. And what was
amazing to us is we had success after
success after success. By going around
the turn of the arch we had enough
support. It was more than just a tripod
effect. By having something similar
to the legs on a chair, we had a good
A-P spread, as we call it, or a good
anterior-posterior spread. The farther
forward the anterior implants are, and
the farther back the implants are in the
posterior, the more stable they are, just
like a chair. So we realized that as long
as you can decrease the torque during
loading, lateral forces get diminished.
And today we know that if there is less
than 150 microns of lateral motion
during the healing phase, we don’t
If you go around
the turn of an
arch with a good
A-P spread,
during the
healing phase
the implants will
take. I am very
comfortable
saying that.
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get fibrous encapsulation. By going
around the turn of an arch, just like
splinting loose teeth around the turn
of an arch, the mobility stops because
the fulcrum of rotation is not through
all of the teeth, or not through all of
the implants. The fulcrum of rotation
is in the tongue area in the center. So
if there’s no easy fulcrum to rotate
around, they don’t move, they don’t
rotate and, therefore, they’re stable.
And today it still stands.
I’ll tell you exactly what Lenny told
me. It’s a different understanding of
what we need to do. If you go around
the turn of an arch with a good A-P
spread, during the healing phase the
implants will take. I am very comfortable
saying that.
Schnitman once did a review on this,
presenting his article from 1990 and
my article from 1997, but between
that there’s almost nothing written
on immediate loading in the 1990s.
It’s amazing. There was one article by
some people from the University of
Pennsylvania. Of course, Henry Salama
did one, but that was only one
case report — just an oddball case.
Now there are hundreds of articles.
But it wasn’t until ’97 that it all broke
loose. So I feel good about that. It’s
a long answer, but a meaningful one
because people get into trouble loading
single teeth or straight-line splints.
When they go around the turn of an
arch, they’re going to be cooking. You
go around the turn of an arch and
splint them together (not originally),
and let everything integrate for two
or three months; then you can do
whatever you want. They integrate
at the same percentage rate as everything
else. Everybody knows that
now, of course. But you don’t want
to do a single tooth and then put it
into occlusion. That’s stupid. Let the
other teeth take on the load during
the healing phase. You just want to
avoid lateral forces during the healing
phase. So, as long as you have good
stability, put a temporary on, keep it
out of occlusion, and then let the other
teeth take on the load during the
healing phase, you can do whatever
you want after that.
DC: In 2000, you wrote an article that
has become the widely adopted standard
that remains unchallenged. The
article talks about the spacing between
implants and preservation of the relative
inter-implant bone height. Why did
it take so long for that to be evaluated?
What caused you to look at that?
DT: That’s a great question. What
caused me to look at it was a patient
named Anne-Marie. Anne-Marie was a
patient in my office, and we did two
implants right next to each other. She
had a high smile line, and I didn’t
know any better. Previously, I’d had
patients with low smile lines and I’d
put two in, and if the papilla was a
little short, it never bothered anybody.
As long as you filled it up and the patient
didn’t hiss during their speaking,
they accepted it as long as the lip line
was low. But Anne-Marie had a high
smile line, and then you could see
normal teeth on the right side, but on
the left side the papilla was too short.
And no matter what I did to stimulate
the papilla like I would between two
teeth with my 5 mm rule, I couldn’t
get it to grow 5 mm. It wasn’t happening.
So the problem was right in front
of us but we didn’t see what it was.
So, I did the study with Sang-Choon
Cho and Steven Wallace, and we
started to look at the distance between
implants. 3 The reason why that paper
was very significant was that, up
to that time, we were all looking
at the threads down the side of the
implant. Think of the shoulder of
the implant. Dr. Jan Lindhe, Dr. Bo
Bergman, Dr. Daniel Buser and all the
– Implant Q&A: An Interview with Dr. Dennis Tarnow – 15

2 mm
1.5 mm
1.5 mm
others were looking at the implant
from the shoulder down, and we all
wanted to know how much bone
loss took place after you connected
the abutment and took it on and off
a few times. Dr. Joachim Hermann,
Dr. Ingemar Abrahamsson and others
did great studies on this. And they
were all looking at different implants,
but they were looking at the vertical
bone loss from where the implantabutment
interface was. This usually
went down to the first thread of these
older implants. Now there’s nothing
magical about the first thread; it’s just
that there’s a 1.5 mm distance. That’s
the biologic width reformation. On the
Brånemark implant, that happened
to be where the first thread was, so
everybody thought it was magical, but
it was pure coincidence.
What we weren’t paying attention to
was something I noticed with my patient
Anne-Marie. When I looked at the
case, I realized I had lost the bone between
the two implants because they
were too close. That’s what it looked
like to me. So I went back, because I
couldn’t get the papilla to grow back.
In fact, on that case I eventually had to
submerge a perfectly healthy implant.
I just published this case recently in
Clinical Advances in Periodontics with
Dr. Paul Fletcher, one of my partners.
And I realized, when I went back to
look at the research, what we were
missing: Everybody was looking at
how much bone loss we had vertically,
but there is a horizontal component to
that bone loss. By having a horizontal
component to bone loss, the question
became how deep was it? That article
with Cho and Wallace was the first to
measure that. It was 1.4 mm on that
typical Brånemark-style implant —
1.4 mm horizontally. If you lose bone
not just vertically down the side but
also horizontally, the biologic width
is three-dimensional. The inflammation
and irritation from the abutment
connection moves the bone away from
it vertically and also horizontally. So
what happens is, if two implants are
3 mm apart, each of them are separate
horizontal components and the
bone peak is not affected. But if two
implants are closer than 3 mm, they’re
going to overlap, and so the 1.5 mm
from one implant and the 1.5 mm
from the other implant overlap and the
bone crest will go down; therefore, the
support for the papilla will be missing.
I thought that was the answer, that I’d
solved the world’s problem. So I told
everybody, “Keep the implants 3 mm
apart, and the bone will be higher and
the papilla will come back.” So I figured
that was the problem. And it still
is a problem; 13 years later it’s still one
of the things you need to pay attention
to. But I wrote that and everybody
went and did that, yet in many cases
the papilla still didn’t come back. So
it wasn’t just that horizontal distance.
Even though the peak of bone wasn’t
being lost, the papilla still didn’t come
back fully. What else was I missing,
along with the rest of the world?
The article written in 2003 4 was really
the pivotal one that finally helped
explain it. I went to five different offices
— Drs. David Garber and Henry
Salama in Atlanta, our office in New
York City, Drs. Stuart Froum, Ann
Magna and Paul Fletcher — and what
we found was the same. We all came
up with the same curve. What was
the height of the tissue between any
two implants? What was the peak of
tissue? Not to the contact point, because
those are two artificial crowns
and it could be any shape. But I asked,
“How much tissue forms over the crest
of bone between any two implants?
What’s the average height?” And we
found the average height was 3.4 mm,
not 5 mm and 6 mm as it is between
two teeth. And that’s when it hit me.
We almost never got to 5 mm between
any two implants, no matter what
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type they were. And what was wrong?
There was a missing piece. Even if the
implants were 3 mm apart, we still had
a problem. The problem was that we
were missing the supracrestal attachment
that a natural tooth has. That’s
why a single-tooth implant looks so
good on the lecture circuit. Everybody
can’t wait to show you a single-tooth
implant because if there’s a healthy
tooth on either side, the biologic
width on a healthy tooth, the connective
tissue fibers and epithelium are
supracrestal. So they actually wind up
helping to support the papilla. That’s
2 mm of biologic width supracrestal,
not subcrestal. But if I have an implant
there instead of a tooth, the biologic
width is subcrestal down to the first
thread. So the biologic width is below
the crest of bone, not above the crest.
That’s why we’re 2 mm short. And
that’s what we need.
So, where are we today? The real challenge
today that we’re all working on
is getting attachments onto an abutment
and keeping them there, and
not continuing to break the seal. And
keeping the biologic width, which we
can get to form on an abutment — we
have enough data to show that certainly
happens. The issue is when we
take an abutment on and off multiple
times as opposed to “one abutment,
one time” — I think Dr. Henry Salama
quoted that. If we keep breaking that
seal, the biologic width goes down. If
we get it right with the initial seating
of the abutment, we want to keep it
there if we can. So, based on Abrahamsson’s
work, maybe one change is
OK, but more than that, and it starts to
drop down. So we’re at a point where
what we must do in order to put two
implants next to each other in the esthetic
zone, with a high smile line and
to keep the papilla, is get supracrestal
biologic width. This is a very big challenge,
and that’s what everybody is
trying to work on now. Between two
centrals we get away with it because
if the papilla is a little short, it’s right
down the middle. So you don’t see any
comparison, you just close it down
with a little fatter contact point and it’s
OK. As long as you have a little scallop
and no black spot, you’re OK, even if
it’s a little short. But central lateral, in
a high smile, with a lateral cuspid? It’s
a nightmare waiting to happen. A high
smile with the natural teeth on the
other side, with good papilla, always
looks lopsided to the eye. So that’s
what we have to be careful about.
People used to
say, ‘Look at my
implant. There’s
no biologic width
on my implant.’
That’s ridiculous.
There’s always a
biologic width on
an implant.
DC: Does implant design play into any
of this?
DT: It sure does. That original article in
2000 that you asked about was without
a platform switch. So now, what we’re
looking at — myself with Dr. Xavier
Vela Nebot and others at the Barcelona
Osseointegration Research Group — is
platform switching. We looked at this
and saw that when you put a platform
switch on an implant, the horizontal
component is no longer 1.4 mm or 1.5
mm like the old Brånemark implant
was. What we realize now is that the
horizontal component is only about
0.3 mm to 0.5 mm. This is because the
platform switch is there, and there’s
an abutment in the middle, and there’s
a shoulder to the implant instead of
being straight up, and the abutment
connection between the bevel, or
shoulder, allows room so the bone
doesn’t have to move as far down to
protect itself from the irritant. The
bone can stay up there higher because
the extra coverage of soft tissue acts
as a buffer between the possible
irritation of the abutment connection
to the bone. Long story short, we lose
less bone down the side when we
have a platform switch; we only see
about 0.3 mm to 0.6 mm, depending
on the system, but under 0.5 mm or in
that range, whereas we used to see 1.5
mm to 2 mm. Now we’re seeing about
0.5 mm down from the shoulder.
That’s because there’s still a biologic
width there.
People used to say, “Look at my implant.
There’s no biologic width on my
implant.” That’s ridiculous. There’s always
a biologic width on an implant.
Once an implant is exposed to the oral
cavity, there’s always a biologic width
— there has to be one. The bone covers
itself with connective tissue in the
periosteum. The periosteum covers itself
with epithelium. So there’s always
a biologic width. We will never change
that. The question is, “Where is it?” Not
whether it exists. On an X-ray it might
look great. The bone may be covering
the shoulder of an implant, if you
place it deep enough. There’s always a
biologic width, but is it on the shoulder,
or even on the abutment? If you
never took off the abutment, it could
be on the abutment. So the bone could
look great, but once you take the abutment
off a few times, the bone will go
down a little — but not as far with a
platform switch. So I think you’re going
to see that platform switching is
here to stay, and I think it will keep
growing, and that almost every company
will eventually have one to offer.
DC: Let’s talk about guided surgery. Is
that something you embrace? How do
you decide when to do a case using a
surgical guide?
DT: That’s an important question. I
think that it is going to get better, but
that it got pushed too far, too quickly.
One of the companies pushed way
– Implant Q&A: An Interview with Dr. Dennis Tarnow – 17

too far, way too quickly: “Teeth in a
day.” “Teeth in a minute.” “Teeth in an
hour.” As soon as I saw that I thought:
“You’ve got to be kidding me. You’re
going to do the final bridge in one
day? That’s a joke.” You’re not going
to be happy with that, not routinely.
You might have a case or two that
work, but not on a regular basis. Not
for everybody, not even for advanced
clinicians. You’re going to suffer problems.
And sure enough, I was right.
Then they backed off to only temporaries
in a day, not the final bridge.
But why? They had to. They were
getting killed, even by some of their
own great researchers who were doing
their prototype work. Why? They
were only getting a 90 percent success
rate in some of these cases. Drs.
Osamu Komiyama and Peter Moy
— great clinicians — were only getting
an 89 to 90 percent survival rate
of these implants, even though they
would normally get 95 to 97 percent.
Part of the problem is the full-arch
case. The full-arch case is the most
difficult, yet that’s where you need
guided surgery the most. And this is
the problem. For the single tooth, I
have all my guides right there — the
adjacent teeth, the opposing dentition
— and I can see where I need to go.
For an advanced clinician, it’s not as
critical. No matter how good you are,
though, when you have all the markers
gone, and you have an edentulous
ridge, you have to ask yourself where
you place it buccal-lingually. Where do
you place it mesiodistally so it doesn’t
come out in an embrasure space?
That’s where I need more information.
So that’s where you’re going to
see guided surgery being used, in the
more difficult cases.
What’s the problem, then? Well, first
you do the proper setup. You know
where the teeth are going to be —
proper bite, proper position. So you
duplicate the denture and make a
radiographic guide with markers on
it. You send the patient to the radiologist,
or you do it in your office.
Whoever does it better be seating the
mock-up denture with the markers on
it in the proper place because if it’s
0.1 mm or 0.2 mm off in the wrong
position mesiodistally, it’s not hooking
onto anything. It just depends on
how the patient is biting. So they get
a CAT scan by a radiologist. But the
radiologist isn’t a dentist, so they put it
in and ask, “Does it feel OK?” And the
patient says: “Well, I guess so. I think
it’s fine. How does it look?” The radiologist
says, “Just hold still.” And they
take a picture. But even if it’s 2 mm
forward, or 2 mm slipped back, the
position of the markers to the ridge is
completely wrong — and you’ve spent
all this time on it. Then you go to your
computer, you’re marking the position
where you want the teeth based on
where that radiographic template was
during the X-ray, and all your markers
are off. So then the surgical template
that you’re going to make now includes
holes for drilling in a place
that you told them was correct, but it
isn’t correct. It’s off because the radiographic
template was put in the wrong
spot. If the radiographic template is
fine, then it’s very accurate, and you’ve
got plenty of bone and plenty of
attached gingiva. But if that’s off, it’s
a nightmare, and that’s when it really
becomes a problem.
So temporaries in an hour, fine. But
not final bridges in an hour. There are
too many variables, too many things
that you might want to change and
modify. Temporaries in an hour are
fine. That’s immediate loading with a
fancy version of the immediate loading
we discussed before. I have no
problem with that, and I recommend
it. But be careful.
When we do these fully edentulous
cases where we’re worried about this
— and other people do this, too — before
we put the radiographic template
in, we’ll put mini implants in: a couple
of implants in the ridge, at least two,
one on each side. Then we reline the
denture that’s going to be used, or the
duplicate denture, so it’s in the right
spot — with just a doughy mix over
the top with something to lock into it.
So now when it goes in, it can only go
in one spot.
DC: It’s indexed.
DT: It’s indexed. We add fixed index
material, so the radiographic template
and then the surgical template get
hooked onto it.
DC: As long as it’s not too stable.
DT: Right [laughing]. So now, we’ll
sometimes save even one tooth in
the treatment plan if the person’s not
edentulous. Sometimes we’ll just save
one or two teeth, just to stabilize the
guide, even though the teeth are going
to come out after the implants are in.
And we do that to help stabilize the
radiographic template, and that stabilizes
the surgical template.
DC: So it leads to a more accurate result.
DT: Absolutely. All the time.
DC: Do you see technology changing the
role of dental labs in restoring implant
cases?
DT: Obviously there are different ways
to come into the digital world. For example,
almost all of your crowns now
at Glidewell are digital. You’re not the
old technician sitting there with wax,
knowing how to use the wax, and
which type of wax —
DC: We don’t have any of those.
DT: Well, if you think about that, you’re
certainly one of the largest labs in the
country, if not the world — you’re all
digitized. I think this is great. What it
has done is that even if someone gives
the lab an old type of impression, not
one that’s scanned, the general dentist
or even a prosthodontist can enter the
digital world right away just by sending
you a model. Everything is digitized after
that. So, I think it’s just going to be
faster and more direct. It can be done
via e-mail and then your electronic waxup,
so to speak, is transferred back. I
think there’s no question that this is the
way it will all go in the future.
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The young dental professionals of
today are so computer literate that
they’re not going to be intimidated
by this technology. Some of the oldtimers,
both laboratory technicians
and dentists, are intimidated. They
want to see a little wax. They want to
take off the corner, round if off a little
bit. But the computer does it in about
10 seconds. Rotate it. Like it. OK —
Boom! — and the computer makes it.
There’s no question that it’s here to
stay, and it’s only going to get better
and will soon be used by everybody.
It’s already being used by all of your
people today. The only question
is when the scanning is going to
take place. Does it take place in the
laboratory off of the model? Or does it
take place in the mouth? Everything is
virtual. Pretty soon you’ll never make
a model. All of the plaster I saw being
poured up will probably become
obsolete — I think soon.
DC: We hope so.
DT: But there’s no question that it
makes sense, especially when the margins
are readable.
DC: Is there any impact on the dentist?
They now see their margins eight inches
around on a screen.
DT: It’s a little intimidating when you
really look at it. That’s why in our
prosthetic program we always have
the students trim their own dies. It’s
the most humbling part of the day.
You may think to yourself, “Did I really
miss that margin? Did I really prep
that tooth that way?” As part of a grad
student program, this is how they become
refined. And in the same way,
the doctors will see their own errors. I
think it will make for better dentistry.
Because if they can do the scanning
without using the old goop and do all
the scanning in the mouth, then they
can look at it right away and do a
digital pick-up, and in five seconds it’s
on the computer, if not sooner. They
can see it on the computer and say: “I
missed that margin, that’s not good. I
didn’t really prep that lingual as well
as I thought. Let me go back right now
and fix it.” So they can take care of it
before the patient has walked out the
door. It’s almost like having loupes
with magnification at the chair. It’s
like doing stuff with a microscope —
DC: — a microscope on steroids.
DT: Right. It blows everything up so
you can see your mistakes or the areas
where you need some fine-tuning. I
think it will lead to better dentistry.
What used to happen is the patient
would leave after you did the goop,
and the doctor never even saw the
poured model during that visit. Then
after they got the model, they’d say,
“Oh, I can’t see the margin.” There was
a bubble there, or something like that.
And they couldn’t do it. The lab would
come back and say they couldn’t read
the margin, or they were afraid to say
it. Then a technician would play with
it, and it just wouldn’t fit well, or it
wasn’t accurate. So, I think it’s here
to stay. I think the biggest problem
is still subgingival, the placement
of margins, and so on. But with
implants having standardized
sizes for the most part so you
know their size and shape, you
can put impression copings on
and not worry. So for implants, as
opposed to teeth, it’s a no-brainer.
Just scan.
DC: No margins.
DT: No margins. So I think digital
scanning is here to stay. IM
References
1. Tarnow DP, Emtiaz S, Classi A. Immediate loading
of threaded implants at stage 1 surgery in
edentulous arches: ten consecutive case reports
with 1- to 5-year data. Int J Oral Maxillofax
Implants. 1997 May-Jun;12(3)319-24.
2. Schnitman PA, Wöhrle PS,
Rubenstein JE. Immediate fixed
interim prostheses supported by
two-stage threaded implants:
methodology and results. J Oral
Implantol. 1990;16(2):96-105.
3. Tarnow DP, Cho SC, Wallace SS.
The effect of inter-implant
distance on the height of
inter-implant bone crest.
J Periodontol. 2000
Apr;71(4)546-9.
4. Tarnow D, Elian N, Fletcher P, Froum S, Magner A,
Cho SC, Salama M, Salama H, Garber DA. Vertical
distance from the crest of bone to the height of the
interproximal papilla between adjacent implants. J
Periodontol. 2003 Dec;74(12):1785-8.
– Implant Q&A: An Interview with Dr. Dennis Tarnow – 19

Mini Implants: Insight from Dr. Gordon Christensen
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Go online for
in-depth content
Mini Implants: Insight from
Dr. Gordon Christensen
with
Gordon J. Christensen, DDS, MSD, Ph.D.
Dr. Gordon Christensen, a pioneer in the field of
implantology and a leading proponent of smalldiameter,
or mini, implants, has shared his knowledge
and experience during his visits to the laboratory. The
following details his recent insights on the current
and future state of mini implants.
Mini implants as a permanent solution
Initially, I was using minis as transitional implants when I
had placed conventional implants and just wanted something
to hold the denture or the fixed bridge in place while
the conventional-diameter implants integrated. I found,
after three or four months of waiting for the conventionaldiameter
implants to integrate, that I seldom could take the
mini implants out easily. In fact, I had a couple that I practically
had to cut out. That was the turning point.
When the early transitional implants were introduced, they
were pure titanium. They were so weak that you could bend
them with your finger. They were not adequate. However,
when Dr. Victor Sendax (one of the first proponents of
small-diameter implants) got together with the IMTEC
Corporation and made them from titanium alloy, they were
significantly stronger. The combination of strength and
– Mini Implants: Insight from Dr. Gordon Christensen – 21

Mini Implants: Insight from Dr. Gordon Christensen
ease of placement, and the fact that they could be loaded
immediately, made me change my mind about using smalldiameter
implants.
Current state of implant placement
My observation is that we are only treating a small fragment
of the American population who could benefit from dental
implants — it’s abominable. At most, maybe 2 percent of
Americans have had an implant. A lot of countries I visit
have 10 percent, 15 percent, 18 percent. We are basically at
nearly zero.
We have aimed at the boutique level, but what about the
other 98 percent? What about the rest of the people who
make around $55,000 a year, the average American salary
for a family? We need to get involved with people who have
a typical income.
Implant dentistry is on fire! It’s going to continue to grow
and grow. It’s going completely beyond what I expected.
But we are only hitting the market with the large-diameter
implants. We’re not involved with the other part of the
population because of high costs. We are going with the big
implants and they only fit in patients with 6 mm of bone
facial-lingual. Who has that? Not people at age 50 or 60 or
70. They usually don’t have that much bone. So the obvious
change is going from just serving the boutique level to
treating typical people.
Why so few dentists are placing implants
I’ve been doing surgical placement of implants for about
25 years. As a prosthodontist, it was a very difficult thing
to get into because the surgeons wanted to dominate the
area. For many years, they did. Now, we are starting to see
general practitioners become more involved. But still, there
is frustration on their part. Are they going to hit a tooth? Are
Implant dentistry is on fire! ...
But we are only hitting
the market with the
large-diameter implants.
We’re not involved with the
other part of the population
because of high costs.
Courtesy of Christopher P. Travis, DDS
they going to hit the sinus? Will they perforate the inferior
alveolar canal? And all the other negatives that are pretty
obvious to any one of us.
Yet, a statistic that I’m going to give you right now is very
clearly oriented toward the desirability of general practitioners
placing implants. We know that about 69 percent of
general dentists will do a third molar impaction. According
to our legal experts, that is potentially far more legally
threatening and problematic than placing an implant — and
I’ll qualify this — in a healthy person with good bone.
We did a survey recently of 140 procedures in dentistry to
identify the difficulty of each on a scale of 1 to 10, 1 being
simple and 10 being extremely difficult. An implant, in a
healthy person with good bone, got a rating of 5. And so
did a Class II composite.
Who does most of the routine surgery in dentistry? The
general dentist. Most general dentists will take out a third
molar, but less than 10 percent will do an implant in a
healthy person with good bone. There is an educational
demand there.
Advantages of mini implants for patients
The primary benefit of mini implants is for a person who
is too debilitated to undergo the surgery necessary for conventional
implant placement; the person who does not have
the money for a complex case, which very often might be
better; or the person who will not accept, or cannot have for
health reasons, a major bone graft.
Advantages of mini implants for clinicians
Simplicity. In the November 2007 CRA ® Newsletter (now
CLINICIANS REPORT ® ), when asked about difficulty of implant
placement, respondents reported placement without
22
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Courtesy of Christopher P. Travis, DDS
Minimal invasiveness is
one of the major benefits
of small-diameter implants.
Another significant advantage
is that they can be
immediately loaded in bone
that is adequate.
a flap as “simple” and placement with a flap as “slightly more
difficult.” That’s about what we saw as the major advantage
to the clinician. I delivered a program at the World Congress
of Minimally Invasive Dentistry (WCMID) on about 20 different
minimally invasive techniques. Minimal invasiveness
is one of the major benefits of small-diameter implants.
Another significant advantage is that they can be immediately
loaded in bone that is adequate. With Type I bone, there’s
no question; I’ve loaded hundreds of them immediately.
Conditions that cause mini implants to fail
Improper radiography and lack of thorough treatment planning
are often the cause of mini implant failure. I strongly
suggest a facial-lingual radiograph for any treatment plan
— either a tomograph or a CBCT scan. The quality and
quantity of bone, as well as the ideal location of the implant,
can be evaluated pre-surgically.
Too much soft tissue thickness on the ridge is another
issue. If the thickness of the soft tissue is more than 2 mm,
the clinician should take a V-wedge out and allow the soft
tissue to heal before even considering making any kind of
an impression. About 2 mm of soft tissue should be the
maximum on the crest.
Too few implants placed can also be a major problem. For
Type I bone, four mini implants in the anterior region of
an edentulous mandible is more than enough. I usually say
two small-diameter implants would equal one conventionaldiameter
implant.
Besides diameter, the length of the implant must be
considered; 10 mm is very borderline. If you’re going
through 2 mm of soft tissue, you really don’t have enough
bone-to-implant contact. The average length used by the
profession is 13 mm.
Regarding lining up the implants — and this is totally empirical
— I do not like anything greater than 15 degrees
from parallel. Usually, the housings will compensate for that
quite nicely. If the divergence is too great, the O-rings will
wear more quickly.
And poorly adjusted occlusion is a total killer. If clinicians attempt
to put minis into a bruxer, they’re kidding themselves.
Finding success with mini implants
Making minis succeed means adequate numbers of implants
and proper treatment planning. It means parallelism. It also
means not having too much soft tissue coronal to the bone.
It means adjusting occlusion well after the prosthesis is
delivered. And, in the event that the bone is of questionable
quality, it means waiting, with a soft denture reline, for
several months before loading. However, most of the smalldiameter
implants I have placed were loaded immediately.
But there is a cautionary note, and that is: recognizing what
makes them fail. If clinicians respect the several points I’ve
mentioned, minis will serve patients well for years.
Small-diameter implants are a revolution in implant therapy.
This is where the action is! Small-diameter implants will
satisfy two-thirds of the population who are not well
served by larger diameter implants. When we wake up and
recognize that and learn how to use those small-diameter
implants, we will have a whole new marketplace in our
practices. IM
Dr. Christensen is founder and director of Practical Clinical Courses (PCC). PCC
offers step-by-step continuing education videos for dentists that show how to place
and restore both conventional and mini implants. For a list of titles, such as “Placing
Mini Implants — Simple, Safe, and Effective” (V2360), and additional information on
these valuable resources, call 800-223-6569 or visit www.pccdental.com.
– Mini Implants: Insight from Dr. Gordon Christensen – 23

my first
implant
with Sascha A. Jovanovic, DDS, MS
Most clinicians who place implants
can easily recall the first
implant case they ever treated. For
Dr. Sascha Jovanovic, the memory is
clear. Dr. Jovanovic has contributed
to the advancement of implantology
for more than two decades. From
founding the Global Institute for
Dental Education (gIDE) to serving
as academic faculty, chairman
and president for various universities,
dental education boards and
organizations, Dr. Jovanovic has
significantly impacted the implant
field, dedicating his clinical work
to dental implant therapy and soft
and hard tissue reconstruction.
Here he recalls where it all began.
After graduating from the University
of Amsterdam in 1986, where I fell in
love with the idea of titanium implants,
my father, a cardiologist, encouraged
me to go to the U.S. Upon his urging, I
packed my things and headed to Loma
Linda University in sunny Southern
California. While there, a patient came
to me with an edentulous lower jaw.
Uncertain of the appropriate treatment
plan, I sought counsel from my
co-resident, Dr. Jaime Lozada, who is
now the director of the implantology
program at Loma Linda. He instructed
me to speak with Dr. Robert James —
the professor I studied under at Loma
Linda — so I could plan the case with
him. Dr. James had a reputation for
his clinical and research work, and
developed the first worldwide, postgraduate
implant dentistry program,
which offered training to general dentists
and specialists.
Dr. Sascha Jovanovic in 1987 (left) during his postgraduate implant training at Loma Linda University in Loma
Linda, Calif., with Dr. Robert James (middle) and Dr. Jaime Lozada (right).
After graduating from the University of
Amsterdam ... where I fell in love with
titanium implants ... I packed my things
and headed to Loma Linda University.
While there, a patient came to me
with an edentulous lower jaw.
– My First Implant: Dr. Sascha Jovanovic – 25

When I reached out to Dr. James, he
invited me to his house to review
the case plan. He took me to his
garage, where he had a machining
lathe, and proceeded to take out a titanium
rod. He looked at the panoramic
radiograph, which was the diagnostic
standard at the time, to estimate the
length of the implants and dimensions
for the edentulous jaw, and started to
make the implants right on the spot
out of the titanium rod. They were customized,
screw-type implants. Most of
my experience stemmed from what I
learned from Dr. Per-Ingvar Brånemark
and the periodontal faculty at the
University of Amsterdam, so I didn’t
know how to react to this.
The next day, I went back to Jaime
Lozada, and I asked, “What else can
we do if I want to have another option?”
He again told me to meet with
Dr. James because he knew of a commercially
available implant from the
Denar Corporation in Anaheim, Calif.
The company later became Steri-Oss,
and then Nobel Biocare. Denar had
consulted with Dr. James on the design
of the implant, and Jaime thought
that particular implant could be a
good fit. I made an appointment to
see Dr. James, and when I mentioned
the Denar implant during our meeting,
he agreed that it might be a suitable
alternative and suggested that I call
the company.
At the young and audacious age of 23,
I called Denar and told them I would
like to place some of their commercially
available implants, asking them
if they would be interested in helping
me. To my surprise, they agreed
and came to Loma Linda, where they
donated a kit to the school’s implant
department. I got started on my first
case and successfully placed six
screw-type tapered implants in the anterior
lower jaw. I still remember the
patient’s name, and as far as I know, it
was a successful case for many years.
So, that was my first experience placing
implants and the start of an exciting
journey in the field of implant dentistry.
The rest, as they say, is history. IM
Dr. Sascha Jovanovic at the gIDE Institute.
I got started on my first case
and successfully placed six screw-type
tapered implants in the anterior lower
jaw. I still remember the patient’s name,
and as far as I know, it was a successful
case for many years.
26
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Go online for
in-depth content
The Clinical Advantages of Custom Abutments:
Why Customization is Rendering
Stock Abutments Obsolete
by
Jack A. Hahn, DDS
As implant therapy continues to expand its role and
popularity as a treatment option for replacing missing
teeth, doctors are dedicating considerable time
and resources toward simplifying clinical methodology and
improving clinical outcomes. Along the way, preferences are
inevitably developed for certain implant systems and restorative
components. Familiarity with the parts we use plays a
key role in approaching cases with confidence. As technological
innovations offer tools for enhancing the restorative
process and outcomes of implant therapy, it is important to
leverage these advancements to better serve patients. At the
same time, efficiencies brought about by these clinical and
technological breakthroughs can help increase the number
of patients we are able to treat.
Custom abutments are just such an advancement. Their advantages,
including patient-specific soft tissue management
during the healing phase and final restorations that adhere
precisely to the patient’s gingival architecture, make them
an excellent option for implant treatment. But many doctors
are hesitant to transition to custom components, having
spent years — even decades — utilizing stock abutments
– The Clinical Advantages of Custom Abutments – 29

the clinical advantages of custom Abutments
for implant cases. This is understandable given the ease
of maintaining an inventory of stock abutments and the
assumption that custom abutments are prohibitively expensive.
Plus, clinicians have successfully restored implant
cases for years with stock abutments. So why switch?
After spending 38 years restoring implant cases with
stock abutments, I was reluctant to switch. I had grown
accustomed to having my own lab with two experienced
technicians. They would take stock abutments and modify
them according to the soft tissue model. Though this protocol
produced successful outcomes, my practice was spending
valuable resources modifying prefabricated components. In
addition, the peri-implant tissue, which had healed around
the generic shape of stock healing components, did not
conform well to the contours of the final abutment, making
delivery of the final restoration more difficult and the
experience less comfortable for the patient. I frequently had
to make chairside adjustments to the abutments to achieve
the proper fit and ideal emergence profile I demand of the
cases I restore, requiring additional chair time.
Death of the Stock Abutment?
Since last May, I have been restoring my implant cases
with custom abutments and all-ceramic crowns and bridges
designed and fabricated by the dental laboratory utilizing
CAD/CAM software. The results have been eye-opening
to say the least. The fit and contours of the final custom
abutments have been close to perfect, adhering nicely to the
soft tissue architecture sculpted by the custom components
used during the healing phase and requiring very little
to no chairside adjustments (Fig. 1). Additionally, the
final abutment margins of these restorations demonstrate
exceptional support of the soft tissue immediately upon
placement (Fig. 2). This result is created by custom abutments
during the healing phase, which train the soft tissue to
achieve optimal gingival contours and help establish ideal
emergence profiles (Figs. 3, 4).
Figure 1: Final custom abutment immediately following delivery. The abutment seated
perfectly and required no chairside adjustments, adhering nicely to the gingival
architecture and margins established by the custom healing abutment.
Figure 2: Final custom abutments, milled from titanium using CAD/CAM technology,
exhibiting tremendous support of the soft tissue around the margins of
the abutments.
Many doctors are hesitant
to transition to custom
components, having spent
years — even decades —
utilizing stock abutments
for implant cases.
3
4
Figures 3, 4: By the time the final custom abutments (top) and crowns (bottom)
are delivered, the custom healing abutments have established optimal emergence
profiles for the restorations, illustrated by the natural fit of the final restorations
for tooth #29 & #30.
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Custom components begin guiding a case toward a predictable
outcome from the very beginning, after an implant is
placed. During the healing phase, the patient-specific contours
of a custom abutment sculpt the peri-implant tissue to
accommodate the final restoration, setting up a smooth and
atraumatic transition when the time comes to deliver the
final custom abutment and crown (Figs. 5–7).
Final custom abutments are available in several materials,
including zirconia, titanium and zirconia with a titanium
base. Though there is considerable and ongoing debate
over the advantages of zirconia versus titanium, zirconia
abutments offer esthetic advantages for patients with a thin
tissue biotype and for cases in the anterior. Zirconia abutments
allow for restorations where the gray color of metal
does not show at the gingival margins or through the soft
tissue, which is a key consideration for cases in the esthetic
zone (Fig. 6). Additionally, crowns and bridges can
be fabricated with more translucency when a tooth-colored
foundation is used. Regardless of which material is used,
the abutment height, margins, contours and emergence profile
are designed and milled with precision using CAD/CAM
technology to meet the needs of individual patients.
5
During the healing phase,
the patient-specific contours
of a custom abutment sculpt
the peri-implant tissue to
accommodate the final
restoration, setting up
a smooth and atraumatic
transition when the time
comes to deliver the final
custom abutment and crown.
6
7
Figures 5–7: Even when patients present with severe gingival trauma (top) — in
this case, damage from a bicycle accident — custom healing abutments effectively
sculpt the gingiva to adhere to the parameters of the final restoration and facilitate
optimal healing. By the time the final restorations are delivered, the contours and
margins of the peri-implant tissue have been trained to accommodate the final custom
abutments (middle) and crowns (bottom). By eliminating concerns about metal
showing through the gingiva, custom abutments fabricated from zirconia (middle)
are an especially attractive option for cases in the esthetic zone.
– The Clinical Advantages of Custom Abutments – 31

the clinical advantages of custom Abutments
The use of delivery jigs when placing custom abutments
further streamlines the restorative process. A delivery jig
serves as a positioning index, eliminating guesswork and
helping to ensure full seating and accurate positioning of the
abutment during placement (Fig. 8). When the appropriate
tooth number is indicated on the labial or buccal wall of
both the jig and the abutment, the task of orienting the
abutment properly is simplified. This is especially helpful in
cases involving multiple implants adjacent to one another,
where the lack of anatomical landmarks can complicate the
placement of the abutments. The proper orientation of the
jig and abutment indicated on the model is easily conveyed
to the patient’s mouth upon delivery, saving valuable
chair time that might otherwise be spent repositioning the
abutment to ensure proper alignment (Figs. 9, 10).
Now that I have converted to using custom abutments, the
final restorations I place typically exhibit a precise fit upon
initial seating. When the tissue has been contoured with
custom healing abutments, chairside adjustments to the
final restorative components are minimized, saving valuable
chair time. And this shouldn’t be a surprise. By guiding cases
toward the final outcome during the healing phase, custom
abutments make delivery of the final restoration a smooth
and predictable endeavor (Figs. 11, 12). I have received many
compliments on the beautiful restorations I have placed
with these custom abutments, and the laboratory certainly
deserves its fair share of the credit.
While the precision, predictability, soft tissue management
and restorative-driven approach offered by patient-specific
components produce optimal functional and esthetic outcomes,
the clinical efficiencies yielded by custom abutments
make them cost-competitive with stock abutments. Though
the apparent convenience and lower price of stock abutments
might suggest that they are the most cost-effective
option, much of the savings offered by generic components
are lost to the expenses associated with the modifications
and chairside adjustments required to establish an acceptable
fit. Because custom abutments promote tissue healing
and sculpt the gingival contours to set up the final restoration,
practices save on the clinical resources and lab fees
involved in modifying stock abutments. Moreover, the prices
for custom abutments continue to improve as CAD/CAM
technologies make additional gains in restorative precision
and efficiency.
Figure 8: The delivery jig helps verify complete and accurate seating of the abutment.
9
10
Figures 9, 10: By carrying over the correct position of the implant from the model
(top) to the patient’s mouth (bottom), the delivery jig simplifies the delivery of the
custom abutment.
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With stock abutments, soft tissue is left to heal around a
generic cylindrical shape, making it difficult to achieve the
ideal emergence profiles fostered by customization. Custom
abutments offer a patient-specific design that sculpts the
gingiva to form the ideal contours, helping to transition cases
toward the final restoration. Components designed and
fabricated with CAD/CAM technology accommodate the
gingival contours of patients with a degree of precision that
is simply not possible when stock abutments are modified
on a conventional soft tissue model.
My conversion to custom abutments is only a microcosm
of what is taking place throughout the industry. Ultimately,
the clinical advantages offered by custom abutments are
rendering the stock abutment obsolete. As more and
more doctors give patient-specific components a try and
experience the efficiency, precision and cost-effectiveness
of custom abutments, the industry’s conversion to digital
customization can only become more pronounced. Practices
run more smoothly and efficiently when abutments arrive at
the clinic ready to place without any adjustments. Though
stock abutments have played an essential role in the rise
of implant dentistry over the years, custom abutments will
inevitably become the restorative components of choice as
their clinical benefits become more widely known. IM
11
12
Figures 11, 12: The final custom abutments (top) and all-ceramic, implant-retained
bridge (bottom) in this case illustrate how effectively custom healing abutments
establish ideal fits, margins and contacts.
– The Clinical Advantages of Custom Abutments – 33

educing treatment time with digital dentistry
36
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Go online for
in-depth content
Reducing Treatment Time
with Digital Dentistry
by
Dean H. Saiki, DDS and
Grant Bullis, Director of Implant R&D and Digital Manufacturing
Edentulous patients with loose and ill-fitting mandibular dentures are
a common sight in the dental office. Often, the maxillary denture fits
well, but the deficient fit of the lower denture limits these patients’
ability to chew certain foods. Even with periodic relines, persistent
soreness makes it difficult for these patients to wear their lower
denture on a regular basis.
provisional fixed denture supported by
four implants. The final fixed restoration
would be delivered after the implants
were fully integrated. The provisional
restoration was designed based on the
patient’s existing, approved esthetics,
occlusion and vertical dimension of occlusion
(VDO).
Case Description
A 72-year-old female patient complained
of a loose lower denture that
was painful to wear and chew with.
A routine examination revealed a pronounced
lack of bone volume in the
lower ridge in conjunction with a relatively
high floor of the mouth, making
relines ineffective in resolving the patient’s
chief complaint.
After a comprehensive examination, including
cone beam computed tomography
(CBCT) imaging, and an in-depth
consultation with the patient, her family
and her physician, the decision was
made to proceed with a screw-retained,
The restorative protocol for this case
used state-of-the-art techniques to
improve the accuracy of implant
placement, optimize the function and
esthetics of the provisional, and reduce
the time required for treatment.
The diagnosis, treatment planning,
surgery, provisional denture and final
restorative steps of her treatment plan
– Reducing Treatment Time with Digital Dentistry – 37

educing treatment time with digital dentistry
all leveraged digital dentistry technologies.
The convergence of these
technologies is enabling simpler, more
convenient and more affordable restorative
protocols.
Diagnosis
The patient had no medical contraindications
for implant surgery. She
was on blood thinners, which were
discontinued for a period of four days
before and two days after the surgery
to mitigate the amount of bleeding
during and after implant placement.
Her periodontal tissues were generally
healthy and free from irritation
because of a recent reline and adjustment
of the lower denture to relieve
sore spots. Her occlusion with the relined
dentures was good, and she had
been functioning in these dentures
for years without any TMJ issues. Her
lower denture’s lack of retention was
her primary motivation for considering
implant therapy.
Figure 1: Though scan appliances must often be
fabricated for CBCT scanning, the patient’s existing
denture was functionally and esthetically sufficient to
serve as the radiographic guide.
Figure 2: Gutta-percha markers were placed in the
patient’s lower denture to serve as radiographic reference
points for the CBCT scans.
Treatment Objectives
The objective of the treatment plan
was to improve patient comfort and
chewing function by replacing the
patient’s existing mandibular denture
with a screw-retained fixed implant
bridge. With sufficient primary stability,
the patient could receive a fixed
provisional at the time of surgery, providing
her with a stable lower denture.
The provisional denture would be
designed with dental CAD software,
using the setup from the existing denture.
The final restoration would also
be produced digitally, beginning with
the CAD/CAM provisional design and
incorporating any adjustments made
to the provisional post-surgery.
Figure 3: A CBCT scan was taken of the scan appliance (in this case, the patient’s existing denture) in the
patient’s mouth.
4
Treatment Planning
Because the occlusion, esthetics and
VDO of the patient’s existing denture
were correct, it was modified to serve
as the CBCT scan appliance (Fig. 1).
Prior to the imaging appointment, six
5
Figures 4, 5: Following dual-scan protocol, in addition
to scanning the patient with the scan appliance
in place, the patient’s existing maxillary denture and
lower denture were scanned outside of the patient’s
mouth.
Figure 6: The scan of the bite registration was used
to digitally articulate the lower and upper dentures.
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The patient’s
existing denture ...
was modified to
serve as the CBCT
scan appliance.
fiducial markers were placed in the lingual
flanges of the patient’s lower denture.
The indentations were made with
a #6 round bur to one-half depth, with
spacing approximated equally around
the flanges. The indentations were then
filled with warm gutta-percha and the
excess was polished off using a rubber
wheel (Fig. 2). The imaging center then
scanned the patient with the marked
denture in place (Fig. 3).
Figure 7: Treatment planning software was used to merge the anatomical data obtained from scanning the
patient with the radiographic guide in place with the STL files of the scan appliance.
To ensure maximum accuracy of the
surgical guide, an accurate scan of
the denture was then taken following
dual-scan protocol, including the intaglio
surface and the fiducial markers.
A NewTom CBCT scanner (Cefla North
America; Charlotte, N.C.) was used to
scan the maxillary denture (Fig. 4),
lower denture (Fig. 5) and bite. From
these DICOM data sets, stereolithography
(STL) files that described the
surface geometry of the scanned objects
were extracted. The bite scan
was used to articulate the scans of the
lower denture scan appliance and the
maxillary denture (Fig. 6). Then, the
CBCT DICOM anatomical data was
carefully registered to the STL files of
the scan appliance (Fig. 7).
Once the data sets were accurately
merged in the treatment planning
software, the implants were virtually
selected and placed at the optimal
positions and angulations for the
available bone volume and prosthesis
support (Fig. 8). The two posterior
implants were angled to fit within the
greatest volume of bone and increase
the anterior-posterior spread of the
Figure 8: The 3-D imaging offered by CBCT scanning was invaluable in evaluating the patient’s underlying anatomy
and determining the ideal placement of the implants.
– Reducing Treatment Time with Digital Dentistry – 39

educing treatment time with digital dentistry
restoration support. Multi-unit abutments
were used to correct the angle
of the two posterior implants and to
provide a common restorative platform
across all implant sites (Fig. 9).
The provisional prosthesis and surgical
guide were designed using the
occlusal and intaglio surface data from
the scan appliance (Fig. 10).
After segmenting the DICOM data
for density, models of the patient’s
mandibular arch (Fig. 11), provisional
denture (Fig. 12) and surgical guide
were 3-D printed, and then articulated
so the entire surgical and prosthetic
stack could be examined (Fig. 13).
Figure 9: After digitally evaluating the quality and
quantity of mandibular bone, implants and multi-unit
abutments were virtually placed with the appropriate
angling and depth for the patient’s bone morphology.
Figure 10: CAD technology was used to design the
provisional denture and surgical guide. Treatment
planning software helped ensure an accurate fit and
conformity to the patient’s anatomy and the virtually
placed implants.
The provisional was designed with
relief for the multi-unit temporary
cylinders (Fig. 14). The surgical guide
incorporated occlusal anatomy to function
with a bite index for anatomically
correct fixation of the guide. A surgical
index was constructed for precise
placement of the surgical guide at the
time of surgery (Fig. 15).
11 12
The provisional
prosthesis and
surgical guide were
designed using the
occlusal and intaglio
surface data from
the scan appliance.
13
Figures 11–13: Models of the patient’s restorative
arch (upper left) and provisional prosthesis (above)
were articulated along with the patient’s bite registration
and a maxillary cast (left) for analysis.
Figure 14: Multi-unit temporary cylinders (shown
here on the mandibular soft tissue model) allowed the
patient’s provisional to function as a fixed prosthesis.
Figure 15: A surgical index was fabricated on the articulated
model between the guide and maxillary cast.
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Implant Placement
The surgical index proved reliable in
accurately positioning the guide for
surgery (Fig. 16). After administering
mandibular anesthesia, the surgical
guide was placed with the aid of the
index, and fixation pins were installed
to hold the guide firmly in place to
begin the surgery.
After using a gingival tissue punch,
the guide was removed to facilitate
removal of tissue at the implant sites.
The index was again used to position
the guide following tissue removal,
and the fixation pins realigned to their
holes without incident. The surgical
guide was used to prepare the osteotomies
and guide the placement of four
4.7 mm implants. Primary stability of
all four implants was acceptable, and
multi-unit abutments were mounted
on top of the implants (Fig. 17).
The temporary prosthesis was held
in place with a luting index, and cold
cure acrylic was used to fix the prosthesis
to the multi-unit temporary
cylinders (Fig. 18). After curing, the
prosthesis was removed and finished
extraorally before being reattached to
the multi-unit abutments (Fig. 19).
Minimal occlusal adjustments were
made immediately after delivery of
the provisional prosthesis. Because
the patient was still under anesthesia,
obtaining an accurate, repeatable
centric occlusion proved challenging.
The patient’s bite was adjusted during
a routine postoperative check a
few days later, and by the third visit,
her bite was comfortable and stable
(Figs. 20a–20c).
The provisional was designed to
remain out of contact with the periimplant
tissue to allow for cleansing. It
also did not cantilever past the distalmost
implant. This abbreviated design
reduced the forces transmitted to the
implants, even though the patient’s
provisional prosthesis was opposed
Figure 16: Before installing the fixation pins, the
surgical index was used to help ensure accurate
positioning of the surgical guide.
Figure 18: A luting index was installed below the provisional
denture, and the prosthesis was processed
to the temporary cylinders with cold cure acrylic.
20a
20c
Figure 17: After verifying primary stability of the
implants, the multi-unit abutments were torqued into
place.
Figure 19: After being finished extraorally, the denture
was reattached to the multi-unit abutments,
serving the patient well as a fixed overdenture until
delivery of the final restoration.
20b
Figures 20a–20c: Retracted lateral and anterior
views of the patient’s mouth with adjusted provisional
denture in place exhibit the proper occlusion and
centric relation that were achieved by the third visit.
– Reducing Treatment Time with Digital Dentistry – 41

educing treatment time with digital dentistry
by a full upper denture. She was
instructed to maintain a soft diet for the
first three months. The implants were
allowed to integrate for six months.
Throughout the entire healing phase,
the patient reported a very stable bite
and was free of TMJ symptoms.
Final Restoration
The final restoration protocol made use
of intraoral scanning, dental CAD/CAM
and 3-D printing to deliver the final
prosthesis in just three appointments.
Digital impressions were taken with
an intraoral scanner at the first appointment.
The second appointment
was for try-in of the combined denture
setup and milled titanium bar. The
definitive prosthesis was delivered at
the final appointment.
Figure 21: A digital impression of the patient’s temporary overdenture in place was taken with an intraoral
scanner.
❯ First Appointment
The esthetics, occlusion and VDO of
the patient’s provisional prosthesis
were correct, so it was used to guide
the design of the final restoration. First,
a scan was taken of the provisional in
the mouth, taking care to capture adjacent
anatomical landmarks (Fig. 21).
Next, the opposing dentition was
scanned. Because a denture served as
the opposing dentition, it was scanned
extraorally (Fig. 22). The patient was
then asked to close, and the bite was
scanned in maximum intercuspation
(Fig. 23).
Next, the provisional was removed,
scanning fixtures were attached to the
multi-unit abutments and the restorative
arch was scanned (Fig. 24). Care
was taken to capture the same adjacent
anatomical landmarks as the first
scan of the provisional. After intraoral
scanning of the edentulous arch was
complete, the provisional denture was
reattached to the multi-unit abutments.
Figure 22: The maxillary denture scan was performed
extraorally.
Figure 23: Scanning the patient’s bite.
At the laboratory, technicians used
the scan data to design the final
prosthesis. The denture and the milled
titanium bar were designed together
Figure 24: After removing the temporary overdenture and attaching scanning fixtures, the edentulous arch was
scanned to capture the position of the multi-unit abutments.
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The final restoration
protocol made
use of intraoral
scanning, dental
CAD/CAM and 3-D
printing to deliver
the final prosthesis
in just three
appointments.
Figure 25: Utilizing the scans of the provisional overdenture, opposing denture and edentulous arch with scanning
fixtures, the laboratory used CAD to design the titanium framework and final prosthesis.
in dental CAD using the scans of the
provisional prosthesis and opposing
denture as design guides (Fig. 25). The
intersecting volume of the milled bar
was then subtracted from the bottom
of the denture to complete the design.
After design, a 3-D model of the final
denture was printed (Fig. 26), and the
titanium bar was milled (Fig. 27). The
denture and bar were mated together,
and a denture mold was made from the
assembly (Figs. 28, 29). After removing
the printed denture model from the
mold, denture teeth were inserted
into the mold, and then affixed to the
milled bar with wax (Fig. 30).
Figure 26: CAD/CAM software and a 3-D printer
were used to produce a prototype of the final prosthesis.
Figure 27: The denture framework was milled from
titanium for a precise fit of less than 20 microns.
❯ Second Appointment
An appointment was made for try-in
of the denture setup. After removing
the provisional prosthesis, the denture
setup was placed with one screw
tightened on the milled bar, and radiographs
were taken to verify passive fit
of the substructure (Figs. 31a–31c). The
denture setup was checked for proper
fit, and a small adjustment was made.
Then, the provisional was reinstalled
and the verified denture setup was
sent back to the lab.
28 29
Figures 28, 29: A mold was fabricated from the combined titanium bar and final denture model.
– Reducing Treatment Time with Digital Dentistry – 43

educing treatment time with digital dentistry
❯ Third Appointment
The lab processed the denture to the
titanium bar with acrylic to finish the
final prosthesis (Fig. 32). The provisional
was removed and the final fixed
implant denture was delivered. The
patient was extremely happy with the
fit, comfort and function of the final
prosthesis (Fig. 33).
Discussion
Achieving adequate primary stability is
a must before proceeding with an implant-retained
provisional or final prosthesis.
Had sufficient primary stability
not been achieved for all of the implants
upon surgical placement, the patient’s
existing denture could have been
used as a provisional after relieving it
to accommodate healing abutments or
cover screws and sutures. Patient comfort
was the primary consideration in
the decision to construct a new provisional
denture instead of modifying the
existing denture, which lacked retention
and would have posed problems if
placed on a new surgical site.
Conclusion
Guided surgery and dental CAD/CAM
are complementary technologies that
can make the surgical and restorative
phases of implant therapy more
efficient and predictable. Guided surgery
offers extremely accurate implant
placement relative to the treatment
plan. Because we can predict the implant
position postsurgically, prosthesis
design can be done pre-surgically.
Advanced treatment protocols that
leverage digital impressions, treatment
planning, guided surgery and dental
CAD/CAM technology are transforming
implant therapy, shortening treatment
times and improving prosthetic
outcomes (Fig. 34). As the technologies
behind implant digital dentistry continue
to evolve and converge, we can
expect further reductions in the time
required to restore implant cases and
increasingly consistent results. IM
Achieving adequate
primary stability
is a must before
proceeding with an
implant-retained
provisional or
final prosthesis.
31a
31c
Figure 32: The framework and setup were processed
into acrylic at the lab to produce the final denture.
Figure 30: Denture teeth were affixed to the denture
setup with wax.
31b
Figures 31a-31c: Radiographs confirmed a passive
fit of the titanium framework.
Figure 33: The final fixed restoration met the esthetic
and functional needs of the patient while eliminating
the retention problems the patient experienced prior
to implant treatment.
44
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Past Protocol
1 st APPOINTMENT
Preliminary impressions
2 nd APPOINTMENT
Jaw relation records and shade selection
3 rd APPOINTMENT
Trial denture setup try-in
4 th APPOINTMENT
Verification jig try-in/final impression
5 th APPOINTMENT
Denture setup/milled framework try-in
6 th APPOINTMENT
Deliver final prosthesis
Current Protocol
Future Protocol
1 st APPOINTMENT
Digital impression
2 nd APPOINTMENT
Milled framework try-in
1 st APPOINTMENT
Digital impression
3 rd APPOINTMENT
Deliver final prosthesis
2 nd APPOINTMENT
Deliver final prosthesis
Figure 34: Digital technologies are streamlining restorative protocols and enhancing the accuracy of implant dentistry, allowing for fewer appointments and more predictable
prosthetic outcomes.
– Reducing Treatment Time with Digital Dentistry – 45

System-specific intraoral workflow
guides are available online.
Intraoral Scanning Guides…
46
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Go online for
in-depth content
PRODUCT
SPOT
light
Two-Day Custom Abutments and Crowns from Intraoral Scans
Clinicians are leveraging their investments in chairside
digital impression systems to reduce the time and cost
of implant therapy. Dental technicians produce custom
abutments and crowns directly from digital impressions
taken with these systems, eliminating the need for physical
models. Doctors and patients alike can benefit from this
simple, convenient and affordable restorative process.
For system-specific information on how to send digital
implant impressions to Glidewell Laboratories, intraoral
workflow guides are available by visiting the “Digital
Impression Systems” page under Dentist, then Services, at
www.glidewelldental.com. IM
From a chairside digital impression, Glidewell Laboratories
will digitally design and fabricate a custom abutment or
crown in two days or less. Doctors save on the cost of impression
materials, shipping to the lab and model work,
and they benefit from lower lab prices on restorations. The
process for taking the digital implant impression and sending
it to the lab is straightforward.
The chairside procedure is as follows:
1. Remove the healing abutment and attach an Inclusive
® Scanning Abutment (available through Glidewell
Direct) to the implant. For Bellatek ® Encode ®
Impression System (Biomet 3i ; Warsaw, Ind.) digital
impressions, it is not necessary to remove the healing
abutment.
2. Take buccal, lingual and occlusal scans of the implant
site.
3. Scan the opposing dentition.
4. Remove the scanning abutment and scan the bite.
5. Electronically submit the digital implant impression
to the lab.
Chairside digital impression scans communicate patient anatomy to the lab with
improved accuracy and efficiency.
CAD/CAM crowns and abutments ship in two days or
less when derived from digital implant impressions.
– Product Spotlight: Two-Day Abutments and Crowns from Intraoral Scans – 47

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BRIDGING THE GAP
Restoring Partially Edentulous Spaces and Maximizing Treatment
Options with the Inclusive ® Tooth Replacement System
by Timothy F. Kosinski, DDS, MAGD
Dental implants have become
an important method of restoring
missing teeth with
function and esthetics. Many edentulous
and partially eden tulous patients
are requesting — some even demanding
— implant therapy. Clinicians are
leveraging the continual improvements
in surgical and restorative technology,
materials and methodology,
and approaching implant cases with
more certainty and predictability than
ever. At the same time, these trends are
broadening clinical flexibility while
allowing us to treat an increasing variety
of den tal conditions with implant therapy.
Whether a case involves a partially
eden tulous space or a fully edentulous
arch, advances in implantology are
maximizing the range of treatment options
available to patients.
The Inclusive ® Tooth Replacement System
(Glidewell Laboratories; New port
Beach, Calif.) offers the many benefits
of clinical flexibility while bringing together
all of the elements required to
provide implant treatment in a single
package, with a streamlined clinical
workflow that can be followed for single
or multi-unit restorations. Regardless of
the indication, this comprehensive approach
to implant dentistry is focused
on the final result throughout the restorative
process, using patient-specific
components and CAD/CAM technology
to help guide any case toward predictable
success.
The placement of dental implants involves
a comprehensive understand ing
of both surgical and prosthetic applications.
Today’s implant dentistry is
restorative driven, and there must be
a clear visualization of the completed
case prior to any surgical intervention.
With the Inclusive Tooth Replacement
System, the final restoration is conveyed
through every phase, from initial
placement of the implant, through
healing or temporization, all the way
to delivery of the final crown; or, as
seen in the case presented here, the
final bridge.
The case that follows involves the
restoration of an edentulous anterior
maxilla. As with all cases, limitations
need to be recognized prior to surgical
– Restoring Partially Edentulous Spaces and Maximizing Treatment Options with the Inclusive Tooth Replacement System – 49

Restoring Partially Edentulous Spaces and Maximizing Treatment Options
placement of any dental implants.
Anatomic considerations must be addressed,
including the position of
nerves and undercuts. The thickness
and angulation of bone, as well as
the integrity of the buccal and lingual
plates, must be studied and clearly
understood. The esthetic zone of the
anterior maxilla is a critical consideration
in achieving an acceptable
restoration for the patient. Simply
placing an implant where there is
adequate bone is no longer acceptable.
Smile design and emergence
profile have developed into art forms
unto themselves. With the Inclusive
Tooth Replacement System, soft tissue
is trained with patient-specific components
from the outset, making establishment
of the emergence profile and
the transition to the final restoration a
smooth and predictable endeavor.
The patient-specific contours of the
Inclusive Tooth Replacement System
custom healing abutments begin training
the soft tissue immediately following
placement of the implants. In
the case presented here, a composite
transitional bridge was fabricated
to further encourage proper tissue
healing while meeting the esthetic
needs of the patient. Following full
osseointegration and healing of the
soft tissue, final impressions were taken
to convey the gingival architecture
and precise position of the implants
to the laboratory for fabrication of the
final restoration.
CASE REPORT
The patient in this case is a 42-year-old
white female who presented with a
mobile conventional bridge spanning
teeth #7–10. She has a fairly high
smile line that made our final prosthetic
esthetics a challenge. Although
With the Inclusive Tooth Replacement System, soft tissue
is trained with patient-specific components from the outset,
making establishment of the emergence profile and the transition
to the final restoration a smooth and predictable endeavor.
her existing bridge was done well,
the patient felt that the prosthetic
teeth were too yellow and too short.
There were no significant health findings
except for her slightly elevated
blood pressure and a prosthetic joint
that required premedication. A bovine
graft had been placed previously by
another clinician following extraction
of non-restorable tooth #8 and #9. The
patient was anxious to obtain a more
stable prosthesis.
As with any edentulous maxillary
anterior space, conventional treatment
options to consider included a removable
partial denture, fabrication of
a longer-span anterior conventional
bridge, or placement of two dental
implants following extraction of the
remaining non-restorable, mobile teeth.
For this particular case, we chose a
4-unit, implant-retained bridge seated
on the maxillary right and left lateral
incisors, combining the use of a
traditional bridge with the clinical
flexibility afforded by recent advances
in implantology.
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1 2
6 7
Figures 1, 2: Preoperative digital periapical radiographs illustrating weakened
right and left maxillary lateral incisors maintaining a 4-unit conventional fixed bridge.
These teeth were mobile and required extraction. The maxillary central incisors
had been extracted and grafted with Bio-Oss ® (Geistlich Pharma North America;
Princeton, N.J.) several years earlier by another clinician.
8
3
Figures 6–8: Physics ® Forceps (Golden Dental Solutions Inc.; Detroit, Mich.) were
used to atraumatically remove the remaining left and right maxillary lateral incisors.
Maintenance of the buccal plates was critical to the ability to immediately place two
Inclusive ® Tapered Implants (Glidewell Laboratories).
4
Figures 3, 4: The patient’s conventional porcelain-fused-to-metal bridge was yellow
in color and no longer stable.
Figure 9: A 2.3 mm diameter pilot drill was positioned palatal to the socket site
and approximately 3 mm palatal to the facial plane, maintaining the integrity of the
buccal plate. Implant depth was determined with the pilot drill.
Figure 5: The pontics were sectioned from the conventional maxillary anterior
bridge.
Figure 10: A 2.8 mm diameter drill was used to widen the osteotomy site.
– Restoring Partially Edentulous Spaces and Maximizing Treatment Options with the Inclusive Tooth Replacement System – 51

Restoring Partially Edentulous Spaces and Maximizing Treatment Options
Figure 11: The final 3.4 mm diameter drill made the final osteotomy site. The site
was slightly undersized, making immediate stability of the first 3.7 mm Inclusive
Tapered Implant possible.
Figure 15: After placement, both implants were torqued to a little more than
35 Ncm, which provided excellent initial implant stability, even in the immediate
extraction sites.
16
17
Figure 12: The 3.7 mm x 11.5 mm Inclusive Tapered Implant was initially hand
tightened into place using the tactile carrier.
Figures 16, 17: Digital periapical radiographs illustrating the implants in proper
position.
18
Figure 13: Inclusive Tapered Implant in place in the surgical site for tooth #7 after
completion of hand tightening.
19 20
Figure 14: A torque wrench was used to tighten the implant to proper depth.
Figures 18–20: Custom impression copings in place over the implants. The
Inclusive Tooth Replacement System provides for fabrication of custom impression
copings that match the patient-specific soft tissue contours of the system’s custom
temporary components. The impression copings are fabricated prior to any surgical
intervention using the hard tissue preoperative casts and proper radiographs.
Because the procedure was atraumatic, with little or no bleeding, the impression
copings approximated proper tissue height, providing a good starting point for ideal
prosthetic reconstruction.
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Figure 21: A polyvinyl siloxane impression was made using the prefabricated
custom impression copings.
Figure 25: The final Inclusive ® Zirconia Custom Abutments (Glidewell Laboratories)
included with the system were fabricated by the dental laboratory and torqued into
place at 25 Ncm.
Figure 22: The prefabricated BioTemps ® provisional bridge (Glidewell Laboratories)
spanning teeth #7–10 was seated over the custom temporary abutments attached
to the implants. Although not perfect at the margins, it allowed for nice tissue healing
prior to final impressions for the final implant-retained bridge.
23
24
Figure 26: Digital periapical radiograph showing one of the fully seated final zirconia
abutments.
Figures 23, 24: After approximately four months of integration, the transitional
appliance and custom temporary abutments were removed, revealing very healthy
pink tissue with trained tissue contours. There was no need for extra anesthesia or
surgical cutting of the tissue.
– Restoring Partially Edentulous Spaces and Maximizing Treatment Options with the Inclusive Tooth Replacement System – 53

Restoring Partially Edentulous Spaces and Maximizing Treatment Options
Figure 27: The final implant-retained bridge was cemented into place.
Figure 30: The final implant-retained bridge accommodates the patient’s high
smile line. The patient was allowed to wear the transitional appliance up until the
final bridge was placed and was minimally inconvenienced during the procedure.
Conclusion
Figure 28: Occlusal view of final implant-retained bridge.
Success with dental implants is based on the need to
achieve primary stabilization and secondary integration of
the titanium fixtures, while maintaining hard and soft tissue
contours, to create long-term function and esthetics. Achieving
these standards is made easier by the customization and
comprehensive approach of the Inclusive Tooth Replacement
System, which allows for surgical predictability, terrific
initial implant stability and reliable osseointegration. Simple
preoperative prosthetic techniques made fabrication of the
final implant-retained bridge in this case as easy as, or easier
than, conventional crowns.
Patients come to us looking for a better smile and improved
function. As practitioners seeking to meet the needs of our
patients, implant therapy has opened up a world of options.
With modern dental technology, predictable restorative
phases and custom components that transition cases
toward patient acceptance of the final restoration, we can
approach every case with confidence in achieving a successful
and esthetic result. IM
Figure 29: Digital periapical radiograph of fully integrated implant and the
final restoration. The clinical flexibility, restorative phases and patient-specific
components of the Inclusive Tooth Replacement System were key in making this
treatment option a predictable success.
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Clinical Case Report
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in-depth content
iTero ® Digital Scanning Technology and
Tooth-Supported Surgical Guides
by
Perry E. Jones, DDS, MAGD
and Zach Dalmau, R&D Project Manager
echnologies such as digital intraoral scanning, CAD software and digital treatment planning are enhancing the
precision of implant therapy while producing predictable restorative outcomes. Patient anatomy can be understood
with remarkable detail through the digital collection of scanning data, and cases can be virtually planned
using computer software.
The following case exhibits the ability of these technologies to create a highly accurate tooth-supported surgical
guide in a 100 percent digital environment, without the use of conventional modeling. Furthermore, the immediate
placement of provisionals demonstrates the accuracy of computer-assisted implant placement because it requires
the screw-retained abutments and temporary crowns to fit in all dimensions of space, including depth, in order to
be delivered properly. Relining of the provisional crowns was not necessary to compensate for fit inaccuracy, further
emphasizing the precision of these convergent technologies.
Ultimately, this case demonstrates how digital technology can be used to capture data and design and fabricate
tooth-supported surgical guides, temporary abutments, cement-retained provisional crowns and final zirconia
restorations with the highest level of accuracy.
Case Description
A 78-year-old male patient presented with two missing
maxillary right bicuspids (Fig. 1). The patient stated that he
had success with past implants on the opposite side of his
upper jaw and wished to have implants placed to restore
the areas of missing dentition. The patient was concerned
about provisionalization for his missing bicuspids. A comprehensive
assessment was completed to evaluate his
condition and provide treatment options.
The patient’s medical history was noncontributory. He
appeared to be a good candidate for implant placement
and implant restoration, especially given his success on
Figure 1: Occlusal view of the patient’s two missing bicuspids (#4 and #5).
– iTero Digital Scanning Technology and Tooth-Supported Surgical Guides – 55

CLINICAL CASE REPORT
the maxillary left side. The three implant fixtures that were
placed some 10 years prior were restored with a screwretained,
cast gold framework prosthesis with an acrylic
matrix and prosthetic teeth. The fixed prosthesis spanned
from the second molar area to the midline.
Given recent advancements in the accuracy of implant placement
using merged-file, tooth-supported surgical guides, it
was decided to provide the patient with an optimized provisional
solution. The option of immediate placement of
custom, provisional screw-retained abutments and temporary
full-coverage crowns was presented to the patient. After
a discussion of the alternatives, benefits and possible complications,
the patient was pleased with this treatment plan.
Figure 2: CBCT scan, axial view.
DIAGNOSTIC FINDINGS
Medical history: Normal healthy patient with no contraindications
to dental treatment or implant placement.
Periodontal: The patient’s periodontal health was within
normal limits, with probing depths of 3–4 mm in posterior
areas with generalized bone loss and recession. Radiographic
data confirmed generalized bone loss. Gingival health was
satisfactory; several areas bled when probed.
Restorative: Examination revealed multiple lost teeth and
restorations. The maxillary left side had been restored with
a screw-retained cast bar with an acrylic matrix and acrylic
teeth. There was poor marginal adaptation of several of
the restorations, but the patient expressed his need for a
phased treatment plan to help defray costs.
Figure 3: iTero scan, occlusal view.
TMJ/Muscles of mastication: Evaluation revealed an apparently
healthy TMJ with no limitation of range of motion, and
no joint pain or joint noise. The patient exhibited dental
wear patterns consistent with bruxism or clenching.
Occlusion: Intercuspation was observed to be acceptable,
given the patient’s past wear history. Maximum intercuspation
appeared to coincide with a position of centric
relation as best as could be determined manually. A full
range of mandibular motion was observed, and the patient
reported no areas of discomfort in positions of maximum
intercuspation, protrusive, eccentric movements or maximum
opening.
Figure 4: Merge of DICOM and STL files.
Treatment Objectives
The overall treatment objective was to use digital technology
to scan, plan, place and immediately provisionalize the areas
of the two missing maxillary left bicuspids, tooth #4 and
#5. Upon satisfactory implant integration, final restorations
Figure 5: Virtual wax-up.
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would be designed and milled from the digital scanning
data without the use of stone models.
Treatment
The patient agreed to the placement of two implants in the
areas of tooth #4 and #5 with the aid of a tooth-supported
surgical guide, and the immediate insertion of two provisional
screw-retained abutments and cement-retained crowns. The
treatment was divided into four phases: planning, placement,
provisionalization and final restoration.
Phase I: Planning
Cone beam computed tomography (CBCT) imaging was
performed to produce digital data in the DICOM file format
(Fig. 2). In order to produce an accurate data field of the
surface morphology of the coronal portions of the maxillary
arch, a digital scan was performed with the iTero ® digital
scanning system (Align Technology; San Jose, Calif.) (Fig. 3).
The iTero scan produced STL files, the standard CAD/CAM
file format. These STL files are easily exported directly from
the iTero scanning machine to the user’s computer. Using
file merge software, the DICOM files and STL files were
merged to create an accurate 3-D rendering for the computer-aided
treatment planning and design phase (Fig. 4).
Figure 6: CAD software used to determine optimal crown and implant positions.
Figure 7: Software design of tooth-supported surgical guide.
Digital scanning produces a virtual model with sufficient
accuracy to ensure that the tooth-supported surgical guide
designed with CAD software fits properly on the tooth surfaces
of the mouth. It must fit with a high level of accuracy
or the guided surgery will be inaccurate.
Merging the STL files with the DICOM files creates an
accurate, virtual, volumetric rendering that can be used for
“crown down” planning of implant placement and implant
restoration. Using CAD software, a virtual wax-up was
created to locate the ideal positions of the crown restorations
(Fig. 5). The software was used to select the implant types
and sizes that would fit properly into the available alveolar
bone without violating structures such as the sinus. The
CAD software was then used to position the implants
optimally in the bone and properly coordinate their
locations with the retention screw access holes planned for
the implant crown restorations (Fig. 6).
After all placement parameters were checked, the digital
plan was saved. A guide was designed using the CAD software
and sent to a 3-D printer using the STL file format
(Fig. 7). The 3-D printed guide provided for metal collimators
sized to the planned Nobel Biocare implants (Fig. 8). Two
different diameters and lengths of implants were selected
due to bone volume considerations. At the site of tooth #4,
Figure 8: Guide design for collimator inserts.
Digital scanning produces a virtual
model with sufficient accuracy to
ensure that the tooth-supported
surgical guide designed with
CAD software fits properly on the
tooth surfaces of the mouth.
– iTero Digital Scanning Technology and Tooth-Supported Surgical Guides – 57

CLINICAL CASE REPORT
a NobelReplace ® Select RP (Regular Platform) tapered implant
(Nobel Biocare; Yorba Linda, Calif.) was chosen, and
at the site of tooth #5, a NobelReplace Select NP (Narrow
Platform) tapered implant (Nobel Biocare) was selected.
An appointment was set to try in the surgical guide and confirm
the fit before starting the surgical procedure. Planned
cutouts placed at the marginal ridge areas adjacent to the
missing teeth allowed for a visual window to confirm the
full seating of the tooth-supported surgical guide (Fig. 9).
Using CAD software, laboratory technicians designed
screw-retained Inclusive ® Custom Temporary Abutments
(Glidewell Laboratories) from the virtual position of the
implant fixtures (Fig. 10). Custom provisional crowns were
designed with the CAD software to fit the custom temporary
abutments’ marginal design (Fig. 11). The crowns were
designed to optimize the buccal and lingual contours and
marginal adaptation, with the occlusal anatomy intentionally
left out of occlusion to minimize occlusal forces on the
implant fixtures (Fig. 12).
The screw-retained Inclusive Custom Temporary Abutments
were milled out of a specially compounded, radiopaque
polyether ether ketone (PEEK). The BioTemps ® crowns
were manufactured using the lab’s CAD/CAM process. Fit
was confirmed between the milled temporary abutments
and the milled crowns. Implant analogs were used to confirm
the fit of the provisional restorations to the implant
fixtures (Fig. 13).
Phase II: Surgical
Local anesthesia consisted of two carpules of 2% lidocaine
with 1/100,000 epinephrine (Fig. 14). The tooth-supported
surgical guide was soaked in antiseptic solution, and full
seating was confirmed using the proximal observation windows
(Fig. 15). The guided surgery drills were used with the
surgical handpiece. A tissue punch (Nobel Biocare; Yorba
Linda, Calif.) was used to remove a cylinder of tissue for
bone level access (Figs. 16, 17). The first osteotomy site was
for tooth #4. The first entry was made with the RP countersink
drill (Nobel Biocare) (Fig. 18). Guided by the 2 mm
guide collimator, the 2 mm twist drill (Nobel Biocare) was
then used (Fig. 19). The precise depth was marked using a
drill stop and markings on the twist drill (Fig. 20). The next
two sequence drills were used, including the NobelReplace
guided drill series for the RP implant size (Fig. 21). The second
osteotomy site — for tooth #5 — was prepared with
the countersink drill, and then with the 2 mm twist drill,
followed by the last sequenced NP drill (Fig. 22).
With the surgical guide in place, and using the implant
fixture holder (Nobel Biocare), each of the implants were
Figure 9: Surgical guide try-in.
Figure 9: Surgical guide try-in.
Figure 10: CAD design of custom temporary abutments.
Figure 11: CAD design of custom provisional crowns.
Figure 12: CAD design and verification of implant crown orientation.
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Figure 13: Inclusive Custom Temporary Abutment on implant analog with custom
BioTemps crown.
Figure 17: Tissue punch being used with the surgical guide.
Figure 14: Administration of local anesthesia.
Figure 18: First drill used in drilling sequence, initial RP countersink drill.
Figure 15: Tooth-supported surgical guide seated in patient’s mouth.
Figure 19: 2 mm twist drill, second drill used in drilling sequence.
Figure 16: Tissue punch used in this case.
Figure 20: 2 mm twist drill with stop inserted into the guide.
– iTero Digital Scanning Technology and Tooth-Supported Surgical Guides – 59

CLINICAL CASE REPORT
rotated into place with about 1 mm of space left between
the shoulder of the implant holder device and the metal ring
of the surgical guide. Using a manual torque wrench, the
implants were rotated into position so that the orientation
dimple was directed straight to the buccal with no off
rotation. The depth placement of the implants was set by
the surgical guide.
Each implant was torqued to 35 Ncm with the dimple to the
buccal and depth controlled by the surgical guide. An Osstell
® ISQ implant stability measuring device with SmartPeg
attachments (Osstell Inc. USA; Linthicum, Md.) was used in
each respective implant fixture, and a reading of about 80
was recorded in each implant site (Fig. 23). This value was
deemed to be excellent for the maxillary bicuspid area.
Phase III: Immediate Provisional
Restoration
The screw-retained custom temporary abutments were each
individually seated and a titanium retention screw was used
to secure them into place (Fig. 24). Each provisional abutment
retention screw was hand-tightened only (Fig. 25). The
milled provisional crowns were delivered, and the fit was
checked (Fig. 26). Remarkably, the implant fixture placement
was such that no rotation adjustment was required. The occlusal
relationships were checked with articulation paper to
verify that there was no occlusal loading. Also remarkable
was the fact that no mesial-distal contact adjustment was required
as verified by floss. The lack of proximal contact was
deemed to be very important as no undue lateral pressure
was to be exerted by the proximal contacts. The esthetic
result looked excellent from the occlusal, as well as from
the buccal (Fig. 27) and anterior views. The patient reported
that the shade match and esthetics were quite acceptable.
Figure 21: Drill in collimator of guide.
Figure 22: Drill series for the NobelReplace NP tapered implant.
The screw-retained custom
temporary abutments were
each individually seated and a
titanium retention screw was used
to secure them into place.
Each provisional abutment retention
screw was hand-tightened only.
Figure 23: The Osstell ISQ implant stability meter’s SmartPegs in place.
Figure 24: Screw-retained Inclusive Custom Temporary Abutment.
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A panoramic radiograph was
taken with the provisional abutments
and crowns in place. It was
determined that the bone-to-implant
integration was sufficient for the
final implant restoration.
Figure 25: The immediately placed screw-retained Inclusive Custom Temporary
Abutments.
Phase IV: Final Restoration
After six months, the implant fixture integration was verified.
The provisional crowns and screw-retained abutments were
removed using a handheld torque wrench; a reverse torque
of 35 Ncm was applied to the implants, and no rotation
was observed. The Osstell integration measurement device
was again used with its SmartPeg devices inserted into
each respective implant, and a reading of 80 was recorded.
A panoramic radiograph was taken with the provisional
abutments and crowns in place (Fig. 28). It was determined
that the bone-to-implant integration was sufficient for the
final implant restoration.
Figure 26: The immediately placed BioTemps provisional crowns.
Inclusive ® Scanning Abutments (Glidewell Direct), designed
to be used with NobelReplace NP and RP implants, were
inserted and the integral threaded screws hand-tightened
with a standard Nobel Biocare wrench (Fig. 29). An iTero
intraoral scan was performed, and the STL file data was sent
directly to the lab. Using CAD/CAM software, screw-retained
BruxZir ® Solid Zirconia crowns (Glidewell Laboratories) —
constructed to interface with the implant fixtures — were
designed and milled at the lab.
Following the iTero digital scanning procedure, the screwretained
provisional abutments were returned to their
respective implant fixtures, the screws were hand-tightened,
Teflon tape was used to protect the screw heads and Cavit
(3M ESPE; St. Paul, Minn.) was placed over each entrance
access chamber. Each individual provisional crown was
cemented with non-eugenol TempBond ® (Kerr Corp.;
Orange, Calif.).
Figure 27: Buccal view of the BioTemps provisional crowns.
Figure 28: Panoramic view of the implants for tooth #4 and #5.
– iTero Digital Scanning Technology and Tooth-Supported Surgical Guides – 61

CLINICAL CASE REPORT
After a few days, the final restorations were completed at
the lab and the two screw-retained BruxZir Solid Zirconia
crowns were delivered to the office (Fig. 30). After removing
the provisional crowns and screw-retained abutments, the
implant fixtures and soft tissue were examined and deemed
to be acceptable for crown delivery (Fig. 31). Each respective
screw-retained BruxZir crown was secured with a titanium
retention screw and torqued to a value of 35 Ncm (Fig. 32).
Teflon tape was placed and the access holes were sealed
with light-cured composite resin (Figs. 33, 34). The occlusion
was checked and did not require adjustment. The proximal
contacts were checked with floss and found to be exceptional.
The esthetic final result was deemed excellent for both patient
and practitioner (Fig. 35).
Figure 29: Inclusive Scanning Abutments in place.
Results
This case helped validate the high level of restorative
success that can be achieved with restorations done from
intraoral scans. It also illustrated how this digital scanning
technology can be used to plan and create tooth-supported
surgical guides. Development of precise surgical guides in a
model-less, 100 percent digital environment offers clinicians
increased confidence for implant placement. The CAD/
CAM-produced Inclusive Custom Temporary Abutments
and BioTemps provisional crowns delivered at the time of
implant placement further added to the optimal outcome
of this case. The final result was nothing less than stellar,
exceeding both patient and provider expectations.
Figure 30: The final screw-retained BruxZir Solid Zirconia crowns.
Development of precise
surgical guides in a model-less,
100 percent digital environment
offers clinicians increased
confidence for implant placement.
Figure 31: Evaluation of soft tissue healing six months post-implant placement.
Figure 32: Occlusal view of screw-retained BruxZir crowns in place.
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Discussion
Several types of technology were involved in this case. The
iTero digital scanning technology was used to create STL
files — representing the surface anatomy of the patient’s
teeth — that could be merged with the CBCT DICOM files
using file merge software. In this manner, a tooth-supported
surgical guide was designed to precisely fit on the patient’s
teeth in a clinical scenario. There can be huge differences in
the fit of tooth-supported surgical guides, especially when
designed using only the DICOM file rendering, as compared
to a merged file that gives the occlusal accuracy of a surface
digital scan. The surface scan in this case was derived from
a direct intraoral scan of the patient’s teeth.
The software used to merge files is available from several
sources and many third-party planners offer this service.
The STL/DICOM file merge is the most critical software
manipulation of the design process. This element of the
process needs more development in order to ensure consistent
spatial positioning of the surface data. The final
implant positioning was developed after a conference call
with the third-party planning service. The CAD software
was used to design the tooth-supported surgical guide. STL
files were sent to a 3-D printer for printing of the surgical
guide. Three-dimensional printing technology is rapidly
becoming an important part of everyday dental practice
and is commonly being used in the laboratory industry. It
is likely that 3-D printing technology will very soon find its
way into the dental office.
Dental CAD/CAM technology was used to design and mill
the provisional screw-retained abutments and crowns. The
success of past cases provided confidence that the implant
placement could be predicted with accuracy. In this case,
the implant placement depth and axial positioning were
precise. There was some degree of rotational positioning
possible to help secure the final placement once the surgical
guide was removed. The provisional fit was so precise in this
case that the custom temporary abutments and BioTemps
crowns were delivered without using a reline material for fit
compensation. Furthermore, there was no adjustment made
to the contacts or occlusion.
An iTero intraoral scanner was used with Inclusive Scanning
Abutments made by Glidewell Laboratories. CAD software
was used to design the screw-retained BruxZir Solid Zirconia
crowns. These crowns were delivered without the need
for occlusal or proximal adjustments.
Figure 33: Access holes protected with Teflon tape.
Figure 34: Occlusal view of BruxZir crowns with access holes sealed with composite
resin.
Figure 35: Buccal view of the final BruxZir restorations.
CAD software was used to design the
screw-retained BruxZir Solid Zirconia
crowns. These crowns were delivered
without the need for occlusal or
proximal adjustments.
– iTero Digital Scanning Technology and Tooth-Supported Surgical Guides – 63

CLINICAL CASE REPORT
Summary
Digital scanning technology used in conjunction with CBCT
scanning can offer a high level of confidence to practitioners
both in terms of implant placement and implant restoration.
This case demonstrated the merged file, “crown down” planning,
virtual implant placement and tooth-supported surgical
guide design that is possible using CAD software. The unique
customization features of 3-D printing technology allowed
for the creation of a tooth-supported surgical guide in a 100
percent digital environment without the use of stone modeling.
The custom provisional restorations demonstrated the
accuracy of the tooth-supported surgical guide because they
were delivered immediately at the time of implant placement
and required no adjustments. Open-source Inclusive Scanning
Abutments used with the NobelReplace implant system
demonstrated that the actual implant position data could
be accurately captured using the chosen intraoral scanning
technology (iTero). The generated STL files could then be directly
sent to the lab for the design and milling of the screwretained
all-zirconia crowns.
As technology races forward, the current challenges of
developing higher levels of accuracy and consistency are
being addressed, providing clinicians with an increased
level of confidence for implant placement and restoration.
This case, but one example of the growing possibilities,
demonstrates just how far we have come! IM
GENERAL REFERENCES
• Abboud M, Orentlicher G. An open system approach for surgical guide production.
J Oral Maxillofac Surg. 2011 Dec;69(12):e519-24.
• Hu XY, et al. [The reliability and accuracy of the digital models reconstructed by conebeam
computed tomography]. Shanghai Kou Qiang Yi Xue. 2011 Oct;20(5):512-6.
• Behneke A, Burwinkel M, Behneke N. Factors influencing transfer accuracy of cone
beam CT-derived template-based implant placement. Clin Oral Implants Res. 2012
Apr;23(4):416-23. Epub 2011 Oct 24.
• Noh H, et al. Registration accuracy in the integration of laser-scanned dental images
into maxillofacial cone-beam computed tomography images. Am J Orthod
Dentofacial Orthop. 2011 Oct;140(4):585-91.
• Wouters V, Mollemans W, Schutyser F. Calibrated segmentation of CBCT and CT
images for digitization of dental prostheses. Int J Comput Assist Radiol Surg. 2011
Sep;6(5):609-16. Epub 2011 May 3.
• Farman AG, Feuerstein P, Levato CM. Using CBCT in the general practice. Compend
Contin Educ Dent. 2011 Mar;32(2):14-6.
• Tarazona B, et al. A comparison between dental measurements taken from CBCT
models and those taken from a digital method. Eur J Orthod. 2013 Feb;35(1). Epub
2011 Mar 22.
• Farman AG. More about CBCT. J Am Dent Assoc. 2011 Mar;142(3):246, 249; author
reply 249-50.
• Schwartz AI. Improving precision with CBCT imaging. Dent Today. 2011 Jan;30(1):
168-71.
• Al-Ekrish AA, Ekram M. A comparative study of the accuracy and reliability of
multidetector computed tomography and cone beam computed tomography in
the assessment of dental implant site dimensions. Dentomaxillofac Radiol. 2011
Feb;40(2):67-75.
• Worthington P, Rubenstein J, Hatcher DC. The role of cone-beam computed tomography
in the planning and placement of implants. J Am Dent Assoc. 2010
Oct;141 Suppl 3:19S-24S.
• Maret D, et al. Accuracy of 3D reconstructions based on cone beam computed
tomography. J Dent Res. 2010 Dec;89(12):1465-9. Epub 2010 Oct 7.
• Chan HL, Misch K, Wang HL. Dental imaging in implant treatment planning.
Implant Dent. 2010 Aug;19(4):288-98.
• Hassan B, et al. Influence of scanning and reconstruction parameters on quality of
three-dimensional surface models of the dental arches from cone beam computed
tomography. Clin Oral Investig. 2010 Jun;14(3):303-10. Epub 2009 Jun 9.
• Scarfe WC, Farman AG. What is cone-beam CT and how does it work? Dent Clin
North Am. 2008 Oct;52(4):707-30, v.
• D’Souza KM, Aras MA. Types of implant surgical guides in dentistry: a review.
J Oral Implantol. 2012 Oct;38(5):643-52. Epub 2011 Sep 9.
• Cassetta M, et al. Accuracy of two stereolithographic surgical templates: a retrospective
study. Clin Implant Dent Relat Res. 2011 Jul 11. Epub ahead of print.
• Nokar S, et al. Accuracy of implant placement using a CAD/CAM surgical guide: an
in vitro study. Int J Oral Maxillofac Implants. 2011 May-Jun;26(3):520-6.
• Frisardi G, et al. Integration of 3D anatomical data obtained by CT imaging and
3D optical scanning for computer aided implant surgery. BMC Med Imaging. 2011
Feb 21;11:5.
• Al-Harbi SA, Sun AY. Implant placement accuracy when using stereolithographic
template as a surgical guide: preliminary results. Implant Dent. 2009 Feb;18(1):46-56.
• van der Zel JM. Implant planning and placement using optical scanning and cone
beam CT technology. J Prosthodont. 2008 Aug;17(6):476-81. Epub 2008 May 9.
• Jones PE. Cadent iTero digital impression case study: full-arch fixed provisional
bridge. DC Dentalcompare. 2009 Jul 8 [cited 2011 Jul 28]. Available from:
http://www.dentalcompare.com/Featured-Articles/2082-Cadent-iTero-Digital-Impression-Case-Study-Full-Arch-Fixed-Provisional-Bridge/.
• Jones PE. From intraoral scan to final custom implant restoration. Inclusive. Fall
2011;2(4):6-13.
• Jones PE. Implant Q&A: an interview with Dr. Perry Jones. Inclusive. Summer 2012;
3(2):42-46.
• Jones PE. Milled modeless crowns. Dental Product Shopper. August 2012;
6(8):76A-79A.
• Jones PE. Creating surgical guides using CBCT and intraoral scanning. Inclusive.
Fall 2012;3(3):83-90.
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Optical Impressions and Full-Arch
Implant Restorations:
Go online for
A Case Study
in-depth content
by Guy Rosenstiel, DMD, MAGD and
Michael McCracken, DDS, Ph.D.
Clinicians strive for accurate impressions and well-fitting
implant restorations. An accurate impression reduces
residual stress in the prosthesis by promoting a better
restorative fit. Unfortunately, highly accurate implant impressions
can be difficult to achieve using conventional methods,
due to distortion factors inherent in both the clinical and laboratory
processes. This paradigm may be shifting, however,
as we continue to explore the use of optical techniques in
taking implant impressions, and the superior accuracy of a
model and restoration resulting from a digital scan becomes
more apparent.
Traditional implant impression techniques use a machined
coping to capture the position and orientation of the implant
in the arch using elastomeric impression materials, such as polyvinyl
siloxane (PVS). This impression is then poured in stone to make
the working cast. The impression technique is classified as “open-tray” if the impression
coping is pulled with the impression, and “closed-tray” if the coping remains in
the mouth after the impression is taken.
Proponents of the open-tray technique argue that this impression
method is more accurate because it avoids introducing stress to
the impression when it is removed from divergent implants.
Others counter that the impression is distorted when the
open-tray impression coping is tightened onto the
analog. Whether the open-tray or closed-tray technique
is used, the consensus regarding conventional
impressions is that the opportunity exists
for introducing error into the impression.
Research has shown that splinting the impression
copings together in the mouth
improves accuracy. 1–7 This improvement
in accuracy may be due to the increased
rigidity of the impression complex, which
resists distortion from torque during analog
attachment. Because of this data, many
– Optical Impressions and Full-Arch Implant Restorations: A Case Study – 67

Optical Impressions and Full-Arch Implant Restorations
clinicians will make an initial impression using a closed-tray
technique, and then construct a custom tray for a second
PVS impression using splinted open-tray impression copings.
While this two-impression technique provides good
clinical results, it is laborious, time-consuming and expensive.
It also fails to address the potential for distortion when
the impression is poured, which can arise due to the presence
of air bubbles or the expansion and contraction of the
stone during the heating and cooling process.
Taking an optical impression is an alternate approach. Using
a digital scanner such as the IOS FastScan ® (IOS Technologies
Inc.; San Diego, Calif.), impression trays and impression
material are replaced by a handheld camera wand that is
used to precisely map the oral cavity (Fig. 1). This eliminates
the potential for material distortion not only during
impression-taking, but also in the production of the working
model, which is printed directly from a digital file rather
than being cast in stone. With the increased accuracy of
this all-digital process (Figs. 2a, 2b), abutments and crowns
exhibit a more precise fit, minimizing the need for chairside
adjustments upon final seating.
A Full-Arch Maxillary Implant Restoration
Detailed in this case report is an optical scanning technique
for a full-arch maxillary implant restoration. Instead of using
impression copings and PVS material, the impression
was made using scanning abutments and an optical scanner.
Data source: Glidewell Laboratories internal data
Figure 1: Across a full arch, the IOS FastScan records up to 250,000 data points, with a standard deviation of only 0.053 microns.
Data source: Glidewell Laboratories internal data
Figures 2a, 2b: A traditional impression for a single crown contains greater than a 100-micron range of error. The IOS FastScan image captures 98 percent of all
data within 50 microns, and 68 percent of data within 20 microns.
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The final restoration was fabricated and delivered in just
three appointments.
First Appointment
The patient presented for restoration following the placement
and osseointegration of seven internal hex implants
(Fig. 3). Following sinus grafting, the implants were placed
in the edentulous maxillary arch in key positions: first
molars, canines and central incisor, with the addition of two
other implants for increased support of the prosthesis. The
patient was temporized with a removable overdenture on
Locator ® Abutments (Zest Anchors; Escondido, Calif.) (Fig.
4). This temporary overdenture was used to evaluate esthetics
and vertical dimension and provide function to the patient.
A bite registration was taken to represent the vertical
dimension with the trial denture in position, and a duplicate
of the overdenture was made to guide the fabrication of the
final prosthesis.
Figure 3: Seven implants were placed in the edentulous maxillary arch.
NOTE: Additional implants may be used to increase stability of the restoration
and help preserve crestal bone levels.
To make the final impression, Inclusive ® Scanning Abutments
(Glidewell Direct; Irvine, Calif.) were attached to
the implants to capture implant position and angulation
(Figs. 5, 6). These polyether ether ketone (PEEK) abutments
have traditionally been used in the laboratory to scan and
digitize conventional impressions. In this technique, they
are used intraorally to eliminate the working cast altogether.
After a light application of powder to the edentulous
Inclusive ® Scanning Abutments
were attached to the implants
to capture implant position and
angulation. These polyether
ether ketone (PEEK) abutments
have traditionally been used in
the laboratory to scan and digitize
conventional impressions.
In this technique, they are
used intraorally to eliminate
the working cast altogether.
Figure 4: A provisional overdenture with three retentive Locator Attachments
was fabricated.
Figure 5: Inclusive Scanning Abutments were attached to capture implant
depth, position and angulation when the optical impression was taken.
– Optical Impressions and Full-Arch Implant Restorations: A Case Study – 69

Optical Impressions and Full-Arch Implant Restorations
ridge and scanning abutments to increase contrast (Fig. 7),
the IOS FastScan, with its large scan field, was used to capture
an optical impression of the arch (Fig. 8).
Attention then turned to the jaw relationship. (Note that the
vertical dimension established by the temporary overdenture
was marked and measured earlier in the appointment
[Fig. 9].) To begin, PVS putty bite registration material was
inserted in the anterior segment, and the patient was guided
into a centric relation (CR) position using bimanual manipulation
at the previously established vertical dimension.
The position was maintained until the material had set. This
position was then repeated and verified. With the bite registration
in place to hold the vertical dimension, the posterior
segments were optically scanned to provide the laboratory
with a CR record (Fig. 10). After bilaterally scanning the posterior
quadrants, support was established on the posterior
regions, and the anterior support was removed to permit
scanning of the anterior segment. Accuracy of the CR record
was later confirmed with the provisional restoration.
Figure 6: Abutment seating was verified with an explorer. NOTE: Radiopaque
abutments allow radiographic verification of complete seating.
The prescription and digital impression were then electronically
submitted to the laboratory — a completely model-less
and paperless transaction. Based on the optical impression
and the trial denture, the laboratory milled seven Inclusive ®
Custom Abutments (Glidewell Laboratories; Newport Beach,
Calif.) from titanium with margins slightly subgingival. These
computer-designed abutments provide exceptional control
of emergence profiles. The custom abutments were received
from the lab, along with a trial framework (Fig. 11) and an
acrylic provisional. The lab also printed a polymer working
model of the arch with the custom abutments in place.
Second Appointment
Figure 7: The edentulous ridge and scanning abutments were lightly coated
with an opaque powder to facilitate a more precise data capture.
At the second appointment, the titanium custom abutments
were placed on the implants and the abutment screws were
torqued to 35 Ncm (Fig. 12). The trial framework fit extremely
well and seated passively. The acrylic provisional (Fig.
13) was seated on the custom abutments to evaluate occlusion,
esthetics and phonetics. The patient, pleased with
the function and esthetics of the provisional, accepted and
wore the provisional for several weeks without the need for
modifications.
Third Appointment
At the third and final appointment, the final metal-ceramic
prosthesis was delivered (Fig. 14). Fitting without adjustment,
the bridge was harmonious with the soft tissue formation
and facial symmetry (Fig. 15). But best of all was the
effect on the patient. Going from a removable denture to a
fixed prosthesis with excellent esthetics was “life-changing”
Figure 8: The IOS FastScan intraoral scanner was used to scan the
patient’s maxillary arch with scanning abutments in place.
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Figure 9: The VDO was measured previously using simple extraoral markings
and a measuring stick.
Figure 12: The seven Inclusive Titanium Custom Abutments were seated on
the implants and torqued to 35 Ncm.
Figure 10: The CR was captured with the optical scanner bilaterally,
and then in the anterior.
Figure 13: All-acrylic provisional seated on a polymer working model.
Figure 11: Trial framework seated on a polymer working model digitally produced
from a 3-D printer.
Figure 14: The final metal-ceramic prosthesis. Per the patient’s request, a
high-value shade was used.
– Optical Impressions and Full-Arch Implant Restorations: A Case Study – 71

Optical Impressions and Full-Arch Implant Restorations
for this man, who stated that he had never had such a nice
smile (Fig. 16). It was one of those moments that make you
glad you chose to be a dentist.
Summary
In assessing the procedure and final results for this full-arch
maxillary case, an optical impression worked flawlessly.
Optical impression techniques are seen by many clinicians
as being as good as or even better than traditional techniques,
given the superior accuracy of the digital scan and
the printed working model. With no impression material
to distort, no concerns about splinting impression copings
or making custom trays, and no stone casting processes,
clinicians can enjoy the ease and accuracy of digital restorations.
As our profession evolves and we continue to adopt
advanced technologies that help to simplify protocols while
saving time and money, look for optical impressions to gain
increased acceptance as the impression technique of the
future. IM
Figure 15: The balance and proportions of the prosthesis were harmonious
with the patient’s facial contours.
Drs. Rosenstiel and McCracken run a training institute for the surgical placement
of implants in Birmingham, Ala. Dentists in the Comprehensive Implant Residency
Program (CIRP) performed the sinus grafts and implants featured in this article.
For more information on this live-surgery, yearlong implant education program, call
256-797-1964 or e-mail info@alabamaimplanteducation.com.
References
1. Avila ED, Moraes FD, Castanharo SM, Del Acqua MA, Mollo Junior FA. Effect of
splinting in accuracy of two implant impression techniques. J Oral Implantol. 2012
Oct 26. Epub ahead of print.
2. Lee SJ, Cho SB. Accuracy of five implant impression technique: effect of splinting
materials and methods. J Adv Prosthodont. 2011 Dec;3(4):177-85. Epub 2011
Dec 28.
3. Mpikos P, Tortopidis D, Galanis C, Kaisarlis G, Koidis P. The effect of impression
technique and implant angulation on the impression accuracy of external- and
internal-connection implants. Int J Oral Maxillofac Implants. 2012 Nov-Dec;
27(6):1422-8.
4. Ongül D, Gökcen-Röhlig B, Sermet B, Keskin H. A comparative analysis of the accuracy
of different direct impression techniques for multiple implants. Aust Dent J.
2012 Jun;57(2):184-9. Epub 2012 Apr 11.
5. Papaspyridakos P, Lal K, White GS, Weber HP, Gallucci GO. Effect of splinted and
nonsplinted impression techniques on the accuracy of fit of fixed implant prostheses
in edentulous patients: a comparative study. Int J Oral Maxillofac Implants.
2011 Nov-Dec;26(6):1267-72.
6. Rutkunas V, Sveikata K, Savickas R. Effects of implant angulation, material selection,
and impression technique on impression accuracy: a preliminary laboratory
study. Int J Prosthodont. 2012 Sep-Oct;25(5):512-5.
7. Tarib NA, Seong TW, Chuen KM, Kun MS, Ahmad M, Kamarudin KH. Evaluation of
splinting implant impression techniques: two dimensional analyses. Eur J Prosthodont
Restor Dent. 2012 Mar;20(1):35-9.
Figure 16: The patient expressed deep gratitude for the service provided,
and the ease and efficiency with which the bridge was fabricated and delivered
in just three appointments.
72
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LAB
SENSE
Go online for
in-depth content
All Together Now:
Inclusive ® Tooth Replacement System Removables
by
Dzevad Ceranic, CDT, Vice President of Lab Operations
The all-in-one concept of the Inclusive ® Tooth Replacement
System has simplified both the clinical and laboratory
parts of the restorative process by assembling everything
needed for implant treatment into a single, comprehensive
package. Now, this system has been extended to provide
single-source implant overdentures for the fully edentulous
patient.
The system provides edentulous patients with an esthetic
and stable prosthesis that improves retention, function
and speech. For the clinician, the restorative process is
streamlined by a consistent and repeatable treatment
protocol, establishing continuity between the different
phases of implant therapy. The system includes all of the
surgical, temporary and final prosthetic components, as
well as the laboratory services required to complete a fully
edentulous case.
This comprehensive approach to implant treatment means
that each phase of the restoration sets up the next for
success, mitigating communication issues that can occur
between steps. For doctors new to implant overdentures, the
all-in-one packaging of implants, restorative components
and laboratory services makes for a smooth and simple
transition. For experienced practitioners, the all-inclusive
system helps to streamline the delivery of treatment.
Cases are planned with the restorative outcome in mind
from the placement of the implants through delivery
of the final denture. Doctors and patients benefit from
the predictability of clinical outcomes that result from a
cohesive and consistent workflow.
This comprehensive approach
to implant treatment means
that each phase of the
restoration sets up the next
for success.
– All Together Now: Inclusive Tooth Replacement System Removables – 73

Production Workflow
A single package that includes laboratory services helps to
maximize clinical efficiency, reduce chair time and minimize
remakes and chairside adjustments. The advantages of this
treatment protocol are best explained by following a Screw-
Retained Hybrid Denture (Fig. 1) as it moves through the
various phases of laboratory production.
All-in-One Package
Screw-Retained Hybrid Dentures are typically indicated
for edentulous patients desiring a replacement for removable
prostheses. The Inclusive Tooth Replacement System
package simplifies tray setup and eliminates the hassle of
selecting components and arranging laboratory services as
doctors move from one phase of treatment to the next. A
complete case includes:
• 6 tapered implants
• Final surgical drill
• 6 titanium healing abutments
• 6 impression copings
• 6 analogs
• Model work
• Implant verification jig
• CAD/CAM milled titanium bar
• Final denture with premium denture teeth
The Process
Step 1: Fabrication of Implant Verification Jig
and Custom Tray
After placement of the implants and completion of the
healing phase, the laboratory receives the preliminary
impression taken by the doctor. A preliminary cast is poured
from this implant-level impression, which, along with the
impression copings it contains, conveys the patient’s tissue
level, gingival contours and position of the implants to the
laboratory. The processing of the preliminary impression
for overdentures is efficient and predictable because cases
are planned from the beginning with the same interfacing
components and restorative-driven approach in mind.
Based on the preliminary impression, the laboratory
technician fabricates the implant verification jig and
custom impression tray. The verification jig is sectioned
and numbered on the preliminary model (Fig. 2) — each
section containing a non-engaging titanium cylinder — and
sent to the clinician along with the custom impression tray
so the final impression can be made. To maximize clinical
flexibility and efficiency, the laboratory will fabricate the
bite block at this stage if requested.
Step 2: Fabrication of Master Cast and Bite Block
Next, the laboratory fabricates the master cast and bite
block. Note that the final impression contains the implant
verification jig, which conveys the exact orientation of the
implants to the laboratory and ensures a precise fit of the
CAD/CAM milled titanium framework that will be designed
and milled after denture try-in and approval. The master
cast incorporates implant analogs in the same orientation
as the implants placed by the surgeon. The bite block is
fabricated onto the master cast (Fig. 3) and articulated
with the opposing cast. In cases where the bite block was
distributed with the implant verification jig, the base plate
is adjusted to fit the master cast. The laboratory technician
incorporates two screw-retained temporary cylinders that
will be used to retain the bite block when jaw relations are
recorded during the next clinical appointment.
Step 3: Articulation of Casts and Setting of
Denture Teeth in Wax
Once the laboratory receives the jaw relation records,
opposing impression, bite registration and working cast,
the models are articulated and the technician carefully sets
the premium denture teeth according to the instructions
provided by the doctor in the prescription (Fig. 4). The
mounted denture setup is sent to the doctor for try-in and
evaluation of centric relation, VDO, esthetics, phonetics,
tooth arrangement, shade and occlusion.
Step 4: Fabrication of Titanium Framework
Once the denture setup is approved, the model and setup
are scanned, and the titanium bar is fabricated. The titanium
framework is designed by the lab technician using CAD/CAM
technology to achieve a precise fit of less than 20 microns
(Fig. 5). The bar is then milled and the denture setup is
transferred onto the framework before being sent to
the doctor for final try-in. By following a predictable,
restorative-driven workflow, the laboratory produces a
well-fitting titanium bar that typically exhibits a passive fit
upon initial seating, minimizing remakes and adjustments.
This simplifies and makes for a smoother clinical process
that enhances the chair time experience and maximizes the
restorative result for the patient.
Step 5: Processing of Acrylic and Denture Teeth
to the Framework
After a final try-in and approval of the combination titanium
bar and transfer setup, the laboratory completes the final
denture by processing the framework and setup into acrylic
(Figs. 6–8). The resulting final prosthesis is accurate, esthetic
74
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Figure 1: The Screw-Retained Hybrid Denture package includes all of the surgical
and restorative components and laboratory services required to complete a fully
edentulous case.
Figure 5: CAD/CAM software is used to design the titanium framework.
Figure 2: Implant verification jig sectioned and numbered on a working model.
Figure 6: The denture teeth are arranged in a denture processing flask for conversion
of the setup into acrylic.
Figure 3: Bite block fabricated onto the master cast.
Figure 7: The titanium bar is prepared for incorporation into the final denture.
Adding an extra layer of acrylic prevents the framework from showing through the
final prosthesis.
Figure 4: The lab technician arranges the denture teeth to be set in wax.
Figure 8: Acrylic is poured into the denture processing flask. The resulting
denture incorporates the titanium framework and denture teeth into the final
prosthesis.
– All Together Now: Inclusive Tooth Replacement System Removables – 75

$3,500
$3,000
$2,500
$2,495
$3,226
and functional. The all-inclusive approach to the case means
that every step along the way has progressed systematically
to achieve an optimal outcome. This restorative procedure
is easily repeated from one case to the next with consistent
and predictable results.
$2,000
$1,500
$1,000
$500
$0
$1,200
$1,000
$800
$600
$400
$200
$0
Figure 10: The Locator ® Overdenture package, which features Locator Abutments
and Attachments (Zest Anchors; Escondido, Calif.), offers a 28 percent cost savings
when compared with the price of purchasing the denture and parts separately.
$4,500
$4,000
$3,500
$3,000
$2,500
$2,000
$1,500
$1,000
$500
$0
Screw-Retained Hybrid Denture Package
Figure 9: The Screw-Retained Hybrid Denture package offers a 23 percent cost savings
when compared with the price of purchasing the denture and parts separately.
$795
Locator Overdenture Package
$3,495
Locator Bar Overdenture Package
Denture + Parts Purchased Separately
$1,102
Denture + Parts Purchased Separately
$4,226
Denture + Parts Purchased Separately
Figure 11: The Locator Bar Overdenture package offers a 27 percent cost savings
when compared with the price of purchasing the denture and parts separately.
Cost-Effectiveness
Because all of the clinical components and laboratory
services that are needed from placement of the implant
through delivery of the final prosthesis are included with
the system, doctors can consult patients knowing exactly
what their cost will be ahead of time. This single-fee
approach eliminates the uncertainty involved in calculating
the component costs and laboratory fees to complete a case.
Comparing the cost of the three overdenture packages with
the total cost of purchasing the components individually
demonstrates how this all-in-one approach to restoring
fully edentulous cases leads to significant cost savings
(Figs. 9–11). Assembling all of the necessary surgical and
restorative components into a single package benefits the
doctor and patient by fostering a smooth and predictable
restoration at a cost-effective price.
Summary
Using this system to treat edentulous cases leads to predictable
and streamlined implant therapy. The system’s
all-inclusive protocol eliminates communication issues that
can arise between the surgical and restorative phases of
treatment. Everything needed for a restoration is in one
package, resulting in a smoother and more cost-effective
process.
Planning cases with a cohesive approach where each phase
of treatment has the same final restoration in mind helps
ensure a predictable outcome. This systemized process is
simple and easy for doctors to repeat as they move from
one case to the next. The efficiencies make affordable, allinclusive
pricing possible, expanding access to implant
therapy to more edentulous patients. IM
76
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CLINICAL
TIP
Managing Implants in Patients with Bruxism
by
Siamak Abai, DDS, MMedSc
For patients who have undergone implant therapy,
the potential for parafunctional developments due to
bruxism is a cause for concern. Consequences can range
from excessive wear on the restoration and surrounding
dentition, to lack of osseointegration, to loosening or fracture
of the implant restoration. Mitigating these consequences
can help ensure the best possible treatment outcome. Given
the paramount importance of the patient’s health and the
long-term viability of the restoration, careful consideration
of implant design and use of an occlusal guard are strongly
recommended to prevent overloading of the implant and
subsequent periodontal issues related to parafunctional
habits such as bruxism.
Clinical research has produced an inconclusive consensus on
the definition of bruxism and its relation to implant dentistry.
However, criteria found throughout the literature allow the
dental community an extrapolation to serve as a diagnostic
aid in everyday practice. Bruxism is the condition classified
by routine diurnal and nocturnal parafunctional activity that
encompasses bracing, clenching, grinding and gnashing of
dentition. 1–5 Published studies present the condition to be
the most common oral habit, purporting that as high as
80 percent of the population display reasonable cause for
classification. 6 As ever-increasing numbers of patients seek
implant treatment, the statistics involving bruxism cannot
be disregarded.
The lack of consensus should not prevent clinicians from
addressing the real risks posed by bruxism to implant
therapy. Patients with bruxism are eliminated from the
majority of clinical trials involving dental implants, delaying
the establishment of a scientific causal relation between
bruxism and implant failure. 1,3 Scenarios involving the
connection of the two topics cannot so easily be deviated
from in actual treatment planning, calling the clinician to be
knowledgeable in both areas. Using indicators such as tooth
wear as clear-cut diagnostic tools in research settings may lead
to false conclusions that can prevent necessary treatment.
The prevalence of tooth wear alone is a misrepresentation
of the current state of bruxism in a patient and is not
indicative of an ongoing problem. 1,5 Practical guidelines for
the treatment of patients with bruxism are based on expert
opinions rather than on clinical literature until conclusive
studies generate a consensus. 4,7 Treatment absent of these
recommendations can result in implant overload.
Implant Complications and Failure
Implant failure can result from biological and biomechanical
complications. Biological complications can be further
subdivided into early and late failures. 1 Characterization
of early failure involves implant loss before the final
prosthetic restoration due to insufficient osseointegration.
Pathological bone loss after osseointegration is the defining
representation of late failure. 1 Excessive and continuous use
of the muscles of mastication allows patients with bruxism
to exhibit higher maximum bite force than their average
counterparts. 6 The resulting compression causes additional
movement throughout the implant, decreasing the likelihood
of an uninterrupted direct interface between implant and
bone. 5 Complications are determined as biomechanical in
cases where one or more of the implant system components
fail; including but not limited to fracture of the implant
itself, loosening of the connecting abutment screw and
excessive wear of the mesostructural components found in
overdentures. 1 Notwithstanding the lack of consensus in the
literature, the success of implant treatment can be greatly
complicated by circumstances presented by bruxism.
The effects of bruxism are compounded when considering
the occlusal resistances exhibited in natural teeth compared
to those in implant restorations. Lacking the periodontal
membrane associated with natural dentition, implants
conduct forces directly into the underlying bone. 4 When a
light force (20 N) is applied, an osseointegrated implant can
only be intruded by 2 µm, whereas a natural tooth can be
intruded by about 50 µm. 1 The lack of compressible structure
highlights the risks associated with bruxing patients. Patient
complaints must be carefully considered when checking
– Clinical Tip: Managing Implants in Patients with Bruxism – 79

occlusion on implant prostheses, as the occlusal perception
level is higher than that for natural dentition. 1
Further occlusal differences are observed due to the
distinction between natural dentition and implant root
efficiency. Moving posteriorly from the anterior, natural
teeth increase 300 percent in surface area from central
to molars, along with an amplification of the number of
roots present. 6 Although implant structures tend to have a
greater surface area, their increase in width is far less than
that of natural dentition, with most implant systems only
seeing a 25 percent to 50 percent increase from smallest to
largest diameter. 6 As forces are increased in patients with
bruxism, augmentation of bone may be required to allow
for increased area of implantation to provide the mandatory
strength. Lack of periodontal structure, as well as diameter
discrepancy, require precise implant design choice on
behalf of the clinician.
Implant Design
Once osseointegration is achieved, the predominant factor
in implant longevity is maintenance of applied force.
Excessive occlusal pressure must be mitigated or even
avoided by the implant. 8 Strength is directly affected by
the surface diameter created by the thread characteristics,
determining the area available to dissipate force under
increased tension. 6
Patients with bruxism require clinicians to choose the
correct thread characteristics in order to create the most
surface area. The strongest materials often cannot withstand
bruxing, requiring the clinician to plan the final restoration
in a manner that removes it from full occlusion during
maximum intercuspation. Using a sheet of shim stock,
the practitioner positions the implant restoration out of
intercuspation by a minimum of 12 µm during centric
occlusion (Fig. 1). This allows the natural dentition to
absorb and mitigate the pressure through its periodontal
ligaments rather than the implant directing the compressive
forces into the bone.
Protection can also be built into the implant by reducing the
overall diameter and creating a narrow occlusal table of the
restoration so that it rests nearly entirely over the implant,
causing the bite forces to be distributed directly through the
implant itself (Fig. 2). This is important in that it reduces the
cantilever effect, which greatly alleviates the chance of bone
loss. 4 Employing particular design specifications will serve
to increase the likelihood of successful implant treatment.
Occlusal Guards
Effective protection of the implant system can be assisted
greatly by the prescription of a hard occlusal splint. Clinicians
often attempt irreversible occlusal treatments or force
the patient to change their lifestyle in an effort to reduce
bruxism, but custom-made acrylic guards can achieve the
same results. 7 Adjacent dysfunction and pathologic tooth
wear are addressed during the fabrication of the orthotic. 5,9
Achieving mutually protected occlusion within the design of
the guard ensures that the implant prosthesis is not subject
to the negative phenomena exhibited by bruxing patients.
The unconscious pressures exerted in nocturnal bruxism
are spread over the entire arch and lessened, rather than
being absorbed at a single location.
Prescription of a hard occlusal splint begins with the
clinician taking maxillary and mandibular polyvinyl
siloxane impressions. A bite registration is also taken at the
minimum opening needed for splint material fabrication,
with the patient’s temporomandibular joints in the centric
occlusion position according to the clinician’s centric
occlusion registration technique. With the patient in this
Figure 1: Depiction of an implant restoration placed out of intercuspation by 12 µm,
or the thickness of a sheet of shim stock.
Figure 2: Depiction of the direction of occlusal forces on a poorly designed implant
restoration versus those exhibited on natural dentition and a properly designed
implant restoration.
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open centric relation, bite registration material is injected
into the posterior openings of both quadrants (Fig. 3).
An additional interocclusal record is taken to capture the
anterior opening in centric relation (Fig. 4).
Figure 3: Bite registration material is injected into the posterior openings of both
quadrants with the patient in open centric relation.
Fabrication of the occlusal splint begins when the laboratory
receives these models and makes a stone cast. Upper and
lower models are mounted onto a thermoforming jig and
articulated to build mutually protected occlusion. The
splint material is then heated and vacuum formed over the
maxillary arch, while the mandibular arch is pressed into
the material to create occlusal relief. The vacuum-formed
splint is then cut free of the model, smoothed, polished and
delivered to the clinician.
During the delivery appointment, the clinician checks the
orthotic in the mouth to ensure proper fit and makes any
necessary adjustments (Fig. 5). Protrusive and laterotrusive
movements are confirmed and the appliance is adjusted to
achieve clinically acceptable, mutually protected occlusion
(Fig. 6). A one-week recall appointment is required to reevaluate
and adjust the occlusion of the splint.
Figure 4: To capture a complete open construction bite at centric relation, bite
registration material is also injected into the anterior opening.
Conclusion
Occlusal guards and proper implant design can negate the
excessive forces exhibited by patients with bruxism, greatly
improving the chances of optimal restorative outcomes.
While current clinical research may not reach consensus
on the effects of bruxism, the practicing clinician must
exhibit a working knowledge for when this situation
inevitably arises. Successful outcomes are determined by
the integration between bone and implant structure, which
can be greatly impeded by undue force. Whereas occlusal
guards may be less critical than proper implant design, the
construction of both agents with a mind toward protection
helps ensure successful treatment. IM
Figure 5: The splint is seated in the patient’s mouth to evaluate fit, retention and
occlusion. Any necessary adjustments are made with a carbide bur.
Figure 6: After complete seating of the splint, the bite is checked with marking
tape to identify any premature occlusion. The splint is adjusted and polished
as needed.
References
1. Komiyama O, Lobbezoo F, De Laat A, Iida T, Kitagawa T, Murakami H, Kato T,
Kawara M. Clinical management of implant prostheses in patients with bruxism.
Int J Biomater. 2012;2012:369063. Epub 2012 Jun 4.
2. Lobbezoo F, Brouwers JE, Cune MS, Naeije M. Dental implants in patients with
bruxing habits. J Oral Rehabil. 2006 Feb;33(2):152-9.
3. Lobbezoo F, Van Der Zaag J, Naeije M. Bruxism: its multiple causes and its effects
on dental implants – an updated review. J Oral Rehabil. 2006 Apr;33(4):293-300.
4. Manfredini D, Bucci MB, Sabattini VB, Lobbezoo F. Bruxism: overview of current
knowledge and suggestions for dental implants planning. Cranio. 2011 Oct;29(4):
304-12.
5. Rouse J. The bruxism triad. Inside Dentistry. 2010 May;6(5):32-42.
6. Misch CE. The effect of bruxism on treatment planning for dental implants. Dent
Today. 2002 Sep; 21(9):76-81.
7. Margeas R. Worn out: how Americans are damaging their teeth. Inside Dentistry.
2007 Sept;3(8).
8. Casullo D. Conservative and predictable implant therapy. A Supplement to Compendium
of Continuing Education in Dentistry. 2011 June;32(1):7-11.
9. Nicolae S. The effects of bruxism on stomatognathic system. ACTA Medica Transilvanica.
2011 Sep;2(3):493-4.
– Clinical Tip: Managing Implants in Patients with Bruxism – 81

SMALL DIAMETER
implants
Benefits of CBCT-Assisted
Guided Surgery
with Timothy F. Kosinski, DDS, MAGD
PATIENTS OFTEN COME TO OUR PRACTICES unable to
tolerate their conventional mandibular complete dentures
any longer, especially if there is significant bone loss. Their
dentures can be unstable and often unretentive, creating sore
spots and diminishing quality of life for the patient. Smalldiameter
dental implants are a viable solution for many of
these issues. They are useful when the clinician is presented
with challenges related to bone quantity, anatomic restraints
such as thin residual ridges, and esthetic complications.
While meeting the goals of implant dentistry by fostering
oral rehabilitation and improved form and function, smalldiameter
implants can also be more cost-effective, addressing
the economic difficulties many patients face.
When dealing with compromised mandibular ridges, cone
beam computed tomography (CBCT) diagnostics allow us to
visualize the patient’s available bone in 3-D and to virtually
place the implants prior to any surgical intervention (Fig. 1).
CBCT scanning is an important tool in the positioning and
placement of dental implants, especially in areas of the
mouth where bone contours are difficult to determine with
conventional radiography and oral palpation alone. This tool
Figure 1: Digital treatment plan for four small-diameter implants.
– Small Diameter Implants: Benefits of CBCT-Assisted Guided Surgery – 83

helps to determine quality and quantity of bone, potential
risks involving surgical placement of dental implants, and
the location of nerves and sinuses.
CBCT scanning software allows for less invasive, more
predictable surgery because there is no longer a need for
full-thickness flap procedures. The implants are placed
using a flapless approach, which is much more comfortable
for the patient and improves postoperative healing.
In reviewing the diagnosis, the clinician can evaluate the
CBCT scan and determine proper implant position with
confidence. A stable surgical guide can then be created
(Fig. 2), which allows for predictable, precise dental implant
placement (Fig. 3). IM
Figure 2: Pilot drill with surgical guide using a flapless protocol.
Figure 3: Post-op scan of final implant placement.
BENEFITS OF DIGITAL TREATMENT PLANNING AND GUIDED SURGERY
IN CONJUNCTION WITH SMALL-DIAMETER IMPLANTS
• 3-D view
• Helps determine quality and quantity of bone
• Helps identify critical anatomical structures pre-surgically
• Ability to plan the case from surgical and prosthetic perspectives
• Accurate transfer of digital treatment plan to the clinical setting utilizing a surgical guide
• Minimally invasive procedure through a flapless approach
• Ideal implant placement
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