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Inclusive®
Restorative Driven Implant Solutions Vol. 2, Issue 3
A Multimedia Publication of Glidewell Laboratories • www.inclusivemagazine.com
Missed Diagnosis Using
2-D Radiography
Dr. Daniel McEowen
Page 14
Implant Q&A:
gIDE’s Dr. Sascha
Jovanovic
Page 18
Digital Treatment Planning
and Mini Implants
Dr. Paresh Patel
Page 25
2.69 mm
4.09 mm
Preserving Facial
Structure with Implant
Overdentures
Dr. Timothy Kosinski
Page 48
1.63 mm
4.36 mm
CAD/CAM Implant Abutment Design
Dr. Bradley Bockhorst and
Dzevad Ceranic, CDT
Page 6

On the Web
Here’s a sneak peek at the additional
Inclusive magazine content available online.
ONLINE Video Presentations
• Glidewell Laboratories’ Alec Di Lullo demonstrates how the latest
CAD/CAM technology is used in the custom design of implant
abutments.
• gIDE academic chairman Dr. Sascha Jovanovic answers questions
pertaining to the stability of implants and the health of their surrounding
tissues.
• Dr. Daniel McEowen summarizes the limitations of 2-D radiography
when compared to 3-D CBCT imaging technology.
• Dr. Paresh Patel performs a guided surgical procedure in which
Inclusive ® Mini Implants are placed in the upper and lower
arches of an edentulous patient.
• Dr. Timothy Kosinski gives his rationale for determining the
appropriate implant and attachment options for overdenture
patients.
Check out the latest online issue of Inclusive
magazine at www.inclusivemagazine.com.
• Dr. Ara Nazarian highlights the intermediate and long-term
benefits of utilizing BioTemps ® Implant Provisionals.
ONLINE CE credit
• Get free CE credit for the material in this issue with each test you
complete and pass. To get started, visit our website and look for
the articles marked with “CE.”
Look for these icons in the pages that follow for extra content
available on our website, www.inclusivemagazine.com.
– www.inclusivemagazine.com –

Contents
ALSO IN THIS ISSUE
32 Clinical Tip: Dental Photography as
a Laboratory Communication Tool
36 A New Generation of Denture Teeth:
The Perfect Route to Esthetic and
Functional Dentures
43 Ensuring a Successful Restorative
Outcome Utilizing BioTemps ®
Implant Provisionals
6
14
18
25
48
CAD/CAM Technology in Implant Abutment Design
Implant abutments custom-designed and milled with today’s digital
CAD/CAM techniques offer several clinical advantages over prefabricated
abutments. Utilizing anterior and posterior case examples,
Glidewell Laboratories’ Dr. Bradley Bockhorst and Dzevad Ceranic,
CDT, discuss the parameters for ensuring proper margins, angle
correction, crown support, emergence profile and more.
Missed Diagnosis Using Conventional Radiography
With the ability to capture three-dimensional views in multiplanar
slices, Cone Beam Computed Tomography (CBCT) is proving superior
to conventional radiography in the evaluation of endodontic
anatomy and dental disease. In a case report, Dr. Daniel McEowen
details a situation in which this advanced imaging technology enabled
him to accurately diagnose an endodontic failure, and to plan
treatment involving immediate, post-extraction implant placement.
Implant Q&A: An Interview with Dr. Sascha Jovanovic
In an Inclusive magazine interview, gIDE founder and academic
chairman Dr. Sascha Jovanovic shares his thoughts on a variety of
implant-related topics. Read what this leading clinician and lecturer
on implant surgery and soft tissue health and esthetics has to say
about some of the many considerations regarding implant therapy.
Three-Dimensional Treatment Planning with Surgical
Guides and Mini Implant-Retained Dentures
To meet the challenge of an edentulous case contraindicating conventional
implant treatment, Dr. Paresh Patel utilizes cutting-edge
digital treatment planning and resulting surgical guides to ensure
the flapless, parallel insertion of mini implants for the retention of
maxillary and mandibular overdentures.
Preserving the Integrity of Facial Structures with
Implant-Retained Overdentures
Bone resorption resulting from edentulism can compromise a person’s
features by allowing a collapse of facial structures. While
conventional dentures may help, they are often unstable and do
nothing to prevent future bone loss. Here, Dr. Timothy Kosinski
describes how dental implant services have been shown to minimize
resorption, thereby maintaining the natural appearance of the face
and smile while improving denture comfort and stability.
– Contents – 1

Letter from the Editor
There are many new dental technologies available today that clinicians can utilize to provide a higher quality of care for
their patients; however, understanding the benefits, proper use and limitations of these technologies is paramount to their
successful application. This issue of Inclusive showcases several of these innovations, ranging from digital treatment planning
and Cone Beam Computed Tomography (CBCT) to CAD/CAM implant abutment design and fabrication.
When placing small-diameter implants, a flapless surgical procedure is often used. In a case report, Dr. Paresh Patel utilizes
a CBCT scan, treatment planning software and guided surgery to plan and place mini implants in a patient with severely
atrophic ridges. Another application of 3-D imaging allows Dr. Daniel McEowen to correctly diagnose the previously undetected
cause of an endodontic failure, which leads to immediate post-extraction implant placement.
CAD/CAM is one of the fastest-growing sectors in dentistry today. This technology enables the dental laboratory to create
custom solutions for your implant cases. Supplementing this issue’s article on the subject (page 6), our online version includes
a step-by-step tutorial presented by Glidewell Laboratories’ Alec Di Lullo demonstrating how this technology is used
in implant abutment design. Understanding the functionality of this software will allow you to direct the lab to provide your
patients with the best possible restorations.
There have also been technological improvements in dental materials. Nobel Biocare’s classic Brånemark System ® hybrid
denture has been around for more than 40 years, and with the introduction of CAD/CAM milled titanium frameworks,
the screw-retained denture is still a standard implant restoration. One of the challenges with this type of prosthesis is the
inevitable wear of the denture teeth and loss of VDO. An article by Thorsten Michel, MDT, details the development of Ivoclar
Vivadent’s SR Phonares ® nano-hybrid composite denture teeth, which offer improved strength and esthetics.
While conventional dentures can provide missing facial support, they are often unstable and do nothing to prevent future
bone loss. Dr. Timothy Kosinski describes how implants have been shown to minimize resorption while providing greater
comfort and stability for denture wearers. Case examples illustrate the decision process for selecting various types of overdentures,
including freestanding attachments, bars and mini implants.
Our featured interview is with Dr. Sascha Jovanovic, a leading clinician and educator on implant esthetics. He shares his
thoughts on the latest implant designs and grafting procedures. Of related concern is the sculpting of the soft tissues, which
can be effectively contoured by a quality temporary restoration. Dr. Ara Nazarian demonstrates this and other benefits of
BioTemps ® in provisionalizing implant cases.
We are also proud to announce the opening of the Glidewell International Technology Center. A primary goal of this
state-of-the-art facility is to educate clinicians on the latest dental technologies, including how to smoothly integrate them
into their practice. For information about upcoming courses, visit www.glidewellce.com.
Dr. Bradley C. Bockhorst
Editor-in-Chief, Clinical Editor
inclusivemagazine@glidewelldental.com
– Letter from the Editor – 3

Publisher
Jim Glidewell, CDT
Editor-in-Chief and clinical editor
Bradley C. Bockhorst, DMD
Managing Editors
Jim Shuck; Mike Cash, CDT
Creative Director
Rachel Pacillas
Contributing editors
David Casper; Dzevad Ceranic, CDT;
Greg Minzenmayer
copy editors
Jennifer Holstein, Eldon Thompson
digital marketing manager
Kevin Keithley
Graphic Designers/Web Designers
Jamie Austin, Deb Evans, Joel Guerra, Audrey Kame,
Lindsey Lauria, Phil Nguyen, Kelley Pelton, Ty Tran
Photographers/Clinical Videographers
Sharon Dowd, James Kwasniewski, Sterling Wright
Illustrator
Phil Nguyen
coordinatorS/AD Representatives
Teri Arthur, Vivian Tsang
If you have questions, comments or suggestions, e-mail us at
inclusivemagazine@glidewelldental.com. Your comments may
be featured in an upcoming issue or on our website.
© 2011 Glidewell Laboratories
Neither Inclusive magazine nor any employees involved in its publication
(“publisher”) makes any warranty, express or implied, or assumes
any liability or responsibility for the accuracy, completeness, or usefulness
of any information, apparatus, product, or process disclosed, or
represents that its use would not infringe proprietary rights. Reference
herein to any specific commercial products, process, or services by
trade name, trademark, manufacturer or otherwise does not necessarily
constitute or imply its endorsement, recommendation, or favoring
by the publisher. The views and opinions of authors expressed
herein do not necessarily state or reflect those of the publisher and
shall not be used for advertising or product endorsement purposes.
CAUTION: When viewing the techniques, procedures, theories and
materials that are presented, you must make your own decisions
about specific treatment for patients and exercise personal professional
judgment regarding the need for further clinical testing or education
and your own clinical expertise before trying to implement new
procedures.
Inclusive is a registered trademark of Glidewell Laboratories.
Contributors
■ Bradley C. Bockhorst, DMD
After receiving his dental degree from Washington
University School of Dental Medicine,
Dr. Bradley Bockhorst served as a Navy Dental
Officer. Dr. Bockhorst is director of clinical technologies
at Glidewell Laboratories, where he
oversees Inclusive ® Digital Implant Treatment
Planning services and is editor-in-chief and
clinical editor of Inclusive magazine. A member of the CDA,
ADA, AO, ICOI and AAID, Dr. Bockhorst lectures internationally
on an array of dental implant topics. Contact him at
800-521-0576 or inclusivemagazine@glidewelldental.com.
■ Dzevad Ceranic, CDT
Dzevad Ceranic began his career at Glidewell
Laboratories while attending Pasadena
City College’s dental laboratory technology
program. In 1999, Dzevad began working at
Glidewell as a waxer and metal finisher, and
soon worked his way up to ceramist. With the
skills acquired as a dental technician, he was
promoted to GM of the Full-Cast department. In this role, he
assisted in facilitating the lab’s transition to CAD/CAM. In 2008,
he took on the company’s rapidly growing Implant department.
Dzevad completed an implants course at UCLA School of Dentistry
in 2009. Today, he leads a team of 170 people at the lab,
implementing cutting-edge technology throughout his department.
Contact him at inclusivemagazine@glidewelldental.com.
■ SASCHA A. JOVANOVIC, DDS, MS
Dr. Sascha Jovanovic received his training in
periodontics, implant dentistry and prosthodontics
at UCLA School of Dentistry, Loma
Linda University and University of Aachen
in Germany, respectively, and holds an M.S.
in oral biology from UCLA. Founder and
academic chairman of the Global Institute
for Dental Education (gIDE) and course director of implant
dentistry for UCLA Continuing Dental Education, he
has dedicated his clinical work for more than 15 years to
dental implant therapy and bone and soft tissue reconstruction.
He is past president of the European Association for
Osseointegration, past board member of the Osseointegration
Foundation and the recipient of many dental industry awards.
He also lectures and publishes extensively. Contact him at
310-820-9641 or sascha@jovanoviconline.com.
4
– www.inclusivemagazine.com –

■ TIMOTHY F. KOSINSKI, DDS, MAGD
Dr. Timothy Kosinski graduated from University
of Detroit Mercy School of Dentistry and
received a Master of Science degree in biochemistry
from Wayne State University School
of Medicine. An adjunct assistant professor
at Mercy School of Dentistry, he serves on the
editorial review board of numerous dental
journals and is a Diplomate of the ABOI/ID, ICOI and AO.
Dr. Kosinski is a Fellow of the AAID and received his Mastership
in the AGD, from which he received the 2009 Lifelong Learning
and Service Recognition award. Contact him at 248-646-8651,
drkosin@aol.com or www.smilecreator.net.
■ FRANK LAUCIELLO, DDS
Dr. Frank Lauciello graduated from SUNY at
Buffalo School of Dental Medicine in 1969
and completed his prosthodontic training at
Buffalo VA Medical Center. Currently a clinical
associate professor in the restorative department
at SUNY at Buffalo, he was director
of the Veterans Administration advanced
program in prosthodontics from 1973 to 1998 and chief of
the dental service from 1996 to 1998. He is also director of
removable prosthodontics for Ivoclar Vivadent and director
of its Implant Esthetics Center of Excellence in Sarasota, Fla.
A Diplomate of the American Board of Prosthodontics, he
has authored numerous articles and textbook chapters and is
actively involved in dental research and product development.
Contact him at frank.lauciello@ivoclarvivadent.com.
■ Thorsten Michel, MDT
Thorsten Michel completed his dental technician
training in 1991 at Mangold dental lab
in Stuttgart, Germany, during which time he
was awarded the prestigious Gysi Prize. After
a stint in the German armed forces, Thorsten
worked for Albrecht Schenk dental lab in
Schwäbisch Gmünd from 1992 to 1994,
and then Winnenden-based Jürgen Dieterich until 1998.
In 2000, he completed master dental technician school in
Freiburg/Breisgau, earning best performance in the examination
for the master craftsman’s diploma. In 2001, he received
the Klaus Kanter award. He currently runs his own dental lab
in Schorndorf, which he started in June 2000. Contact him at
info@michel-zahntechnik.de.
■ ARA NAZARIAN, DDS, DICOI
Dr. Ara Nazarian maintains a private practice
in Troy, Mich., with an emphasis on comprehensive
and restorative care. He is the director
of the Reconstructive Dentistry Institute,
a Diplomate of the ICOI, and has conducted
lectures and hands-on workshops on esthetic
materials and dental implants throughout
the U.S., Europe, New Zealand and Australia. Dr. Nazarian
is also the creator of the DemoDent patient education model
system. His articles have been published in many of today’s
popular dental publications. Contact him at 248-457-0500 or
www.aranazariandds.com.
■ Daniel McEowen, DDS
Dr. Daniel McEowen is a 1982 graduate of
Loma Linda University School of Dentistry and
has been in private practice for 26 years. He
currently practices in Hagerstown, Md., in a
multidiscipline practice. A founding member
and Master of the World Clinical Laser Institute
(WCLI), he lectures and trains internationally
in laser dentistry techniques, and teaches a course for erbium
and diode lasers with the Masters of Laser Dentistry. He has
been active in obtaining FDA approval of oral surgery techniques
using erbium lasers. Dr. McEowen also owns 3D
Imaging Center in Maryland, lectures throughout the U.S. on
cone beam technology, and is an advanced trainer for PreXion
3D cone beam systems. He is active in implantology and a
member of the ICOI. Contact him at drdan13106@gmail.com.
■ Paresh B. PATEL, DDS
Dr. Paresh Patel is a graduate of University of
North Carolina at Chapel Hill School of Dentistry
who has been practicing since 1996. He
has a passion for keeping up with the changing
technology and materials in dentistry. As
a Master in the International Academy of Mini
Dental Implants (IAMDI), he has placed more
than 2,500 mini implants and has worked as a lecturer and
clinical consultant on mini implants for various companies.
Dr. Patel belongs to numerous dental organizations, including
the ADA, North Carolina Dental Society and AACD, and
is also a member and president of the Iredell County Dental
Society in Mooresville, N.C. Contact him at 704-799-0552 or
pareshpateldds2@gmail.com.
– Contributors – 5

CAD/CAM Technology in
Implant Abutment Design
Go online for
in-depth content
by Bradley C. Bockhorst, DMD and
Dzevad Ceranic, CDT
Custom abutments provide
numerous clinical advantages
over prefabricated
abutments. Utilizing CAD/CAM
technology, the dental technician
can precisely design and
fabricate the restoration according
to the clinician’s prescription.
Modifications can be made
to the transgingival section,
the margin and the angle of
the abutment. The base, height
and taper of the abutment can
also be designed to provide
support and retention for the
crown. This article will discuss
the clinical parameters that must
be considered when designing
an implant abutment. Anterior
and posterior case examples
handled at Glidewell Laboratories
(Newport Beach, Calif.) will
illustrate the primary features
that can be designed into an
abutment using computer-aided
technology.
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■ The Transgingival Section
Various designs have been used over the years for the section
of the abutment extending from the top of the implant
through the soft tissue. Early root-form endosseous implant
systems advocated a straight-walled design through the gingiva.
1,2 However, this resulted in ridge-lap crown designs
that presented hygienic and esthetic challenges.
Inclusive ® Custom
Implant Abutments
In the 1990s, abutment systems were introduced to create
an “emergence profile.” 3–6 In this scenario, the base of the
abutment flares as it rises coronally from the top of the
implant. The premise of this design is that the restoration
emerges through the soft tissue in a similar way to the natural
clinical crown. While providing an esthetic, cleansable
result, this design requires that clinical precautions be taken
to avoid excessive pressure on the labial tissue, which can
lead to recession. 7
Research has been conducted and some products brought
to market with concave transgingival sections. 8 The concept
behind this design is that creating a thicker band of gingiva
around the abutment will stabilize the soft tissue and mask
the gray color of the titanium abutment at the gingival margin.
A potential challenge with this design is that removing
or replacing the abutment would likely necessitate anesthetizing
of the patient. The narrow neck design could also
lead to thin, potentially weak abutment walls.
So is the best transgingival design straight, convex or concave?
The appropriate solution depends on the case. If the
patient’s soft tissue is thin, the abutment may need to flare
out beginning at the top of the implant. Interproximally, the
abutment can be designed to provide support for the papillae.
If the patient’s soft tissue is thicker, the abutment can be
straight or only slightly flared at the top of the implant and
begin flaring just below the crest of the soft tissue.
Glidewell Laboratories offers three types of customized
implant abutments under the Inclusive brand
name: a titanium abutment, a zirconia abutment and
a zirconia to titanium hybrid. Titanium abutments are
used in all areas of the mouth, while zirconia abutments
offer an esthetic option for anterior cases,
particularly if the patient has a thin biotype. The zirconia
hybrid abutment provides a titanium-to-titanium
interface with the implant, as well as a deeper
abutment-to-implant interface. For this hybrid abutment,
an anatomically correct zirconia structure is
luted to a titanium insert in the laboratory using resin
cement.
Utilizing CAD/CAM technology,
the dental technician can
precisely design and fabricate
the restoration according
to the clinician’s prescription.
– CAD/CAM Technology in Implant Abutment Design – 7

So is the best transgingival
design straight, convex or
concave? The appropriate
solution depends on the case.
When seating the abutment, a critical factor is what is placed
on the implant. A properly fabricated provisional restoration
is ideal to help shape and sculpt the soft tissue contours. If
a stock healing abutment is chosen, one with a flare similar
to the tooth being replaced should be used. The soft tissue
and/or the abutment should be adjusted if blanching occurs
upon delivery and does not dissipate within 10 minutes, as
excessive pressure on the tissue can lead to recession. A
periapical radiograph should be taken to verify complete
seating of the abutment.
■ Setting the Margin
For cemented implant restorations, the location of the
margin is even more critical than on natural preps. Several
studies have emphasized the detrimental effect of excess
cement on peri-implant bone and soft tissue. 9,10 Using a
scan of the model, the margin can be set approximately
1 mm below the crest of the soft tissue in esthetic areas.
Typically, it will be placed at or 0.5 mm below the crest
interproximally and lingually/palatally, which provides an
esthetic result and easy access for the complete removal
of excess cement. The shoulder of the margin can also be
planned based on the intended crown type.
■ Crown Support and Retention
Virtual design of the abutment allows the technician to create
the ideal base to support the crown. Retention of the
crown is based on the height and taper of the abutment. 12
CAD software allows the abutment and crown to be visualized
to determine the optimal abutment base width and
height. A six-degree taper is typically provided for retention.
The height of the abutment should be maximized, with
consideration given to providing adequate occlusal/incisal
space for the crown. Finally, the cement space for the crown
can be precisely adjusted.
Using a scan of the model, the
margin can be set ... which
provides an esthetic result and
easy access for the complete
removal of excess cement.
■ Anterior Case Example
■ Angle Correction
If the trajectory of the implant diverges from the position
of the crown of the tooth to be replaced, the abutment can
be designed to correct this angle. 11 Custom abutments can
be manufactured to correct divergence; however, it is not
recommended to exceed 20 degrees of angle correction.
From a biomechanical perspective, severe angles should be
avoided and worked out during the planning stage. Off-axis
loading, particularly in single-tooth restorations, should be
avoided or minimized as much as possible.
Figure 1: Using 3Shape CAD software, the margin of the abutment is set following
the gingival contours. The grid can be used as a measurement aid. The transgingival
section of the abutment fills the sulcus and creates the base for the restoration.
NOTE: Glidewell Laboratories will virtually blanch the tissue no more than
0.5 mm, unless specified otherwise on the lab prescription.
8
– www.inclusivemagazine.com –

Figure 2: A full-contour crown is placed over the abutment and the interproximal
contacts are adjusted. Because implants have no periodontal ligament and
therefore no give, long, broad, light interproximal contacts are designed. Once the
crown is designed, the supragingival section of the abutment is adjusted to create
adequate space, support and retention for the restoration.
CAD software allows the
abutment and crown to
be visualized to determine
the optimal abutment base
width and height.
Figure 3: The height of the abutment is adjusted in relation to the crown.
Figure 5: Adjustments are made to the palatal contours.
Figure 4: The mesial-distal width of the abutment is adjusted.
Figure 6: The labial contours and spacing are adjusted.
– CAD/CAM Technology in Implant Abutment Design – 9

■ Posterior Case Example
Figure 7: Incisal view of the abutment with screw access opening and crown
Figure 1: Using the same CAD software as in the previous case, the margin and
transgingival section are set.
Figure 8: Cross-sectional view of the abutment and crown
Figure 2: A full-contour crown is placed over the abutment, and the occlusal and
interproximal contacts are adjusted (red circles).
Once the crown is
designed, the supragingival
section of the abutment is
adjusted to create adequate
space, support and retention
for the restoration.
Figure 3: The height and taper of the abutment is adjusted.
10
– www.inclusivemagazine.com –

■ Conclusion
The use of CAD/CAM technology to design and fabricate
custom abutments provides numerous clinical advantages.
This method allows the clinician to specify design criteria
and material choice on the lab prescription. The abutment
is then custom-designed for the specific case and precisionmilled,
resulting in a superior restoration.
■ References
Figure 4: Adjustments are made to the labial, lingual/palatal and interproximal
contours.
1. Adell R, Eriksson B, Lekholm U, Brånemark PI, Jemt T. Long-term follow-up study
of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral
Maxillofac Implants. 1990;5(4):347–59.
2. Spiekermann H, Jansen VK, Richter EJ. A 10-year follow-up study of IMZ and TPS
implants in the edentulous mandible using bar-retained overdentures. Int J Oral
Maxillofac Implants. 1995 Mar-Apr;10(2):231–43.
3. Daftary F. Dentoalveolar morphology: evaluation of natural root form versus cylindrical
implant fixtures. Pract Periodontics Aesthet Dent. 1997 May;9(4):469–77;
quiz 478.
4.King KO. Implant abutment emergence profile: key to esthetics. J Oral Implantol.
1996;22(1):27–30.
5. Lazzara R. Esthetic excellence with implant abutments. Dent Econ. 1993 Mar;
83(3):83–4, 89.
6. Salinas TJ, Sadan A. Establishing soft tissue integration with natural tooth-shaped
abutments. Pract Periodontics Aesthet Dent. 1998 Jan-Feb;10(1):35–42; quiz 44.
7. Su H, Gonzalez-Martin O, Weisgold A, Lee E. Considerations of implant abutment
and crown contour: critical contour and subcritical contour. Int J Periodontics
Restorative Dent. 2010 Aug;30(4):335–43.
8. Redemagni M, Cremonesi S, Garlini G, Maiorana C. Soft tissue stability with
immediate implants and concave abutments. Eur J Esthet Dent. 2009 Winter;
4(4):328-37.
9. Chik FF, Chan WK, Pow EHN, Chow TW. Management of non-restorable maxillary
premolars with immediate implants, immediate provisional restorations, and
definitive screw-retained CAD/CAM zirconia abutment crowns: a report of five
cases. Hong Kong Dent J. 2009;6:31–8.
10. Goodacre CJ, Bernal GB, Rungcharassaeng K. Clinical complications with
implants and implant prostheses. J Prosthet Dent. 2003;90:121–32.
11. Wu T, Liao W, Dai N, Tang C. Design of a custom angled abutment for dental
implants using computer-aided design and nonlinear finite element analysis.
J Biomech. 2010 Jul 20;43(10):1941–46.
12. Emms M, Tredwin CJ, Setchell DJ, Moles DR. The effects of abutment wall height,
platform size, and screw access channel filling method on resistance to dislodgement
of cement-retained, implant-supported restorations. J Prosthodont.
2007 Jan-Feb;16(1):3–9.
Figure 5: Once the abutment design is completed, the file is transferred to a 5-axis
milling machine and the abutment is fabricated.
– CAD/CAM Technology in Implant Abutment Design – 11

Chairside Processing of LOCATOR ® Attachments into an Existing Denture
Introduced in 2001, the Locator Attachment is the third generation of attachments from Zest Anchors and the worldwide
standard for overdenture retention. A common clinical indication for Locator Attachments is the retrofit of an existing
overdenture. This can easily be accomplished by any clinician and is a great treatment plan that introduces implant
retention to the neediest patients.
Case presentation by John C. Bain, DDS, Farmington, Ark.
Step 1: Remove healing abutments
and place the appropriate
Locator Abutment, ensuring the
top 1.5 mm of the abutment remains
above the gingival tissue.
Step 2: Hand-tighten into place,
and then torque to 30 Ncm or to
the value recommended for the
specific implant system (as documented
in the system's IFU).
Step 3: Place block-out ring over
the Locator Abutment. This will
prevent acrylic resin from flowing
into any exposed undercut
area, facilitating removal of the
denture once the material is set.
Step 4: Insert the Black Processing
Male in the Locator
Denture Cap and place on the
abutment in the mouth.
Step 5: Place indicator paste
on the denture to coincide with
the location of the Locator Abutments
in the mouth.
Step 6: Using an acrylic bur,
relieve the denture in the areas
where the denture caps will rest.
Minimal relief is recommended,
followed by repeated intraoral
verification to ensure the residual
integrity of the denture base.
Step 7: Clean the receptor sites
with alcohol to ensure the removal
of any residual material.
Step 8: Apply resin-curing primer
and bonding agent to the denture
receptor sites.
Step 9: Fill each receptor site
with light-cure acrylic resin.
Step 10: Dry the denture caps
and apply resin-curing primer
and bonding agent. Next, apply
light-cure resin.
Step 11: Seat the denture back
in the mouth and confirm proper
occlusion. Light-cure the denture
in the areas of the Locator
Denture Caps.
Step 12: Remove the denture
and inspect for any voids. If
necessary, fill any voids and
then final-cure the denture for
an additional one minute.
Step 13: Remove the Black Processing
Males using the Locator
Core Tool and insert the appropriate
final male components.
“The Locator Implant Attachment is our attachment
of choice. We like its versatility and the
availability of abutments for any implant system
we use. Our patients can immediately insert and
remove their overdentures with little instruction,
making them very happy and saving us a great
deal of chairtime.”
– Robert L. Blackwell, DDS , Alton, Ill.
“I have been using Locator Attachments to
restore my patients for over 10 years. The
precision, predictability and durability of the
attachments have been outstanding. The fact
that I rarely need to replace the males has
increased my productivity and profitability. Locator
has truly improved my patients’ quality of life."
– Robert C. Vogel, DDS,
Palm Beach Gardens, Fla.

Missed Diagnosis Using Conventional
2-D Radiography
Go online for
in-depth content
by Daniel McEowen, DDS
Cone Beam Computed Tomography (CBCT) is
becoming increasingly popular in dentistry for
diagnosis and treatment planning. Use of this three-dimensional
imaging technology can increase diagnostic accuracy compared
to conventional two-dimensional digital periapical and panoramic
radiography. The inherent distortions and limitations
of 2-D radiographs make it much more difficult to complete
an accurate case diagnosis. Some of these limitations include:
elongation and foreshortening of the target tissues, overlap of
structures in front of or behind the target tissues, tissue density
that is not easily interpreted in bone or soft tissues, and resolution
differences of various film and digital receptors.
Many of the issues associated with conventional 2-D radiography
can be eliminated or greatly reduced with the use of 3-D
CBCT. CBCT uses a cone-shaped beam and digital processing to
create a 3-D image that does not contain magnification, distortion
and overlap of anatomy. Before investing in 3-D imaging, a
clinician will need to choose a “field of view” (FOV). FOV refers
to the area of the anatomy that is captured by the scan. Medium
FOV CBCT scanners offer focal spot sizes down to 0.15 mm
and voxel sizes down to 0.076 mm. The size of the focal spot
and each voxel (volume pixel) determines the resolution of the
image; the smaller the focal spot and voxel, the better the resolution.
1,2 Smaller focal spot sizes and higher resolution enable
clinicians to make very accurate diagnoses in most cases. CBCT
also offers multiplanar views (MPV) in slices as thin as 0.05
mm thick. These MPV are cross sections through the volume of
information in axial (x-z axes), coronal (x-y axes) and saggital
(z-y axes) views. Using sophisticated software, the volume can
be sliced at any oblique direction to view pathology from virtually
any angle and thickness. The ability to view diseased areas
in different planes can eliminate guesswork during diagnosis
and help determine the least invasive procedure necessary to
eliminate the dental disease.
Use of threedimensional
imaging
technology can
increase diagnostic
accuracy compared
to conventional
two-dimensional
digital periapical
and panoramic
radiography.
The following case study illustrates how using CBCT technology
can improve the success of endodontic diagnosis and treatment.
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Figure 1: Pre-endodontic treatment 2009, patient is having
pain. A 2-D periapical radiograph reveals no apparent
pathology.
Figure 2: Pre-extraction 2011, a 2-D periapical radiograph
shows little to no disease. There is a slight radiolucency at
the distal midpoint of the root.
Case Report
The ability to view
diseased areas in
different planes can
eliminate guesswork
during diagnosis and
help determine
the least invasive
procedure necessary
to eliminate the
dental disease.
This case follows the three-year treatment of a 38-year-old
female with a history of failed root canal procedures and
eventual extractions. In 2009, she presented with vague pain
in the lower right mandibular quadrant and complained she
could not bite in the area. A digital periapical radiograph
taken in September 2009 of the lower right bicuspids and
molars revealed no apparent pathology (Fig. 1). Tooth #28
had slight pain with percussion and some fleeting pain to
cold on the buccal surface lasting less than five seconds.
At some point in the three months prior to her visit, a new
crown had been placed on tooth #5. An occlusal adjustment
was performed on this crown to relieve the stress on
tooth #28.
Several months later, the patient was again seen in the
office for tooth #28. Her symptoms had worsened and she
was experiencing prolonged discomfort in the tooth. Pulp
testing indicated a nonvital root and root canal treatment
was completed. A new periapical radiograph was taken
at this appointment but did not show definitive periapical
pathology. Her symptoms were eliminated and she returned
to normal use and function on tooth #28.
Eighteen months passed and the patient returned for extreme
pain in tooth #28. A new periapical radiograph was
taken that revealed little to no abnormal pathology (Fig. 2).
A CBCT scan was also taken that revealed a large lesion on
– Missed Diagnosis Using Conventional 2-D Radiography – 15

Figure 3: Pre-extraction 2011 (same day
as 2-D periapical), a CBCT scan reveals
a moderate-sized radiolucency at the
midpoint of the root. This is a 0.07 mm
saggital slice.
Figure 4: Pre-extraction axial slice (0.07
mm) showing the extent of the lesion to
the distal
Figure 5: A 2-D radiograph showing the immediate
post-extraction placement of the implant in
the modified socket.
the distal side of the root (Fig. 3). Further examination of the
scan revealed a lateral canal midway down the root with a
3 mm by 5 mm area of radiolucency in the interproximal
bone (Fig. 4). Root canal retreatment was discussed with the
patient and refused. Having been successfully treated with
dental implants in the past, she decided on implant treatment
instead. Immediate implant placement after extraction
was selected as the treatment of choice because it would
greatly decrease the patient’s treatment time.
Luxators were used to atraumatically remove the offending
tooth, and surgical spoons were used to mechanically
debride the socket. The granuloma was removed in its
entirety, and the entire area of the socket was decontaminated
using laser energy. Osteotomy drills were then used to
modify the socket, and an implant was immediately placed
in the modified socket (Fig. 5). The discrepancy between the
socket shape and the diameter of the implant on the buccal
and lingual was less than 1.5 mm, so no additional grafting
materials were placed. Within two to four months, native
bone will fill in the gap.
A postoperative CBCT scan taken immediately after implant
placement revealed the position and the engagement of
the implant in the apical half of the socket (Figs. 6, 7). The
patient is healing well and will soon move forward with
the final restoration. Compared to the 2-D periapical radiographs,
the 3-D and MPV views provided by the CBCT scan
enabled us to make a much more complete diagnosis.
Immediate implant
placement after
extraction was
selected as the
treatment of
choice because
it would greatly
decrease the
patient’s
treatment time.
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Figure 6: CBCT saggital image taken immediately after
placement of the implant
Figure 7: Coronal slice (0.07 mm) post implant placement
showing buccal to lingual span in the existing extraction site
Compared to the
2-D periapical
radiographs,
the 3-D and MPV
views provided by
the CBCT scan
enabled us
to make a much
more complete
diagnosis.
Conclusion
Three-dimensional CBCT offers a more complete view of
dental anatomy and disease than traditional 2-D radiography
alone. Using this technology allows the clinician to
more accurately evaluate endodontic anatomy and better
diagnose the true extent of dental disease. Having a more
accurate diagnosis results in a more appropriate treatment
plan and helps guide a patient’s treatment toward a successful
outcome.
For clinical questions, contact Dr. Daniel McEowen at drdan13106@gmail.com. For
technical questions, contact Keith Bateman at kbateman@prexion.com.
References
1. Law J. The influence of focal spot size on image resolution. Br J Radiol. 1993
May;66(785):441–46.
2. Cesmeli E, Berry JL, Carr JJ. Tube focal spot size and power capability
impact image quality in the evaluation of intracoronary stents. Proc. SPIE
5745. 2005;676–84. doi:10.1117/12.596035.
– Missed Diagnosis Using Conventional 2-D Radiography – 17

Implant Q&A:
An Interview with Dr. Sascha Jovanovic
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in-depth content
Interview of Sascha A. Jovanovic, DDS, MS
by Bradley C. Bockhorst, DMD
Dr. Sascha Jovanovic is
founder and academic
chairman of the Global Institute
for Dental Education (gIDE) and
course director of implant dentistry for
UCLA Continuing Dental Education. A leading
clinician and lecturer on implant surgery
and soft tissue health and esthetics, he recently took
time to share his thoughts on these subjects with Inclusive
magazine at gIDE’s global headquarters in Los Angeles.
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Dr. Bradley Bockhorst: Before we get started with the interview,
can you share with us a little bit of background information
on gIDE and about the studio where we are right now?
Dr. Sascha Jovanovic: Of course. First of all, it’s a pleasure
to be part of this interview. gIDE was started as a training,
education and research institute in 2003 based on utilizing
today’s new digital technology to distribute information and
knowledge efficiently and swiftly. We’re kind of shrinking
the world of dentists, and we are able to give continuing
education to our colleagues and friends very efficiently and
on their time schedules. So it’s online streaming, it’s digital
downloads, it’s utilizing learning tablets. And my favorite is
the blended learning, which combines in-person training
and online education.
Now, to do this — we started about eight years ago, when
gIDE was founded — we needed a recording studio. We’re
very lucky to be here today in this building, which formerly
was the studio of The Beach Boys. In this area where we
are right now, one of their famous songs could have been
created. So it’s fun for us to be here as dentists, as educators
and as clinicians because we can give a little creative juice
to the education we provide.
BB: Very fun history. The first several questions I have for you
are related to your thoughts and experiences with various
implant and abutment designs. With that in mind, what is the
influence of the implant surface on crestal bone stability?
SJ: We know today that implant surfaces can affect bone
and soft tissue positively. We like an implant to have a
micro or moderately roughened surface, so the bone integration
and stability in the full length of the implant can be
maintained. We also know that a polished neck loses more
crestal bone than an enhanced surface. So when I place an
implant, I always choose an implant that has a roughened
surface all the way up the neck of the implant.
We like an implant to have a micro
or moderately roughened surface,
so the bone integration and stability
in the full length of the implant can
be maintained.
BB: The next question is related to that collar design. You prefer
to have it going all the way to the top of the implant?
SJ: Right. When you look at the neck of the implant, which
is the next point to think about, the most important bone
from a standpoint of soft tissue is the crestal bone. So that’s
why, when we evaluate patients over the long term, we
always want to know what the crestal bone stability is. When
you are evaluating an implant system, here also you want to
know the crestal bone stability. In addition to surface characteristics,
new research nicely shows that implants with a
straight neck or a reverse-neck design are even better for
crestal bone stability.
Implants with a straight neck or a
reverse-neck design are even better
for crestal bone stability.
There is a tendency to move away from implants with
a countersink, like the traditional Brånemark System ®
implants (Nobel Biocare; Yorba Linda, Calif.), in the esthetic
zone — versus something that has more of a straight neck,
such as NobelReplace ® (Nobel Biocare), the most widely
used two-piece implant system. And, currently, implant
designs are being introduced with a reverse-neck design.
Those, again, seem to be better on maintaining the bone.
These are promising results, and that’s definitely the direction
the research is going.
BB: Now, on top of the implant, what abutment materials have
you found to be the most biocompatible?
SJ: Abutment materials are a big topic of discussion because
we have titanium, which we’ve had for the longest
period of time. Later on we had alumina. Today we have
zirconia. And, of course, we have the gold alloy abutments,
like the UCLA-type abutments. Then we have temporary
abutments — which many companies were using or are
still using — which are made out of plastic or some form
of acrylic.
When we look at animal research, it’s very clear that there
are only two materials that are stable for soft tissue, and
those are titanium and zirconia. Now, of course, we can say
animal research is not the same as human clinical data, but
we try to follow the information that is available to us.
– Implant Q&A: An Interview with Dr. Sascha Jovanovic – 19

There are only two materials that
are stable for soft tissue, and those
are titanium and zirconia.
In my practice, I prefer to use titanium or zirconia in a case
that is well planned with good implant position. But, sometimes
you have the unusually complex case, and then we
can still use gold alloy, with the knowledge that we might
lose some crestal bone and soft tissue. Therefore, it’s better
not to use this material in the esthetic zone.
BB: There have been various transgingival designs for abutments
— everything from convex to straight to concave designs.
Which design have you found to best support peri-implant
health and esthetics?
SJ: Well, the tendency that’s been more and more supported
in the last few years is that platform switching, or
the use of abutments with reduced width in relation to the
implant diameter, promotes better soft tissue stability and
improves soft tissue health. Abutments are reduced or, as
you mentioned, some even have a concave design, which is
something we can do today with CAD/CAM. So, for me, it’s
very important to use, at max, a diameter of an abutment
that is the same size as the implant. I won’t use those divergent
ones because divergence means mechanical stress to
the tissues, and mechanical stress to the soft tissues means
an increased risk of recession.
Platform switching, or the use of
abutments with reduced width in
relation to the implant diameter,
promotes better soft tissue stability
and improves soft tissue health.
BB: To make sure I understand, you prefer a straight emergence?
And at what point, from a peri-implant standpoint, do
you like to start having that emergence profile?
SJ: This is very case dependent, as you can imagine. The
best way I can explain it is: Imagine we’re looking at a tulip.
(I’m Dutch, so I love tulips, of course.) Like a tulip, the
stem, which is the abutment, should be really nice and narrow,
and once we come close to the gingival margin, that’s
where we can emerge out. So let’s say about 0.5 mm or so
below the gingival margin is where the crown goes to its
full emergence.
BB: In clinical practice, there are some procedures in which
you’re taking abutments on and off a lot. What impact does
that have on the surrounding tissues?
SJ: This is clear-cut because the research studies show that
implant design is unrelated to bone loss or bone stability. As
an example, if you use a two-stage or a two-piece implant
versus a one-piece implant, the bone stays stable until we
start to remove the abutments. So, as soon as we do impressions
or some type of laboratory work or change — boom!
We get a reaction. And the reaction is usually soft tissue inflammation.
Soft tissue inflammation leads to inflammation
in the bone, which leads to bone loss. Bone loss leads to
potential risk for gingival recession.
So it’s very crucial for any clinician to try to pick the final
abutment as early as possible. A suggestion for clinical practice
is that implant impressions be taken as early as possible.
It could be at the time of implant placement or at
the time of uncovering. And then we select an abutment
that, if possible, is the permanent abutment for the case.
Now, I realize that’s not always possible. You need to be
well equipped and you need to plan the case well, but that
would be the ideal.
It’s very crucial for any clinician to
try to pick the final abutment as
early as possible.
Another good clinical practice is to leave a stock abutment
in for at least two to three months, so the soft tissues are
stable, and then make one more abutment switch at that
time. So you might have two abutment changes. But don’t
do what we used to do in the old days, where we removed
abutments frequently, as this sometimes creates a negative
result which, of course, none of us want.
BB: Back to implant placement. What do you find is the ideal
interproximal space between the implant and the adjacent
roots?
SJ: Spacing between implants and any other anatomical
structures is very important for preservation of the existing
periodontal and bone tissue. We have information in the
literature that suggests that between adjoining implants you
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need a minimum of 3 mm to 4 mm, which is a good, safe
space. Between an implant and a natural tooth, you need
2 mm or more. This will support the periodontal ligament,
and the more bone we have, the better.
Between adjoining implants you
need a minimum of 3 mm to 4 mm
... Between an implant and a natural
tooth, you need 2 mm or more.
So when you are planning a case, you probably want fewer
implants in the anterior region because you want to have
optimal soft tissue, and you also want to have smaller
diameters. In my private practice, for example, I don’t place
wide-platform implants in the anterior region because it
compromises the soft tissue. I select regular and sometimes
even narrow implants. In addition to this, think about cases
where you have to place multiple implants next to each
other. Often cases are better if you bring in a pontic, so you
have more bone and soft tissue to work with. So, less is
better, and increase the spacing between implants.
BB: How do you handle the cases of, say you’re doing a single
tooth — maybe it’s a narrow maxillary lateral incisor or lower
incisor — and you just don’t have that 2 mm on either side?
How are you handling those cases?
SJ: Well, those are difficult cases. So my recommendation
is: When you are dealing with difficult anatomical conditions,
be very careful, because you are setting yourself
up for a dangerous situation, in which tissue can be lost.
Unfortunately, I see many cases in my practice that are redo
cases, and a loss of the periodontal ligament and papilla on
a natural tooth.
If you have, let’s say, less experience with implants, my recommendation
would always be: Stay away from those cases;
leave that up to colleagues who have more experience, who
know what the pitfalls are. Because the worst you can do is
try to do the best you can for your patient and, in the end,
you get a negative result. So those are not good cases. Get
enough tissue. Get enough space.
BB: What is your ideal position for the top of the implant in
relation to the crest of the bone?
SJ: I published in 1997 a scientific paper describing my
observations about the ideal relationship of the neck of the
implant and the connection with the abutment to the soft
tissue margin. And we concluded that everything is related to
the biological width. The biological width around implants
is approximately 3 mm, so that’s the soft tissue dimension
around implants and around abutments. The goal today will
always be to place the implant neck no deeper than 3 mm
below your optimal gingival margin. And once you know
what your optimal gingival margin is, which should come
from your diagnosis and models, then you count back and
you place the implant about 3 mm below that.
We concluded that everything is
related to the biological width.
So, now, what does that mean in many clinical situations?
When the crest has bone loss, there’s a part of the implant
neck that is going to be exposed. And with that implant
neck, now you need to make a decision. Should I do a grafting
to bring that bone back, or should I maybe place the
implant deeper and then accept that the crown is going to
be longer and there is going to be gingival recession? This
may be acceptable for some patients with a low lip line.
The goal today will always be to
place the implant neck no deeper
than 3 mm below your optimal
gingival margin.
BB: Along the same line, if you decide you are going to do
grafting, when do you determine that it is truly indicated and
which procedures you should perform?
SJ: Bone grating, of course, is extremely important. You can
see how soft tissue is related to bone. Remember, we have
this bone frame, which really sets up the soft tissue. The
soft tissue dimension is stable; it’s 3 mm to 3.5 mm. So just
always keep that in mind. We make a decision before we
start the case, and that is: Should this case be grafted, so we
can get into this good range of 3 mm to 3.5 mm of soft tissue?
Or maybe the patient doesn’t want to do it; maybe they
accept pink porcelain; maybe the patient accepts a longer
crown. Then, of course, that is discussed with the patient.
But, in principle, we graft most cases if we need optimal
soft tissue dimensions.
– Implant Q&A: An Interview with Dr. Sascha Jovanovic – 21

BB: Do you have a material of choice for grafting?
SJ: The most used procedure, which is evidence-based
in the literature — and we have been doing this now for
20 years — is the GBR principle, which is the Guided Bone
Regeneration principle. This is basically the principle where
we use bone grafts based on particulate — some of it is autogenous,
which is the gold standard, and some of it could
be a biomaterial — and then we cover this with a barrier
membrane, which could be resorbable or nonresorbable.
This will, first of all, stabilize the bone graft for regeneration
purposes and, secondly, exclude the soft tissue and bacteria
from invading, so we don’t have a loss of that bone.
BB: Another question along the line of bone grafting: If you
are going to do a delayed case — say you’re going to extract a
tooth and then place an implant later — would you typically
graft that socket?
SJ: Yes, socket grafting is something that is more of a norm
today. So I would always recommend socket grafting to any
clinician and to any colleague for sure in the single-rooted
teeth — which basically means everything that is toward
the anterior — because it will prevent collapse of the buccal
plate, it will maintain more of the soft tissue, and it will
improve the stability of the soft tissue dimension.
I would always recommend socket
grafting to any clinician and to any
colleague for sure in the singlerooted
teeth.
Socket grafting is a very successful procedure, and various
materials work. It could be a biomaterial; it could be
a growth factor; it could be an autogenous bone graft.
But, important as always, the extraction socket needs to
be clean. The infection, which often was there with the
tooth, needs to be cleaned out. So, sometimes you need
to spend more time on extraction and cleaning it out than
just on a grafting procedure. That’s very important because,
unfortunately, I’ve seen a lot of socket grafting which came
back, and the material is just laying around, and it didn’t do
anything. So that is not a good idea.
BB: Once you’ve cleaned out the socket and you’ve grafted,
what do you typically like to cover it up with?
SJ: Socket grafting, as you know, has different options. The
first option, which of course most of us will look at, is to
use a barrier membrane. This can be either a nonresorbable
material — today there’s the dense PTFE material — or we
can use a resorbable material. Then there are also some
new materials. We have collagen grafts, which are thicker;
they have a thickness of about 5 mm. These help us to, first
of all, stabilize the soft tissue and the bone graft, and they
also allow the soft tissue to creep in. And then we have a
procedure that is called socket seal surgery. Socket seal surgery
is a procedure that has been around for a long time.
Cobi Landsberg published something on this, quite nicely,
and he’s using a free gingival graft to stabilize the bone
graft and the soft tissue.
BB: We’ve talked a lot about hard tissue grafting. What’s the
benefit of soft tissue grafting in implant cases?
SJ: What you are focusing on, Brad, is really soft tissue
esthetics and health. But you can see that there are a lot of
things which are happening to soft tissue before we really
get to it, when we are talking about bones, implants, abutments,
etc.
Why soft tissue grafting? Soft tissue grafting is important because
whenever we remove teeth, or whenever we lose teeth,
soft tissue dimension shrinks. So, we often go from gingival
thickness to something thin. And implants, they don’t have
that stability like a tooth has. What we try to do with soft
tissue grafting is to actually increase the thickness. So we
create a new gingival biotype, which is thicker. And what
does that do? This could prevent recession again, improve
esthetics because we won’t have that metal shadowing
through, and give a more natural look. So it is resistance
to recession, resistance to bone loss because the biological
width is more stable, and also it gives better soft tissue
esthetics and health.
BB: Over the last couple of years, there have been a lot of
lectures on connective tissue grafting, particularly in the
esthetic zone. What’s coming across is that labial bone loss is
inevitable, no matter what you do. Have you found that to be
the case? And then do you have to use connective tissue grafting
basically as a cosmetic Band-Aid? Or what’s been your experience
as far as maintaining that labial bone?
What we try to do with soft tissue
grafting is to actually increase the
thickness. So we create a new
gingival biotype, which is thicker.
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SJ: Connective tissue grafting leads into or follows up on
the question you just asked. Let me refer to a very nice
study that we published in 2009, where we looked at vertical
bone augmentation using the GBR principle. And what
we saw there, when we did a combo — a bone graft and
a connective tissue graft — is that we always had better
crestal bone stability.
So, you have to think about it. Soft tissue is very delicate,
so when you don’t have enough soft tissue, bone has a
tendency to shrink more, to lose a little bit more. What connective
tissue does is it, first of all, thickens the soft tissue.
It prevents bone from losing too much, so it kind of keeps
it in a healthy range. And, of course, it improves again the
end outcome, which is esthetics and health.
BB: Very good. Then, for a final question, is a temporary restoration
required for controlling the final soft tissue esthetics?
SJ: Yes, absolutely. This is a tough one because, obviously,
a lot of patients want to have a final restoration as fast as
possible. I always say to my patients that a temporary is like
a prototype. We need to shape and support the soft tissues
in such a way that we know that they’re stable. We don’t
want to have a situation where we now see recession. So,
potentially, we have a final crown in place and the tissues
are not there yet, the gingival papilla is not there yet, and
then we have recession again.
BB: To start wrapping things up, first I’d like to thank you for
taking the time to talk with me. We went through a lot in a
short period. If there are clinicians reading this who want to
get more education and training on different types of hard and
soft tissue grafting and esthetics, what would you recommend?
SJ: Well, our field is full of needs for training and education.
This is a great field. I’m very passionate about it. I love
this area and have been involved in it, thankfully, for more
than 20 years. If you want to get more involved with this
and get more training in soft tissue grafting, choose the
right partners for you. It could be one mentor whom you
trust, it could be an institute that you trust, it could be a university,
or it could be a mix of each. But go through training
and education as much as you can. Think about it like this:
For us, what’s most important is how much experience you
have. Then of course there’s skill. What’s your skill level?
Skill can improve and experience can improve. So, go for it;
find the right partner and learn as much as you can. I’m still
learning every single day.
We need to shape and support the
soft tissues in such a way that we
know that they’re stable.
So I would urge every single patient, especially in the
esthetic zone, to go through a temporary phase. And, again,
the same thing for the clinician; we need to have something
which gives us a better result. And the better result
definitely is there when we first do a prototype, create the
abutment correctly, create the emergence correctly, and
then let the soft tissue flow in. And this soft tissue growth
and stabilization around abutments and around temporaries
could go for more than 12 months. So make sure that you
leave the spaces in. Make sure that you have the abrasion
spaces into which soft tissues can flow. And don’t worry
about the black triangles right then because we have the
potential to regenerate soft tissues interproximally between
3 mm to 5 mm. But you have to give it time to fill in, and
that’s the temporary phase.
– Implant Q&A: An Interview with Dr. Sascha Jovanovic – 23

– www.inclusivemagazine.com –

Three-Dimensional Treatment Planning
with Surgical Guides and
Mini Implant-Retained Dentures
Go online for
in-depth content
by Paresh B. Patel, DDS
At no time in the history of dentistry has the
blending of new technologies and concepts
given rise to the sheer number of exciting possibilities we
face today. For example, implant dentistry has benefited
tremendously from the incorporation of 3-D Cone Beam
Computed Tomography (CBCT) and the ability to mill a surgical
placement guide. It is now possible to take a CBCT
scan and, from the resulting data, virtually place mini dental
implants in such a way as to maximize the available bone,
increase parallelism and avoid vital structures (Figs. 1a, 1b).
Planning a case in this virtual environment also reduces surgical
and healing time because it allows the doctor to safely
utilize a flapless procedure during the actual placement.
What’s more, this digital treatment plan can be performed
without requiring the doctor to leave his office. With a
PC and an Internet connection, he can work through all
details of the proposed treatment plan with a skilled digital
technician via Web conference. There is no learning curve
required to operate the software, as the assisting technician
handles this on the doctor’s behalf, repositioning implants
as directed with just a few mouse clicks. Adding this kind
of technology to your armamentarium will help ensure a
smooth surgical outcome and increase patient acceptance
of a prosthetically driven treatment plan.
Figures 1a, 1b: Digital treatment plan demonstrating virtual placement of
mini implants
It is now possible to take a CBCT scan and, from the resulting data,
virtually place mini dental implants in such a way as to maximize the
available bone, increase parallelism and avoid vital structures.
– Three-Dimensional Treatment Planning with Surgical Guides and Mini Implant-Retained Dentures – 25

Figures 2a, 2b: The patient’s edentulous maxilla and mandible
Ridges for which mini implants
are ideally suited often leaves
them supported on both sides by
high-density cortical plate.
Figure 3: Preoperative panoramic X-ray revealing bilateral pneumatization of
the maxillary sinus
Mini implants have been used successfully to improve the
retention of dentures. 1 With the average age of our population
increasing as people continue to live longer, the need
to improve patients’ lives with secure full dentures is growing.
2 Many edentulous patients present with inadequate
bone width for the placement of traditional implants, which
can require 6 mm of bone or more in the buccal-lingual
dimension. To reach the necessary bone width, these patients
would have to undergo expensive, time-consuming
bone grafting procedures. Even if grafting is not required,
many elderly patients are dissuaded by the cost and trauma
associated with implant surgery. A mini implant, however,
can be placed in as little as 3 mm of buccal-lingual bone
width. The single-stage placement protocol is simpler and
less traumatic. Fewer office visits are required because mini
implants allow for immediate loading in the presence of primary
stability, which is facilitated by an auto-advancing design
that compresses and condenses the surrounding bone
rather than drilling it away. In addition, the narrow ridges
for which mini implants are ideally suited often leaves them
supported on both sides by high-density cortical plate. In
terms of affordability, these smaller implants provide a costeffective
solution that enables more patients to move forward
with implant therapy, due to the reduced number of
parts needed in the surgical and the laboratory phases. 3
CASE REPORT
The patient in this case, a 55-year-old female, had had all
her remaining maxillary and mandibular teeth extracted 11
months prior (Figs. 2a, 2b). At that time, she had received
conventional maxillary and mandibular dentures. Her chief
complaint was that these dentures were nonretentive and
nonfunctional, becoming dislodged or falling out whenever
she ate or spoke. Although the extractions were recent and
she was not a denture wearer for a considerable amount of
time, there was already excessive resorption noted in the
mandible. Radiographically, bilateral pneumatization of the
maxillary sinus was also noted (Fig. 3).
Prior to obtaining a CT scan, reline impressions were taken
with Impregum brand impression material (3M ESPE; St.
Paul, Minn.), and the dentures were sent to Glidewell Laboratories
(Newport Beach, Calif.) (Figs. 4a, 4b). From that set
of impressions, upper and lower dual-scan appliances were
fabricated (Figs. 5a, 5b). It is important to note here that the
accuracy of each surgical guide depends greatly on the accuracy
of the impression taken for each scan appliance. Any
reduction in movement of the surgical guide will increase
the accuracy and likely success of the final implant placement.
Using the GXCB-500 powered by i-CAT ® (Gendex
Dental Systems; Des Plaines, Ill.), three CT scans were taken
— one of the patient with the scan appliances in the mouth,
and one of each scan appliance by itself. From these scans,
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The accuracy of each surgical guide depends greatly on the
accuracy of the impression taken for each scan appliance.
Figures 4a, 4b: Maxillary and mandibular reline impressions
Figures 5a, 5b: Upper and lower arch dual-scan appliances fabricated at
Glidewell Laboratories
the Inclusive ® Mini Implants (Glidewell Laboratories) selected
for this procedure could be virtually placed utilizing Blue
Sky Plan ® software (Blue Sky Bio; Grayslake, Ill.).
Next, a Web conference was scheduled with the Inclusive
Digital Treatment Planning team. At the time of the actual
conference session, the restoratively driven treatment plan
was mostly complete. Vital structures, placement paths and
parallelism of the implants had already been identified. The
Digital Treatment Planning team saves the doctor valuable
time by completing most of the tedious tasks in advance. In
this case, I confirmed the final implant positions and, with
the approved plan, the surgical guides were milled.
For the retention of a maxillary overdenture, it is recommended
that six mini implants be placed in the premaxillary
region. To retain a mandibular overdenture, no fewer
than four mini implants should be placed anterior to the
mental foramina. 4 The smaller number of implants required
in the mandible is due to the increased bone density
It is recommended that
six mini implants be placed in
the premaxillary region. To retain
a mandibular overdenture,
no fewer than four mini implants
should be placed anterior to
the mental foramina.
– 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
tissue anomalies can be factored into the digital treatment plan.
Figure 6: Maxillary surgical guide in place
Figure 8: First Inclusive Mini Implant hand-tightened into place
Figure 7: A 1.5 mm diameter pilot drill used to depth
Figure 9: Inclusive Mini Implants rotated to depth using the Inclusive Mini
Implant Handpiece Driver
compared to that found in the maxilla. In this case, it was
decided that 1.5 mm diameter guide sleeves would be used
for the 2.2 mm diameter Inclusive Mini Implants to be
placed in the mandible. Due to the softer bone of the maxilla,
it was decided that 1.5 mm sleeves would also be used
for the thicker, 2.5 mm diameter Inclusive Mini Implants
placed there. In denser bone, I would have asked for 1.7
mm diameter sleeves for use in the maxilla.
Even though the placement of mini dental implants is relatively
simple and straightforward, a common argument
against placing them is that the surgery is performed “blind.” 5
Critics contend that by not raising a flap, as is the recommended
protocol when placing mini implants, the doctor
cannot accurately gauge the proper insertion path. With a
CT scan, however, all of the patient’s anatomy and soft tissue
anomalies can be factored into the digital treatment plan.
This digital treatment plan is not merely a “best guess”; rather,
it provides a true representation of the anticipated clinical
outcome. The surgical guide used to translate the virtual
outcome to a physical outcome is precisely fabricated by a
computer-controlled milling station, and the guide sleeves
are placed to tight tolerances. As a result, the opportunity for
error during placement is significantly reduced.
The patient was draped, and a clean operating environment
was established. A preoperative rinse with Peridex
(3M ESPE) was performed prior to local infiltration with
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Cook-Waite Lidocaine ® HCI 2% and Epinephrine 1:100,000
(Kodak Dental Systems; Rochester, N.Y.). The upper surgical
guide was inserted and stabilized by both the doctor
and assistant (Fig. 6). Once a confirmed fit was verified, the
1.5 mm diameter pilot drill was introduced into the guide
sleeve (Fig. 7). The guide sleeve orients the pilot drill in the
correct trajectory. The top of the sleeves are set at 9 mm
from the top of the implant, and this vertical distance must
be accounted for when determining proper drill depth. The
recommended procedure for unguided site preparation is
to drill to a depth that is approximately one-half the length
of the implant, plus the tissue depth. In this case, the six
mini implants to be placed in the maxilla were each 10 mm
in length, so half of that length (5 mm) plus the tissue depth
(approximately 2 mm) accounted for 7 mm of drill depth.
Adding the 9 mm length for the guide sleeves necessitated
an overall drill depth of 16 mm. Each Cortical Bone Drill
included with the Inclusive Mini Implant System has depth
markings at 10 mm, 13 mm and 15 mm, so drilling to 16 mm
meant drilling just past the last mark on the drill.
The drilling process was conducted at 1250 RPM under
copious irrigation using the MD 20 Dual Motor System
(Nouvag USA; Lake Hughes, Calif.). For the best chance of
long-term implant success, it is important to minimize tissue
damage and thermal trauma to the bone. 6 Because Inclusive
Mini Implants are self-tapping, only a single pilot drill is
required; no additional finishing bits or bone formers are
needed. The implant will follow the path created by the
pilot drill and compress and condense the bone to help
achieve immediate primary stability. In certain cases, it is
possible to engage both cortical plates for even greater stability.
All six pilot holes were made following the same process,
and the surgical guide was removed. A periodontal
probe was used to confirm that all pilot holes in the cortical
bone did not perforate in the buccal-lingual dimension.
Figure 10: Pilot drill engaged in the mandibular surgical guide
The implant will follow
the path created by
the pilot drill and
compress and condense
the bone to help
achieve immediate
primary stability.
One at a time, the Inclusive Mini Implants were removed
from their sterile packs and glass vials and hand-tightened
with the attached carrier until they were difficult to turn
(Fig. 8). The Handpiece Mini Implant Driver attachment
was then used to gently rotate each mini implant to depth
(Fig. 9). Final seating was verified at 35 Ncm using the
Torque/Ratchet Wrench included in the Inclusive Surgical
Instrumentation Kit.
The same process was repeated for the mandible using the
lower surgical guide (Fig. 10). In this case, the Inclusive Mini
Implants were 13 mm in length, so the pilot drill was taken
to a depth of approximately 18 mm, or almost to the hub.
The overall length of the pilot drill from cutting tip to shank
is approximately 20 mm. Once again, final seating was verified
at 35 Ncm to ensure primary stability (Fig. 11).
Figure 11: Final placement of four Inclusive Mini Implants in the mandible
– Three-Dimensional Treatment Planning with Surgical Guides and Mini Implant-Retained Dentures – 29

Following successful placement of all mini implants, Blu-
Bite HP bite registration material (Henry Schein; Melville,
N.Y.) was injected onto the intaglio surface of the dentures
to help indicate where the dentures would need to be relieved
to allow for passive fit over the mini implant heads
(Figs. 12a, 12b). An NTI ® Universal Cutter pear-shaped bur
(Axis Dental; Coppell, Texas) was used to help create the
appropriate-shaped spaces (Figs. 13a–13d). The acrylic bur
is 2.9 mm wide and cuts a hole that is just the right size
for the O-ball head of the mini implant. With a few circular
strokes, you can easily widen the hole to accommodate the
full O-ring Housing, which is approximately 3.5 mm tall
and 4.75 mm wide.
Once the majority of acrylic was removed, Dr. Thompson’s
Color Transfer Applicators (Great Plains Dental Products;
Kingman, Kan.) were used to mark the tops of the O-balls.
Any marks that transferred to the dentures indicated additional
acrylic that had to be removed to ensure a completely
passive fit (Figs. 14a, 14b).
A soft reline was performed chairside using COE-SOFT reline
material (GC America; Alsip, Ill.) to stabilize the existing
denture during the healing phase. This gives the mini implants
a chance to osseointegrate fully before more stressful
loads are placed upon them. In a few weeks, a new set
of Inclusive Mini Implant Overdentures will be fabricated,
Figures 12a, 12b: Bite registration material injected onto the intaglio surface of the dentures
Figures 13a–13d: Pear-shaped acrylic bur used to relieve the dentures
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with the O-ring Housings built in. Had the patient been satisfied
with the esthetics of her existing mandibular denture,
we could have performed a chairside pickup of the O-rings
during the same visit, using a hard reline material like Triad
DuaLine (Dentsply; York, Pa.). With regard to the maxillary
denture, it is preferable to perform a soft reline in order to
assure proper osseointegration. Even so, this should take a
matter of weeks, rather than months, as in the case of most
traditional implants.
A postoperative CT scan was then taken. The cross-sectional
slices demonstrate the implants in almost the exact positions
proposed by our digital treatment plan. They confirm
our preoperative goals of taking full advantage of the available
bone while keeping the implants as parallel as possible
(Fig. 15). Had we attempted this case without the use of a
digitally milled surgical guide, these goals would have been
far more difficult to achieve.
Conclusion
The Inclusive Mini Implant System, particularly when used
in concert with Digital Treatment Planning services, represents
an ideal opportunity for general practitioners to
become involved in implant dentistry. In today’s repressed
economy, offering this kind of valuable, inexpensive treatment
enables cost-conscious patients to enjoy the many
benefits of secure, retentive dentures. The use of CBCT, digital
planning and surgical guides helps to reduce clinician
stress, save chairtime and ensure a predictable outcome.
The flapless technique allows for minimal patient discomfort
and a greater chance for immediate loading — aspects
that improve overall client satisfaction. These simplified
protocols and conservative procedures are made possible
by integrating advanced technology and new materials into
everyday implant dentistry.
Figures 14a, 14b: Color transfer process used to verify passive fit over the
implant heads
The use of CBCT, digital
planning and surgical guides
helps to reduce clinician stress,
save chairtime and ensure a
predictable outcome.
References
1. Misch K, Neiva R. Small-diameter implants for optimal stabilization of implantsupported
overdentures. Pract Proced Aesthet Dent. 2007 Aug;19(7):428–31.
2. U.S. Census Bureau, Population Division, Population Projections Branch.
National population projections I: summary files. Total population by age, sex, race,
and Hispanic origin. Available at: www.census.gov/population/www/projections/
natsum-T3.html.
3. Clinical Research Associates. Small-diameter ‘mini’ implants — user status report.
CRA Newsletter. 2007;31:1–2.
4. Bulard RA, Vance JB. Multi-clinic evaluation using mini-dental implants for
long-term denture stabilization: a preliminary biometric evaluation. Compend Contin
Educ Dent. 2005 Dec;26(12):892–97.
5. Flanagan D. Flapless dental implant placement. J Oral Implantol. 2007;33(2):75–83.
6. Sharawy M, Misch CE, Weller N, et al. Heat generation during implant drilling:
significance of motor speed. I Oral Maxillofac Surg. 2002 Oct;60:1160–69.
Figure 15: Postoperative CT scan showing parallelism of the maxillary and
mandibular implants
– Three-Dimensional Treatment Planning with Surgical Guides and Mini Implant-Retained Dentures – 31

Clinical Tip:
Dental Photography
as a Laboratory
Communication Tool
Go online for
in-depth content
by Bradley C. Bockhorst, DMD
Patient photographs are one of the most useful tools available to a clinician when working up a case and
communicating with the laboratory, and they can be especially helpful when treating edentulous cases. For a
trial denture setup, tooth arrangement, shade, midline, vertical dimension of occlusion and closest speaking space can be
evaluated. When deciding between an overdenture and a screw-retained denture, a trial denture without a labial flange can
be used to evaluate the transition line in relation to the smile line and midface support. Including photographs with your
lab prescription can prove invaluable in helping the technician achieve your desired treatment goals.
The images that follow illustrate this technique. Like the old axiom states: A picture can say a thousand words!
Figure 1a: With the patient’s lips closed, measure
the vertical dimension of occlusion. Then ask the
patient to swallow and let his or her lower jaw relax
to evaluate the vertical dimension at rest.
Figure 1b: With the patient’s lips slightly open, evaluate
the incisal edge position and closest speaking
space by asking the patient to pronounce “f,” “ch”
and “s” sounds.
A trial denture
without a labial
flange can
be used to
evaluate the
transition line
in relation to
the smile line
and midface
support.
Figure 2a: Smile line
Figure 2b: High smile line
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Figure 3a: Smile line without prosthesis
Figure 4a: Profile with labial flange
Figure 3b: High smile line without prosthesis.
NOTE: The maxillary ridge can be seen.
Figure 4b: Profile without labial flange
Including
photographs
with your lab
prescription
can prove
invaluable in
helping the
technician
achieve your
desired
treatment
goals.
Figure 5a: Evaluating the incisal horizontal plane
in relation to the interpupillary line
Figure 5b: Evaluating the midline
– Clinical Tip: Dental Photography as a Laboratory Communication Tool – 33

800-854-0970

www.glidewellce.com

Welcome to the Glidewell International Technology Center.
The opening of this educational center marks another milestone
for Glidewell Laboratories. It signifies the efforts of so
many, and highlights our continued evolution over more than
40 years of growth.
We have become a hybrid organization, crossing the traditional
boundaries of dental technology with the digital manufacture
of our restorations, while also fabricating the raw materials,
components and systems that comprise those restorations.
Whether you look at our development of intraoral scanners,
the design and manufacture of implants, abutments and
related components, or the various materials like BruxZir ® and
our forthcoming product Obsidian , we seem to be blazing a
new trail. Why? the others ask. Why won’t Glidewell just follow
everyone else and stick to making standard restorations?
Well, I could provide a number of reasons. Chief among them is the pursuit of knowledge. In our
40-plus years, we have assimilated a wealth of it. You will find that we are unique. We understand
the needs of both the patient and the clinician. We work with dentists every day to solve difficult
cases that demand innovative restorative solutions. From that, we continue to develop a vast array
of products that meet those needs.
Our goal with this technology center is to emulate the efforts of world-class dental education facilities
like the Pankey Institute and the Scottsdale Center, while focusing our offerings on practical,
innovative solutions to everyday clinical challenges. This is not merely an implant sales facility, a
materials-selling operation, or a means to highlight intraoral scanning and its digital progeny. Rather,
it is our intent to share and advance the widespread knowledge of these and other advanced technologies
and techniques for the fundamental purpose of making a positive difference in the lives of
our patients and those of us who serve them.
This center recognizes the extreme complexity of oral rehabilitation and the need for many different
treatment modalities. It will have at its core an emphasis on all things digital: digital scanning, digital
treatment planning, digitally processed surgical guides, digitally manufactured implant components
and restorations, and the digital manufacture of final crown & bridge restorations — along with the
digital compilation of all treatment data, with archive retrieval at one’s fingertips. This new digital era
allows us to bring about more predictable results, increase the consistency and quality of restorations,
and help improve the oral health of many who are now suffering.
Whatever the direction these emerging technologies take, rest assured that we will be here to
study them together. We may not have quite the square footage as some of the other well-known
educational centers, but we intend to make every bit as big an impact on the industry. From this
location, we aim to provide measurable, patient-related results that will do nothing less than change
the direction of dentistry worldwide. We must believe that what we are doing is that important,
because success starts with vision and requires a lot of hard work.
James R. Glidewell, CDT
President, CEO

GLIDEWELL
INTERNATIONAL TECHNOLOGY CENTER
Enjoy presentations on the most advanced dental technologies and techniques
presented in multimedia format in our 40-seat interactive classroom auditorium.
Observe live surgical and prosthetic procedures
in our fully functional operatory and surgical
suite featuring state-of-the-art dental equipment,
including a PreXion 3D Cone Beam CT scanner.

Sign up for a course today!
Take part in intensive hands-on
surgical and prosthetic workshops
exploring the latest techniques
taught by experienced
clinicians and technicians.
Learn what’s new in virtual design and CAD/CAM technology, and
how to smoothly integrate these innovations into your practice.

Date Course Name Instructor Course # Tuition
August
3 Ten Keys for Grafting Success Dr. Sascha Jovanovic B111-110803 $49
4
To See, or Not to See, That Is the Question:
Exploring Relationships of CBCT Liability,
Accurate Diagnosis and Image Resolution
(sponsored by PreXion)
Dr. Sanjay Mallya A116-110804 $49
12 The Modern Restorative Practice Dr. Michael DiTolla C110-110812 $99
19
20
15
23
9/30–10/1
Rehabilitating the Atrophic Edentulous
Patient Using Small-Diameter Implants
Rehabilitating the Atrophic Edentulous
Patient Using Small-Diameter Implants
State-of-the-Art Impressions
and Digital Restorative Dentistry
Using the IOS FastScan ® System
The Fundamentals of Oral
Appliance Therapy for Sleep Apnea
Medical Billing for the Comprehensive
Dental and Surgical Practice
September
October
Dr. Paresh Patel B112-110819 $395
Dr. Paresh Patel B113-110820 $395
Dr. Michael DiTolla A118-110915 $49
Dr. Todd Morgan E110-110923 $299
Dr. Olya Zahrebelny D111-110930 $900/$750
7 The Modern Restorative Practice Dr. Michael DiTolla C111-111007 $99
8
The Use of CAD/CAM for
Custom Abutments for Technicians
Alec Di Lullo/
Shawn Ramirez
G110-111008 $99
14–15
Treating the Edentulous Patient: The Quest
for Beauty and Functional Excellence (Part 1)
Dr. Burton Melton C112-111014 $300
19 Implant Surgery for the Dental Assistant TBD F110-111019 $49
November
3 PreXion (course specifics coming soon) TBD A119-111103 TBD
10
11–12
State-of-the-Art Impressions
and Digital Restorative Dentistry
Using the IOS FastScan ® System
Treating the Edentulous Patient: The Quest for
Beauty and Functional Excellence (Part 2)
Dr. Michael DiTolla A120-111110 $49
Dr. Burton Melton C113-111111 $300
18 Digital Implant Treatment Planning Workshop Dr. Bradley Bockhorst B114-111118 $49
December
2
3
Rehabilitating the Atrophic Edentulous
Patient Using Small-Diameter Implants
Rehabilitating the Atrophic Edentulous
Patient Using Small-Diameter Implants
Dr. Paresh Patel B115-111202 $395
Dr. Paresh Patel B116-111203 $395
Please visit www.glidewellce.com for the most up-to-date course details and to register.

A New Generation of Denture Teeth
The Perfect Route to
Esthetic and Functional Dentures
PRODUCT
SPOTLIGHT
by Thorsten Michel, MDT
Introduction
When fabricating removable dentures, finding suitable anterior teeth that provide the
superior esthetics very discerning patients demand can prove challenging. To meet the
requirements of an individual case, prefabricated denture teeth must very often be modified
to incorporate age- and indication-related characteristics. This challenge led me to look for
a solution to this problem. The purpose of this article is to summarize my experience with,
and provide insight into, the development process that led to the creation of SR Phonares ®
denture teeth from Ivoclar Vivadent.
Figures 1, 2: Outstanding overall esthetics of the anterior teeth
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Discussion
Figure 3: Natural facial design
Figure 4: Natural palatal design
Starting the process involved modeling upper
and lower tooth molds that were a reflection
of their natural counterparts. These molds
featured all the special characteristics missing
from existing prefabricated denture teeth
(Figs. 1, 2). It is the first impression, the overall
esthetic appearance that is conveyed in the first
few seconds in which a tooth is viewed, that
counts. These first few seconds are of crucial
importance because this is the time it takes
someone to decide whether the tooth lives
up to his or her expectations. In order to
achieve a natural esthetic outcome, lifelike
tooth molds with facial and palatal surfaces that
feature a truly anatomical design and impart
an impression of natural dentition are essential
(Figs. 3–6).
The objective in modeling esthetic tooth molds
is to achieve a vibrant but not overly exaggerated
facial texture and a practical palatal and
lingual design, which supports clear speech and
phonetics rather than hampering it. In addition,
anterior teeth that have a harmonious, layered
Figure 5: Example of a naturally designed palatal aspect
Figure 6: Silver powder discloses details of the exemplary palatal design.
In order to achieve a
natural esthetic
outcome, lifelike tooth
molds with facial and
palatal surfaces that
feature a truly
anatomical design and
impart an impression
of natural dentition
are essential.
– A New Generation of Denture Teeth: The Perfect Route to Esthetic and Functional Dentures – 37

Another important
aspect is to have a
comprehensive range
of molds from which
to choose … This led to
the development of
age-related tooth molds.
design and selectively incorporated opalescent
and translucent areas, which impart a lifelike
appearance, are preferred (Figs. 7, 8).
Figure 7: Example of a harmonious layering and a natural-looking opalescent
effect
Another important aspect is to have a comprehensive
range of molds from which to choose.
To meet this requirement, I incorporated several
tooth characteristics that can also be found
in nature. This led to the development of agerelated
tooth molds, which take into account
the needs of patients at different stages in life.
This allows for the selection of tooth molds
based on an individual patient’s age.
There are three simple steps for choosing
suitable tooth molds. First, the basic shape is
selected, based on whether the teeth should
have a more youthful or distinctive look. Then
the desired degree of wear is chosen. In this
respect, both the incisal and facial curvature are
of importance. While teeth with more rounded
incisal edges and a pronounced facial curvature
are designed for use in young patients (Fig. 9),
those with more heavily abraded incisal edges
and a flatter facial curvature are suitable for patients
in the more advanced age group (Fig. 10).
These features are based on the natural aging
process that occurs in the oral cavity over time.
In the third and last step, the size or dimension
of each tooth is determined using a diagnostic
cast of the case. For this purpose, the teeth
are classified into “small,” “medium” and “large”
categories. Tooth molds for smaller and larger
alveolar ridges are available.
Figure 8: The vibrant facial texture meets the highest esthetic demands
Figure 9: A rounded tooth shape and lighter shades for younger patients
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Removable dentures should
provide optimum “white
esthetics.” This is especially
true for implant-borne
removable dentures.
Figure 10: More distinctive tooth molds and darker shades for patients in the
more advanced age group
In a time when the focus is on esthetic dentistry, removable
dentures should provide optimum “white esthetics”
(Fig. 11). This is especially true for implant-borne
removable dentures because all parties involved (i.e., the
patient, clinician and dental lab technician) place high
expectations on the esthetic outcome and function of
this complex and expensive type of restoration.
In order to achieve ideal “white esthetics,” the interproximal
contours of anterior teeth should allow for the teeth
to be lined up very closely without creating the impression
of a “white wall.” The proximal “Set & Fit” design
of SR Phonares denture teeth allows teeth to be set up
in diverse positions, without producing open gingival
embrasures, or “black triangles,” that then need to be
filled with denture base material. Even when dealing
with highly rotated teeth, a natural-looking tooth setup
can be accomplished (Fig. 12).
Creating a soft transition between the clinical crown
and the tooth neck section optimizes the esthetics, as it
facilitates modeling of the gingival contours. Placing a
wax layer that tapers toward the cervical portion of the
clinical crown creates the impression of naturally grown
gingival tissue.
To effectively cover a frame and implant abutments, a
cervical design that accommodates implant abutments
with an emergence profile of approximately 5 mm in
diameter was also created. In most cases, no adjustments
with tooth-colored material are required in the proximal
anterior regions.
Figure 11: Unparalleled “white esthetics”
The proximal “Set & Fit”
design of SR Phonares
denture teeth allows teeth
to be set up in diverse
positions, without producing
open gingival embrasures,
or “black triangles.”
Figure 12: Ideal proximal closure due to “Set & Fit” design
– A New Generation of Denture Teeth: The Perfect Route to Esthetic and Functional Dentures – 39

In addition to their advanced anterior tooth design, SR
Phonares denture teeth are characterized by extraordinarily
high wear resistance, thanks to their Nano Hybrid
Composite (NHC) material composition. Due to the
fact that implants are firmly anchored to the alveolar
bone, materials of extremely high strength are required
in the fabrication of implant-borne removable dentures.
As these dentures are not supported by soft tissue,
masticatory forces are transferred completely to the materials
used in the restorative process, which exposes
them to very high levels of stress. SR Phonares NHC
anterior tooth molds are not exclusively indicated for
implant-borne dentures, however. They are perfectly
suited for complete and partial denture prosthetics.
SR Phonares Denture Teeth
Q&A
Courtesy of Dr. Frank Lauciello, Ivoclar Vivadent
SR Phonares denture
teeth are characterized
by extraordinarily high
wear resistance, thanks
to their Nano Hybrid
Composite (NHC)
material composition.
Conclusion
Ivoclar Vivadent’s SR Phonares denture teeth closely replicate
the shape and surface texture of natural dentition.
The teeth feature a harmonious four-layer design and
exhibit natural opalescence and fluorescence. Their new
NHC material has been proven to provide high durability
and excellent resistance to wear and plaque accretion.
SR Phonares denture teeth also feature a well-balanced
labial and palatal design. Due to their specially designed
interdental closures, a natural-looking appearance of the
denture can be achieved with ease. These denture teeth
allow the dental technician to achieve precise, highquality
results with minimal effort or difficulty.
Q: Why did Ivoclar develop SR
Phonares denture teeth?
A: SR Phonares NHC denture teeth were developed
in response to market demands for higher
esthetics and wear resistance in complete, partial
and implant-retained denture prostheses.
500
450
400
350
300
250
200
150
100
50
0
In vitro wear study of denture tooth materials
Pin-on-block with steatite antagonist, after 120,000 cycles
NHC material
SR
Phonares
Isosit
Highly crosslinked
PMMA
Cross-linked
PMMA
Source: Dr. Dipl. Ing. (FH) Martin Rosentritt, 08/2009, University of Regensburg.
Q: What are the benefits of a
composite tooth?
A: Ivoclar Vivadent spent several years developing
its Nano Hybrid Composite, a unique material
that yields true-to-nature esthetics and
increased wear resistance over conventional
resin materials. This new technology provides
the opportunity for clinicians and technologists
to prescribe and create truly esthetic
removable restorations with long-term results.
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SOFT
PMMA Clusters
BOLD
YOUTHFUL
UNIVERSAL
Q: How does this new
generation of Nano Hybrid
Composite bond to resin
denture base materials?
A: The unique properties of the NHC material
yield good bonding results. The
NHC material has inclusions of PMMA
(polymethylmethacrylate) material that
promotes bond strength and durability.
The highest bond strengths have been
recorded when processed with the SR
Ivocap Injection System.
MATURE
SR Phonares denture teeth are available
as a premium option on all conventional
dentures, partials, overdentures and
screw-retained dentures from Glidewell
Laboratories (Newport Beach, Calif.).
Q: How were the molds
developed?
A: Like the NHC material, the SR Phonares
anterior molds were a new development.
Each mold was artfully designed
to express individual patient characteristics
(“soft” or “bold”) and age (“youthful,”
“universal” or “mature”).
– A New Generation of Denture Teeth: The Perfect Route to Esthetic and Functional Dentures – 41

Ensuring a Successful Restorative Outcome
Utilizing BioTemps ® Implant Provisionals
Go online for
in-depth content
by Ara Nazarian DDS, DICOI
Although widely utilized in conventional crown & bridge applications, provisional restorations have traditionally
been underused in implant therapy. Time-intensive surgical procedures may make the dentist and
patient reluctant to dedicate additional chairtime to the proper fabrication of a “mere temporary.” This unfortunate attitude
often ends up costing even more time and expense at subsequent appointments, and can cause the overall quality of the
final restoration to suffer. A properly planned provisional can serve a variety of functions critical to the long-term success
of an implant case. With the convenience and affordability of provisional splinted crowns and full-arch bridges such as
BioTemps ® Implant Provisionals (Glidewell Laboratories; Newport Beach, Calif.), clinicians owe it to their patients to
educate them regarding the multiple benefits of incorporating a provisional solution in the overall treatment plan.
Provisional restorations may be fixed or removable and are made from a variety of materials. The most common forms of
temporary restorations are fixed bridges supported by retained natural teeth, resin-bonded bridges and removable temporary
partials, or flippers. BioTemps represent a fixed solution because they can be cemented or screw-retained. The decision
to use a provisional restoration and which type to use depends greatly on the patient’s specific needs and preferences. At
its simplest, a provisional serves as the interim prosthesis while implants heal and a definitive restoration is fabricated. But
if its effectiveness is maximized, a provisional restorative prosthesis provides four principal benefits:
1. Protects the underlying implants or bone-grafted sites from direct occlusal loads
The long-term success of any implant-borne restoration depends heavily on the integration of the supporting implant.
A proper provisional must therefore protect the surgical site from occlusal forces during the healing process, preventing
micro-movement of the implant and any associated bone grafts. BioTemps are designed to seat passively over healing areas,
shielding them from stresses that might adversely affect osseointegration. When a pontic span exceeds three units, a cast-metal
substructure is indicated, giving the provisional additional strength. Wire or Kevlar ® fiber reinforcement (DuPont; Wilmington,
Del.) is also available.
2. Protects the underlying gingival tissues
Along with preserving bone health, a provisional must protect its underlying gingival tissues. BioTemps not only preserve
tissue, but they can also be used to shape the associated soft tissue during the maturation phase. They have been shown to
promote contoured healing for ovate pontics or anterior extractions, and can help shape the sulcus around implants. The
ability to manage and sculpt the surrounding soft tissue leads to greater predictability in the seating of the final prosthesis.
This is particularly helpful in the esthetic zone, where elements such as gingival margins and contours, papilla, and final
emergence profile play a key role in replicating the proper morphology of natural dentition.
3. Determines the future position, support, shape and shade of the final prosthesis
Beyond helping to establish the health and shape of the supportive tissues, a provisional restoration can act as the
blueprint for the final prosthesis. The restorative dentist is therefore able to obtain a hands-on feel for the eventual
solution using a working prototype in the actual oral environment. Every aspect of form, fit and function can be
evaluated. As an example, screw-retained BioTemps over implants can help create a predictable path of insertion, on
which many other elements are based. And it’s not just the dentist who will appreciate this “trial run.” By experiencing his
– Ensuring a Successful Restorative Outcome Utilizing BioTemps Implant Provisionals – 43

or her restoration on an interim basis, the patient is
given a chance to assess it before undergoing placement
of the definitive prosthesis. If either dentist or patient
is dissatisfied with the provisional in any way, the
appropriate adjustments can be made. Once approved,
dimensions and morphology can be precisely transferred
to the laboratory via impression for use in the fabrication
of the final restoration, increasing the likelihood of patient
acceptance during that final visit.
4. Restores and enhances esthetics and phonetics
Patient acceptance of any prosthesis is generally determined
by both esthetics and function. If the prosthesis is
unesthetic, inhibits accustomed phonetics, or otherwise
fails to function in accordance with the patient’s expectations,
then he or she is likely to experience dissatisfaction.
There is little excuse for this in an implant case, where
the restoration is designed “from the ground up” and is
therefore less likely to face the constraints of preexisting
structures. Natural or wear-related imperfections such as
diastemas or limited vertical dimension can be corrected
with the provisional just as they can with the final restoration.
Using a provisional to test and determine acceptable
morphology enables the dentist and patient to verify overall
appearance and function. Once again, any required
adjustments can easily be made chairside to the provisional
and then reflected in the final restoration.
With all that provisionals can contribute, the question becomes,
why forego their inclusion in treatment planning
dental implants? One reason is that provisional restorations
are often left until the end of an appointment, when time
is limited. But time spent in their construction is more than
repaid in time saved doing additional procedures, adjustments
and remakes in the future. This is especially true of a
provisional like BioTemps, which can be prefabricated from
an impression or preoperative model and delivered prior to
surgery for a simple, efficient chairside reline.
Another reason given for avoiding provisionals is the notion
that they are merely a short-term solution; however, implant
healing times can require weeks or months, particularly if
bone grafts are prescribed. Does the patient really wish to
tolerate inadequate esthetics or decreased function for this
prolonged period?
A third complaint is the associated expense of a provisional.
Given the high costs of many implant procedures, customers
may look to trim those costs wherever possible, and a
“disposable” temporary may appear to be a good place to
start. However, a patient concerned with the affordability of
a provisional should consider the affordability of not using
one. What are the possible costs of a treatment plan lacking
a suitable provisional aspect? BioTemps over implants are
reasonably priced and present an exceptional value to many
patients, once they understand the overall manner in which
these provisionals can contribute to the success of their case.
To maximize their effectiveness, provisional restorations
should be carefully planned prior to the surgical phase.
Various techniques are available to achieve optimal protection
and continued function without compromising
esthetics. Working together, the restorative dentist and the
laboratory should determine which techniques best fulfill
the specific requirements of each case. Proper management
will contribute to satisfying the patient’s expectations and
help ensure a successful final solution.
A well-designed provisional restoration is predicated upon
four key factors:
1. The ultimate restorative plan
The objective of an implant-supported prosthesis is to provide
a functional and cosmetically acceptable form of
tooth replacement. Every aspect of a provisional prosthesis
should contribute to the realization of this ultimate goal.
Anything that might counteract, marginalize or degrade
the quality of the definitive restoration should be avoided.
2.The number and location of the dental implants
Implants serve as the foundation for any implant-borne
restorative solution. Thus, any provisional must properly
consider the structural framework on which it will be laid.
For example, it was mentioned earlier that wire, fiber or
cast-metal reinforcement is recommended in BioTemps
provisional restorations with a pontic span greater than
three units. Occlusal forces and potential bone stress are
also critical factors that are deeply affected by the underlying
implant configuration.
3. The bone quality and quantity
Just as an implant-borne restoration is only as reliable
as the implants on which it is placed, the success of those
implants is only as reliable as the overall health of the
surrounding osseous tissue. Bone lacking in quality or
quantity may require special consideration such as severe
implant angulation or grafting procedures, which may in
turn dictate certain aspects of both the provisional and the
definitive restoration.
4. The needs and desires of the patient
The success of a restorative prosthesis relies heavily on the
perception of the receiving patient. An unhappy patient
makes for an unhappy dentist. While it is the dentist’s
responsibility to educate and advise the patient as to all
options and considerations related to the case, the obligation
to listen to and accept the patient’s stated goals and
preferences remains. This applies to all aspects of the treatment
plan, and the role of a provisional is no exception.
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CASE 1
The following case depicts the utilization of BioTemps as a full maxillary implant-supported,
screw-retained provisional restoration.
Figure 1: Preoperative smile view depicting unattractive smile
Figure 2: Preoperative occlusal view of maxillary arch
Figure 3: Occlusal view of healed maxillary arch after extractions
Figure 4: Atraumatic placement of eight dental implants
Figure 5: Screw-retained maxillary BioTemps placed and access holes covered
Figure 6: Postoperative smile using BioTemps Implant Provisionals
– Ensuring a Successful Restorative Outcome Utilizing BioTemps Implant Provisionals – 45

CASE 2
The following case depicts a cemented BioTemps provisional restoration.
Figure 1: Preoperative view of patient with missing lateral incisors
Figure 2: Implants prior to abutment preparation
Figure 3: Prepared natural central incisors and lateral implant abutments
Figure 4: Relined BioTemps provisional restoration in place
Conclusion
BioTemps Implant Provisionals can play a valuable role in managing clinical situations to ensure success with the final
prosthesis. They can be used to evaluate esthetic, phonetic and occlusal function prior to delivery of the final implant restorations,
while preserving or enhancing the condition of the peri-implant and gingival tissues. They provide patients with
natural-looking temporaries at any stage of implant treatment, and serve as an excellent prototype by which to evaluate
shade and contours, leading to greater patient acceptance and a superior definitive restoration. They are also useful as a
communication tool between members of the treatment team, which in many cases consists of the restorative clinician,
implant surgeons, dental laboratory technicians and the patient. Clinicians should be aware of the different types of provisional
restorations and their indications for use when planning implant-retained restorations. If planned and fabricated
properly, this temporary prosthesis can become an integral part of the overall restorative solution.
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Preserving the Integrity
of Facial Structures with
Implant-Retained Overdentures
Go online for
in-depth content
by Timothy F. Kosinski, DDS, MAGD
The Centers for Disease Control and Prevention
(CDC) has reported that by age 50, Americans
have lost an average of 12 teeth and, among adults aged
65 to 74 years, 26 percent are completely edentulous. Care of
the edentulous patient has been changed by the emergence of
implant-supported restorations, which are a viable alternative
to traditional denture fabrication. However, there are still many
general practitioners who have not committed to making dental
implant treatment a significant part of their practice. They may
let potential drawbacks such as surgical or prosthetic training,
perceived cost, concern about the profitability of implant cases,
or lack of insurance coverage stand in their way of providing
innovative and successful dental implant treatment services to
their patients.
Implant manufacturers and dental laboratories such as Glidewell
Laboratories (Newport Beach, Calif.) are presenting product
innovations that have made implant dentistry simpler for dentists
restoring implants and easier for patients receiving implant
therapy. Implant placement and immediate implant function
have become popular as long as there is an absence of infection,
and adequate bone quantity and quality. These innovations
make implant dentistry more attractive to both patients and the
restorative dentist.
As clinicians, it is imperative that we educate and counsel our
patients as to the benefits of quality care irrespective of insurance
benefits or financial limitations. A patient should be made
aware of all available options without tailoring discussion solely
to his or her dental insurance benefits. We should encourage
the best overall care plan and provide alternatives to treatment
in order of most effective to least effective, including no treatment
at all.
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Many people are unaware of the relationship between their teeth and the bone that supports them. Along with
the maxillary and mandibular bone, teeth provide the support for facial contours. Changes in these structures,
then, will cause changes in facial features. The loss of teeth can result in wrinkles around the mouth and lips
and the collapse of facial structures, causing an overall “caved-in” appearance. When teeth are absent over a
prolonged period of time, the bone that supported these teeth will gradually resorb. Dental implants can preserve
the integrity of facial structures by minimizing this bone resorption. The implants act like natural teeth in
that they provide stress to the bone, which helps stimulate blood flow and maintain the existing bone contours.
Dental implants are thus used to create a more stable foundation for replacement teeth, whether they are used
under removable or fixed appliances.
Maintaining the natural appearance of the face and smile can be challenging, but dental implants have proven
to be an excellent starting point compared to conventional complete dentures. For one, the generation of baby
boomers does not like to look and feel old. When the corners of the mouth droop, wrinkles appear around the
lips and the distance between the nose and chin decreases, esthetics are compromised. Second, even well-fitting
dentures result in a decrease in natural chewing function, which may in turn lead to digestive issues resulting in
a myriad of potential health issues. Third, while conventional dentures do serve the basic purpose of replacing
missing teeth and providing structural support to the lips, they may actually accelerate the resorption process
by pressing down on the gingiva and underlying bone as the wearer eats. Regardless, the inevitable, continued
bone loss will cause the facial structures to further collapse over time, necessitating prosthetic relines to compensate
for the physical changes.
This article aims to demonstrate just a few of the prosthetic options available today in restoring form and
function using dental implant-retained overdentures. Our hope with these designs is to dramatically enhance
our patients’ quality of life by achieving one or more of the following goals: to preserve the integrity of facial
structures not only immediately but over time, restore the mouth area to as natural a state as possible, increase
stability and the patient’s sense of security that his or her teeth will not become dislodged or fall out during
basic activities (eating, laughing, sneezing, kissing), improve physical appearance, improve health by facilitating
proper digestion and nutrition, improve the taste of food, eliminate the need for denture adhesives, and improve
self-confidence and self-esteem.
To reiterate, the advantages of conventional complete dentures is that they restore some basic tooth function
in edentulous situations and provide lip support. Disadvantages include accelerated bone resorption, relatively
frequent replacement or relines, and the inability to eat some foods properly, affecting digestion and overall
health. Dental implant-supported overdentures, however, provide greater comfort and stability than conventional
dentures, and they do a better job of restoring lip support, maintaining facial structures and minimizing
bone resorption.
The fabrication of any stable removable appliance begins with careful diagnosis and case planning. Regardless
of the patient’s age, it is imperative that his or her concerns and desires be taken into account in order to
make the final prosthesis acceptable. Improving form and function can be a difficult challenge in any complete
denture situation. Fortunately, implants represent an outstanding treatment option for dramatically improving
denture stability and increasing chewing ability. Endosseous implant designs have proven to offer an excellent
prognosis and are reliable retainers for overdentures.
Dental implant-supported overdentures …
provide greater comfort and stability than
conventional dentures, and they do a better
job of restoring lip support, maintaining facial
structures and minimizing bone resorption.
– Preserving the Integrity of Facial Structures with Implant-Retained Overdentures – 49

Figure 1: Pre-op smile with conventional maxillary complete
denture in position
Case 1
The first case demonstrated here involves a female patient who
had worn a conventional maxillary complete denture for more
than 20 years. Opposing the conventional maxillary denture
was an implant-retained mandibular overdenture that had also
been in place for many years. Having appreciated the stability
and function of the mandibular overdenture, she had requested
investigation of a similar prosthesis in the maxilla. This desire
increased over time because her maxillary denture needed to
be relined several times, and the form and function of her existing
conventional denture diminished. The patient exhibited no
significant medical concerns other than severe horizontal bone
loss in the premaxillary area. Ridge augmentation had been discussed
many times in the past, but the invasive procedure had
always been declined.
Current options were discussed with the patient, including fabrication
of a new conventional denture and ridge augmentation
procedures followed by dental implant therapy. The patient
elected a simple approach in the surgical placement of four
dental implants in the posterior maxilla. The surgical design
was determined with CT diagnosis and placement using a CT
surgical stent. The implant planning software was used to visualize
the patient’s entire mouth anatomy in three dimensions.
The computer software accurately simulated the placement of
dental implants prior to ever touching the patient. We found adequate
bone in the posterior maxilla, but not acceptable bone in
the anterior maxilla. This implant planning and placement software
provided a high level of comfort and safety for the patient,
reducing surgical and restorative time by giving us an accurate
3-D plan prior to implant placement.
Figure 1 illustrates the closed vertical dimension of occlusion.
Figure 2 illustrates the postoperative CT scan, showing proper
positioning of the four dental implants. Conventional techniques
Figure 2: Post-surgical CT scan illustrating final position of
integrated dental implants
Implant planning and placement
software provided a high level
of comfort and safety for the
patient, reducing surgical and
restorative time by giving us
an accurate 3-D plan prior to
implant placement.
Figure 3: Conventional occlusal rim positioned to increase
the vertical dimension of occlusion
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were used to visualize tooth position using stable record bases
and occlusal rims. The intent was to increase the vertical dimension
to give the patient a younger look (Fig. 3). Anterior teeth
were set to the desired esthetics. Following integration of the
implants, accurate impressions of the fixtures were taken intraorally
using traditional impression copings splinted together
with acrylic. The intent was to maximize the stability of the
impression technique (Fig. 4). The stable record base with anterior
teeth waxed into position was hollowed out (Fig. 5) and
an impression made with polysiloxane materials (Fig. 6). The
laboratory then created an extremely accurate master cast with
tissue approximations (Fig. 7).
In this case, Locator ® attachments (Zest Anchors; Escondido,
Calif.) were used as the retentive devices for a maxillary, horseshoe-shaped
overdenture. Because of the posterior position of
the implants and the relatively porous quality of the bone in the
area, I considered placing a cross-arch bar splint with attachments
to retain the overdenture. However, a careful evaluation
incorporating the esthetic concerns of the patient resulted in an
inability to increase the vertical dimension of occlusion excessively.
It was therefore determined that there was not enough
intraocclusal space to provide for proper bar fabrication — not
while maintaining the preferred esthetics. The use of Locator
attachments eliminated my concern with intraocclusal distance
and final esthetics (Fig. 8). These attachments resist wear and
maintain satisfactory retention for up to 56,000 cycles of function.
This system proved appropriate where occlusal clearance
became an issue. The Locator attachments come in a variety
of retention strengths, from extra light to heavy. This type of
prosthesis allowed for excellent retention and stability for this
patient. The attachments were positioned extracoronally to
allow for good tissue adaptation and easy maintenance with a
toothbrush or end-tufted brush.
Figure 4: Splinted impression copings
Figure 5: Hollowed-out record base used to pick up the
splinted impression copings
Figure 9 illustrates the underside of the palateless maxillary
implant-retained overdenture with the Locator attachments. Note
that a cast framework was incorporated to provide strength to
the prosthesis and secondary splinting of the implants. Figure 10
shows how the palate is exposed, allowing for better tasting of
A cast framework was
incorporated to provide
strength to the prosthesis
and secondary splinting
of the implants.
Figure 6: Final, accurate pickup impression using polysiloxane
materials
Figure 7: Accurate master cast
– Preserving the Integrity of Facial Structures with Implant-Retained Overdentures – 51

food and elimination of the gag reflex, yet still providing outstanding
stability and retention. Figure 11 illustrates our final
smile design, which created a younger look for the patient. This
patient exhibited a positive end result because of her understanding
of the limiting factors involved in this case and her desire
to limit more aggressive, invasive surgical procedures. However,
she was made aware that bone loss was continuing in her maxilla
and appreciated our attempt to minimize that bone loss in
the future. Her chewing function was deemed more efficient,
and her speaking was excellent. The patient no longer worried
about her prosthesis slipping or loosening during function.
Figure 8: Locator attachments seated intraorally
Figure 9: Underside of palateless implant-retained maxillary
overdenture with Locator attachments precisely positioned
Figure 10: Intraoral occlusal view of palateless overdenture
Case 2
The second case demonstrated here involves a woman who had
had conventional maxillary and mandibular complete dentures
for many years. Because of the lack of horizontal bone thickness,
conventional dental implant placement would be difficult.
However, the patient’s quality of life was diminished because
her conventional mandibular denture was unstable and had
begun to create functional problems. Small-diameter implants
were chosen to restore stability in a mandibular overdenture
due to their size. Four small-diameter implants were surgically
placed in the symphysis without complication. CT diagnosis
and a CT surgical stent were used to ensure proper angulation
and depth.
Figure 12 illustrates the preoperative, narrow mandibular ridge
responsible for the patient’s complaint. Figure 13 shows the
parallel position of four small-diameter implants, which will
be used to stabilize a new implant-retained overdenture. The
I-Mini ® Dental Implant System (OCO Biomedical; Albuquerque,
N.M.) used here incorporates a rather simple impression
technique that utilizes plastic snap-on impression copings
(Fig. 14). Vinyl polysiloxane impression material is injected
around the pickup impression copings using a well-made custom
tray (Fig. 15). Laboratory analogs are placed into the copings
after removal from the mouth, to be used to fabricate an
accurate master cast (Fig. 16). Simple O-ring attachments
seated in metal housings serve as the retentive mechanism
(Figs. 17a, 17b). Combining a new conventional maxillary complete
denture with the patient’s very stable small-diameter
mandibular implant overdenture improved her vertical dimension
of occlusion and final esthetics (Fig. 18).
Placing conventional-sized implants in this patient’s mandible
would have been difficult, due to the minimal size of the alveolar
crest. Small-diameter implants gave me an option to restore
function and stability to the patient’s prosthesis. This treatment
option represents a great service to a group of patients who
may not otherwise experience the benefits of implant dentistry.
Figure 11: Final smile design
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Figure 12: Severely resorbed mandibular ridge
Figure 16: Laboratory analogs placed into the pickup copings
for the fabrication of an accurate master cast
Figure 13: Four small-diameter implants ideally positioned
Figure 14: Impression pickup copings snapped into place
Figures 17a, 17b: Conventional O-ring attachments provide
retention for the overdenture
Figure 15: Vinyl polysiloxane impression material used in an
accurate custom tray to pick up the impression copings
Figure 18: Final smile design with increased vertical dimension
– Preserving the Integrity of Facial Structures with Implant-Retained Overdentures – 53

Case 3
Our final case involves a completely edentulous patient who
had never worn any type of prosthesis. Figure 19 illustrates
the wrinkles present around the patient’s mouth and loss of
lip support. Although in her forties, she looked and felt much
older. Conventional dental implant surgical procedures were
completed, with four implants placed in the edentulous mandible
and five implants placed in the edentulous maxilla. At the
time of surgery, it was determined that a sixth dental implant in
the maxillary left cuspid area could not be predictably placed
due to the thinness of the bone. A dental CT was not performed
prior to this surgical intervention, so a typical flap procedure
was used to allow for a more detailed visual examination of the
subgingival structures during the placement procedure.
A custom milled
bar would be used,
which would splint
the maxillary implants
and allow for
fabrication of parallel
attachments.
After discussing prosthetic options with the patient, it was determined
that removable implant-retained overdentures would
provide her proper lip and tissue support, help maintain the
quantity of bone in both arches over time and dramatically improve
function. The patient had tried a conventional, full-palate
maxillary complete denture, but was unable to tolerate it due
to a severe gag reflex. This is another example of where it is
imperative that we listen to the patient’s concerns and desires
if we hope to make the final prosthesis acceptable. Doing so
ensures the quality of life enhancement provided by dental implants
will be rewarding to the dentist and gratifying to the
patient.
Following integration of the mandibular dental implants, a conventional
impression was made by seating impression copings
into the properly placed and parallel implants (Fig. 20) using a
custom tray (Fig. 21). Due to the ideal positioning of the four
mandibular implants, Locator attachments were used as the
retentive mechanism for the overdenture. Because of their
design, the patient is able to easily align and seat the overdenture
into position. Figure 22 illustrates the four mandibular
Locator attachments intraorally positioned. Figure 23 shows the
intaglio surface of the overdenture with the four Locator housings
and retentive male attachments. It was more difficult to
parallel the five maxillary dental implants, and therefore it was
determined that, rather than use single Locator attachments, a
custom milled bar would be used (Fig. 24), which would splint
the maxillary implants and allow for fabrication of parallel
attachments to be built into the framework (Fig. 25). In
the final analysis, we were able to predictably provide the
patient dramatic improvement in esthetics, function and support
for the facial soft tissue. Figure 26 illustrates the beaming smile
of the very happy patient.
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Figure 19: Facial photograph of our third patient, who presented
with complete edentulism
Figure 23: Underside of the mandibular implant-retained
overdenture showing the four Locator housings and retentive
male attachments
Figure 20: Impression copings placed intraorally
Figure 24: Maxillary implant-retained custom milled bar
Figure 21: Final impression with impression copings picked
up using an open-tray technique
Figure 25: Maxillary implant-retained overdenture
Figure 22: Four mandibular Locator attachments ideally
positioned
Figure 26: Final esthetic result of maxillary and mandibular
implant-retained overdentures
– Preserving the Integrity of Facial Structures with Implant-Retained Overdentures – 55

Conclusion
Follow-up care for implant-retained overdentures includes clinical
assessment for abutment stability, mobility of the implants
and plaque accumulation. Because the perimucosal seal is vital
to protecting the underlying connective tissue, probing healthy
implants is not advised. Radiographs should be taken yearly to
determine bone position and contour. Metal scalers and ultrasonic
instruments may damage the titanium abutment surface;
therefore, plastic or graphite scalers are preferred.
The general dentist has an obligation to provide patients with the
most innovative and proven techniques available. CT scans and
scanning software make surgical placement of implants rather
routine. Anatomical anomalies are virtually determined before
ever touching the patient. With good implant placement comes
more routine and predictable prosthetic reconstruction. Because
the general practitioner is the professional the patient consults
with and trusts concerning their dental condition, all clinicians
should educate themselves on the newest treatment modalities.
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