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Inclusive®<br />
Restorative Driven Implant Solutions Vol. 2, Issue 3<br />
A Multimedia Publication of <strong>Glidewell</strong> Laboratories • www.inclusivemagazine.com<br />
Missed Diagnosis Using<br />
2-D Radiography<br />
Dr. Daniel McEowen<br />
Page 14<br />
Implant Q&A:<br />
gIDE’s Dr. Sascha<br />
Jovanovic<br />
Page 18<br />
Digital Treatment Planning<br />
and Mini Implants<br />
Dr. Paresh Patel<br />
Page 25<br />
2.69 mm<br />
4.09 mm<br />
Preserving Facial<br />
Structure with Implant<br />
Overdentures<br />
Dr. Timothy Kosinski<br />
Page 48<br />
1.63 mm<br />
4.36 mm<br />
CAD/CAM Implant Abutment Design<br />
Dr. Bradley Bockhorst and<br />
Dzevad Ceranic, CDT<br />
Page 6
On the Web<br />
Here’s a sneak peek at the additional<br />
Inclusive magazine content available online.<br />
ONLINE Video Presentations<br />
• <strong>Glidewell</strong> Laboratories’ Alec Di Lullo demonstrates how the latest<br />
CAD/CAM technology is used in the custom design of implant<br />
abutments.<br />
• gIDE academic chairman Dr. Sascha Jovanovic answers questions<br />
pertaining to the stability of implants and the health of their surrounding<br />
tissues.<br />
• Dr. Daniel McEowen summarizes the limitations of 2-D radiography<br />
when compared to 3-D CBCT imaging technology.<br />
• Dr. Paresh Patel performs a guided surgical procedure in which<br />
Inclusive ® Mini Implants are placed in the upper and lower<br />
arches of an edentulous patient.<br />
• Dr. Timothy Kosinski gives his rationale for determining the<br />
appropriate implant and attachment options for overdenture<br />
patients.<br />
Check out the latest online issue of Inclusive<br />
magazine at www.inclusivemagazine.com.<br />
• Dr. Ara Nazarian highlights the intermediate and long-term<br />
benefits of utilizing BioTemps ® Implant Provisionals.<br />
ONLINE CE credit<br />
• Get free CE credit for the material in this issue with each test you<br />
complete and pass. To get started, visit our website and look for<br />
the articles marked with “CE.”<br />
Look for these icons in the pages that follow for extra content<br />
available on our website, www.inclusivemagazine.com.<br />
– www.inclusivemagazine.com –
Contents<br />
ALSO IN THIS ISSUE<br />
32 Clinical Tip: <strong>Dental</strong> Photography as<br />
a Laboratory Communication Tool<br />
36 A New Generation of Denture Teeth:<br />
The Perfect Route to Esthetic and<br />
Functional Dentures<br />
43 Ensuring a Successful Restorative<br />
Outcome Utilizing BioTemps ®<br />
Implant Provisionals<br />
6<br />
14<br />
18<br />
25<br />
48<br />
CAD/CAM Technology in Implant Abutment Design<br />
Implant abutments custom-designed and milled with today’s digital<br />
CAD/CAM techniques offer several clinical advantages over prefabricated<br />
abutments. Utilizing anterior and posterior case examples,<br />
<strong>Glidewell</strong> Laboratories’ Dr. Bradley Bockhorst and Dzevad Ceranic,<br />
CDT, discuss the parameters for ensuring proper margins, angle<br />
correction, crown support, emergence profile and more.<br />
Missed Diagnosis Using Conventional Radiography<br />
With the ability to capture three-dimensional views in multiplanar<br />
slices, Cone Beam Computed Tomography (CBCT) is proving superior<br />
to conventional radiography in the evaluation of endodontic<br />
anatomy and dental disease. In a case report, Dr. Daniel McEowen<br />
details a situation in which this advanced imaging technology enabled<br />
him to accurately diagnose an endodontic failure, and to plan<br />
treatment involving immediate, post-extraction implant placement.<br />
Implant Q&A: An Interview with Dr. Sascha Jovanovic<br />
In an Inclusive magazine interview, gIDE founder and academic<br />
chairman Dr. Sascha Jovanovic shares his thoughts on a variety of<br />
implant-related topics. Read what this leading clinician and lecturer<br />
on implant surgery and soft tissue health and esthetics has to say<br />
about some of the many considerations regarding implant therapy.<br />
Three-Dimensional Treatment Planning with Surgical<br />
Guides and Mini Implant-Retained Dentures<br />
To meet the challenge of an edentulous case contraindicating conventional<br />
implant treatment, Dr. Paresh Patel utilizes cutting-edge<br />
digital treatment planning and resulting surgical guides to ensure<br />
the flapless, parallel insertion of mini implants for the retention of<br />
maxillary and mandibular overdentures.<br />
Preserving the Integrity of Facial Structures with<br />
Implant-Retained Overdentures<br />
Bone resorption resulting from edentulism can compromise a person’s<br />
features by allowing a collapse of facial structures. While<br />
conventional dentures may help, they are often unstable and do<br />
nothing to prevent future bone loss. Here, Dr. Timothy Kosinski<br />
describes how dental implant services have been shown to minimize<br />
resorption, thereby maintaining the natural appearance of the face<br />
and smile while improving denture comfort and stability.<br />
– Contents – 1
Letter from the Editor<br />
There are many new dental technologies available today that clinicians can utilize to provide a higher quality of care for<br />
their patients; however, understanding the benefits, proper use and limitations of these technologies is paramount to their<br />
successful application. This issue of Inclusive showcases several of these innovations, ranging from digital treatment planning<br />
and Cone Beam Computed Tomography (CBCT) to CAD/CAM implant abutment design and fabrication.<br />
When placing small-diameter implants, a flapless surgical procedure is often used. In a case report, Dr. Paresh Patel utilizes<br />
a CBCT scan, treatment planning software and guided surgery to plan and place mini implants in a patient with severely<br />
atrophic ridges. Another application of 3-D imaging allows Dr. Daniel McEowen to correctly diagnose the previously undetected<br />
cause of an endodontic failure, which leads to immediate post-extraction implant placement.<br />
CAD/CAM is one of the fastest-growing sectors in dentistry today. This technology enables the dental laboratory to create<br />
custom solutions for your implant cases. Supplementing this issue’s article on the subject (page 6), our online version includes<br />
a step-by-step tutorial presented by <strong>Glidewell</strong> Laboratories’ Alec Di Lullo demonstrating how this technology is used<br />
in implant abutment design. Understanding the functionality of this software will allow you to direct the lab to provide your<br />
patients with the best possible restorations.<br />
There have also been technological improvements in dental materials. Nobel Biocare’s classic Brånemark System ® hybrid<br />
denture has been around for more than 40 years, and with the introduction of CAD/CAM milled titanium frameworks,<br />
the screw-retained denture is still a standard implant restoration. One of the challenges with this type of prosthesis is the<br />
inevitable wear of the denture teeth and loss of VDO. An article by Thorsten Michel, MDT, details the development of Ivoclar<br />
Vivadent’s SR Phonares ® nano-hybrid composite denture teeth, which offer improved strength and esthetics.<br />
While conventional dentures can provide missing facial support, they are often unstable and do nothing to prevent future<br />
bone loss. Dr. Timothy Kosinski describes how implants have been shown to minimize resorption while providing greater<br />
comfort and stability for denture wearers. Case examples illustrate the decision process for selecting various types of overdentures,<br />
including freestanding attachments, bars and mini implants.<br />
Our featured interview is with Dr. Sascha Jovanovic, a leading clinician and educator on implant esthetics. He shares his<br />
thoughts on the latest implant designs and grafting procedures. Of related concern is the sculpting of the soft tissues, which<br />
can be effectively contoured by a quality temporary restoration. Dr. Ara Nazarian demonstrates this and other benefits of<br />
BioTemps ® in provisionalizing implant cases.<br />
We are also proud to announce the opening of the <strong>Glidewell</strong> International Technology Center. A primary goal of this<br />
state-of-the-art facility is to educate clinicians on the latest dental technologies, including how to smoothly integrate them<br />
into their practice. For information about upcoming courses, visit www.glidewellce.com.<br />
Dr. Bradley C. Bockhorst<br />
Editor-in-Chief, Clinical Editor<br />
inclusivemagazine@glidewelldental.com<br />
– Letter from the Editor – 3
Publisher<br />
Jim <strong>Glidewell</strong>, CDT<br />
Editor-in-Chief and clinical editor<br />
Bradley C. Bockhorst, DMD<br />
Managing Editors<br />
Jim Shuck; Mike Cash, CDT<br />
Creative Director<br />
Rachel Pacillas<br />
Contributing editors<br />
David Casper; Dzevad Ceranic, CDT;<br />
Greg Minzenmayer<br />
copy editors<br />
Jennifer Holstein, Eldon Thompson<br />
digital marketing manager<br />
Kevin Keithley<br />
Graphic Designers/Web Designers<br />
Jamie Austin, Deb Evans, Joel Guerra, Audrey Kame,<br />
Lindsey Lauria, Phil Nguyen, Kelley Pelton, Ty Tran<br />
Photographers/Clinical Videographers<br />
Sharon Dowd, James Kwasniewski, Sterling Wright<br />
Illustrator<br />
Phil Nguyen<br />
coordinatorS/AD Representatives<br />
Teri Arthur, Vivian Tsang<br />
If you have questions, comments or suggestions, e-mail us at<br />
inclusivemagazine@glidewelldental.com. Your comments may<br />
be featured in an upcoming issue or on our website.<br />
© 2011 <strong>Glidewell</strong> Laboratories<br />
Neither Inclusive magazine nor any employees involved in its publication<br />
(“publisher”) makes any warranty, express or implied, or assumes<br />
any liability or responsibility for the accuracy, completeness, or usefulness<br />
of any information, apparatus, product, or process disclosed, or<br />
represents that its use would not infringe proprietary rights. Reference<br />
herein to any specific commercial products, process, or services by<br />
trade name, trademark, manufacturer or otherwise does not necessarily<br />
constitute or imply its endorsement, recommendation, or favoring<br />
by the publisher. The views and opinions of authors expressed<br />
herein do not necessarily state or reflect those of the publisher and<br />
shall not be used for advertising or product endorsement purposes.<br />
CAUTION: When viewing the techniques, procedures, theories and<br />
materials that are presented, you must make your own decisions<br />
about specific treatment for patients and exercise personal professional<br />
judgment regarding the need for further clinical testing or education<br />
and your own clinical expertise before trying to implement new<br />
procedures.<br />
Inclusive is a registered trademark of <strong>Glidewell</strong> Laboratories.<br />
Contributors<br />
■ Bradley C. Bockhorst, DMD<br />
After receiving his dental degree from Washington<br />
University School of <strong>Dental</strong> Medicine,<br />
Dr. Bradley Bockhorst served as a Navy <strong>Dental</strong><br />
Officer. Dr. Bockhorst is director of clinical technologies<br />
at <strong>Glidewell</strong> Laboratories, where he<br />
oversees Inclusive ® Digital Implant Treatment<br />
Planning services and is editor-in-chief and<br />
clinical editor of Inclusive magazine. A member of the CDA,<br />
ADA, AO, ICOI and AAID, Dr. Bockhorst lectures internationally<br />
on an array of dental implant topics. Contact him at<br />
800-521-0576 or inclusivemagazine@glidewelldental.com.<br />
■ Dzevad Ceranic, CDT<br />
Dzevad Ceranic began his career at <strong>Glidewell</strong><br />
Laboratories while attending Pasadena<br />
City College’s dental laboratory technology<br />
program. In 1999, Dzevad began working at<br />
<strong>Glidewell</strong> as a waxer and metal finisher, and<br />
soon worked his way up to ceramist. With the<br />
skills acquired as a dental technician, he was<br />
promoted to GM of the Full-Cast department. In this role, he<br />
assisted in facilitating the lab’s transition to CAD/CAM. In 2008,<br />
he took on the company’s rapidly growing Implant department.<br />
Dzevad completed an implants course at UCLA School of Dentistry<br />
in 2009. Today, he leads a team of 170 people at the lab,<br />
implementing cutting-edge technology throughout his department.<br />
Contact him at inclusivemagazine@glidewelldental.com.<br />
■ SASCHA A. JOVANOVIC, DDS, MS<br />
Dr. Sascha Jovanovic received his training in<br />
periodontics, implant dentistry and prosthodontics<br />
at UCLA School of Dentistry, Loma<br />
Linda University and University of Aachen<br />
in Germany, respectively, and holds an M.S.<br />
in oral biology from UCLA. Founder and<br />
academic chairman of the Global Institute<br />
for <strong>Dental</strong> Education (gIDE) and course director of implant<br />
dentistry for UCLA Continuing <strong>Dental</strong> Education, he<br />
has dedicated his clinical work for more than 15 years to<br />
dental implant therapy and bone and soft tissue reconstruction.<br />
He is past president of the European Association for<br />
Osseointegration, past board member of the Osseointegration<br />
Foundation and the recipient of many dental industry awards.<br />
He also lectures and publishes extensively. Contact him at<br />
310-820-9641 or sascha@jovanoviconline.com.<br />
4<br />
– www.inclusivemagazine.com –
■ TIMOTHY F. KOSINSKI, DDS, MAGD<br />
Dr. Timothy Kosinski graduated from University<br />
of Detroit Mercy School of Dentistry and<br />
received a Master of Science degree in biochemistry<br />
from Wayne State University School<br />
of Medicine. An adjunct assistant professor<br />
at Mercy School of Dentistry, he serves on the<br />
editorial review board of numerous dental<br />
journals and is a Diplomate of the ABOI/ID, ICOI and AO.<br />
Dr. Kosinski is a Fellow of the AAID and received his Mastership<br />
in the AGD, from which he received the 2009 Lifelong Learning<br />
and Service Recognition award. Contact him at 248-646-8651,<br />
drkosin@aol.com or www.smilecreator.net.<br />
■ FRANK LAUCIELLO, DDS<br />
Dr. Frank Lauciello graduated from SUNY at<br />
Buffalo School of <strong>Dental</strong> Medicine in 1969<br />
and completed his prosthodontic training at<br />
Buffalo VA Medical Center. Currently a clinical<br />
associate professor in the restorative department<br />
at SUNY at Buffalo, he was director<br />
of the Veterans Administration advanced<br />
program in prosthodontics from 1973 to 1998 and chief of<br />
the dental service from 1996 to 1998. He is also director of<br />
removable prosthodontics for Ivoclar Vivadent and director<br />
of its Implant Esthetics Center of Excellence in Sarasota, Fla.<br />
A Diplomate of the American Board of Prosthodontics, he<br />
has authored numerous articles and textbook chapters and is<br />
actively involved in dental research and product development.<br />
Contact him at frank.lauciello@ivoclarvivadent.com.<br />
■ Thorsten Michel, MDT<br />
Thorsten Michel completed his dental technician<br />
training in 1991 at Mangold dental lab<br />
in Stuttgart, Germany, during which time he<br />
was awarded the prestigious Gysi Prize. After<br />
a stint in the German armed forces, Thorsten<br />
worked for Albrecht Schenk dental lab in<br />
Schwäbisch Gmünd from 1992 to 1994,<br />
and then Winnenden-based Jürgen Dieterich until 1998.<br />
In 2000, he completed master dental technician school in<br />
Freiburg/Breisgau, earning best performance in the examination<br />
for the master craftsman’s diploma. In 2001, he received<br />
the Klaus Kanter award. He currently runs his own dental lab<br />
in Schorndorf, which he started in June 2000. Contact him at<br />
info@michel-zahntechnik.de.<br />
■ ARA NAZARIAN, DDS, DICOI<br />
Dr. Ara Nazarian maintains a private practice<br />
in Troy, Mich., with an emphasis on comprehensive<br />
and restorative care. He is the director<br />
of the Reconstructive Dentistry Institute,<br />
a Diplomate of the ICOI, and has conducted<br />
lectures and hands-on workshops on esthetic<br />
materials and dental implants throughout<br />
the U.S., Europe, New Zealand and Australia. Dr. Nazarian<br />
is also the creator of the DemoDent patient education model<br />
system. His articles have been published in many of today’s<br />
popular dental publications. Contact him at 248-457-0500 or<br />
www.aranazariandds.com.<br />
■ Daniel McEowen, DDS<br />
Dr. Daniel McEowen is a 1982 graduate of<br />
Loma Linda University School of Dentistry and<br />
has been in private practice for 26 years. He<br />
currently practices in Hagerstown, Md., in a<br />
multidiscipline practice. A founding member<br />
and Master of the World Clinical Laser Institute<br />
(WCLI), he lectures and trains internationally<br />
in laser dentistry techniques, and teaches a course for erbium<br />
and diode lasers with the Masters of Laser Dentistry. He has<br />
been active in obtaining FDA approval of oral surgery techniques<br />
using erbium lasers. Dr. McEowen also owns 3D<br />
Imaging Center in Maryland, lectures throughout the U.S. on<br />
cone beam technology, and is an advanced trainer for PreXion<br />
3D cone beam systems. He is active in implantology and a<br />
member of the ICOI. Contact him at drdan13106@gmail.com.<br />
■ Paresh B. PATEL, DDS<br />
Dr. Paresh Patel is a graduate of University of<br />
North Carolina at Chapel Hill School of Dentistry<br />
who has been practicing since 1996. He<br />
has a passion for keeping up with the changing<br />
technology and materials in dentistry. As<br />
a Master in the International Academy of Mini<br />
<strong>Dental</strong> Implants (IAMDI), he has placed more<br />
than 2,500 mini implants and has worked as a lecturer and<br />
clinical consultant on mini implants for various companies.<br />
Dr. Patel belongs to numerous dental organizations, including<br />
the ADA, North Carolina <strong>Dental</strong> Society and AACD, and<br />
is also a member and president of the Iredell County <strong>Dental</strong><br />
Society in Mooresville, N.C. Contact him at 704-799-0552 or<br />
pareshpateldds2@gmail.com.<br />
– Contributors – 5
CAD/CAM Technology in<br />
Implant Abutment Design<br />
Go online for<br />
in-depth content<br />
by Bradley C. Bockhorst, DMD and<br />
Dzevad Ceranic, CDT<br />
Custom abutments provide<br />
numerous clinical advantages<br />
over prefabricated<br />
abutments. Utilizing CAD/CAM<br />
technology, the dental technician<br />
can precisely design and<br />
fabricate the restoration according<br />
to the clinician’s prescription.<br />
Modifications can be made<br />
to the transgingival section,<br />
the margin and the angle of<br />
the abutment. The base, height<br />
and taper of the abutment can<br />
also be designed to provide<br />
support and retention for the<br />
crown. This article will discuss<br />
the clinical parameters that must<br />
be considered when designing<br />
an implant abutment. Anterior<br />
and posterior case examples<br />
handled at <strong>Glidewell</strong> Laboratories<br />
(Newport Beach, Calif.) will<br />
illustrate the primary features<br />
that can be designed into an<br />
abutment using computer-aided<br />
technology.<br />
6<br />
– www.inclusivemagazine.com –
■ The Transgingival Section<br />
Various designs have been used over the years for the section<br />
of the abutment extending from the top of the implant<br />
through the soft tissue. Early root-form endosseous implant<br />
systems advocated a straight-walled design through the gingiva.<br />
1,2 However, this resulted in ridge-lap crown designs<br />
that presented hygienic and esthetic challenges.<br />
Inclusive ® Custom<br />
Implant Abutments<br />
In the 1990s, abutment systems were introduced to create<br />
an “emergence profile.” 3–6 In this scenario, the base of the<br />
abutment flares as it rises coronally from the top of the<br />
implant. The premise of this design is that the restoration<br />
emerges through the soft tissue in a similar way to the natural<br />
clinical crown. While providing an esthetic, cleansable<br />
result, this design requires that clinical precautions be taken<br />
to avoid excessive pressure on the labial tissue, which can<br />
lead to recession. 7<br />
Research has been conducted and some products brought<br />
to market with concave transgingival sections. 8 The concept<br />
behind this design is that creating a thicker band of gingiva<br />
around the abutment will stabilize the soft tissue and mask<br />
the gray color of the titanium abutment at the gingival margin.<br />
A potential challenge with this design is that removing<br />
or replacing the abutment would likely necessitate anesthetizing<br />
of the patient. The narrow neck design could also<br />
lead to thin, potentially weak abutment walls.<br />
So is the best transgingival design straight, convex or concave?<br />
The appropriate solution depends on the case. If the<br />
patient’s soft tissue is thin, the abutment may need to flare<br />
out beginning at the top of the implant. Interproximally, the<br />
abutment can be designed to provide support for the papillae.<br />
If the patient’s soft tissue is thicker, the abutment can be<br />
straight or only slightly flared at the top of the implant and<br />
begin flaring just below the crest of the soft tissue.<br />
<strong>Glidewell</strong> Laboratories offers three types of customized<br />
implant abutments under the Inclusive brand<br />
name: a titanium abutment, a zirconia abutment and<br />
a zirconia to titanium hybrid. Titanium abutments are<br />
used in all areas of the mouth, while zirconia abutments<br />
offer an esthetic option for anterior cases,<br />
particularly if the patient has a thin biotype. The zirconia<br />
hybrid abutment provides a titanium-to-titanium<br />
interface with the implant, as well as a deeper<br />
abutment-to-implant interface. For this hybrid abutment,<br />
an anatomically correct zirconia structure is<br />
luted to a titanium insert in the laboratory using resin<br />
cement.<br />
Utilizing CAD/CAM technology,<br />
the dental technician can<br />
precisely design and fabricate<br />
the restoration according<br />
to the clinician’s prescription.<br />
– CAD/CAM Technology in Implant Abutment Design – 7
So is the best transgingival<br />
design straight, convex or<br />
concave? The appropriate<br />
solution depends on the case.<br />
When seating the abutment, a critical factor is what is placed<br />
on the implant. A properly fabricated provisional restoration<br />
is ideal to help shape and sculpt the soft tissue contours. If<br />
a stock healing abutment is chosen, one with a flare similar<br />
to the tooth being replaced should be used. The soft tissue<br />
and/or the abutment should be adjusted if blanching occurs<br />
upon delivery and does not dissipate within 10 minutes, as<br />
excessive pressure on the tissue can lead to recession. A<br />
periapical radiograph should be taken to verify complete<br />
seating of the abutment.<br />
■ Setting the Margin<br />
For cemented implant restorations, the location of the<br />
margin is even more critical than on natural preps. Several<br />
studies have emphasized the detrimental effect of excess<br />
cement on peri-implant bone and soft tissue. 9,10 Using a<br />
scan of the model, the margin can be set approximately<br />
1 mm below the crest of the soft tissue in esthetic areas.<br />
Typically, it will be placed at or 0.5 mm below the crest<br />
interproximally and lingually/palatally, which provides an<br />
esthetic result and easy access for the complete removal<br />
of excess cement. The shoulder of the margin can also be<br />
planned based on the intended crown type.<br />
■ Crown Support and Retention<br />
Virtual design of the abutment allows the technician to create<br />
the ideal base to support the crown. Retention of the<br />
crown is based on the height and taper of the abutment. 12<br />
CAD software allows the abutment and crown to be visualized<br />
to determine the optimal abutment base width and<br />
height. A six-degree taper is typically provided for retention.<br />
The height of the abutment should be maximized, with<br />
consideration given to providing adequate occlusal/incisal<br />
space for the crown. Finally, the cement space for the crown<br />
can be precisely adjusted.<br />
Using a scan of the model, the<br />
margin can be set ... which<br />
provides an esthetic result and<br />
easy access for the complete<br />
removal of excess cement.<br />
■ Anterior Case Example<br />
■ Angle Correction<br />
If the trajectory of the implant diverges from the position<br />
of the crown of the tooth to be replaced, the abutment can<br />
be designed to correct this angle. 11 Custom abutments can<br />
be manufactured to correct divergence; however, it is not<br />
recommended to exceed 20 degrees of angle correction.<br />
From a biomechanical perspective, severe angles should be<br />
avoided and worked out during the planning stage. Off-axis<br />
loading, particularly in single-tooth restorations, should be<br />
avoided or minimized as much as possible.<br />
Figure 1: Using 3Shape CAD software, the margin of the abutment is set following<br />
the gingival contours. The grid can be used as a measurement aid. The transgingival<br />
section of the abutment fills the sulcus and creates the base for the restoration.<br />
NOTE: <strong>Glidewell</strong> Laboratories will virtually blanch the tissue no more than<br />
0.5 mm, unless specified otherwise on the lab prescription.<br />
8<br />
– www.inclusivemagazine.com –
Figure 2: A full-contour crown is placed over the abutment and the interproximal<br />
contacts are adjusted. Because implants have no periodontal ligament and<br />
therefore no give, long, broad, light interproximal contacts are designed. Once the<br />
crown is designed, the supragingival section of the abutment is adjusted to create<br />
adequate space, support and retention for the restoration.<br />
CAD software allows the<br />
abutment and crown to<br />
be visualized to determine<br />
the optimal abutment base<br />
width and height.<br />
Figure 3: The height of the abutment is adjusted in relation to the crown.<br />
Figure 5: Adjustments are made to the palatal contours.<br />
Figure 4: The mesial-distal width of the abutment is adjusted.<br />
Figure 6: The labial contours and spacing are adjusted.<br />
– CAD/CAM Technology in Implant Abutment Design – 9
■ Posterior Case Example<br />
Figure 7: Incisal view of the abutment with screw access opening and crown<br />
Figure 1: Using the same CAD software as in the previous case, the margin and<br />
transgingival section are set.<br />
Figure 8: Cross-sectional view of the abutment and crown<br />
Figure 2: A full-contour crown is placed over the abutment, and the occlusal and<br />
interproximal contacts are adjusted (red circles).<br />
Once the crown is<br />
designed, the supragingival<br />
section of the abutment is<br />
adjusted to create adequate<br />
space, support and retention<br />
for the restoration.<br />
Figure 3: The height and taper of the abutment is adjusted.<br />
10<br />
– www.inclusivemagazine.com –
■ Conclusion<br />
The use of CAD/CAM technology to design and fabricate<br />
custom abutments provides numerous clinical advantages.<br />
This method allows the clinician to specify design criteria<br />
and material choice on the lab prescription. The abutment<br />
is then custom-designed for the specific case and precisionmilled,<br />
resulting in a superior restoration.<br />
■ References<br />
Figure 4: Adjustments are made to the labial, lingual/palatal and interproximal<br />
contours.<br />
1. Adell R, Eriksson B, Lekholm U, Brånemark PI, Jemt T. Long-term follow-up study<br />
of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral<br />
Maxillofac Implants. 1990;5(4):347–59.<br />
2. Spiekermann H, Jansen VK, Richter EJ. A 10-year follow-up study of IMZ and TPS<br />
implants in the edentulous mandible using bar-retained overdentures. Int J Oral<br />
Maxillofac Implants. 1995 Mar-Apr;10(2):231–43.<br />
3. Daftary F. Dentoalveolar morphology: evaluation of natural root form versus cylindrical<br />
implant fixtures. Pract Periodontics Aesthet Dent. 1997 May;9(4):469–77;<br />
quiz 478.<br />
4.King KO. Implant abutment emergence profile: key to esthetics. J Oral Implantol.<br />
1996;22(1):27–30.<br />
5. Lazzara R. Esthetic excellence with implant abutments. Dent Econ. 1993 Mar;<br />
83(3):83–4, 89.<br />
6. Salinas TJ, Sadan A. Establishing soft tissue integration with natural tooth-shaped<br />
abutments. Pract Periodontics Aesthet Dent. 1998 Jan-Feb;10(1):35–42; quiz 44.<br />
7. Su H, Gonzalez-Martin O, Weisgold A, Lee E. Considerations of implant abutment<br />
and crown contour: critical contour and subcritical contour. Int J Periodontics<br />
Restorative Dent. 2010 Aug;30(4):335–43.<br />
8. Redemagni M, Cremonesi S, Garlini G, Maiorana C. Soft tissue stability with<br />
immediate implants and concave abutments. Eur J Esthet Dent. 2009 Winter;<br />
4(4):328-37.<br />
9. Chik FF, Chan WK, Pow EHN, Chow TW. Management of non-restorable maxillary<br />
premolars with immediate implants, immediate provisional restorations, and<br />
definitive screw-retained CAD/CAM zirconia abutment crowns: a report of five<br />
cases. Hong Kong Dent J. 2009;6:31–8.<br />
10. Goodacre CJ, Bernal GB, Rungcharassaeng K. Clinical complications with<br />
implants and implant prostheses. J Prosthet Dent. 2003;90:121–32.<br />
11. Wu T, Liao W, Dai N, Tang C. Design of a custom angled abutment for dental<br />
implants using computer-aided design and nonlinear finite element analysis.<br />
J Biomech. 2010 Jul 20;43(10):1941–46.<br />
12. Emms M, Tredwin CJ, Setchell DJ, Moles DR. The effects of abutment wall height,<br />
platform size, and screw access channel filling method on resistance to dislodgement<br />
of cement-retained, implant-supported restorations. J Prosthodont.<br />
2007 Jan-Feb;16(1):3–9.<br />
Figure 5: Once the abutment design is completed, the file is transferred to a 5-axis<br />
milling machine and the abutment is fabricated.<br />
– CAD/CAM Technology in Implant Abutment Design – 11
Chairside Processing of LOCATOR ® Attachments into an Existing Denture<br />
Introduced in 2001, the Locator Attachment is the third generation of attachments from Zest Anchors and the worldwide<br />
standard for overdenture retention. A common clinical indication for Locator Attachments is the retrofit of an existing<br />
overdenture. This can easily be accomplished by any clinician and is a great treatment plan that introduces implant<br />
retention to the neediest patients.<br />
Case presentation by John C. Bain, DDS, Farmington, Ark.<br />
Step 1: Remove healing abutments<br />
and place the appropriate<br />
Locator Abutment, ensuring the<br />
top 1.5 mm of the abutment remains<br />
above the gingival tissue.<br />
Step 2: Hand-tighten into place,<br />
and then torque to 30 Ncm or to<br />
the value recommended for the<br />
specific implant system (as documented<br />
in the system's IFU).<br />
Step 3: Place block-out ring over<br />
the Locator Abutment. This will<br />
prevent acrylic resin from flowing<br />
into any exposed undercut<br />
area, facilitating removal of the<br />
denture once the material is set.<br />
Step 4: Insert the Black Processing<br />
Male in the Locator<br />
Denture Cap and place on the<br />
abutment in the mouth.<br />
Step 5: Place indicator paste<br />
on the denture to coincide with<br />
the location of the Locator Abutments<br />
in the mouth.<br />
Step 6: Using an acrylic bur,<br />
relieve the denture in the areas<br />
where the denture caps will rest.<br />
Minimal relief is recommended,<br />
followed by repeated intraoral<br />
verification to ensure the residual<br />
integrity of the denture base.<br />
Step 7: Clean the receptor sites<br />
with alcohol to ensure the removal<br />
of any residual material.<br />
Step 8: Apply resin-curing primer<br />
and bonding agent to the denture<br />
receptor sites.<br />
Step 9: Fill each receptor site<br />
with light-cure acrylic resin.<br />
Step 10: Dry the denture caps<br />
and apply resin-curing primer<br />
and bonding agent. Next, apply<br />
light-cure resin.<br />
Step 11: Seat the denture back<br />
in the mouth and confirm proper<br />
occlusion. Light-cure the denture<br />
in the areas of the Locator<br />
Denture Caps.<br />
Step 12: Remove the denture<br />
and inspect for any voids. If<br />
necessary, fill any voids and<br />
then final-cure the denture for<br />
an additional one minute.<br />
Step 13: Remove the Black Processing<br />
Males using the Locator<br />
Core Tool and insert the appropriate<br />
final male components.<br />
“The Locator Implant Attachment is our attachment<br />
of choice. We like its versatility and the<br />
availability of abutments for any implant system<br />
we use. Our patients can immediately insert and<br />
remove their overdentures with little instruction,<br />
making them very happy and saving us a great<br />
deal of chairtime.”<br />
– Robert L. Blackwell, DDS , Alton, Ill.<br />
“I have been using Locator Attachments to<br />
restore my patients for over 10 years. The<br />
precision, predictability and durability of the<br />
attachments have been outstanding. The fact<br />
that I rarely need to replace the males has<br />
increased my productivity and profitability. Locator<br />
has truly improved my patients’ quality of life."<br />
– Robert C. Vogel, DDS,<br />
Palm Beach Gardens, Fla.
Missed Diagnosis Using Conventional<br />
2-D Radiography<br />
Go online for<br />
in-depth content<br />
by Daniel McEowen, DDS<br />
Cone Beam Computed Tomography (CBCT) is<br />
becoming increasingly popular in dentistry for<br />
diagnosis and treatment planning. Use of this three-dimensional<br />
imaging technology can increase diagnostic accuracy compared<br />
to conventional two-dimensional digital periapical and panoramic<br />
radiography. The inherent distortions and limitations<br />
of 2-D radiographs make it much more difficult to complete<br />
an accurate case diagnosis. Some of these limitations include:<br />
elongation and foreshortening of the target tissues, overlap of<br />
structures in front of or behind the target tissues, tissue density<br />
that is not easily interpreted in bone or soft tissues, and resolution<br />
differences of various film and digital receptors.<br />
Many of the issues associated with conventional 2-D radiography<br />
can be eliminated or greatly reduced with the use of 3-D<br />
CBCT. CBCT uses a cone-shaped beam and digital processing to<br />
create a 3-D image that does not contain magnification, distortion<br />
and overlap of anatomy. Before investing in 3-D imaging, a<br />
clinician will need to choose a “field of view” (FOV). FOV refers<br />
to the area of the anatomy that is captured by the scan. Medium<br />
FOV CBCT scanners offer focal spot sizes down to 0.15 mm<br />
and voxel sizes down to 0.076 mm. The size of the focal spot<br />
and each voxel (volume pixel) determines the resolution of the<br />
image; the smaller the focal spot and voxel, the better the resolution.<br />
1,2 Smaller focal spot sizes and higher resolution enable<br />
clinicians to make very accurate diagnoses in most cases. CBCT<br />
also offers multiplanar views (MPV) in slices as thin as 0.05<br />
mm thick. These MPV are cross sections through the volume of<br />
information in axial (x-z axes), coronal (x-y axes) and saggital<br />
(z-y axes) views. Using sophisticated software, the volume can<br />
be sliced at any oblique direction to view pathology from virtually<br />
any angle and thickness. The ability to view diseased areas<br />
in different planes can eliminate guesswork during diagnosis<br />
and help determine the least invasive procedure necessary to<br />
eliminate the dental disease.<br />
Use of threedimensional<br />
imaging<br />
technology can<br />
increase diagnostic<br />
accuracy compared<br />
to conventional<br />
two-dimensional<br />
digital periapical<br />
and panoramic<br />
radiography.<br />
The following case study illustrates how using CBCT technology<br />
can improve the success of endodontic diagnosis and treatment.<br />
14<br />
– www.inclusivemagazine.com –
Figure 1: Pre-endodontic treatment 2009, patient is having<br />
pain. A 2-D periapical radiograph reveals no apparent<br />
pathology.<br />
Figure 2: Pre-extraction 2011, a 2-D periapical radiograph<br />
shows little to no disease. There is a slight radiolucency at<br />
the distal midpoint of the root.<br />
Case Report<br />
The ability to view<br />
diseased areas in<br />
different planes can<br />
eliminate guesswork<br />
during diagnosis and<br />
help determine<br />
the least invasive<br />
procedure necessary<br />
to eliminate the<br />
dental disease.<br />
This case follows the three-year treatment of a 38-year-old<br />
female with a history of failed root canal procedures and<br />
eventual extractions. In 2009, she presented with vague pain<br />
in the lower right mandibular quadrant and complained she<br />
could not bite in the area. A digital periapical radiograph<br />
taken in September 2009 of the lower right bicuspids and<br />
molars revealed no apparent pathology (Fig. 1). Tooth #28<br />
had slight pain with percussion and some fleeting pain to<br />
cold on the buccal surface lasting less than five seconds.<br />
At some point in the three months prior to her visit, a new<br />
crown had been placed on tooth #5. An occlusal adjustment<br />
was performed on this crown to relieve the stress on<br />
tooth #28.<br />
Several months later, the patient was again seen in the<br />
office for tooth #28. Her symptoms had worsened and she<br />
was experiencing prolonged discomfort in the tooth. Pulp<br />
testing indicated a nonvital root and root canal treatment<br />
was completed. A new periapical radiograph was taken<br />
at this appointment but did not show definitive periapical<br />
pathology. Her symptoms were eliminated and she returned<br />
to normal use and function on tooth #28.<br />
Eighteen months passed and the patient returned for extreme<br />
pain in tooth #28. A new periapical radiograph was<br />
taken that revealed little to no abnormal pathology (Fig. 2).<br />
A CBCT scan was also taken that revealed a large lesion on<br />
– Missed Diagnosis Using Conventional 2-D Radiography – 15
Figure 3: Pre-extraction 2011 (same day<br />
as 2-D periapical), a CBCT scan reveals<br />
a moderate-sized radiolucency at the<br />
midpoint of the root. This is a 0.07 mm<br />
saggital slice.<br />
Figure 4: Pre-extraction axial slice (0.07<br />
mm) showing the extent of the lesion to<br />
the distal<br />
Figure 5: A 2-D radiograph showing the immediate<br />
post-extraction placement of the implant in<br />
the modified socket.<br />
the distal side of the root (Fig. 3). Further examination of the<br />
scan revealed a lateral canal midway down the root with a<br />
3 mm by 5 mm area of radiolucency in the interproximal<br />
bone (Fig. 4). Root canal retreatment was discussed with the<br />
patient and refused. Having been successfully treated with<br />
dental implants in the past, she decided on implant treatment<br />
instead. Immediate implant placement after extraction<br />
was selected as the treatment of choice because it would<br />
greatly decrease the patient’s treatment time.<br />
Luxators were used to atraumatically remove the offending<br />
tooth, and surgical spoons were used to mechanically<br />
debride the socket. The granuloma was removed in its<br />
entirety, and the entire area of the socket was decontaminated<br />
using laser energy. Osteotomy drills were then used to<br />
modify the socket, and an implant was immediately placed<br />
in the modified socket (Fig. 5). The discrepancy between the<br />
socket shape and the diameter of the implant on the buccal<br />
and lingual was less than 1.5 mm, so no additional grafting<br />
materials were placed. Within two to four months, native<br />
bone will fill in the gap.<br />
A postoperative CBCT scan taken immediately after implant<br />
placement revealed the position and the engagement of<br />
the implant in the apical half of the socket (Figs. 6, 7). The<br />
patient is healing well and will soon move forward with<br />
the final restoration. Compared to the 2-D periapical radiographs,<br />
the 3-D and MPV views provided by the CBCT scan<br />
enabled us to make a much more complete diagnosis.<br />
Immediate implant<br />
placement after<br />
extraction was<br />
selected as the<br />
treatment of<br />
choice because<br />
it would greatly<br />
decrease the<br />
patient’s<br />
treatment time.<br />
16<br />
– www.inclusivemagazine.com –
Figure 6: CBCT saggital image taken immediately after<br />
placement of the implant<br />
Figure 7: Coronal slice (0.07 mm) post implant placement<br />
showing buccal to lingual span in the existing extraction site<br />
Compared to the<br />
2-D periapical<br />
radiographs,<br />
the 3-D and MPV<br />
views provided by<br />
the CBCT scan<br />
enabled us<br />
to make a much<br />
more complete<br />
diagnosis.<br />
Conclusion<br />
Three-dimensional CBCT offers a more complete view of<br />
dental anatomy and disease than traditional 2-D radiography<br />
alone. Using this technology allows the clinician to<br />
more accurately evaluate endodontic anatomy and better<br />
diagnose the true extent of dental disease. Having a more<br />
accurate diagnosis results in a more appropriate treatment<br />
plan and helps guide a patient’s treatment toward a successful<br />
outcome.<br />
For clinical questions, contact Dr. Daniel McEowen at drdan13106@gmail.com. For<br />
technical questions, contact Keith Bateman at kbateman@prexion.com.<br />
References<br />
1. Law J. The influence of focal spot size on image resolution. Br J Radiol. 1993<br />
May;66(785):441–46.<br />
2. Cesmeli E, Berry JL, Carr JJ. Tube focal spot size and power capability<br />
impact image quality in the evaluation of intracoronary stents. Proc. SPIE<br />
5745. 2005;676–84. doi:10.1117/12.596035.<br />
– Missed Diagnosis Using Conventional 2-D Radiography – 17
Implant Q&A:<br />
An Interview with Dr. Sascha Jovanovic<br />
Go online for<br />
in-depth content<br />
Interview of Sascha A. Jovanovic, DDS, MS<br />
by Bradley C. Bockhorst, DMD<br />
Dr. Sascha Jovanovic is<br />
founder and academic<br />
chairman of the Global Institute<br />
for <strong>Dental</strong> Education (gIDE) and<br />
course director of implant dentistry for<br />
UCLA Continuing <strong>Dental</strong> Education. A leading<br />
clinician and lecturer on implant surgery<br />
and soft tissue health and esthetics, he recently took<br />
time to share his thoughts on these subjects with Inclusive<br />
magazine at gIDE’s global headquarters in Los Angeles.<br />
18<br />
– www.inclusivemagazine.com –
Dr. Bradley Bockhorst: Before we get started with the interview,<br />
can you share with us a little bit of background information<br />
on gIDE and about the studio where we are right now?<br />
Dr. Sascha Jovanovic: Of course. First of all, it’s a pleasure<br />
to be part of this interview. gIDE was started as a training,<br />
education and research institute in 2003 based on utilizing<br />
today’s new digital technology to distribute information and<br />
knowledge efficiently and swiftly. We’re kind of shrinking<br />
the world of dentists, and we are able to give continuing<br />
education to our colleagues and friends very efficiently and<br />
on their time schedules. So it’s online streaming, it’s digital<br />
downloads, it’s utilizing learning tablets. And my favorite is<br />
the blended learning, which combines in-person training<br />
and online education.<br />
Now, to do this — we started about eight years ago, when<br />
gIDE was founded — we needed a recording studio. We’re<br />
very lucky to be here today in this building, which formerly<br />
was the studio of The Beach Boys. In this area where we<br />
are right now, one of their famous songs could have been<br />
created. So it’s fun for us to be here as dentists, as educators<br />
and as clinicians because we can give a little creative juice<br />
to the education we provide.<br />
BB: Very fun history. The first several questions I have for you<br />
are related to your thoughts and experiences with various<br />
implant and abutment designs. With that in mind, what is the<br />
influence of the implant surface on crestal bone stability?<br />
SJ: We know today that implant surfaces can affect bone<br />
and soft tissue positively. We like an implant to have a<br />
micro or moderately roughened surface, so the bone integration<br />
and stability in the full length of the implant can be<br />
maintained. We also know that a polished neck loses more<br />
crestal bone than an enhanced surface. So when I place an<br />
implant, I always choose an implant that has a roughened<br />
surface all the way up the neck of the implant.<br />
We like an implant to have a micro<br />
or moderately roughened surface,<br />
so the bone integration and stability<br />
in the full length of the implant can<br />
be maintained.<br />
BB: The next question is related to that collar design. You prefer<br />
to have it going all the way to the top of the implant?<br />
SJ: Right. When you look at the neck of the implant, which<br />
is the next point to think about, the most important bone<br />
from a standpoint of soft tissue is the crestal bone. So that’s<br />
why, when we evaluate patients over the long term, we<br />
always want to know what the crestal bone stability is. When<br />
you are evaluating an implant system, here also you want to<br />
know the crestal bone stability. In addition to surface characteristics,<br />
new research nicely shows that implants with a<br />
straight neck or a reverse-neck design are even better for<br />
crestal bone stability.<br />
Implants with a straight neck or a<br />
reverse-neck design are even better<br />
for crestal bone stability.<br />
There is a tendency to move away from implants with<br />
a countersink, like the traditional Brånemark System ®<br />
implants (Nobel Biocare; Yorba Linda, Calif.), in the esthetic<br />
zone — versus something that has more of a straight neck,<br />
such as NobelReplace ® (Nobel Biocare), the most widely<br />
used two-piece implant system. And, currently, implant<br />
designs are being introduced with a reverse-neck design.<br />
Those, again, seem to be better on maintaining the bone.<br />
These are promising results, and that’s definitely the direction<br />
the research is going.<br />
BB: Now, on top of the implant, what abutment materials have<br />
you found to be the most biocompatible?<br />
SJ: Abutment materials are a big topic of discussion because<br />
we have titanium, which we’ve had for the longest<br />
period of time. Later on we had alumina. Today we have<br />
zirconia. And, of course, we have the gold alloy abutments,<br />
like the UCLA-type abutments. Then we have temporary<br />
abutments — which many companies were using or are<br />
still using — which are made out of plastic or some form<br />
of acrylic.<br />
When we look at animal research, it’s very clear that there<br />
are only two materials that are stable for soft tissue, and<br />
those are titanium and zirconia. Now, of course, we can say<br />
animal research is not the same as human clinical data, but<br />
we try to follow the information that is available to us.<br />
– Implant Q&A: An Interview with Dr. Sascha Jovanovic – 19
There are only two materials that<br />
are stable for soft tissue, and those<br />
are titanium and zirconia.<br />
In my practice, I prefer to use titanium or zirconia in a case<br />
that is well planned with good implant position. But, sometimes<br />
you have the unusually complex case, and then we<br />
can still use gold alloy, with the knowledge that we might<br />
lose some crestal bone and soft tissue. Therefore, it’s better<br />
not to use this material in the esthetic zone.<br />
BB: There have been various transgingival designs for abutments<br />
— everything from convex to straight to concave designs.<br />
Which design have you found to best support peri-implant<br />
health and esthetics?<br />
SJ: Well, the tendency that’s been more and more supported<br />
in the last few years is that platform switching, or<br />
the use of abutments with reduced width in relation to the<br />
implant diameter, promotes better soft tissue stability and<br />
improves soft tissue health. Abutments are reduced or, as<br />
you mentioned, some even have a concave design, which is<br />
something we can do today with CAD/CAM. So, for me, it’s<br />
very important to use, at max, a diameter of an abutment<br />
that is the same size as the implant. I won’t use those divergent<br />
ones because divergence means mechanical stress to<br />
the tissues, and mechanical stress to the soft tissues means<br />
an increased risk of recession.<br />
Platform switching, or the use of<br />
abutments with reduced width in<br />
relation to the implant diameter,<br />
promotes better soft tissue stability<br />
and improves soft tissue health.<br />
BB: To make sure I understand, you prefer a straight emergence?<br />
And at what point, from a peri-implant standpoint, do<br />
you like to start having that emergence profile?<br />
SJ: This is very case dependent, as you can imagine. The<br />
best way I can explain it is: Imagine we’re looking at a tulip.<br />
(I’m Dutch, so I love tulips, of course.) Like a tulip, the<br />
stem, which is the abutment, should be really nice and narrow,<br />
and once we come close to the gingival margin, that’s<br />
where we can emerge out. So let’s say about 0.5 mm or so<br />
below the gingival margin is where the crown goes to its<br />
full emergence.<br />
BB: In clinical practice, there are some procedures in which<br />
you’re taking abutments on and off a lot. What impact does<br />
that have on the surrounding tissues?<br />
SJ: This is clear-cut because the research studies show that<br />
implant design is unrelated to bone loss or bone stability. As<br />
an example, if you use a two-stage or a two-piece implant<br />
versus a one-piece implant, the bone stays stable until we<br />
start to remove the abutments. So, as soon as we do impressions<br />
or some type of laboratory work or change — boom!<br />
We get a reaction. And the reaction is usually soft tissue inflammation.<br />
Soft tissue inflammation leads to inflammation<br />
in the bone, which leads to bone loss. Bone loss leads to<br />
potential risk for gingival recession.<br />
So it’s very crucial for any clinician to try to pick the final<br />
abutment as early as possible. A suggestion for clinical practice<br />
is that implant impressions be taken as early as possible.<br />
It could be at the time of implant placement or at<br />
the time of uncovering. And then we select an abutment<br />
that, if possible, is the permanent abutment for the case.<br />
Now, I realize that’s not always possible. You need to be<br />
well equipped and you need to plan the case well, but that<br />
would be the ideal.<br />
It’s very crucial for any clinician to<br />
try to pick the final abutment as<br />
early as possible.<br />
Another good clinical practice is to leave a stock abutment<br />
in for at least two to three months, so the soft tissues are<br />
stable, and then make one more abutment switch at that<br />
time. So you might have two abutment changes. But don’t<br />
do what we used to do in the old days, where we removed<br />
abutments frequently, as this sometimes creates a negative<br />
result which, of course, none of us want.<br />
BB: Back to implant placement. What do you find is the ideal<br />
interproximal space between the implant and the adjacent<br />
roots?<br />
SJ: Spacing between implants and any other anatomical<br />
structures is very important for preservation of the existing<br />
periodontal and bone tissue. We have information in the<br />
literature that suggests that between adjoining implants you<br />
20<br />
– www.inclusivemagazine.com –
need a minimum of 3 mm to 4 mm, which is a good, safe<br />
space. Between an implant and a natural tooth, you need<br />
2 mm or more. This will support the periodontal ligament,<br />
and the more bone we have, the better.<br />
Between adjoining implants you<br />
need a minimum of 3 mm to 4 mm<br />
... Between an implant and a natural<br />
tooth, you need 2 mm or more.<br />
So when you are planning a case, you probably want fewer<br />
implants in the anterior region because you want to have<br />
optimal soft tissue, and you also want to have smaller<br />
diameters. In my private practice, for example, I don’t place<br />
wide-platform implants in the anterior region because it<br />
compromises the soft tissue. I select regular and sometimes<br />
even narrow implants. In addition to this, think about cases<br />
where you have to place multiple implants next to each<br />
other. Often cases are better if you bring in a pontic, so you<br />
have more bone and soft tissue to work with. So, less is<br />
better, and increase the spacing between implants.<br />
BB: How do you handle the cases of, say you’re doing a single<br />
tooth — maybe it’s a narrow maxillary lateral incisor or lower<br />
incisor — and you just don’t have that 2 mm on either side?<br />
How are you handling those cases?<br />
SJ: Well, those are difficult cases. So my recommendation<br />
is: When you are dealing with difficult anatomical conditions,<br />
be very careful, because you are setting yourself<br />
up for a dangerous situation, in which tissue can be lost.<br />
Unfortunately, I see many cases in my practice that are redo<br />
cases, and a loss of the periodontal ligament and papilla on<br />
a natural tooth.<br />
If you have, let’s say, less experience with implants, my recommendation<br />
would always be: Stay away from those cases;<br />
leave that up to colleagues who have more experience, who<br />
know what the pitfalls are. Because the worst you can do is<br />
try to do the best you can for your patient and, in the end,<br />
you get a negative result. So those are not good cases. Get<br />
enough tissue. Get enough space.<br />
BB: What is your ideal position for the top of the implant in<br />
relation to the crest of the bone?<br />
SJ: I published in 1997 a scientific paper describing my<br />
observations about the ideal relationship of the neck of the<br />
implant and the connection with the abutment to the soft<br />
tissue margin. And we concluded that everything is related to<br />
the biological width. The biological width around implants<br />
is approximately 3 mm, so that’s the soft tissue dimension<br />
around implants and around abutments. The goal today will<br />
always be to place the implant neck no deeper than 3 mm<br />
below your optimal gingival margin. And once you know<br />
what your optimal gingival margin is, which should come<br />
from your diagnosis and models, then you count back and<br />
you place the implant about 3 mm below that.<br />
We concluded that everything is<br />
related to the biological width.<br />
So, now, what does that mean in many clinical situations?<br />
When the crest has bone loss, there’s a part of the implant<br />
neck that is going to be exposed. And with that implant<br />
neck, now you need to make a decision. Should I do a grafting<br />
to bring that bone back, or should I maybe place the<br />
implant deeper and then accept that the crown is going to<br />
be longer and there is going to be gingival recession? This<br />
may be acceptable for some patients with a low lip line.<br />
The goal today will always be to<br />
place the implant neck no deeper<br />
than 3 mm below your optimal<br />
gingival margin.<br />
BB: Along the same line, if you decide you are going to do<br />
grafting, when do you determine that it is truly indicated and<br />
which procedures you should perform?<br />
SJ: Bone grating, of course, is extremely important. You can<br />
see how soft tissue is related to bone. Remember, we have<br />
this bone frame, which really sets up the soft tissue. The<br />
soft tissue dimension is stable; it’s 3 mm to 3.5 mm. So just<br />
always keep that in mind. We make a decision before we<br />
start the case, and that is: Should this case be grafted, so we<br />
can get into this good range of 3 mm to 3.5 mm of soft tissue?<br />
Or maybe the patient doesn’t want to do it; maybe they<br />
accept pink porcelain; maybe the patient accepts a longer<br />
crown. Then, of course, that is discussed with the patient.<br />
But, in principle, we graft most cases if we need optimal<br />
soft tissue dimensions.<br />
– Implant Q&A: An Interview with Dr. Sascha Jovanovic – 21
BB: Do you have a material of choice for grafting?<br />
SJ: The most used procedure, which is evidence-based<br />
in the literature — and we have been doing this now for<br />
20 years — is the GBR principle, which is the Guided Bone<br />
Regeneration principle. This is basically the principle where<br />
we use bone grafts based on particulate — some of it is autogenous,<br />
which is the gold standard, and some of it could<br />
be a biomaterial — and then we cover this with a barrier<br />
membrane, which could be resorbable or nonresorbable.<br />
This will, first of all, stabilize the bone graft for regeneration<br />
purposes and, secondly, exclude the soft tissue and bacteria<br />
from invading, so we don’t have a loss of that bone.<br />
BB: Another question along the line of bone grafting: If you<br />
are going to do a delayed case — say you’re going to extract a<br />
tooth and then place an implant later — would you typically<br />
graft that socket?<br />
SJ: Yes, socket grafting is something that is more of a norm<br />
today. So I would always recommend socket grafting to any<br />
clinician and to any colleague for sure in the single-rooted<br />
teeth — which basically means everything that is toward<br />
the anterior — because it will prevent collapse of the buccal<br />
plate, it will maintain more of the soft tissue, and it will<br />
improve the stability of the soft tissue dimension.<br />
I would always recommend socket<br />
grafting to any clinician and to any<br />
colleague for sure in the singlerooted<br />
teeth.<br />
Socket grafting is a very successful procedure, and various<br />
materials work. It could be a biomaterial; it could be<br />
a growth factor; it could be an autogenous bone graft.<br />
But, important as always, the extraction socket needs to<br />
be clean. The infection, which often was there with the<br />
tooth, needs to be cleaned out. So, sometimes you need<br />
to spend more time on extraction and cleaning it out than<br />
just on a grafting procedure. That’s very important because,<br />
unfortunately, I’ve seen a lot of socket grafting which came<br />
back, and the material is just laying around, and it didn’t do<br />
anything. So that is not a good idea.<br />
BB: Once you’ve cleaned out the socket and you’ve grafted,<br />
what do you typically like to cover it up with?<br />
SJ: Socket grafting, as you know, has different options. The<br />
first option, which of course most of us will look at, is to<br />
use a barrier membrane. This can be either a nonresorbable<br />
material — today there’s the dense PTFE material — or we<br />
can use a resorbable material. Then there are also some<br />
new materials. We have collagen grafts, which are thicker;<br />
they have a thickness of about 5 mm. These help us to, first<br />
of all, stabilize the soft tissue and the bone graft, and they<br />
also allow the soft tissue to creep in. And then we have a<br />
procedure that is called socket seal surgery. Socket seal surgery<br />
is a procedure that has been around for a long time.<br />
Cobi Landsberg published something on this, quite nicely,<br />
and he’s using a free gingival graft to stabilize the bone<br />
graft and the soft tissue.<br />
BB: We’ve talked a lot about hard tissue grafting. What’s the<br />
benefit of soft tissue grafting in implant cases?<br />
SJ: What you are focusing on, Brad, is really soft tissue<br />
esthetics and health. But you can see that there are a lot of<br />
things which are happening to soft tissue before we really<br />
get to it, when we are talking about bones, implants, abutments,<br />
etc.<br />
Why soft tissue grafting? Soft tissue grafting is important because<br />
whenever we remove teeth, or whenever we lose teeth,<br />
soft tissue dimension shrinks. So, we often go from gingival<br />
thickness to something thin. And implants, they don’t have<br />
that stability like a tooth has. What we try to do with soft<br />
tissue grafting is to actually increase the thickness. So we<br />
create a new gingival biotype, which is thicker. And what<br />
does that do? This could prevent recession again, improve<br />
esthetics because we won’t have that metal shadowing<br />
through, and give a more natural look. So it is resistance<br />
to recession, resistance to bone loss because the biological<br />
width is more stable, and also it gives better soft tissue<br />
esthetics and health.<br />
BB: Over the last couple of years, there have been a lot of<br />
lectures on connective tissue grafting, particularly in the<br />
esthetic zone. What’s coming across is that labial bone loss is<br />
inevitable, no matter what you do. Have you found that to be<br />
the case? And then do you have to use connective tissue grafting<br />
basically as a cosmetic Band-Aid? Or what’s been your experience<br />
as far as maintaining that labial bone?<br />
What we try to do with soft tissue<br />
grafting is to actually increase the<br />
thickness. So we create a new<br />
gingival biotype, which is thicker.<br />
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SJ: Connective tissue grafting leads into or follows up on<br />
the question you just asked. Let me refer to a very nice<br />
study that we published in 2009, where we looked at vertical<br />
bone augmentation using the GBR principle. And what<br />
we saw there, when we did a combo — a bone graft and<br />
a connective tissue graft — is that we always had better<br />
crestal bone stability.<br />
So, you have to think about it. Soft tissue is very delicate,<br />
so when you don’t have enough soft tissue, bone has a<br />
tendency to shrink more, to lose a little bit more. What connective<br />
tissue does is it, first of all, thickens the soft tissue.<br />
It prevents bone from losing too much, so it kind of keeps<br />
it in a healthy range. And, of course, it improves again the<br />
end outcome, which is esthetics and health.<br />
BB: Very good. Then, for a final question, is a temporary restoration<br />
required for controlling the final soft tissue esthetics?<br />
SJ: Yes, absolutely. This is a tough one because, obviously,<br />
a lot of patients want to have a final restoration as fast as<br />
possible. I always say to my patients that a temporary is like<br />
a prototype. We need to shape and support the soft tissues<br />
in such a way that we know that they’re stable. We don’t<br />
want to have a situation where we now see recession. So,<br />
potentially, we have a final crown in place and the tissues<br />
are not there yet, the gingival papilla is not there yet, and<br />
then we have recession again.<br />
BB: To start wrapping things up, first I’d like to thank you for<br />
taking the time to talk with me. We went through a lot in a<br />
short period. If there are clinicians reading this who want to<br />
get more education and training on different types of hard and<br />
soft tissue grafting and esthetics, what would you recommend?<br />
SJ: Well, our field is full of needs for training and education.<br />
This is a great field. I’m very passionate about it. I love<br />
this area and have been involved in it, thankfully, for more<br />
than 20 years. If you want to get more involved with this<br />
and get more training in soft tissue grafting, choose the<br />
right partners for you. It could be one mentor whom you<br />
trust, it could be an institute that you trust, it could be a university,<br />
or it could be a mix of each. But go through training<br />
and education as much as you can. Think about it like this:<br />
For us, what’s most important is how much experience you<br />
have. Then of course there’s skill. What’s your skill level?<br />
Skill can improve and experience can improve. So, go for it;<br />
find the right partner and learn as much as you can. I’m still<br />
learning every single day.<br />
We need to shape and support the<br />
soft tissues in such a way that we<br />
know that they’re stable.<br />
So I would urge every single patient, especially in the<br />
esthetic zone, to go through a temporary phase. And, again,<br />
the same thing for the clinician; we need to have something<br />
which gives us a better result. And the better result<br />
definitely is there when we first do a prototype, create the<br />
abutment correctly, create the emergence correctly, and<br />
then let the soft tissue flow in. And this soft tissue growth<br />
and stabilization around abutments and around temporaries<br />
could go for more than 12 months. So make sure that you<br />
leave the spaces in. Make sure that you have the abrasion<br />
spaces into which soft tissues can flow. And don’t worry<br />
about the black triangles right then because we have the<br />
potential to regenerate soft tissues interproximally between<br />
3 mm to 5 mm. But you have to give it time to fill in, and<br />
that’s the temporary phase.<br />
– Implant Q&A: An Interview with Dr. Sascha Jovanovic – 23
– www.inclusivemagazine.com –
Three-Dimensional Treatment Planning<br />
with Surgical Guides and<br />
Mini Implant-Retained Dentures<br />
Go online for<br />
in-depth content<br />
by Paresh B. Patel, DDS<br />
At no time in the history of dentistry has the<br />
blending of new technologies and concepts<br />
given rise to the sheer number of exciting possibilities we<br />
face today. For example, implant dentistry has benefited<br />
tremendously from the incorporation of 3-D Cone Beam<br />
Computed Tomography (CBCT) and the ability to mill a surgical<br />
placement guide. It is now possible to take a CBCT<br />
scan and, from the resulting data, virtually place mini dental<br />
implants in such a way as to maximize the available bone,<br />
increase parallelism and avoid vital structures (Figs. 1a, 1b).<br />
Planning a case in this virtual environment also reduces surgical<br />
and healing time because it allows the doctor to safely<br />
utilize a flapless procedure during the actual placement.<br />
What’s more, this digital treatment plan can be performed<br />
without requiring the doctor to leave his office. With a<br />
PC and an Internet connection, he can work through all<br />
details of the proposed treatment plan with a skilled digital<br />
technician via Web conference. There is no learning curve<br />
required to operate the software, as the assisting technician<br />
handles this on the doctor’s behalf, repositioning implants<br />
as directed with just a few mouse clicks. Adding this kind<br />
of technology to your armamentarium will help ensure a<br />
smooth surgical outcome and increase patient acceptance<br />
of a prosthetically driven treatment plan.<br />
Figures 1a, 1b: Digital treatment plan demonstrating virtual placement of<br />
mini implants<br />
It is now possible to take a CBCT scan and, from the resulting data,<br />
virtually place mini dental implants in such a way as to maximize the<br />
available bone, increase parallelism and avoid vital structures.<br />
– Three-Dimensional Treatment Planning with Surgical Guides and Mini Implant-Retained Dentures – 25
Figures 2a, 2b: The patient’s edentulous maxilla and mandible<br />
Ridges for which mini implants<br />
are ideally suited often leaves<br />
them supported on both sides by<br />
high-density cortical plate.<br />
Figure 3: Preoperative panoramic X-ray revealing bilateral pneumatization of<br />
the maxillary sinus<br />
Mini implants have been used successfully to improve the<br />
retention of dentures. 1 With the average age of our population<br />
increasing as people continue to live longer, the need<br />
to improve patients’ lives with secure full dentures is growing.<br />
2 Many edentulous patients present with inadequate<br />
bone width for the placement of traditional implants, which<br />
can require 6 mm of bone or more in the buccal-lingual<br />
dimension. To reach the necessary bone width, these patients<br />
would have to undergo expensive, time-consuming<br />
bone grafting procedures. Even if grafting is not required,<br />
many elderly patients are dissuaded by the cost and trauma<br />
associated with implant surgery. A mini implant, however,<br />
can be placed in as little as 3 mm of buccal-lingual bone<br />
width. The single-stage placement protocol is simpler and<br />
less traumatic. Fewer office visits are required because mini<br />
implants allow for immediate loading in the presence of primary<br />
stability, which is facilitated by an auto-advancing design<br />
that compresses and condenses the surrounding bone<br />
rather than drilling it away. In addition, the narrow ridges<br />
for which mini implants are ideally suited often leaves them<br />
supported on both sides by high-density cortical plate. In<br />
terms of affordability, these smaller implants provide a costeffective<br />
solution that enables more patients to move forward<br />
with implant therapy, due to the reduced number of<br />
parts needed in the surgical and the laboratory phases. 3<br />
CASE REPORT<br />
The patient in this case, a 55-year-old female, had had all<br />
her remaining maxillary and mandibular teeth extracted 11<br />
months prior (Figs. 2a, 2b). At that time, she had received<br />
conventional maxillary and mandibular dentures. Her chief<br />
complaint was that these dentures were nonretentive and<br />
nonfunctional, becoming dislodged or falling out whenever<br />
she ate or spoke. Although the extractions were recent and<br />
she was not a denture wearer for a considerable amount of<br />
time, there was already excessive resorption noted in the<br />
mandible. Radiographically, bilateral pneumatization of the<br />
maxillary sinus was also noted (Fig. 3).<br />
Prior to obtaining a CT scan, reline impressions were taken<br />
with Impregum brand impression material (3M ESPE; St.<br />
Paul, Minn.), and the dentures were sent to <strong>Glidewell</strong> Laboratories<br />
(Newport Beach, Calif.) (Figs. 4a, 4b). From that set<br />
of impressions, upper and lower dual-scan appliances were<br />
fabricated (Figs. 5a, 5b). It is important to note here that the<br />
accuracy of each surgical guide depends greatly on the accuracy<br />
of the impression taken for each scan appliance. Any<br />
reduction in movement of the surgical guide will increase<br />
the accuracy and likely success of the final implant placement.<br />
Using the GXCB-500 powered by i-CAT ® (Gendex<br />
<strong>Dental</strong> Systems; Des Plaines, Ill.), three CT scans were taken<br />
— one of the patient with the scan appliances in the mouth,<br />
and one of each scan appliance by itself. From these scans,<br />
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The accuracy of each surgical guide depends greatly on the<br />
accuracy of the impression taken for each scan appliance.<br />
Figures 4a, 4b: Maxillary and mandibular reline impressions<br />
Figures 5a, 5b: Upper and lower arch dual-scan appliances fabricated at<br />
<strong>Glidewell</strong> Laboratories<br />
the Inclusive ® Mini Implants (<strong>Glidewell</strong> Laboratories) selected<br />
for this procedure could be virtually placed utilizing Blue<br />
Sky Plan ® software (Blue Sky Bio; Grayslake, Ill.).<br />
Next, a Web conference was scheduled with the Inclusive<br />
Digital Treatment Planning team. At the time of the actual<br />
conference session, the restoratively driven treatment plan<br />
was mostly complete. Vital structures, placement paths and<br />
parallelism of the implants had already been identified. The<br />
Digital Treatment Planning team saves the doctor valuable<br />
time by completing most of the tedious tasks in advance. In<br />
this case, I confirmed the final implant positions and, with<br />
the approved plan, the surgical guides were milled.<br />
For the retention of a maxillary overdenture, it is recommended<br />
that six mini implants be placed in the premaxillary<br />
region. To retain a mandibular overdenture, no fewer<br />
than four mini implants should be placed anterior to the<br />
mental foramina. 4 The smaller number of implants required<br />
in the mandible is due to the increased bone density<br />
It is recommended that<br />
six mini implants be placed in<br />
the premaxillary region. To retain<br />
a mandibular overdenture,<br />
no fewer than four mini implants<br />
should be placed anterior to<br />
the mental foramina.<br />
– Three-Dimensional Treatment Planning with Surgical Guides and Mini Implant-Retained Dentures – 27
With a CT scan ... all of the patient’s anatomy and soft<br />
tissue anomalies can be factored into the digital treatment plan.<br />
Figure 6: Maxillary surgical guide in place<br />
Figure 8: First Inclusive Mini Implant hand-tightened into place<br />
Figure 7: A 1.5 mm diameter pilot drill used to depth<br />
Figure 9: Inclusive Mini Implants rotated to depth using the Inclusive Mini<br />
Implant Handpiece Driver<br />
compared to that found in the maxilla. In this case, it was<br />
decided that 1.5 mm diameter guide sleeves would be used<br />
for the 2.2 mm diameter Inclusive Mini Implants to be<br />
placed in the mandible. Due to the softer bone of the maxilla,<br />
it was decided that 1.5 mm sleeves would also be used<br />
for the thicker, 2.5 mm diameter Inclusive Mini Implants<br />
placed there. In denser bone, I would have asked for 1.7<br />
mm diameter sleeves for use in the maxilla.<br />
Even though the placement of mini dental implants is relatively<br />
simple and straightforward, a common argument<br />
against placing them is that the surgery is performed “blind.” 5<br />
Critics contend that by not raising a flap, as is the recommended<br />
protocol when placing mini implants, the doctor<br />
cannot accurately gauge the proper insertion path. With a<br />
CT scan, however, all of the patient’s anatomy and soft tissue<br />
anomalies can be factored into the digital treatment plan.<br />
This digital treatment plan is not merely a “best guess”; rather,<br />
it provides a true representation of the anticipated clinical<br />
outcome. The surgical guide used to translate the virtual<br />
outcome to a physical outcome is precisely fabricated by a<br />
computer-controlled milling station, and the guide sleeves<br />
are placed to tight tolerances. As a result, the opportunity for<br />
error during placement is significantly reduced.<br />
The patient was draped, and a clean operating environment<br />
was established. A preoperative rinse with Peridex <br />
(3M ESPE) was performed prior to local infiltration with<br />
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Cook-Waite Lidocaine ® HCI 2% and Epinephrine 1:100,000<br />
(Kodak <strong>Dental</strong> Systems; Rochester, N.Y.). The upper surgical<br />
guide was inserted and stabilized by both the doctor<br />
and assistant (Fig. 6). Once a confirmed fit was verified, the<br />
1.5 mm diameter pilot drill was introduced into the guide<br />
sleeve (Fig. 7). The guide sleeve orients the pilot drill in the<br />
correct trajectory. The top of the sleeves are set at 9 mm<br />
from the top of the implant, and this vertical distance must<br />
be accounted for when determining proper drill depth. The<br />
recommended procedure for unguided site preparation is<br />
to drill to a depth that is approximately one-half the length<br />
of the implant, plus the tissue depth. In this case, the six<br />
mini implants to be placed in the maxilla were each 10 mm<br />
in length, so half of that length (5 mm) plus the tissue depth<br />
(approximately 2 mm) accounted for 7 mm of drill depth.<br />
Adding the 9 mm length for the guide sleeves necessitated<br />
an overall drill depth of 16 mm. Each Cortical Bone Drill<br />
included with the Inclusive Mini Implant System has depth<br />
markings at 10 mm, 13 mm and 15 mm, so drilling to 16 mm<br />
meant drilling just past the last mark on the drill.<br />
The drilling process was conducted at 1250 RPM under<br />
copious irrigation using the MD 20 Dual Motor System<br />
(Nouvag USA; Lake Hughes, Calif.). For the best chance of<br />
long-term implant success, it is important to minimize tissue<br />
damage and thermal trauma to the bone. 6 Because Inclusive<br />
Mini Implants are self-tapping, only a single pilot drill is<br />
required; no additional finishing bits or bone formers are<br />
needed. The implant will follow the path created by the<br />
pilot drill and compress and condense the bone to help<br />
achieve immediate primary stability. In certain cases, it is<br />
possible to engage both cortical plates for even greater stability.<br />
All six pilot holes were made following the same process,<br />
and the surgical guide was removed. A periodontal<br />
probe was used to confirm that all pilot holes in the cortical<br />
bone did not perforate in the buccal-lingual dimension.<br />
Figure 10: Pilot drill engaged in the mandibular surgical guide<br />
The implant will follow<br />
the path created by<br />
the pilot drill and<br />
compress and condense<br />
the bone to help<br />
achieve immediate<br />
primary stability.<br />
One at a time, the Inclusive Mini Implants were removed<br />
from their sterile packs and glass vials and hand-tightened<br />
with the attached carrier until they were difficult to turn<br />
(Fig. 8). The Handpiece Mini Implant Driver attachment<br />
was then used to gently rotate each mini implant to depth<br />
(Fig. 9). Final seating was verified at 35 Ncm using the<br />
Torque/Ratchet Wrench included in the Inclusive Surgical<br />
Instrumentation Kit.<br />
The same process was repeated for the mandible using the<br />
lower surgical guide (Fig. 10). In this case, the Inclusive Mini<br />
Implants were 13 mm in length, so the pilot drill was taken<br />
to a depth of approximately 18 mm, or almost to the hub.<br />
The overall length of the pilot drill from cutting tip to shank<br />
is approximately 20 mm. Once again, final seating was verified<br />
at 35 Ncm to ensure primary stability (Fig. 11).<br />
Figure 11: Final placement of four Inclusive Mini Implants in the mandible<br />
– Three-Dimensional Treatment Planning with Surgical Guides and Mini Implant-Retained Dentures – 29
Following successful placement of all mini implants, Blu-<br />
Bite HP bite registration material (Henry Schein; Melville,<br />
N.Y.) was injected onto the intaglio surface of the dentures<br />
to help indicate where the dentures would need to be relieved<br />
to allow for passive fit over the mini implant heads<br />
(Figs. 12a, 12b). An NTI ® Universal Cutter pear-shaped bur<br />
(Axis <strong>Dental</strong>; Coppell, Texas) was used to help create the<br />
appropriate-shaped spaces (Figs. 13a–13d). The acrylic bur<br />
is 2.9 mm wide and cuts a hole that is just the right size<br />
for the O-ball head of the mini implant. With a few circular<br />
strokes, you can easily widen the hole to accommodate the<br />
full O-ring Housing, which is approximately 3.5 mm tall<br />
and 4.75 mm wide.<br />
Once the majority of acrylic was removed, Dr. Thompson’s<br />
Color Transfer Applicators (Great Plains <strong>Dental</strong> Products;<br />
Kingman, Kan.) were used to mark the tops of the O-balls.<br />
Any marks that transferred to the dentures indicated additional<br />
acrylic that had to be removed to ensure a completely<br />
passive fit (Figs. 14a, 14b).<br />
A soft reline was performed chairside using COE-SOFT reline<br />
material (GC America; Alsip, Ill.) to stabilize the existing<br />
denture during the healing phase. This gives the mini implants<br />
a chance to osseointegrate fully before more stressful<br />
loads are placed upon them. In a few weeks, a new set<br />
of Inclusive Mini Implant Overdentures will be fabricated,<br />
Figures 12a, 12b: Bite registration material injected onto the intaglio surface of the dentures<br />
Figures 13a–13d: Pear-shaped acrylic bur used to relieve the dentures<br />
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with the O-ring Housings built in. Had the patient been satisfied<br />
with the esthetics of her existing mandibular denture,<br />
we could have performed a chairside pickup of the O-rings<br />
during the same visit, using a hard reline material like Triad<br />
DuaLine (Dentsply; York, Pa.). With regard to the maxillary<br />
denture, it is preferable to perform a soft reline in order to<br />
assure proper osseointegration. Even so, this should take a<br />
matter of weeks, rather than months, as in the case of most<br />
traditional implants.<br />
A postoperative CT scan was then taken. The cross-sectional<br />
slices demonstrate the implants in almost the exact positions<br />
proposed by our digital treatment plan. They confirm<br />
our preoperative goals of taking full advantage of the available<br />
bone while keeping the implants as parallel as possible<br />
(Fig. 15). Had we attempted this case without the use of a<br />
digitally milled surgical guide, these goals would have been<br />
far more difficult to achieve.<br />
Conclusion<br />
The Inclusive Mini Implant System, particularly when used<br />
in concert with Digital Treatment Planning services, represents<br />
an ideal opportunity for general practitioners to<br />
become involved in implant dentistry. In today’s repressed<br />
economy, offering this kind of valuable, inexpensive treatment<br />
enables cost-conscious patients to enjoy the many<br />
benefits of secure, retentive dentures. The use of CBCT, digital<br />
planning and surgical guides helps to reduce clinician<br />
stress, save chairtime and ensure a predictable outcome.<br />
The flapless technique allows for minimal patient discomfort<br />
and a greater chance for immediate loading — aspects<br />
that improve overall client satisfaction. These simplified<br />
protocols and conservative procedures are made possible<br />
by integrating advanced technology and new materials into<br />
everyday implant dentistry.<br />
Figures 14a, 14b: Color transfer process used to verify passive fit over the<br />
implant heads<br />
The use of CBCT, digital<br />
planning and surgical guides<br />
helps to reduce clinician stress,<br />
save chairtime and ensure a<br />
predictable outcome.<br />
References<br />
1. Misch K, Neiva R. Small-diameter implants for optimal stabilization of implantsupported<br />
overdentures. Pract Proced Aesthet Dent. 2007 Aug;19(7):428–31.<br />
2. U.S. Census Bureau, Population Division, Population Projections Branch.<br />
National population projections I: summary files. Total population by age, sex, race,<br />
and Hispanic origin. Available at: www.census.gov/population/www/projections/<br />
natsum-T3.html.<br />
3. Clinical Research Associates. Small-diameter ‘mini’ implants — user status report.<br />
CRA Newsletter. 2007;31:1–2.<br />
4. Bulard RA, Vance JB. Multi-clinic evaluation using mini-dental implants for<br />
long-term denture stabilization: a preliminary biometric evaluation. Compend Contin<br />
Educ Dent. 2005 Dec;26(12):892–97.<br />
5. Flanagan D. Flapless dental implant placement. J Oral Implantol. 2007;33(2):75–83.<br />
6. Sharawy M, Misch CE, Weller N, et al. Heat generation during implant drilling:<br />
significance of motor speed. I Oral Maxillofac Surg. 2002 Oct;60:1160–69.<br />
Figure 15: Postoperative CT scan showing parallelism of the maxillary and<br />
mandibular implants<br />
– Three-Dimensional Treatment Planning with Surgical Guides and Mini Implant-Retained Dentures – 31
Clinical Tip:<br />
<strong>Dental</strong> Photography<br />
as a Laboratory<br />
Communication Tool<br />
Go online for<br />
in-depth content<br />
by Bradley C. Bockhorst, DMD<br />
Patient photographs are one of the most useful tools available to a clinician when working up a case and<br />
communicating with the laboratory, and they can be especially helpful when treating edentulous cases. For a<br />
trial denture setup, tooth arrangement, shade, midline, vertical dimension of occlusion and closest speaking space can be<br />
evaluated. When deciding between an overdenture and a screw-retained denture, a trial denture without a labial flange can<br />
be used to evaluate the transition line in relation to the smile line and midface support. Including photographs with your<br />
lab prescription can prove invaluable in helping the technician achieve your desired treatment goals.<br />
The images that follow illustrate this technique. Like the old axiom states: A picture can say a thousand words!<br />
Figure 1a: With the patient’s lips closed, measure<br />
the vertical dimension of occlusion. Then ask the<br />
patient to swallow and let his or her lower jaw relax<br />
to evaluate the vertical dimension at rest.<br />
Figure 1b: With the patient’s lips slightly open, evaluate<br />
the incisal edge position and closest speaking<br />
space by asking the patient to pronounce “f,” “ch”<br />
and “s” sounds.<br />
A trial denture<br />
without a labial<br />
flange can<br />
be used to<br />
evaluate the<br />
transition line<br />
in relation to<br />
the smile line<br />
and midface<br />
support.<br />
Figure 2a: Smile line<br />
Figure 2b: High smile line<br />
32<br />
– www.inclusivemagazine.com –
Figure 3a: Smile line without prosthesis<br />
Figure 4a: Profile with labial flange<br />
Figure 3b: High smile line without prosthesis.<br />
NOTE: The maxillary ridge can be seen.<br />
Figure 4b: Profile without labial flange<br />
Including<br />
photographs<br />
with your lab<br />
prescription<br />
can prove<br />
invaluable in<br />
helping the<br />
technician<br />
achieve your<br />
desired<br />
treatment<br />
goals.<br />
Figure 5a: Evaluating the incisal horizontal plane<br />
in relation to the interpupillary line<br />
Figure 5b: Evaluating the midline<br />
– Clinical Tip: <strong>Dental</strong> Photography as a Laboratory Communication Tool – 33
800-854-0970
www.glidewellce.com
Welcome to the <strong>Glidewell</strong> International Technology Center.<br />
The opening of this educational center marks another milestone<br />
for <strong>Glidewell</strong> Laboratories. It signifies the efforts of so<br />
many, and highlights our continued evolution over more than<br />
40 years of growth.<br />
We have become a hybrid organization, crossing the traditional<br />
boundaries of dental technology with the digital manufacture<br />
of our restorations, while also fabricating the raw materials,<br />
components and systems that comprise those restorations.<br />
Whether you look at our development of intraoral scanners,<br />
the design and manufacture of implants, abutments and<br />
related components, or the various materials like BruxZir ® and<br />
our forthcoming product Obsidian , we seem to be blazing a<br />
new trail. Why? the others ask. Why won’t <strong>Glidewell</strong> just follow<br />
everyone else and stick to making standard restorations?<br />
Well, I could provide a number of reasons. Chief among them is the pursuit of knowledge. In our<br />
40-plus years, we have assimilated a wealth of it. You will find that we are unique. We understand<br />
the needs of both the patient and the clinician. We work with dentists every day to solve difficult<br />
cases that demand innovative restorative solutions. From that, we continue to develop a vast array<br />
of products that meet those needs.<br />
Our goal with this technology center is to emulate the efforts of world-class dental education facilities<br />
like the Pankey Institute and the Scottsdale Center, while focusing our offerings on practical,<br />
innovative solutions to everyday clinical challenges. This is not merely an implant sales facility, a<br />
materials-selling operation, or a means to highlight intraoral scanning and its digital progeny. Rather,<br />
it is our intent to share and advance the widespread knowledge of these and other advanced technologies<br />
and techniques for the fundamental purpose of making a positive difference in the lives of<br />
our patients and those of us who serve them.<br />
This center recognizes the extreme complexity of oral rehabilitation and the need for many different<br />
treatment modalities. It will have at its core an emphasis on all things digital: digital scanning, digital<br />
treatment planning, digitally processed surgical guides, digitally manufactured implant components<br />
and restorations, and the digital manufacture of final crown & bridge restorations — along with the<br />
digital compilation of all treatment data, with archive retrieval at one’s fingertips. This new digital era<br />
allows us to bring about more predictable results, increase the consistency and quality of restorations,<br />
and help improve the oral health of many who are now suffering.<br />
Whatever the direction these emerging technologies take, rest assured that we will be here to<br />
study them together. We may not have quite the square footage as some of the other well-known<br />
educational centers, but we intend to make every bit as big an impact on the industry. From this<br />
location, we aim to provide measurable, patient-related results that will do nothing less than change<br />
the direction of dentistry worldwide. We must believe that what we are doing is that important,<br />
because success starts with vision and requires a lot of hard work.<br />
James R. <strong>Glidewell</strong>, CDT<br />
President, CEO
GLIDEWELL<br />
INTERNATIONAL TECHNOLOGY CENTER<br />
Enjoy presentations on the most advanced dental technologies and techniques<br />
presented in multimedia format in our 40-seat interactive classroom auditorium.<br />
Observe live surgical and prosthetic procedures<br />
in our fully functional operatory and surgical<br />
suite featuring state-of-the-art dental equipment,<br />
including a PreXion 3D Cone Beam CT scanner.
Sign up for a course today!<br />
Take part in intensive hands-on<br />
surgical and prosthetic workshops<br />
exploring the latest techniques<br />
taught by experienced<br />
clinicians and technicians.<br />
Learn what’s new in virtual design and CAD/CAM technology, and<br />
how to smoothly integrate these innovations into your practice.
Date Course Name Instructor Course # Tuition<br />
August<br />
3 Ten Keys for Grafting Success Dr. Sascha Jovanovic B111-110803 $49<br />
4<br />
To See, or Not to See, That Is the Question:<br />
Exploring Relationships of CBCT Liability,<br />
Accurate Diagnosis and Image Resolution<br />
(sponsored by PreXion)<br />
Dr. Sanjay Mallya A116-110804 $49<br />
12 The Modern Restorative Practice Dr. Michael DiTolla C110-110812 $99<br />
19<br />
20<br />
15<br />
23<br />
9/30–10/1<br />
Rehabilitating the Atrophic Edentulous<br />
Patient Using Small-Diameter Implants<br />
Rehabilitating the Atrophic Edentulous<br />
Patient Using Small-Diameter Implants<br />
State-of-the-Art Impressions<br />
and Digital Restorative Dentistry<br />
Using the IOS FastScan ® System<br />
The Fundamentals of Oral<br />
Appliance Therapy for Sleep Apnea<br />
Medical Billing for the Comprehensive<br />
<strong>Dental</strong> and Surgical Practice<br />
September<br />
October<br />
Dr. Paresh Patel B112-110819 $395<br />
Dr. Paresh Patel B113-110820 $395<br />
Dr. Michael DiTolla A118-110915 $49<br />
Dr. Todd Morgan E110-110923 $299<br />
Dr. Olya Zahrebelny D111-110930 $900/$750<br />
7 The Modern Restorative Practice Dr. Michael DiTolla C111-111007 $99<br />
8<br />
The Use of CAD/CAM for<br />
Custom Abutments for Technicians<br />
Alec Di Lullo/<br />
Shawn Ramirez<br />
G110-111008 $99<br />
14–15<br />
Treating the Edentulous Patient: The Quest<br />
for Beauty and Functional Excellence (Part 1)<br />
Dr. Burton Melton C112-111014 $300<br />
19 Implant Surgery for the <strong>Dental</strong> Assistant TBD F110-111019 $49<br />
November<br />
3 PreXion (course specifics coming soon) TBD A119-111103 TBD<br />
10<br />
11–12<br />
State-of-the-Art Impressions<br />
and Digital Restorative Dentistry<br />
Using the IOS FastScan ® System<br />
Treating the Edentulous Patient: The Quest for<br />
Beauty and Functional Excellence (Part 2)<br />
Dr. Michael DiTolla A120-111110 $49<br />
Dr. Burton Melton C113-111111 $300<br />
18 Digital Implant Treatment Planning Workshop Dr. Bradley Bockhorst B114-111118 $49<br />
December<br />
2<br />
3<br />
Rehabilitating the Atrophic Edentulous<br />
Patient Using Small-Diameter Implants<br />
Rehabilitating the Atrophic Edentulous<br />
Patient Using Small-Diameter Implants<br />
Dr. Paresh Patel B115-111202 $395<br />
Dr. Paresh Patel B116-111203 $395<br />
Please visit www.glidewellce.com for the most up-to-date course details and to register.
A New Generation of Denture Teeth<br />
The Perfect Route to<br />
Esthetic and Functional Dentures<br />
PRODUCT<br />
SPOTLIGHT<br />
by Thorsten Michel, MDT<br />
Introduction<br />
When fabricating removable dentures, finding suitable anterior teeth that provide the<br />
superior esthetics very discerning patients demand can prove challenging. To meet the<br />
requirements of an individual case, prefabricated denture teeth must very often be modified<br />
to incorporate age- and indication-related characteristics. This challenge led me to look for<br />
a solution to this problem. The purpose of this article is to summarize my experience with,<br />
and provide insight into, the development process that led to the creation of SR Phonares ®<br />
denture teeth from Ivoclar Vivadent.<br />
Figures 1, 2: Outstanding overall esthetics of the anterior teeth<br />
36<br />
– www.inclusivemagazine.com –
Discussion<br />
Figure 3: Natural facial design<br />
Figure 4: Natural palatal design<br />
Starting the process involved modeling upper<br />
and lower tooth molds that were a reflection<br />
of their natural counterparts. These molds<br />
featured all the special characteristics missing<br />
from existing prefabricated denture teeth<br />
(Figs. 1, 2). It is the first impression, the overall<br />
esthetic appearance that is conveyed in the first<br />
few seconds in which a tooth is viewed, that<br />
counts. These first few seconds are of crucial<br />
importance because this is the time it takes<br />
someone to decide whether the tooth lives<br />
up to his or her expectations. In order to<br />
achieve a natural esthetic outcome, lifelike<br />
tooth molds with facial and palatal surfaces that<br />
feature a truly anatomical design and impart<br />
an impression of natural dentition are essential<br />
(Figs. 3–6).<br />
The objective in modeling esthetic tooth molds<br />
is to achieve a vibrant but not overly exaggerated<br />
facial texture and a practical palatal and<br />
lingual design, which supports clear speech and<br />
phonetics rather than hampering it. In addition,<br />
anterior teeth that have a harmonious, layered<br />
Figure 5: Example of a naturally designed palatal aspect<br />
Figure 6: Silver powder discloses details of the exemplary palatal design.<br />
In order to achieve a<br />
natural esthetic<br />
outcome, lifelike tooth<br />
molds with facial and<br />
palatal surfaces that<br />
feature a truly<br />
anatomical design and<br />
impart an impression<br />
of natural dentition<br />
are essential.<br />
– A New Generation of Denture Teeth: The Perfect Route to Esthetic and Functional Dentures – 37
Another important<br />
aspect is to have a<br />
comprehensive range<br />
of molds from which<br />
to choose … This led to<br />
the development of<br />
age-related tooth molds.<br />
design and selectively incorporated opalescent<br />
and translucent areas, which impart a lifelike<br />
appearance, are preferred (Figs. 7, 8).<br />
Figure 7: Example of a harmonious layering and a natural-looking opalescent<br />
effect<br />
Another important aspect is to have a comprehensive<br />
range of molds from which to choose.<br />
To meet this requirement, I incorporated several<br />
tooth characteristics that can also be found<br />
in nature. This led to the development of agerelated<br />
tooth molds, which take into account<br />
the needs of patients at different stages in life.<br />
This allows for the selection of tooth molds<br />
based on an individual patient’s age.<br />
There are three simple steps for choosing<br />
suitable tooth molds. First, the basic shape is<br />
selected, based on whether the teeth should<br />
have a more youthful or distinctive look. Then<br />
the desired degree of wear is chosen. In this<br />
respect, both the incisal and facial curvature are<br />
of importance. While teeth with more rounded<br />
incisal edges and a pronounced facial curvature<br />
are designed for use in young patients (Fig. 9),<br />
those with more heavily abraded incisal edges<br />
and a flatter facial curvature are suitable for patients<br />
in the more advanced age group (Fig. 10).<br />
These features are based on the natural aging<br />
process that occurs in the oral cavity over time.<br />
In the third and last step, the size or dimension<br />
of each tooth is determined using a diagnostic<br />
cast of the case. For this purpose, the teeth<br />
are classified into “small,” “medium” and “large”<br />
categories. Tooth molds for smaller and larger<br />
alveolar ridges are available.<br />
Figure 8: The vibrant facial texture meets the highest esthetic demands<br />
Figure 9: A rounded tooth shape and lighter shades for younger patients<br />
38<br />
– www.inclusivemagazine.com –
Removable dentures should<br />
provide optimum “white<br />
esthetics.” This is especially<br />
true for implant-borne<br />
removable dentures.<br />
Figure 10: More distinctive tooth molds and darker shades for patients in the<br />
more advanced age group<br />
In a time when the focus is on esthetic dentistry, removable<br />
dentures should provide optimum “white esthetics”<br />
(Fig. 11). This is especially true for implant-borne<br />
removable dentures because all parties involved (i.e., the<br />
patient, clinician and dental lab technician) place high<br />
expectations on the esthetic outcome and function of<br />
this complex and expensive type of restoration.<br />
In order to achieve ideal “white esthetics,” the interproximal<br />
contours of anterior teeth should allow for the teeth<br />
to be lined up very closely without creating the impression<br />
of a “white wall.” The proximal “Set & Fit” design<br />
of SR Phonares denture teeth allows teeth to be set up<br />
in diverse positions, without producing open gingival<br />
embrasures, or “black triangles,” that then need to be<br />
filled with denture base material. Even when dealing<br />
with highly rotated teeth, a natural-looking tooth setup<br />
can be accomplished (Fig. 12).<br />
Creating a soft transition between the clinical crown<br />
and the tooth neck section optimizes the esthetics, as it<br />
facilitates modeling of the gingival contours. Placing a<br />
wax layer that tapers toward the cervical portion of the<br />
clinical crown creates the impression of naturally grown<br />
gingival tissue.<br />
To effectively cover a frame and implant abutments, a<br />
cervical design that accommodates implant abutments<br />
with an emergence profile of approximately 5 mm in<br />
diameter was also created. In most cases, no adjustments<br />
with tooth-colored material are required in the proximal<br />
anterior regions.<br />
Figure 11: Unparalleled “white esthetics”<br />
The proximal “Set & Fit”<br />
design of SR Phonares<br />
denture teeth allows teeth<br />
to be set up in diverse<br />
positions, without producing<br />
open gingival embrasures,<br />
or “black triangles.”<br />
Figure 12: Ideal proximal closure due to “Set & Fit” design<br />
– A New Generation of Denture Teeth: The Perfect Route to Esthetic and Functional Dentures – 39
In addition to their advanced anterior tooth design, SR<br />
Phonares denture teeth are characterized by extraordinarily<br />
high wear resistance, thanks to their Nano Hybrid<br />
Composite (NHC) material composition. Due to the<br />
fact that implants are firmly anchored to the alveolar<br />
bone, materials of extremely high strength are required<br />
in the fabrication of implant-borne removable dentures.<br />
As these dentures are not supported by soft tissue,<br />
masticatory forces are transferred completely to the materials<br />
used in the restorative process, which exposes<br />
them to very high levels of stress. SR Phonares NHC<br />
anterior tooth molds are not exclusively indicated for<br />
implant-borne dentures, however. They are perfectly<br />
suited for complete and partial denture prosthetics.<br />
SR Phonares Denture Teeth<br />
Q&A<br />
Courtesy of Dr. Frank Lauciello, Ivoclar Vivadent<br />
SR Phonares denture<br />
teeth are characterized<br />
by extraordinarily high<br />
wear resistance, thanks<br />
to their Nano Hybrid<br />
Composite (NHC)<br />
material composition.<br />
Conclusion<br />
Ivoclar Vivadent’s SR Phonares denture teeth closely replicate<br />
the shape and surface texture of natural dentition.<br />
The teeth feature a harmonious four-layer design and<br />
exhibit natural opalescence and fluorescence. Their new<br />
NHC material has been proven to provide high durability<br />
and excellent resistance to wear and plaque accretion.<br />
SR Phonares denture teeth also feature a well-balanced<br />
labial and palatal design. Due to their specially designed<br />
interdental closures, a natural-looking appearance of the<br />
denture can be achieved with ease. These denture teeth<br />
allow the dental technician to achieve precise, highquality<br />
results with minimal effort or difficulty.<br />
Q: Why did Ivoclar develop SR<br />
Phonares denture teeth?<br />
A: SR Phonares NHC denture teeth were developed<br />
in response to market demands for higher<br />
esthetics and wear resistance in complete, partial<br />
and implant-retained denture prostheses.<br />
500<br />
450<br />
400<br />
350<br />
300<br />
250<br />
200<br />
150<br />
100<br />
50<br />
0<br />
In vitro wear study of denture tooth materials<br />
Pin-on-block with steatite antagonist, after 120,000 cycles<br />
NHC material<br />
SR<br />
Phonares<br />
Isosit<br />
Highly crosslinked<br />
PMMA<br />
Cross-linked<br />
PMMA<br />
Source: Dr. Dipl. Ing. (FH) Martin Rosentritt, 08/2009, University of Regensburg.<br />
Q: What are the benefits of a<br />
composite tooth?<br />
A: Ivoclar Vivadent spent several years developing<br />
its Nano Hybrid Composite, a unique material<br />
that yields true-to-nature esthetics and<br />
increased wear resistance over conventional<br />
resin materials. This new technology provides<br />
the opportunity for clinicians and technologists<br />
to prescribe and create truly esthetic<br />
removable restorations with long-term results.<br />
40<br />
– www.inclusivemagazine.com –
SOFT<br />
PMMA Clusters<br />
BOLD<br />
YOUTHFUL<br />
UNIVERSAL<br />
Q: How does this new<br />
generation of Nano Hybrid<br />
Composite bond to resin<br />
denture base materials?<br />
A: The unique properties of the NHC material<br />
yield good bonding results. The<br />
NHC material has inclusions of PMMA<br />
(polymethylmethacrylate) material that<br />
promotes bond strength and durability.<br />
The highest bond strengths have been<br />
recorded when processed with the SR<br />
Ivocap Injection System.<br />
MATURE<br />
SR Phonares denture teeth are available<br />
as a premium option on all conventional<br />
dentures, partials, overdentures and<br />
screw-retained dentures from <strong>Glidewell</strong><br />
Laboratories (Newport Beach, Calif.).<br />
Q: How were the molds<br />
developed?<br />
A: Like the NHC material, the SR Phonares<br />
anterior molds were a new development.<br />
Each mold was artfully designed<br />
to express individual patient characteristics<br />
(“soft” or “bold”) and age (“youthful,”<br />
“universal” or “mature”).<br />
– A New Generation of Denture Teeth: The Perfect Route to Esthetic and Functional Dentures – 41
Ensuring a Successful Restorative Outcome<br />
Utilizing BioTemps ® Implant Provisionals<br />
Go online for<br />
in-depth content<br />
by Ara Nazarian DDS, DICOI<br />
Although widely utilized in conventional crown & bridge applications, provisional restorations have traditionally<br />
been underused in implant therapy. Time-intensive surgical procedures may make the dentist and<br />
patient reluctant to dedicate additional chairtime to the proper fabrication of a “mere temporary.” This unfortunate attitude<br />
often ends up costing even more time and expense at subsequent appointments, and can cause the overall quality of the<br />
final restoration to suffer. A properly planned provisional can serve a variety of functions critical to the long-term success<br />
of an implant case. With the convenience and affordability of provisional splinted crowns and full-arch bridges such as<br />
BioTemps ® Implant Provisionals (<strong>Glidewell</strong> Laboratories; Newport Beach, Calif.), clinicians owe it to their patients to<br />
educate them regarding the multiple benefits of incorporating a provisional solution in the overall treatment plan.<br />
Provisional restorations may be fixed or removable and are made from a variety of materials. The most common forms of<br />
temporary restorations are fixed bridges supported by retained natural teeth, resin-bonded bridges and removable temporary<br />
partials, or flippers. BioTemps represent a fixed solution because they can be cemented or screw-retained. The decision<br />
to use a provisional restoration and which type to use depends greatly on the patient’s specific needs and preferences. At<br />
its simplest, a provisional serves as the interim prosthesis while implants heal and a definitive restoration is fabricated. But<br />
if its effectiveness is maximized, a provisional restorative prosthesis provides four principal benefits:<br />
1. Protects the underlying implants or bone-grafted sites from direct occlusal loads<br />
The long-term success of any implant-borne restoration depends heavily on the integration of the supporting implant.<br />
A proper provisional must therefore protect the surgical site from occlusal forces during the healing process, preventing<br />
micro-movement of the implant and any associated bone grafts. BioTemps are designed to seat passively over healing areas,<br />
shielding them from stresses that might adversely affect osseointegration. When a pontic span exceeds three units, a cast-metal<br />
substructure is indicated, giving the provisional additional strength. Wire or Kevlar ® fiber reinforcement (DuPont; Wilmington,<br />
Del.) is also available.<br />
2. Protects the underlying gingival tissues<br />
Along with preserving bone health, a provisional must protect its underlying gingival tissues. BioTemps not only preserve<br />
tissue, but they can also be used to shape the associated soft tissue during the maturation phase. They have been shown to<br />
promote contoured healing for ovate pontics or anterior extractions, and can help shape the sulcus around implants. The<br />
ability to manage and sculpt the surrounding soft tissue leads to greater predictability in the seating of the final prosthesis.<br />
This is particularly helpful in the esthetic zone, where elements such as gingival margins and contours, papilla, and final<br />
emergence profile play a key role in replicating the proper morphology of natural dentition.<br />
3. Determines the future position, support, shape and shade of the final prosthesis<br />
Beyond helping to establish the health and shape of the supportive tissues, a provisional restoration can act as the<br />
blueprint for the final prosthesis. The restorative dentist is therefore able to obtain a hands-on feel for the eventual<br />
solution using a working prototype in the actual oral environment. Every aspect of form, fit and function can be<br />
evaluated. As an example, screw-retained BioTemps over implants can help create a predictable path of insertion, on<br />
which many other elements are based. And it’s not just the dentist who will appreciate this “trial run.” By experiencing his<br />
– Ensuring a Successful Restorative Outcome Utilizing BioTemps Implant Provisionals – 43
or her restoration on an interim basis, the patient is<br />
given a chance to assess it before undergoing placement<br />
of the definitive prosthesis. If either dentist or patient<br />
is dissatisfied with the provisional in any way, the<br />
appropriate adjustments can be made. Once approved,<br />
dimensions and morphology can be precisely transferred<br />
to the laboratory via impression for use in the fabrication<br />
of the final restoration, increasing the likelihood of patient<br />
acceptance during that final visit.<br />
4. Restores and enhances esthetics and phonetics<br />
Patient acceptance of any prosthesis is generally determined<br />
by both esthetics and function. If the prosthesis is<br />
unesthetic, inhibits accustomed phonetics, or otherwise<br />
fails to function in accordance with the patient’s expectations,<br />
then he or she is likely to experience dissatisfaction.<br />
There is little excuse for this in an implant case, where<br />
the restoration is designed “from the ground up” and is<br />
therefore less likely to face the constraints of preexisting<br />
structures. Natural or wear-related imperfections such as<br />
diastemas or limited vertical dimension can be corrected<br />
with the provisional just as they can with the final restoration.<br />
Using a provisional to test and determine acceptable<br />
morphology enables the dentist and patient to verify overall<br />
appearance and function. Once again, any required<br />
adjustments can easily be made chairside to the provisional<br />
and then reflected in the final restoration.<br />
With all that provisionals can contribute, the question becomes,<br />
why forego their inclusion in treatment planning<br />
dental implants? One reason is that provisional restorations<br />
are often left until the end of an appointment, when time<br />
is limited. But time spent in their construction is more than<br />
repaid in time saved doing additional procedures, adjustments<br />
and remakes in the future. This is especially true of a<br />
provisional like BioTemps, which can be prefabricated from<br />
an impression or preoperative model and delivered prior to<br />
surgery for a simple, efficient chairside reline.<br />
Another reason given for avoiding provisionals is the notion<br />
that they are merely a short-term solution; however, implant<br />
healing times can require weeks or months, particularly if<br />
bone grafts are prescribed. Does the patient really wish to<br />
tolerate inadequate esthetics or decreased function for this<br />
prolonged period?<br />
A third complaint is the associated expense of a provisional.<br />
Given the high costs of many implant procedures, customers<br />
may look to trim those costs wherever possible, and a<br />
“disposable” temporary may appear to be a good place to<br />
start. However, a patient concerned with the affordability of<br />
a provisional should consider the affordability of not using<br />
one. What are the possible costs of a treatment plan lacking<br />
a suitable provisional aspect? BioTemps over implants are<br />
reasonably priced and present an exceptional value to many<br />
patients, once they understand the overall manner in which<br />
these provisionals can contribute to the success of their case.<br />
To maximize their effectiveness, provisional restorations<br />
should be carefully planned prior to the surgical phase.<br />
Various techniques are available to achieve optimal protection<br />
and continued function without compromising<br />
esthetics. Working together, the restorative dentist and the<br />
laboratory should determine which techniques best fulfill<br />
the specific requirements of each case. Proper management<br />
will contribute to satisfying the patient’s expectations and<br />
help ensure a successful final solution.<br />
A well-designed provisional restoration is predicated upon<br />
four key factors:<br />
1. The ultimate restorative plan<br />
The objective of an implant-supported prosthesis is to provide<br />
a functional and cosmetically acceptable form of<br />
tooth replacement. Every aspect of a provisional prosthesis<br />
should contribute to the realization of this ultimate goal.<br />
Anything that might counteract, marginalize or degrade<br />
the quality of the definitive restoration should be avoided.<br />
2.The number and location of the dental implants<br />
Implants serve as the foundation for any implant-borne<br />
restorative solution. Thus, any provisional must properly<br />
consider the structural framework on which it will be laid.<br />
For example, it was mentioned earlier that wire, fiber or<br />
cast-metal reinforcement is recommended in BioTemps<br />
provisional restorations with a pontic span greater than<br />
three units. Occlusal forces and potential bone stress are<br />
also critical factors that are deeply affected by the underlying<br />
implant configuration.<br />
3. The bone quality and quantity<br />
Just as an implant-borne restoration is only as reliable<br />
as the implants on which it is placed, the success of those<br />
implants is only as reliable as the overall health of the<br />
surrounding osseous tissue. Bone lacking in quality or<br />
quantity may require special consideration such as severe<br />
implant angulation or grafting procedures, which may in<br />
turn dictate certain aspects of both the provisional and the<br />
definitive restoration.<br />
4. The needs and desires of the patient<br />
The success of a restorative prosthesis relies heavily on the<br />
perception of the receiving patient. An unhappy patient<br />
makes for an unhappy dentist. While it is the dentist’s<br />
responsibility to educate and advise the patient as to all<br />
options and considerations related to the case, the obligation<br />
to listen to and accept the patient’s stated goals and<br />
preferences remains. This applies to all aspects of the treatment<br />
plan, and the role of a provisional is no exception.<br />
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CASE 1<br />
The following case depicts the utilization of BioTemps as a full maxillary implant-supported,<br />
screw-retained provisional restoration.<br />
Figure 1: Preoperative smile view depicting unattractive smile<br />
Figure 2: Preoperative occlusal view of maxillary arch<br />
Figure 3: Occlusal view of healed maxillary arch after extractions<br />
Figure 4: Atraumatic placement of eight dental implants<br />
Figure 5: Screw-retained maxillary BioTemps placed and access holes covered<br />
Figure 6: Postoperative smile using BioTemps Implant Provisionals<br />
– Ensuring a Successful Restorative Outcome Utilizing BioTemps Implant Provisionals – 45
CASE 2<br />
The following case depicts a cemented BioTemps provisional restoration.<br />
Figure 1: Preoperative view of patient with missing lateral incisors<br />
Figure 2: Implants prior to abutment preparation<br />
Figure 3: Prepared natural central incisors and lateral implant abutments<br />
Figure 4: Relined BioTemps provisional restoration in place<br />
Conclusion<br />
BioTemps Implant Provisionals can play a valuable role in managing clinical situations to ensure success with the final<br />
prosthesis. They can be used to evaluate esthetic, phonetic and occlusal function prior to delivery of the final implant restorations,<br />
while preserving or enhancing the condition of the peri-implant and gingival tissues. They provide patients with<br />
natural-looking temporaries at any stage of implant treatment, and serve as an excellent prototype by which to evaluate<br />
shade and contours, leading to greater patient acceptance and a superior definitive restoration. They are also useful as a<br />
communication tool between members of the treatment team, which in many cases consists of the restorative clinician,<br />
implant surgeons, dental laboratory technicians and the patient. Clinicians should be aware of the different types of provisional<br />
restorations and their indications for use when planning implant-retained restorations. If planned and fabricated<br />
properly, this temporary prosthesis can become an integral part of the overall restorative solution.<br />
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Preserving the Integrity<br />
of Facial Structures with<br />
Implant-Retained Overdentures<br />
Go online for<br />
in-depth content<br />
by Timothy F. Kosinski, DDS, MAGD<br />
The Centers for Disease Control and Prevention<br />
(CDC) has reported that by age 50, Americans<br />
have lost an average of 12 teeth and, among adults aged<br />
65 to 74 years, 26 percent are completely edentulous. Care of<br />
the edentulous patient has been changed by the emergence of<br />
implant-supported restorations, which are a viable alternative<br />
to traditional denture fabrication. However, there are still many<br />
general practitioners who have not committed to making dental<br />
implant treatment a significant part of their practice. They may<br />
let potential drawbacks such as surgical or prosthetic training,<br />
perceived cost, concern about the profitability of implant cases,<br />
or lack of insurance coverage stand in their way of providing<br />
innovative and successful dental implant treatment services to<br />
their patients.<br />
Implant manufacturers and dental laboratories such as <strong>Glidewell</strong><br />
Laboratories (Newport Beach, Calif.) are presenting product<br />
innovations that have made implant dentistry simpler for dentists<br />
restoring implants and easier for patients receiving implant<br />
therapy. Implant placement and immediate implant function<br />
have become popular as long as there is an absence of infection,<br />
and adequate bone quantity and quality. These innovations<br />
make implant dentistry more attractive to both patients and the<br />
restorative dentist.<br />
As clinicians, it is imperative that we educate and counsel our<br />
patients as to the benefits of quality care irrespective of insurance<br />
benefits or financial limitations. A patient should be made<br />
aware of all available options without tailoring discussion solely<br />
to his or her dental insurance benefits. We should encourage<br />
the best overall care plan and provide alternatives to treatment<br />
in order of most effective to least effective, including no treatment<br />
at all.<br />
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Many people are unaware of the relationship between their teeth and the bone that supports them. Along with<br />
the maxillary and mandibular bone, teeth provide the support for facial contours. Changes in these structures,<br />
then, will cause changes in facial features. The loss of teeth can result in wrinkles around the mouth and lips<br />
and the collapse of facial structures, causing an overall “caved-in” appearance. When teeth are absent over a<br />
prolonged period of time, the bone that supported these teeth will gradually resorb. <strong>Dental</strong> implants can preserve<br />
the integrity of facial structures by minimizing this bone resorption. The implants act like natural teeth in<br />
that they provide stress to the bone, which helps stimulate blood flow and maintain the existing bone contours.<br />
<strong>Dental</strong> implants are thus used to create a more stable foundation for replacement teeth, whether they are used<br />
under removable or fixed appliances.<br />
Maintaining the natural appearance of the face and smile can be challenging, but dental implants have proven<br />
to be an excellent starting point compared to conventional complete dentures. For one, the generation of baby<br />
boomers does not like to look and feel old. When the corners of the mouth droop, wrinkles appear around the<br />
lips and the distance between the nose and chin decreases, esthetics are compromised. Second, even well-fitting<br />
dentures result in a decrease in natural chewing function, which may in turn lead to digestive issues resulting in<br />
a myriad of potential health issues. Third, while conventional dentures do serve the basic purpose of replacing<br />
missing teeth and providing structural support to the lips, they may actually accelerate the resorption process<br />
by pressing down on the gingiva and underlying bone as the wearer eats. Regardless, the inevitable, continued<br />
bone loss will cause the facial structures to further collapse over time, necessitating prosthetic relines to compensate<br />
for the physical changes.<br />
This article aims to demonstrate just a few of the prosthetic options available today in restoring form and<br />
function using dental implant-retained overdentures. Our hope with these designs is to dramatically enhance<br />
our patients’ quality of life by achieving one or more of the following goals: to preserve the integrity of facial<br />
structures not only immediately but over time, restore the mouth area to as natural a state as possible, increase<br />
stability and the patient’s sense of security that his or her teeth will not become dislodged or fall out during<br />
basic activities (eating, laughing, sneezing, kissing), improve physical appearance, improve health by facilitating<br />
proper digestion and nutrition, improve the taste of food, eliminate the need for denture adhesives, and improve<br />
self-confidence and self-esteem.<br />
To reiterate, the advantages of conventional complete dentures is that they restore some basic tooth function<br />
in edentulous situations and provide lip support. Disadvantages include accelerated bone resorption, relatively<br />
frequent replacement or relines, and the inability to eat some foods properly, affecting digestion and overall<br />
health. <strong>Dental</strong> implant-supported overdentures, however, provide greater comfort and stability than conventional<br />
dentures, and they do a better job of restoring lip support, maintaining facial structures and minimizing<br />
bone resorption.<br />
The fabrication of any stable removable appliance begins with careful diagnosis and case planning. Regardless<br />
of the patient’s age, it is imperative that his or her concerns and desires be taken into account in order to<br />
make the final prosthesis acceptable. Improving form and function can be a difficult challenge in any complete<br />
denture situation. Fortunately, implants represent an outstanding treatment option for dramatically improving<br />
denture stability and increasing chewing ability. Endosseous implant designs have proven to offer an excellent<br />
prognosis and are reliable retainers for overdentures.<br />
<strong>Dental</strong> implant-supported overdentures …<br />
provide greater comfort and stability than<br />
conventional dentures, and they do a better<br />
job of restoring lip support, maintaining facial<br />
structures and minimizing bone resorption.<br />
– Preserving the Integrity of Facial Structures with Implant-Retained Overdentures – 49
Figure 1: Pre-op smile with conventional maxillary complete<br />
denture in position<br />
Case 1<br />
The first case demonstrated here involves a female patient who<br />
had worn a conventional maxillary complete denture for more<br />
than 20 years. Opposing the conventional maxillary denture<br />
was an implant-retained mandibular overdenture that had also<br />
been in place for many years. Having appreciated the stability<br />
and function of the mandibular overdenture, she had requested<br />
investigation of a similar prosthesis in the maxilla. This desire<br />
increased over time because her maxillary denture needed to<br />
be relined several times, and the form and function of her existing<br />
conventional denture diminished. The patient exhibited no<br />
significant medical concerns other than severe horizontal bone<br />
loss in the premaxillary area. Ridge augmentation had been discussed<br />
many times in the past, but the invasive procedure had<br />
always been declined.<br />
Current options were discussed with the patient, including fabrication<br />
of a new conventional denture and ridge augmentation<br />
procedures followed by dental implant therapy. The patient<br />
elected a simple approach in the surgical placement of four<br />
dental implants in the posterior maxilla. The surgical design<br />
was determined with CT diagnosis and placement using a CT<br />
surgical stent. The implant planning software was used to visualize<br />
the patient’s entire mouth anatomy in three dimensions.<br />
The computer software accurately simulated the placement of<br />
dental implants prior to ever touching the patient. We found adequate<br />
bone in the posterior maxilla, but not acceptable bone in<br />
the anterior maxilla. This implant planning and placement software<br />
provided a high level of comfort and safety for the patient,<br />
reducing surgical and restorative time by giving us an accurate<br />
3-D plan prior to implant placement.<br />
Figure 1 illustrates the closed vertical dimension of occlusion.<br />
Figure 2 illustrates the postoperative CT scan, showing proper<br />
positioning of the four dental implants. Conventional techniques<br />
Figure 2: Post-surgical CT scan illustrating final position of<br />
integrated dental implants<br />
Implant planning and placement<br />
software provided a high level<br />
of comfort and safety for the<br />
patient, reducing surgical and<br />
restorative time by giving us<br />
an accurate 3-D plan prior to<br />
implant placement.<br />
Figure 3: Conventional occlusal rim positioned to increase<br />
the vertical dimension of occlusion<br />
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were used to visualize tooth position using stable record bases<br />
and occlusal rims. The intent was to increase the vertical dimension<br />
to give the patient a younger look (Fig. 3). Anterior teeth<br />
were set to the desired esthetics. Following integration of the<br />
implants, accurate impressions of the fixtures were taken intraorally<br />
using traditional impression copings splinted together<br />
with acrylic. The intent was to maximize the stability of the<br />
impression technique (Fig. 4). The stable record base with anterior<br />
teeth waxed into position was hollowed out (Fig. 5) and<br />
an impression made with polysiloxane materials (Fig. 6). The<br />
laboratory then created an extremely accurate master cast with<br />
tissue approximations (Fig. 7).<br />
In this case, Locator ® attachments (Zest Anchors; Escondido,<br />
Calif.) were used as the retentive devices for a maxillary, horseshoe-shaped<br />
overdenture. Because of the posterior position of<br />
the implants and the relatively porous quality of the bone in the<br />
area, I considered placing a cross-arch bar splint with attachments<br />
to retain the overdenture. However, a careful evaluation<br />
incorporating the esthetic concerns of the patient resulted in an<br />
inability to increase the vertical dimension of occlusion excessively.<br />
It was therefore determined that there was not enough<br />
intraocclusal space to provide for proper bar fabrication — not<br />
while maintaining the preferred esthetics. The use of Locator<br />
attachments eliminated my concern with intraocclusal distance<br />
and final esthetics (Fig. 8). These attachments resist wear and<br />
maintain satisfactory retention for up to 56,000 cycles of function.<br />
This system proved appropriate where occlusal clearance<br />
became an issue. The Locator attachments come in a variety<br />
of retention strengths, from extra light to heavy. This type of<br />
prosthesis allowed for excellent retention and stability for this<br />
patient. The attachments were positioned extracoronally to<br />
allow for good tissue adaptation and easy maintenance with a<br />
toothbrush or end-tufted brush.<br />
Figure 4: Splinted impression copings<br />
Figure 5: Hollowed-out record base used to pick up the<br />
splinted impression copings<br />
Figure 9 illustrates the underside of the palateless maxillary<br />
implant-retained overdenture with the Locator attachments. Note<br />
that a cast framework was incorporated to provide strength to<br />
the prosthesis and secondary splinting of the implants. Figure 10<br />
shows how the palate is exposed, allowing for better tasting of<br />
A cast framework was<br />
incorporated to provide<br />
strength to the prosthesis<br />
and secondary splinting<br />
of the implants.<br />
Figure 6: Final, accurate pickup impression using polysiloxane<br />
materials<br />
Figure 7: Accurate master cast<br />
– Preserving the Integrity of Facial Structures with Implant-Retained Overdentures – 51
food and elimination of the gag reflex, yet still providing outstanding<br />
stability and retention. Figure 11 illustrates our final<br />
smile design, which created a younger look for the patient. This<br />
patient exhibited a positive end result because of her understanding<br />
of the limiting factors involved in this case and her desire<br />
to limit more aggressive, invasive surgical procedures. However,<br />
she was made aware that bone loss was continuing in her maxilla<br />
and appreciated our attempt to minimize that bone loss in<br />
the future. Her chewing function was deemed more efficient,<br />
and her speaking was excellent. The patient no longer worried<br />
about her prosthesis slipping or loosening during function.<br />
Figure 8: Locator attachments seated intraorally<br />
Figure 9: Underside of palateless implant-retained maxillary<br />
overdenture with Locator attachments precisely positioned<br />
Figure 10: Intraoral occlusal view of palateless overdenture<br />
Case 2<br />
The second case demonstrated here involves a woman who had<br />
had conventional maxillary and mandibular complete dentures<br />
for many years. Because of the lack of horizontal bone thickness,<br />
conventional dental implant placement would be difficult.<br />
However, the patient’s quality of life was diminished because<br />
her conventional mandibular denture was unstable and had<br />
begun to create functional problems. Small-diameter implants<br />
were chosen to restore stability in a mandibular overdenture<br />
due to their size. Four small-diameter implants were surgically<br />
placed in the symphysis without complication. CT diagnosis<br />
and a CT surgical stent were used to ensure proper angulation<br />
and depth.<br />
Figure 12 illustrates the preoperative, narrow mandibular ridge<br />
responsible for the patient’s complaint. Figure 13 shows the<br />
parallel position of four small-diameter implants, which will<br />
be used to stabilize a new implant-retained overdenture. The<br />
I-Mini ® <strong>Dental</strong> Implant System (OCO Biomedical; Albuquerque,<br />
N.M.) used here incorporates a rather simple impression<br />
technique that utilizes plastic snap-on impression copings<br />
(Fig. 14). Vinyl polysiloxane impression material is injected<br />
around the pickup impression copings using a well-made custom<br />
tray (Fig. 15). Laboratory analogs are placed into the copings<br />
after removal from the mouth, to be used to fabricate an<br />
accurate master cast (Fig. 16). Simple O-ring attachments<br />
seated in metal housings serve as the retentive mechanism<br />
(Figs. 17a, 17b). Combining a new conventional maxillary complete<br />
denture with the patient’s very stable small-diameter<br />
mandibular implant overdenture improved her vertical dimension<br />
of occlusion and final esthetics (Fig. 18).<br />
Placing conventional-sized implants in this patient’s mandible<br />
would have been difficult, due to the minimal size of the alveolar<br />
crest. Small-diameter implants gave me an option to restore<br />
function and stability to the patient’s prosthesis. This treatment<br />
option represents a great service to a group of patients who<br />
may not otherwise experience the benefits of implant dentistry.<br />
Figure 11: Final smile design<br />
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Figure 12: Severely resorbed mandibular ridge<br />
Figure 16: Laboratory analogs placed into the pickup copings<br />
for the fabrication of an accurate master cast<br />
Figure 13: Four small-diameter implants ideally positioned<br />
Figure 14: Impression pickup copings snapped into place<br />
Figures 17a, 17b: Conventional O-ring attachments provide<br />
retention for the overdenture<br />
Figure 15: Vinyl polysiloxane impression material used in an<br />
accurate custom tray to pick up the impression copings<br />
Figure 18: Final smile design with increased vertical dimension<br />
– Preserving the Integrity of Facial Structures with Implant-Retained Overdentures – 53
Case 3<br />
Our final case involves a completely edentulous patient who<br />
had never worn any type of prosthesis. Figure 19 illustrates<br />
the wrinkles present around the patient’s mouth and loss of<br />
lip support. Although in her forties, she looked and felt much<br />
older. Conventional dental implant surgical procedures were<br />
completed, with four implants placed in the edentulous mandible<br />
and five implants placed in the edentulous maxilla. At the<br />
time of surgery, it was determined that a sixth dental implant in<br />
the maxillary left cuspid area could not be predictably placed<br />
due to the thinness of the bone. A dental CT was not performed<br />
prior to this surgical intervention, so a typical flap procedure<br />
was used to allow for a more detailed visual examination of the<br />
subgingival structures during the placement procedure.<br />
A custom milled<br />
bar would be used,<br />
which would splint<br />
the maxillary implants<br />
and allow for<br />
fabrication of parallel<br />
attachments.<br />
After discussing prosthetic options with the patient, it was determined<br />
that removable implant-retained overdentures would<br />
provide her proper lip and tissue support, help maintain the<br />
quantity of bone in both arches over time and dramatically improve<br />
function. The patient had tried a conventional, full-palate<br />
maxillary complete denture, but was unable to tolerate it due<br />
to a severe gag reflex. This is another example of where it is<br />
imperative that we listen to the patient’s concerns and desires<br />
if we hope to make the final prosthesis acceptable. Doing so<br />
ensures the quality of life enhancement provided by dental implants<br />
will be rewarding to the dentist and gratifying to the<br />
patient.<br />
Following integration of the mandibular dental implants, a conventional<br />
impression was made by seating impression copings<br />
into the properly placed and parallel implants (Fig. 20) using a<br />
custom tray (Fig. 21). Due to the ideal positioning of the four<br />
mandibular implants, Locator attachments were used as the<br />
retentive mechanism for the overdenture. Because of their<br />
design, the patient is able to easily align and seat the overdenture<br />
into position. Figure 22 illustrates the four mandibular<br />
Locator attachments intraorally positioned. Figure 23 shows the<br />
intaglio surface of the overdenture with the four Locator housings<br />
and retentive male attachments. It was more difficult to<br />
parallel the five maxillary dental implants, and therefore it was<br />
determined that, rather than use single Locator attachments, a<br />
custom milled bar would be used (Fig. 24), which would splint<br />
the maxillary implants and allow for fabrication of parallel<br />
attachments to be built into the framework (Fig. 25). In<br />
the final analysis, we were able to predictably provide the<br />
patient dramatic improvement in esthetics, function and support<br />
for the facial soft tissue. Figure 26 illustrates the beaming smile<br />
of the very happy patient.<br />
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Figure 19: Facial photograph of our third patient, who presented<br />
with complete edentulism<br />
Figure 23: Underside of the mandibular implant-retained<br />
overdenture showing the four Locator housings and retentive<br />
male attachments<br />
Figure 20: Impression copings placed intraorally<br />
Figure 24: Maxillary implant-retained custom milled bar<br />
Figure 21: Final impression with impression copings picked<br />
up using an open-tray technique<br />
Figure 25: Maxillary implant-retained overdenture<br />
Figure 22: Four mandibular Locator attachments ideally<br />
positioned<br />
Figure 26: Final esthetic result of maxillary and mandibular<br />
implant-retained overdentures<br />
– Preserving the Integrity of Facial Structures with Implant-Retained Overdentures – 55
Conclusion<br />
Follow-up care for implant-retained overdentures includes clinical<br />
assessment for abutment stability, mobility of the implants<br />
and plaque accumulation. Because the perimucosal seal is vital<br />
to protecting the underlying connective tissue, probing healthy<br />
implants is not advised. Radiographs should be taken yearly to<br />
determine bone position and contour. Metal scalers and ultrasonic<br />
instruments may damage the titanium abutment surface;<br />
therefore, plastic or graphite scalers are preferred.<br />
The general dentist has an obligation to provide patients with the<br />
most innovative and proven techniques available. CT scans and<br />
scanning software make surgical placement of implants rather<br />
routine. Anatomical anomalies are virtually determined before<br />
ever touching the patient. With good implant placement comes<br />
more routine and predictable prosthetic reconstruction. Because<br />
the general practitioner is the professional the patient consults<br />
with and trusts concerning their dental condition, all clinicians<br />
should educate themselves on the newest treatment modalities.<br />
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