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Restorative Driven Implant Solutions Vol. 3, Issue 3

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

Implant Position in the Esthetic Zone

Dr. Siamak Abai

Page 27

Immediate and Post-Placement

Utilization of the Inclusive ®

Tooth Replacement Solution

Drs. Bradley Bockhorst and Darrin Wiederhold

Page 53

Creating Surgical Guides Using

CBCT and Intraoral Scanning

Dr. Perry Jones

Page 83


NEW! Hygienist’s Corner

with Susan Wingrove, RDH

Page 15

‘My First Implant’

Industry Pioneer Dr. Jack Hahn

Recalls First Implant Case —

And the Rest Is History

Page 11

Implant Q&A:

Dr. David Little

San Antonio, Texas

Page 39

On the Web

Here’s a sneak peek at additional

Inclusive magazine content available online

ONLINE Video Presentations

■ Dr. Bradley Bockhorst details the process by which the Inclusive ®

Tooth Replacement Solution can be used to efficiently and predictably

restore a missing mandibular molar.

■ Dr. Siamak Abai outlines spatial and angular considerations for the

optimal placement of dental implants in the esthetic zone.

■ Dr. David Little discusses some of the exciting services made possible

by cutting-edge dental technologies, emphasizing the beneficial

nature of personalized diagnoses and treatments.

■ Dr. Michael DiTolla illustrates the use of a lab-fabricated verifi cation

jig to obtain an accurate occlusal relationship in distal free-end cases.

Glidewell Laboratories unveils the Open Platform Inclusive Tooth

Replacement Solution, expanding this revolutionary treatment package

to accommodate other popular implant brands.

■ Drs. Darrin Wiederhold and Bradley Bockhorst demonstrate the

clinician’s option with the Inclusive Tooth Replacement Solution to

immediately temporize an implant with custom healing components

or to provide patient-specific temporization post-implant placement.

■ Dzevad Ceranic, CDT, and Glidewell staff showcase the advantages,

increasing popularity, and industry-leading quality of Inclusive ®

Custom Abutments.

Check out the latest issue of Inclusive

magazine online or via your smartphone

at www.inclusivemagazine.com

■ Dr. Christopher Travis reviews the symptoms, causes, and treatment

of dry mouth, promoting implant-borne restorations as a solution

for the partially or fully edentulous xerostomia patient.

■ Dr. Perry Jones highlights the merging of CBCT and intraoral

scanning technology to create precise surgical guides for safer,

more predictable implant surgeries.

Look for these icons on the pages that follow

for additional content available online

ONLINE CE credit

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

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

the articles marked with “CE.”

– www.inclusivemagazine.com –



Restoring Mandibular Single Teeth with the

Inclusive Tooth Replacement Solution

The replacement of missing mandibular molars with single-tooth,

implant-borne restorations provides many benefits over fixed partial

dentures, and is by far the most common indication for implant treatment,

according to laboratory statistics. Dr. Bradley Bockhorst offers

a detailed walkthrough of the process by which the Inclusive Tooth

Replacement Solution can be used to simplify the restorative process

and provide a predictable outcome for this common restoration.


Implant Position in the Esthetic Zone

Proper implant positioning is patient- and quite often implant-specific,

making prosthetic treatment planning and pre-placement protocol

paramount for achieving predictable restorative results. Dr. Siamak

Abai, staff dentist of clinical research at Glidewell Laboratories, details

some of the established parameters with regard to implant spacing and

angulation, and highlights the use of advanced tools such as Inclusive

Digital Treatment Planning services and the Inclusive Tooth Replacement

Solution to execute precise control over each individual case.


Implant Q&A: An Interview with Dr. David Little

In this interview, a Texas-sized passion for excellence and commitment

to improving quality of life for edentulous patients comes through as

Dr. David Little weighs in on several aspects of what makes today’s

progressive dental practice a success. Find out what this general dentist

has to say on topics ranging from building a truly interdisciplinary

practice, to incorporating advanced technologies, to educating the

entire team, to treatment planning for patients as if they were family.


Photo Essay: Immediate and Post-Placement

Utilization of the Inclusive Tooth Replacement Solution

The Inclusive Tooth Replacement Solution enables clinicians to

place and immediately temporize single-unit implants in edentulous

spaces. It can also be used in cases where the implant has already

been placed. With a pair of case reports, Drs. Darrin Wiederhold

and Bradley Bockhorst illustrate the simplified, predictable process

by which this versatile, one-of-a-kind solution addresses implant

placement and soft tissue healing in a manner that will help pave

the path to a superior final restoration.

– Contents – 1





Treating Xerostomia Patients:

A Clinical Conversation with Dr. Christopher Travis

Dentists are often the first to identify patients who are experiencing

the effects of xerostomia, or dry mouth. Here, Dr. Christopher

Travis offers a brief refresher on oral anatomy and the major sets

of salivary glands as he explores the symptoms, causes, treatment

options, and advantages of dental implants for xerostomia patients.

Implant prostheses can provide a good solution for these patients.

Creating Surgical Guides Using CBCT and

Intraoral Scanning

Among recent advances in the use of Align Technology’s iTero

optical scanner is the ability to merge its generic STL files

directly with CBCT DICOM files to allow for the creation of very

precise, tooth-borne surgical guides. In this clinical case report,

Dr. Perry Jones showcases the use of oral scanning technology to

plan implant placement, create a precise surgical guide in a virtual

environment, place implant fixtures, and restore those implants —

all without the use of a conventional analog model.

“Rules of 10” — Guidelines for Successful

Planning and Treatment of Mandibular Edentulism

Using Dental Implants

The three “Rules of 10” for treatment planning dental implant therapy

in the edentulous mandible are designed to improve the success

of both endosseous implants and the prosthesis. These so-called

rules acknowledge and provide a method to control the mechanical

environment, addressing factors affecting implant and prosthesis

longevity. Dr. Lyndon Cooper, et al., outline and provide support

for these rules, then illustrate their application in the treatment of

mandibular edentulism.


8 Trends in Implant Dentistry

Average Number of Implants per Case

11 My First Implant

Dr. Jack Hahn

15 Hygienist’s Corner

A Probing Question

31 Small Diameter Implants

Planning from the

Prosthetic Perspective

35 Clinical Tip

Bone Quality Based Drilling

Protocol: Achieving High

Primary Stability

47 Product Spotlight

Inclusive Tooth Replacement

Solution: Open Platform

49 Clinical Tip

Obtaining Accurate Occlusal Records

in Kennedy Class I and Class II

Implant Cases

65 Clinical Tip

When a Flapless Approach

Makes Sense

67 Lab Sense

Best in Class: Inclusive

Custom Abutments


– www.inclusivemagazine.com –


Jim Glidewell, CDT

Editor-in-Chief and clinical editor

Bradley C. Bockhorst, DMD

Managing Editors

David Casper, Jennifer Holstein, Barbara Young

Creative Director

Rachel Pacillas

Contributing editors

Greg Minzenmayer; Dzevad Ceranic, CDT;

Eldon Thompson

copy editors

David Frickman, Megan Strong

digital marketing manager

Kevin Keithley

Graphic Designers/Web Designers

Emily Arata, Jamie Austin, Deb Evans,

Kevin Greene, Joel Guerra, Audrey Kame,

Phil Nguyen, Kelley Pelton, Melanie Solis,

Ty Tran, Makara You


Sharon Dowd, Mariela Lopez,

James Kwasniewski, Andrew Lee,

Marc Repaire, Sterling Wright, Maurice Wyble


Phil Nguyen

coordinatorS/AD Representatives

Teri Arthur, Vivian Tsang

If you have questions, comments or suggestions, e-mail us at

inclusivemagazine@glidewelldental.com. Your comments may

be featured in an upcoming issue or on our website.

© 2012 Glidewell Laboratories

Neither Inclusive magazine nor any employees involved in its publication

(“publisher”) makes any warranty, express or implied, or assumes

any liability or responsibility for the accuracy, completeness, or usefulness

of any information, apparatus, product, or process disclosed, or

represents that its use would not infringe proprietary rights. Reference

herein to any specific commercial products, process, or services by

trade name, trademark, manufacturer or otherwise does not necessarily

constitute or imply its endorsement, recommendation, or favoring

by the publisher. The views and opinions of authors expressed

herein do not necessarily state or reflect those of the publisher and

shall not be used for advertising or product endorsement purposes.

CAUTION: When viewing the techniques, procedures, theories and

materials that are presented, you must make your own decisions

about specific treatment for patients and exercise personal professional

judgment regarding the need for further clinical testing or education

and your own clinical expertise before trying to implement new


Inclusive is a registered trademark of Inclusive Dental Solutions.


– www.inclusivemagazine.com –

Letter from the Editor

There are many axioms used in implantology, such as, “begin with the end

in mind” and “implant dentistry is a restorative procedure with a surgical

component,” all pointing to the importance of proper diagnosis and case

work-up. Addressing this topic we have: an article on implant planning

in the esthetic zone, penned by our own Dr. Siamak Abai; an interview

with Dr. David Little, where we look at treating the edentulous patient;

and, because treatment planning should be considered not just from the

surgical perspective but from the prosthetic aspect as well, we’ve included

an informative article by Dr. Lyndon Cooper, et al., with guidelines for

restoring edentulous mandibles. Our Small Diameter Implants column

reviews the importance of planning from the prosthetic perspective for

overdenture cases.

As you’ve seen in the last few issues, the Inclusive ® Tooth Replacement

Solution has the potential to change the way implant dentistry is practiced.

We are pleased to announce the expansion of this comprehensive solution

for other major implant platforms, as well as post-placement utilization

of its patient-specific components. For more on this topic, check out our

product spotlight (page 47) and photo essay (page 53).

In our My First Implant column, we feature one of implant dentistry’s

pioneers, Dr. Jack Hahn, who takes us back to 1969 — when another

revolution entirely was taking place. We are confident you’ll enjoy this

retrospective from a clinician who has made major contributions to

implantology. We are also introducing a new column that will focus on a

very critical aspect of implant dentistry: the role of the dental hygienist.

Susan Wingrove, RDH, skillfully kicks off the Hygienist’s Corner with her

discussion of evaluating implants at the recall appointment.

These are exciting times. The field of implant dentistry is rapidly advancing,

and we are committed to keeping you up to date with new technologies

and procedures as we continue to provide easy, convenient, and

affordable solutions for you and your patients.

Wishing you continued success,

Dr. Bradley C. Bockhorst

Editor-in-Chief, Clinical Editor


– Letter from the Editor – 5


■ Bradley C. Bockhorst, DMD

After receiving his dental degree from

Washington University School of Dental

Medicine, Dr. Bradley Bockhorst served

as a Navy Dental Officer. Dr. Bockhorst is

director of clinical technologies at Glidewell

Laboratories, where he oversees Inclusive ®

Digital Implant Treatment Planning services

and is editor-in-chief and clinical editor of Inclusive

magazine. A member of the CDA, ADA, AO, ICOI and the

AAID, Dr. Bockhorst lectures internationally on an array

of dental implant topics. Contact him at 800-521-0576 or



Dzevad Ceranic began his career at Glidewell

Laboratories while attending Pasadena

City College’s dental laboratory technology

program. In 1999, Dzevad began working at

Glidewell as a waxer and metal finisher, then

as a ceramist. He was then promoted to general

manager of the Full-Cast department. In 2008,

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

and in 2009 completed an eight-month implants course

at UCLA School of Dentistry. Today, Dzevad leads an implant

team of more than 250 employees at the lab. Contact him at



Dr. Siamak Abai earned his DDS degree from

Columbia University in 2004, followed by

two years of residency in general dentistry.

After two years of general private practice in

Huntington Beach, Calif., Dr. Abai returned

to academia and received an MMedSc degree

and a certificate in prosthodontics from

Harvard University. Before joining Glidewell in January

2012, he practiced at the Wöhrle Dental Implant Clinic in

Newport Beach. Dr. Abai brings nearly 10 years of clinical,

research, and lecturing experience to his role as staff dentist

of clinical research at Glidewell Laboratories. Contact him at



Dr. Lyndon Cooper serves as a professor

and current chair of the University of North

Carolina at Chapel Hill School of Dentistry

Department of Prosthodontics and has an

adjunct appointment at the UNC School of

Medicine. Dr. Cooper is also director of the

graduate prosthodontics program and the

Bone Biology and Implant Therapy Laboratory. He is a

Diplomate of the American Board of Prosthodontics and

current president of the American College of Prosthodontics

Board of Directors. His lab’s research findings have been

presented in more than 70 publications. Contact him at



Grant Bullis, director of implant R&D and

digital manufacturing at Glidewell Laboratories,

began his dental industry career at

Steri-Oss (now a subsidiary of Nobel Biocare)

in 1997. Since joining the lab in 2007,

Grant has been integral in obtaining FDA

510(k) clearances for the company’s Inclusive

® Custom Implant Abutments. In 2010, he was promoted

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

product development, and manufacturing. Grant has

a degree in mechanical CAD/CAM from Irvine Valley College

and an MBA from Keller Graduate School of Management.

Contact him at inclusivemagazine@glidewelldental.com.


Dr. Jack Hahn earned his DDS from Ohio State

University College of Dentistry, and completed

postgraduate coursework at Boston University,

New York University, the University of Michigan

and the University of Kentucky. A pioneer in the

field who developed the NobelReplace ® dental

implant system for Nobel Biocare, Dr. Hahn

has been actively involved in placing and restoring implants for

40 years. In addition to lecturing to dentists around the world,

he maintains a private practice in Cincinnati, Ohio, focused

on placing and restoring implants. In 2004, he received the

Aaron Gershkoff Lifetime Achievement Award in implant

dentistry. Contact him at replace7@mac.com.


– www.inclusivemagazine.com –


Dr. Perry Jones received his DDS from

Virginia Commonwealth University School of

Dentistry, where he has held adjunct faculty

positions since 1976. He maintains a private

practice in Richmond, Va. One of the first GP

Invisalign ® providers, Dr. Jones has been a

member of Align’s Speaker Team since 2002,

presenting more than 250 Invisalign presentations. He has

been involved with CADENT optical scanning technology

since its release to the GP market and is currently beta

testing its newest software. Dr. Jones belongs to numerous

dental associations and is a fellow of the AGD. Contact him

at perry@drperryjones.com.


Dr. Christopher Travis received his dental

degree and certificate in prosthodontics from

USC School of Dentistry, where he served as an

assistant clinical professor in predoctoral and

graduate prosthodontics. For the past 30 years,

he has maintained a full-time private practice

specializing in prosthodontics in Laguna

Hills, Calif. Dr. Travis is director of the Charles Stuart Study

Group in Laguna Hills, prosthodontic coordinator for the

Newport Harbor Academy of Dentistry and active member of

the Pacific Coast Society for Prosthodontics, American College

of Prosthodontists and AO, as well as a Fellow of the ACD.

Contact him at 949-683-7456 or surfnswim@fea.net.


Dr. David Little received his DDS at the University

of Texas Health Science Center at San

Antonio Dental School and now maintains a

multidisciplinary, state-of-the-art dental practice

in San Antonio, Texas. An accomplished

national and international speaker, professor,

and author, he also serves the dental profession

as a clinical researcher focusing on implants, laser surgery,

and dental materials. As a professional consultant, he shares

his expertise on emerging restorative techniques and materials

with industry peers. Highly respected for his proficiency in

team motivation, Dr. Little’s vision, leadership, and experience

are recognized worldwide. Contact him at dlittledds@aol.com.


Dr. Darrin Wiederhold received his DMD

in 1997 from Temple University School of

Dentistry and a master’s degree in oral

biology in 2006 from Medical University

of Ohio at Toledo. He has worked in several

private practices, and as a staff dentist for

the U.S. Navy and the Glidewell Laboratories

Implant department. While at Glidewell, he performed implant

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

training facility and helped support the lab’s digital treatment

planning and guided surgery services. He is currently in private

practice in San Diego, Calif. Contact him at 619-469-4144

or DMWDMD97@hotmail.com.


After completing dental school at University of

North Carolina at Chapel Hill and a prosthodontic

residency at University of Alabama at

Birmingham, Dr. Michael McCracken received

a Ph.D in biomedical engineering for research

related to growth factors and healing of implants

in compromised hosts. Dr. McCracken is

a professor in the department of general dental sciences at UAB

School of Dentistry, where he has also served as associate dean

for education, director of graduate prosthodontics, and director

of the implant training program. He maintains an active

research program within the university and a private practice

focused on implant dentistry. He also lectures internationally.

Contact him at inclusivemagazine@glidewelldental.com.


Susan Wingrove is a national and international

speaker and practicing dental

hygienist, who does regeneration research as

a consultant for Regena Therapeutics and

instrument design for Paradise Dental Technologies

Inc. She designed the Wingrove

Implant Series, ACE probes, and Queen of

Hearts instruments. A member of the AO and The Implant

Consortium (TIC), she is also a published author on implant

dentistry who has written articles for Hygienetown and the

British Society of Dental Hygiene and Therapy, as well as the

textbook “Peri-Implant Therapy for the Dental Hygienist: A

Clinical Guide to Implant Maintenance” (Wiley-Blackwell).

Contact her at sswinrdh@gmail.com.

– Contributors – 7

Trends in

Implant Dentistry

Average Number of Implants per Case

With the large number of implant-borne cases fabricated at Glidewell Laboratories, certain

evolving trends have come to light. Here are some stats about the number of implants that

are being placed per case.

1 Implant 2 Implants 3 Implants 4 Implants 5+ Implants

Number of Implants per Case


Number of Implants per Case












Data Source: Glidewell Laboratories January 2010–August 2012


– www.inclusivemagazine.com –

In an evaluation of more than 70,000 cases,

the average number of implants per case is

Of all the cases we have processed

over the last three years…


66%…were single teeth

Number of Implants per Case

2012 YTD

Number of Implants per Case

January 2010–August 2012








2 % 11%


Watch here for emerging trends

Check back here for more observations in the next issue.

– Trends in Implant Dentistry: Average Number of Implants per Case – 9

my first


with Jack A. Hahn, DDS

ack in the summer of 1969, against the

backdrop of the cultural craziness that

was the late sixties, there was another,

quieter revolution taking place. Not man

walking on the moon. Not the Beatles’ “Sgt. Pepper”

album taking hold of a generation. But a sign of the

times that technologies were changing the way we

do things across professions, including the field of

dentistry. Here, Dr. Jack Hahn recalls placing his

first implant, an experience that would set the

course for the rest of his professional life — and

the lives of his future patients.

– My First Implant: Dr. Jack Hahn – 11

We’ve Come a Long Way

From subperiosteal implants…

...to combined root-form and blade implants…

...to the modern endosseous designs and CAD/CAM restorations of today.

I got interested in implants when a patient

came into my office one summer, decades ago, holding a

shoebox that contained no less than 17 sets of dentures. She

had a severely atrophic mandible that made it impossible

to retain a mandibular conventional denture — and she

was an emotional wreck. Her husband, who was a wellrespected

orthopedic surgeon, explained that she was a

dental cripple and that this condition had all but destroyed

their social lives. They declined invitations to parties and

avoided going out in public because she couldn’t wear her

lower teeth. So sad. At the time I didn’t think there was any

hope, and I told her so. (But the seed was planted.)

Then, I ran into her husband at a hospital function. He’d

since read about dental implants in an orthopedic journal,

but I told him those things didn’t work. “There is infection

and rejection.” That’s what we were told in school. In short,

I gave them no solution or possibility for a better quality

of life. I saw the husband yet again about five months later

at a hospital meeting. He had since taken his wife to New

York, and a Dr. Linkow had placed a subperiosteal implant

that changed their lives. She could eat anything. They were

able to go out in public again. And her self-confidence improved

significantly. He said to me, “Implant dentistry is

the future,” and that I should learn all about it — or get left

behind. This advice, coming from an orthopedic surgeon,

was a wake-up call.

In January of 1970, I went to New York to take Dr. Leonard

Linkow’s course. It was two days with a hands-on portion

where the participants placed an endosseous blade in a

clear plastic model. In order to take the course, you had to


– www.inclusivemagazine.com –

The House that Jack Built

Inspired by that first experience, Dr. Jack Hahn went

on to develop implant techniques and devices known

for their simple yet ingenious designs that are used

around the world today.

1977 Miter blade-form implants

1979 Titanodont root-form implants

1986 Steri-Oss root-form and blade implants


NobelReplace ® Tapered implant

(Nobel Biocare)

I didn’t sleep the

night before.

Evolution in Immediate Function

purchase the implant kit, which consisted of 12 one-piece

blades, 700 XXL burs, depth gauge, mallet, pliers, and seating

instrument. A channel was prepared, and the implants

were malleted into place using the seating instruments. As

the implants were one piece with an abutment portion,

one or two of the anterior abutment teeth were prepared,

and an immediate provisional restoration was placed for

immediate function. Three to six weeks post-insertion,

impressions were taken for the final restoration: basically,

a fixed bridge.

Two months after completing the course, my first potential

implant patient was sitting in my office for a consultation.

She was bilaterally edentulous from the second premolars

in the posterior mandible back. Her partial denture was

wrapped in Kleenex in her purse. She said: “I can’t wear

this thing, and I hate it. I want something permanent.”

I told her that I had just taken an implant course, that

she would be my first patient, and that I didn’t know if

the things I demonstrated to her on my model would last

10 minutes or 10 years. But she had good height and width

of bone, so it seemed to me to be an ideal case. I told her

we could do one side first, see how it went, and do the

other side a month later. I also told her that because it was

my first implant, I wouldn’t charge her for the implant, only

the fixed bridge. She said, “Let’s do it.”

In March of that same year, we scheduled Irma from 1:30

p.m. to 5 p.m. I didn’t sleep the night before. I kept going

over in my mind the incision, reflection of the soft tissue,

implant groove preparation, implant placement, suturing,

and fabrication of the provisional restoration.

– My First Implant: Dr. Jack Hahn – 13

Sage advice for doctors

new to implants


Enroll in an introductory

course. Get a feel for whether implant

dentistry is right for you.



Educate yourself by enrolling

in multiple courses. If implant

dentistry is something you want to

pursue, take an adequate number

of courses — and wait until you feel

confident in doing implant procedures.

Learn basic surgical

techniques. Aside from identifying

important anatomical structures,

diagnosis, treatment planning,

radiographic interpretation and basic

implant prosthetic principles — it’s

critical that you understand basic

surgical techniques.

Start with an ideal case. Look

for cases that have a good level of

height and width of bone. Also, you

want anatomical safe regions, such

as the anterior mandible and single

tooth replacements in both arches,

eliminating three-unit bridges.

Implant dentistry

changed my life,

as well as the

lives of thousands

of my patients.

I started the procedure at 1:30 p.m. and had the provisional

cemented by 3:30 p.m. Everything went absolutely perfectly.

I was so excited that I said to my partner, “I don’t

want to do anything else.” Replacing what nature had taken

away was, from that instant on, exactly what I wanted to

do for the rest of my professional life. Four weeks later, I

placed her final bridge and placed the other implant on the

opposite side. I told her that I’d have to charge her for that

one because now I was an expert. We both laughed. She

hugged me and said that I changed her life. Irma passed

away in October 2000, 30 years later, with her implants and

bridge still functioning until the day she died.

After that first time, I went on to place many implant

restorations, all types and various systems, over the next

42 years. I estimate that I have placed and restored more

than 30,000 implants. IM


– www.inclusivemagazine.com –



A Probing Question

with Susan S. Wingrove, RDH

When assessing for peri-implant disease, “bleeding on

probing” (BOP) is invaluable in the diagnostic process for

peri-implant mucositis, and probing depths are valuable

in assessing loss of bone support around osseointegrated

implants. 1,2 An important yet controversial component of

the assessment is probing the dental implant.

Some implant surgeons recommend not probing the

implant, or waiting three to six months following abutment

attachment to avoid disrupting the perimucosal seal. 3 The

perimucosal seal is fragile, and penetration during probing

can introduce pathogens and jeopardize the success of the

implant. Recent studies show that 0.15 Ncm may represent

the threshold pressure to be applied in order to avoid false

positive BOP readings around oral implants. 4 Currently,

clinicians are using 0.15 Ncm–0.20 Ncm of pressure, but most

agree that probing around dental implants is more sensitive

than probing natural teeth; thus, caution should be used. 4

Emerging research holds that probing is not harmful,

however, and is actually essential to the overall health of the

implant. Complete regeneration of junctional epithelium and

establishment of new epithelial attachment has been studied,

revealing that probing around osseointegrated implants

does not appear to have detrimental effects on the perimucosal

seal. 5 Peri-implantitis infections occur in 28 to 56 percent

of implants after five years. 6 An increase in reported cases

of peri-implant diseases (collective term for inflammatory

lesions, mucositis, and peri-implantitis) is a significant reason

for monitoring and probing dental implants.

The hygienist needs to know baseline measurements to be

able to distinguish health from disease, or loss of osseointegration.

This can give the hygienist a way of determining

at recall visits whether detrimental changes have occurred.

Also, if more than one hygienist is employed in the office,

measurement with compatible probes in millimeters for all

inflammation, exposed threads, or bone loss on films allow

for more accurate monitoring and consistency.

Courtesy of PDT Inc.

Figure 1: Note difference in flexibility between metal probe (left) and plastic

probe (right)

There is a recommended protocol for probing dental

implants. First, the complexity of implants makes the

flexibility of the probe essential. Now with more platformswitching

implants, narrow implants, and fixed prostheses,

the tip needs to be flexible to follow the anatomy of the

implant and get an accurate reading. Using a flexible

plastic probe reduces the potential for trauma to the

perimucosal seal and the risk of scratching the implant’s

surface (Fig. 1).

– Hygienist’s Corner: A Probing Question – 15

Protocol for Probing of Dental Implants

Record the baseline measurements at the first implant maintenance appointment or after

the allotted three months.

● Use a flexible probe with 1 mm markings to de-plaque, which may be adequate

supportive therapy.

● Place the probe parallel to the long axis of the implant, six measurements per implant,

and identify a location on the restoration as a monitor marker.

● Gently probe using light pressure (only 0.15 Ncm) to check the clinical parameters.

For new patients, record a baseline and note placement date, doctor who placed the implant,

and any other details.

Record if inflammation, bleeding on probing, cement, or exudate are present.

Report findings to the dentist for evaluation.

The hygienist needs to know

baseline measurements

to be able to distinguish

health from disease,

or loss of osseointegration.

Second, record a probe baseline measurement, at a specific

location, to establish a clinical parameter for the patient’s

record (Fig. 2). Place the probe parallel to the long axis of

the implant, six measurements per implant, and identify

a location on the restoration as a monitor marker. Record

this baseline measurement in the patient notes at the first

maintenance appointment after the allotted three months. 7

Ideally the measurement should read 2.5 mm–5 mm or

less, depending on soft tissue depth, with no other signs of

inflammation. 8 Compare this measurement to the baseline,

and if the probe depth changes, note this in the chart. If

the implant has a probing depth of 5 mm–6 mm or greater,

bleeding, or a presence of exudate, a radiograph should

be taken to assess the implant, and the doctor needs to

evaluate for bone loss. 9


– www.inclusivemagazine.com –

Probe using only 0.15 Ncm of pressure so as not to jeopardize the success

of the implant by possibly introducing pathogens into the peri-implant sulcus,

or by damaging the delicate fibers that surround the implant.

Courtesy of Dr. J Remien

Courtesy of Nancy Adair, RDH

Hygiene Excellence Inc.

Figure 2: Recording and probing the baseline

Figure 3: Probing the dental implant

Third, probe using only 0.15 Ncm of pressure so as not

to jeopardize the success of the implant by possibly

introducing pathogens into the peri-implant sulcus, or by

damaging the delicate fibers that surround the implant

(Fig. 3). The perimucosal seal of the implant is fragile and

more susceptible to trauma from probing than a natural

periodontal ligament. If the tissue is healthy, the probe will

stop at the coronal level, and if inflammation is present,

the probe tip will penetrate close to the bone.

Finally, use the probe as a measuring device for documenting

inflammation and measuring exposed implant threads

for monitoring. Continue to record and monitor by comparing

the measurement to the baseline at every implant

maintenance appointment. If probe depths have changed

or inflammation, bleeding on probing, cement, or exudate

are present, bring this information to the dentist’s attention

per proper protocol for probing of implants.

Using proper protocol, probing is one of the key monitoring

tools in evaluating the health of the tissue surrounding

the dental implant. Inflammation or bleeding on probing

should not occur with healthy peri-implant tissue. Keep in

mind that peri-implant infections can progress more rapidly

than an infection in a natural tooth. Therefore, monitoring

the tissue surrounding the dental implant is critical in the

overall long-term success of the implant. IM

– Hygienist’s Corner: A Probing Question – 17

Using proper protocol, probing is one of the key monitoring tools

in evaluating the health of the tissue surrounding the dental implant.


1. Salvi GE, Lang NP. Diagnostic parameters for monitoring peri-implant conditions.

Int J Oral Maxillofac Implants. 2004;19 Suppl:116-127.

2. Lang NP, Mombelli A, Tonetti MS, Brägger U, Hämmerle CH. Clinical trials on

therapies for peri-implant infections. Ann Periodontol. 1997 Mar:2(1):343-356.

3. Bauman GR, Mills M, Rapley JW, Hallmon WH. Clinical parameters of evaluation

during implant maintenance. Int J Oral Maxillofac Implants. 1992 Summer;


4. Gerber JA, Tan WC, Balmer TE, Salvi GE, Lang NP. Bleeding on probing and

pocket probing depth in relation to probing pressure and mucosal health around

oral implants. Clin Oral Implants Res. 2009 Jan:20(1):75-78.

5. Etter TH, Hakanson I, Lang NP, Trejo PM, Caffesse RG. Healing after standardized

clinical probing of the peri-implant soft tissue seal: a histomorphometric study in

dogs. Clin Oral Implants Res. 2002 Dec;13(6):571-580.

6. Nogueira-Filho G, Iacopino AM, Tenenbaum HC. Prognosis in implant dentistry:

a system for classifying the degree of peri-implant mucosal inflammation. J Can

Dent Assoc. 2011;77:b8.

7. Mombellli A, Mühle T, Brägger U, Lang NP, Bürgin WB. Comparison of periodontal

and peri-implant probing by depth-force pattern analysis. Clin Oral Implant

Res. 1997 Dec;8(6):448-454.

8. Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis: Mosby;2008:1061.

9. Stuart J. Froum, DDS. My patient’s implant is bleeding; what do I do? DentistryIQ,

July 13, 2011.


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Restoring Mandibular Single Teeth

with the Inclusive Tooth Replacement Solution

Go online for

in-depth content


Bradley C. Bockhorst, DMD

While the prosthetic rehabilitation of

full-arch cases provides a tremendous

service for the patient and can be very

professionally rewarding for the clinician, single

tooth replacement is by far the most common

implant restoration. Restoring single posterior

teeth with implants provides a viable treatment

option and has been well documented. 1-5 Of the

single posterior teeth, the first molar, or “money

tooth” as termed by Dr. Curtis Jansen, very

often requires replacement. 6 At the Glidewell

Laboratories operatory, 59 percent of the single

Inclusive ® Tapered Implants placed have been

in the posterior mandible.

One of the most obvious concerns when placing

implants in the posterior mandible is identifying

and avoiding the inferior alveolar nerve (IAN). 7

This can be accomplished through the use of

appropriate radiography and proper planning.

– Restoring Mandibular Single Teeth with the Inclusive Tooth Replacement Solution – 19

Conventional implant planning typically involves the use

of a periapical radiograph (PA) and/or a panoramic film.

The drawback to these types of two-dimensional images is

distortion. The PA should be taken with a paralleling technique

to avoid vertical distortion as much as possible. A

radiographic marker of known diameter (e.g., 5 mm ball

bearing) can be used to determine the distortion in the

planned implant site. The marker is measured on the film

to determine the distortion factor in that area. A transparent

overlay can be used as an aid to determine the correct

implant selection (Fig. 1).

Another option is a CT scan. Cone beam scanners provide a

three-dimensional image and a precise method for identification

of the IAN. 8 The patient’s scan can be imported into

planning software, the mandibular canal identified, and the

implant placed in a virtual environment (Fig. 2).

In the case presented here, the canal was well differentiated

and identified. The mandibular canal is typically identifiable.

However, there are situations where the cortical bone

surrounding the canal is not dense and therefore does not

show up radiographically. These cases present a significant

challenge. One rule of thumb for first molars is to not drill

deeper than the roots of the adjacent teeth.

An optical scan of the model provides a clear view of

the anatomy of the teeth and the soft tissue (Fig. 3). The

appropriate-sized implant is placed within the confines of

the available bone (Fig. 4). It is important to be aware that the

drills are approximately 1 mm longer than the stated length

of the implant. The trajectory of the implant is aimed toward

the opposing stamp cusp through the center of the

occlusal table.

Figure 1: Implant radiographic template for Inclusive Tapered Implants

Figure 2: Digital Treatment Plan


The osteotomy should be prepared with the aid of a

surgical or prosthetic guide. The prosthetic component of

the Inclusive ® Tooth Replacement Solution is a traditional

surgical stent designed to convey the ideal position of the

implant platform from the restorative perspective (Figs. 5, 6).

By starting the osteotomy using this guide, the implant will

be inserted in the appropriate location to take advantage of

the custom temporary abutment and BioTemps ® provisional

crown. The prosthetic guide is intended for prosthetic

reference only, and does not take into consideration any

anatomical landmarks or contraindications. This guide

should be used in combination with the radiographic and

clinical information to determine the best position for

the implant.

Figure 3: View of mandibular arch with proposed implant trajectory

A surgical guide based on the virtual plan utilizing a CBCT

scan of the patient provides the option of drill depth and

angulation control. Based on the amount of guidance

desired, a surgical guide can be produced that guides the

pilot drill. Subsequent drilling with progressively wider


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Figure 4: Cross-sectional view of proposed implant site

Figure 7: Universal SurgiGuide

Figure 5: The Inclusive Tooth Replacement Solution prosthetic guide

Figure 8: Universal SurgiGuide in situ

surgical drills (as needed) and implant placement are

performed freehand.

If additional guidance is needed, Universal SurgiGuides (Materialise

Dental; Glen Burnie, Md.) are available (Figs. 7, 8).

In these cases, all the drills can be guided. The implant is

placed freehand once the osteotomy has been created.

At the time of placement, a custom healing abutment can be

delivered (Figs. 9, 10). The custom healing abutment allows

you to start anatomically sculpting the soft tissues at the

time of surgery.

Figure 6: Prosthetic guide in situ

A custom temporary abutment and BioTemps crown also

are provided with the Inclusive Tooth Replacement Solution.

If high primary stability is achieved and the crown is

taken well out of occlusion, the implant can be temporized

at the time of surgery. Due to the occlusal forces that can be

exerted in the molar region, another approach would be to

utilize the custom healing abutment at the time of surgery

and provisionalize the case at a later date.

– Restoring Mandibular Single Teeth with the Inclusive Tooth Replacement Solution – 21


Temporization utilizing the Inclusive Tooth Replacement

Solution consists of seating the custom temporary abut ment,

then relining and cementing the BioTemps provisional crown

(Fig. 11). If a screw-retained temporary is preferred, after

adjustments are made, an occlusal hole is drilled through

the crown (Fig. 12). The abutment and internal surfaces are

roughened up to help create mechanical retention. A guide

pin is used to maintain the screw opening, and the crown is

luted to the abutment with permanent cement. The crownabutment

assembly is then delivered to the implant (Fig. 13),

and the abutment screw is tightened to 15 Ncm (Fig. 14).

The occlusal screw is covered with a piece of Teflon tape

and the access opening sealed with composite (Fig. 15). The

crown should be out of occlusion (Fig. 16).

Figure 9: Inclusive Tooth Replacement Solution custom healing abutment

Final Impressions

The final impression is made with the Inclusive Tooth

Replacement Solution custom impression coping (Fig. 17).

The custom impression coping allows you to transfer the

position of the implant as well as the soft tissue contours to

the master cast. The custom impression coping is seated on

the implant and the screw is tightened (Fig. 18).

The access opening is sealed with soft wax to prevent

impression material from flowing into the coping (Fig. 19).

The closed-tray impression is made following standard

technique. When the material has set, the impression is

pulled. The impression coping is removed and replaced

with the healing abutment or provisional restoration. The

shade is selected (Fig. 20) and clinical photos are taken.

A bite registration and impression of the opposing arch

are made. The pre-populated Inclusive Tooth Replacement

Solution lab prescription is filled out and the case sent to

the lab.

Figure 10: Custom healing abutment in place with access opening sealed

Laboratory Fabrication

Upon receipt, the lab will mount the custom impression

coping on an implant analog (Fig. 21) and reseat it back

into the impression (Fig. 22). A soft tissue model will be

poured (Fig. 23), the case articulated, and the final restoration


Figure 11: Custom temporary abutment and BioTemps crown

Based on the clinician’s preference, a cemented or screwretained

prosthesis can be ordered. In this case, the

cemented restoration consisted of an Inclusive ® All-Zirconia

Custom Abutment (Figs. 24a, 24b) and an IPS e.max ® crown

(Ivoclar Vivadent; Amherst, N.Y.) (Fig. 25). An acrylic jig is

fabricated to aid in seating the abutment (Figs. 26a, 26b).

Final Delivery: Cement-Retained Crown

When the healing abutment or provisional restoration

is removed, the soft tissues will have healed to more

Figure 12: After adjustments, a hole is drilled through the crown and the

crown cemented to the abutment.


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Figure 13: Seated provisional restoration

Figure 17: Custom impression coping

Figure 14: The abutment screw is tightened

Figure 18: The impression coping is seated

Figure 15: The occlusal access opening is sealed

Figure 19: The screw access opening is sealed with soft wax

Figure 16: The temporary crown is out of occlusion

Figure 20: Shade selection

– Restoring Mandibular Single Teeth with the Inclusive Tooth Replacement Solution – 23

anatomically correct contours (Fig. 27). The abutment is

seated utilizing the jig (Fig. 28) and the screw tightened

to 35 Ncm (Fig. 29). The jig is then removed (Fig. 30). The

crown is seated and the margins and interproximal and

occlusal contacts are checked (Figs. 31a, 31b). Any necessary

adjustments are made. There should be light centric contact

with a firm bite and no lateral contacts. The interproximal

contacts should be light. The abutment screw is tightened

once more to 35 Ncm, and the access opening sealed with

a piece of Teflon tape. The crown is cemented in place

with RelyX Unicem Self-Adhesive Resin Cement (3M ESPE;

St. Paul, Minn.). All excess cement must be meticulously

removed. A PA was taken to verify complete seating and

cement removal (Fig. 32).

Final Delivery:

IPS e.max Screw-Retained Crown

If a screw-retained crown was selected (Figs. 33a–33c), the

one-piece restoration is seated on the implant (Fig. 34). The

abutment screw is tightened to 35 Ncm utilizing the jig

(Fig. 35). The interproximal and occlusal contacts are

checked and adjusted as needed (Fig. 36). The screw access

opening is sealed with a piece of Teflon tape and an occlusal

composite (Fig. 37).

Figure 22: Assembly reseated into impression


Replacement of missing mandibular molars with singletooth

implant-borne restorations provides many benefits

over fixed partial dentures. It avoids having to prep adjacent

teeth, it makes hygiene easier for the patient, and it allows

for flexure of the mandible. 2 The osteotomy can be created

conventionally or through a guided surgical procedure.

The Inclusive Tooth Replacement Solution provides the

components to simplify the restorative process and provide

a superior final restoration for this common restoration. IM

Figure 23: Soft tissue model

Figures 24a, 24b: Inclusive All-Zirconia Custom Abutment

Figure 21: Custom impression coping mounted on implant analog

Figure 25: Inclusive All-Zirconia Custom Abutment and IPS e.max crown


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Figures 26a, 26b: Acrylic abutment seating jig

Figure 30: The jig is removed

Figure 27: The provisional restoration is removed

Figures 31a, 31b: After adjustments, the IPS e.max crown is cemented in place

Figure 28: The abutment is seated with the jig

Figure 32: PA verifying seating and cement removal

Figure 29: The abutment screw is tightened to 35 Ncm

Figures 33a–33c: IPS e.max screw-retained crown

– Restoring Mandibular Single Teeth with the Inclusive Tooth Replacement Solution – 25


1. Becker W, Becker BE. Replacement of maxillary and mandibular molars with single

endosseous implant restorations: a retrospective study. J Prosthet Dent. 1995 Jul;


2. Misch CE, Misch-Dietsh F, Silc J, Barboza E, Cianciola LJ, Kazor C. Posterior

implant single-tooth replacement and status of adjacent teeth during a 10-year

period: a retrospective report. J Periodontol. 2008 Dec;79(12):2378-82.

3.Misch CE. Endosteal implants for posterior single tooth replacement: alternatives,

indications, contraindications, and limitations. J Oral Implantol. 1999;25(2):80-94.

4. Ekfeldt A, Carlsson GE, Börjesson G. Clinical evaluation of single tooth restorations

supported by osseointegrated implants: a retrospective study. Int J Oral

Maxillofac Implants. 1994 Mar-Apr;9(2):179–83.

5. Muftu A, Chapman RJ. Replacing posterior teeth with freestanding implants: fouryear

prosthodontic results of a prospective study. J Am Dent Assoc. 1998 Aug;


6. Jansen C. Presentation given at the Academy of Osseointegration 2012 Annual

Meeting, Phoenix, Ariz.

7. Anderson LC, Kosinski TF, Mentag PJ. A review of the intraosseous course of the

nerves of the mandible. J Oral Implantol. 1991;17(4):394-403.

8. Alhassani AA, AlGhamdi AS. Inferior alveolar nerve injury in implant dentistry: diagnosis,

causes, prevention, and management. J Oral Implantol. 2010;36(5):401-7.

Epub 2010 Jun 14.

Figure 34: Abutment screw tightened utilizing jig

Figure 35: IPS e.max screw-retained crown seated

Figure 36: Occlusion verified

Figure 37: Access opening sealed with composite


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Go online for

in-depth content


Siamak Abai, DDS, MMedSc

Since the advent of modern root

form osseointegrated implant

dentistry in 1952 by Per-Ingvar

Brånemark 1 and colleagues, clinicians

have strived for improvements in

implant positioning in the esthetic

zone to achieve predictable restorative

and esthetic results. Years of clinical

experience in congruence with controlled

clinical studies have led to

established parameters as a guide

for these results. Prosthetic treatment

planning and establishing a set clinical

protocol prior to implant placement

are paramount. It is important to note

that proper implant positioning is

patient- and often implant-specific, and

that inter-patient generalizations can

result in myopic treatment planning

and decrease the predictability of an

esthetic outcome.

Treatment planning prior to implant placement traditionally

begins with comprehensive medical and dental evaluation,

articulated diagnostic casts, periapical and panoramic radiographs,

cone beam computed tomography (CBCT) scans, and

a diagnostic wax-up. Patient demands must always be taken

into consideration prior to surgery, and presurgical mockups

may be necessary to convey the information to the patient.

Prosthetic treatment planning helps the clinician with a

restorative-driven implant placement rather than a bonedriven

approach, with the latter leading to poor abutment

angulations and drastically reduced restorative options. Bone

augmentation is often necessary in order to achieve optimal

residual ridge dimensions prior to implant placement.

The inventive work of Sir Godfrey Hounsfield 2 and the

advancement of CBCT technology have led the dental

profession into a new realm of dimensional accuracy that

is often unattainable with conventional dental radiography.

In combination with the use of a surgical or guided stent,

proper 3-D positioning of a dental implant has become

an attainable goal, leading to increased confidence for

the clinician and accurate clinical results. The importance

– Implant Position in the Esthetic Zone – 27


of the implant position can be manifested in the four

dimensionally sensitive positioning criteria: mesiodistal,

labiolingual, and apico-coronal location, as well as implant

angulation. 3 The ultimate goal is not only to avoid adjacent

sensitive structures, but to respect the biological principles

that have been established to achieve esthetic results.


Correct implant position in a mesiodistal orientation allows

the clinician to avoid iatrogenic damage to adjacent critical

structures. Maintaining adequate distance from adjacent

teeth also helps preserve crestal bone and interproximal

papillary height. When placing an implant adjacent to a

tooth, it has been shown that crestal bone peak is based on

and maintained by the bone level of the teeth adjacent to

the missing space. A minimum distance of 1.5 mm between

implant and existing dentition has been determined to

prevent damage to the adjacent teeth and to provide proper

osseointegration and gingival contours 4–6 (Fig. 1a). Implants

placed too closely together can reduce the height of the

inter-implant bone crest, and a distance of less than 3 mm

between two adjacent implants leads to increased bone

loss. It has been shown that a distance of more than 3 mm

between two adjacent implants preserves the interproximal

bone peak and results in 0.45 mm of resorption on average,

giving a better chance of proper interproximal papillary

height (Fig. 1b). If the space between implants is 3 mm

or less, the average resorption of the interproximal bone

peak increases to 1.04 mm, compromising support for the

interdental papilla. 4,7 As a result, wide-bodied implants less

than 3 mm apart in the esthetic zone would compromise

the desired outcome.


Labiolingual implant position is often determined by the

gingival biotype, occlusal considerations of opposing teeth,

and desired emergence profile. An implant placed too far

labially can cause bone dehiscence and gingival recession

leading to exposure or show-through of the implant collar.

An implant placed too far lingually can cause prosthetic

difficulties with ridge-lap restorations that can be unhygienic

and unesthetic. A thickness of 1.8 mm of labial bone has

been determined to be critical in maintaining an implant soft

tissue profile and increasing the likelihood of an esthetic

outcome 8 (Fig. 2). Labially oriented implants compromise

the subgingival emergence profile development, creating

long crowns and misalignment of the collar with respect to

the adjacent teeth. 9


Peri-implant crestal bone stability plays a critical role in the

presence of interdental papilla. 10 Many factors contribute

to crestal bone resorption, including existing anatomy, surgical

trauma, overloading, peri-implantitis, implant surface

characteristics, microgap at the implant-abutment junction,

Figure 1a: Minimum distance of 1.5 mm between implant and existing dentition

Figure 1b: Minimum distance of 3 mm between two adjacent implants

Figure 2: Proper labiolingual placement with 1.8 mm thickness of labial bone


– www.inclusivemagazine.com –

type of connection between implant, and prosthetic components.

11 Several factors are cause for concern in the

apico-coronal placement of implants. Implants placed too

shallow may reveal the metal collar of the implant through

the gingiva. Countersinking implants below the level of

the crestal bone may give prosthetic advantages with more

running room for prosthetic components and tissue contouring,

but can lead to crestal bone loss due to the location

of a microgap at the implant-abutment interface. The

ideal solution to exposure of the implant collar would be

the placement of an implant equicrestal or subcrestal to

the ridge. However, the existing microgap at the implantabutment

junction leads to bone resorption due to periimplant

inflammation. 12 It is suggested that an implant collar

be located 2 mm apical to the CEJ of an adjacent tooth

if no gingival recession is present 13 (Fig. 3). Implant diameter

also plays a role in apico-coronal position, with smaller

diameter implants needing more space for soft-tissue development

and tissue contouring.

Figure 4: Proper implant angulation with screw access in the cingulum area

Figure 3: Lateral view of implant placed with the collar at the level of crestal bone

with adjacent teeth CEJ 2 mm coronal to the collar of the implant


Implant angulation is particularly important in treatment

planning for screw-retained restorations. Implants angled

too far labially compromise the placement of the restorative

screw, leaving the clinician with fewer restorative options.

Implants angled too far lingually can result in unhygienic

and unesthetic prosthetic design. For every millimeter

of lingual inclination, the implant should be placed an

additional millimeter apically in order to create an optimal

emergence profile. 14 In general, implant angulation should

mimic angulation of adjacent teeth so long as they are

in reasonable alignment (Fig. 4). Furthermore, maxillary

anterior regions require a subtle palatal angulation to



The Inclusive ® Tooth Replacement Solution was developed

by Glidewell Laboratories as a complete, prosthetically

driven method of restoring missing dentition. The solution

comprises treatment planning, implant placement, patientspecific

temporization, and the definitive restoration

(Figs. 5a–5f). When utilizing the comprehensive range of

Inclusive Digital Treatment Planning services for guided

implant surgeries and restorations, the clinician has absolute

and precise control of each step. This results in an efficient

and accurate workflow that is beneficial for the clinician and,

ultimately, the patient. With the Inclusive Tooth Replacement

Solution, the clinician has control of the four dimensions of

implant placement in the esthetic zone, creating a consistently

predictable result. Having a single source of services and

materials is also advantageous in providing a more affordable

yet high-value product for patients.

increase labial soft tissue bulk. 15 – Implant Position in the Esthetic Zone – 29


Figure 5a: Inclusive Tapered Implant at placement

Figure 5b: Inclusive custom healing abutment in place

Figure 5c: Contoured soft tissue sulcus after healing

Figure 5d: Screw-retained IPS e.max ® crown (Ivoclar

Vivadent; Amherst, N.Y.) in place

Figure 5e: PA to verify seating of crown

Figure 5f: Buccal view of final restoration at delivery



1. Albrektsson T, Brånemark PI, Hansson HA, Lindstrom J. Osseointegrated titanium

implants. Requirements for ensuring a long-lasting, direct bone-to-bone

implant anchorage in man. Acta Orthop Scand. 1981;52(2):155-70.

2. Hounsfield GN. Computerized transverse axial scanning (tomography): Part I.

Description of system. Br J Radiol .1973;46:1016-22.

3. Al-Sabbagh M. Implants in the esthetic zone. Dent Clin N Am. 2006 Jul;50(3):


4. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the

height of inter-implant bone crest. J Periodontol. 2000 Apr;71(4):546-49.

5. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone thickness on

facial marginal bone response: stage 1 placement through stage 2 uncovering.

Ann Periodontol. 2000 Dec;5(1):119–28.

6. Saadoun AP, LeGall M, Touati B. Selection and ideal tridimensional implant position

for soft tissue aesthetics. Pract Periodontics Aesthet Dent. 1999 Nov-Dec;


7. Degidi M, Perrotti V, Shibli JA, Novaes AB, Piatelli A, Lezzi G. Equicrestal and

subcrestal dental implants: a histologic and histomorphometric evaluation of

nine retrieved human implants. J Periodontol. 2011 May;82(5):708-15. Epub

2010 Dec 7.

8. Hermann JS, Buser D, Schenk RK, Schoolfield JD, Cochran DL. Biological width

around one- and two-piece titanium implants. Clin Oral Implants Res. 2001 Dec;


9. Kazor CE, Al-Shammari K, Sarment DP, Misch CE, Wang HL. Implant plastic

surgery: a review and rationale. J Oral Implantol. 2004;30(4):240-54.

10. Berglundh T, Lindhe J. Dimension of the periimplant mucosa. Biological width

revisited. J Clin Periodontol. 1996 Oct;23(10):971-73.

11. Hermann F, Lerner H, Palti A. Factors influencing the preservation of the

periimplant marginal bone. Implant Dent. 2007 Jun;16(2):165-75.

12. Broggini N, McManus LM, Hermann JS, Medina RK, Buser D, Cochran DL.

Peri-implant inflammation defined by the implant-abutment interface. J Dent

Res. 2006 May;85(5):473-78.

13. Saadoun AP, LeGall M, Touati B. Selection and ideal tridimensional implant

position for soft tissue aesthetics. Pract Periodontics Aesthet Dent. 1999


14. Potashnick SR. Soft tissue modeling for the esthetic single-tooth implant restoration.

J Esthet Dent. 1998;10(3):121-31.

15. Tishler M. Dental implants in the esthetic zone. Considerations for form and

function. N Y State Dent J. 2004 Mar;70(3):22-6.


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Planning from the

Prosthetic Perspective

with Bradley C. Bockhorst, DMD

Whether you’re placing small-diameter or conventionaldiameter

implants for an overdenture, the case must be

planned from surgical and prosthetic perspectives. The

restorative aspect of the Inclusive ® Mini Implant involves

encasing the O-ring housings within the denture base and

creating a parallel line of draw.

O-ring Housing Dimensions

4.75 mm

The height of the O-ring housing is 3.5 mm (Fig. 1). There

is a space of approximately 1.0 mm between the top of

the collar and the base of the O-ring housing to allow

the housing to be rotated in cases where the implants

are divergent. The housings can accommodate up to

30 degrees of angular divergence between implants.

However, the implants should be placed parallel to one

another as much as possible to provide an ideal prosthetic

fit and to avoid excessive wearing of the O-rings.

There should be a minimum of 3 mm thickness of acrylic

in the denture base above the housing to provide adequate

strength to the prosthesis. Therefore, there should be at

least 8 mm of vertical space from the top of the collar. The

denture teeth would be in addition to this space.

1.0 mm

Figure 1: O-ring housing with 3.5 mm height

3.5 mm

– Small Diameter Implants: Planning from the Prosthetic Perspective – 31

Figure 2a: Cast framework

Figure 2b: Framework incorporated into overdenture

Providing implant-retained

overdentures can be one of the

most professionally rewarding

aspects of your practice.

Figure 3: Virtual framework design with strut over attachment housing

If vertical space is lacking, a cast framework can be incorporated

into the new denture to provide strength (Figs. 2a, 2b).

Frameworks are designed to have a strut over the top of the

attachment housing (Fig. 3).

In mandibular overdenture cases, it is customary to place

four mini implants within the symphysis area with as wide

an anterior-posterior spread as possible while still ensuring

an adequate margin of safety from the nerve (Fig. 4a).

In maxillary overdenture cases, it is customary to place six

mini implants anterior to the sinuses (Fig. 4b). The O-ring

housings are 4.75 mm in diameter, and there should be at

least 2 mm of acrylic between these metal housings in the

denture base (Fig. 5). Therefore, the centers of the implants

should be at least 7 mm apart.

Providing implant-retained overdentures can be one of

the most professionally rewarding aspects of your practice

— and it can be life-changing for your patients. Planning

from both the prosthetic perspective and the surgical

perspective will help the cases go smoothly and minimize

future complications. IM


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Mandibular Spacing

Maxillary Spacing

Figure 4a: Typical placement of mini implants in the mandible

Figure 4b: Typical placement of mini implants in the maxilla

Figure 5: Digital treatment plan for four Inclusive Mini Implants in an edentulous mandible. Cross-sectional view (upper right quadrant) shows O-ring housing well positioned

within the denture base.

– Small Diameter Implants: Planning from the Prosthetic Perspective – 33



Bone Quality Based Drilling Protocol:

Achieving High Primary Stability


Darrin M. Wiederhold, DMD, MS

Figure 1:

Planning software

used to evaluate

relative bone

density showing

Type IV bone


by implant surgeons is the creation of the osteotomy for

implant placement. Without a well-developed osteotomy

site, both the immediate surgical and future restorative

success of the case can be compromised. There are various

factors that must be considered when performing the

osteotomy, such as location, angulation, and spacing for

multiple implants. Critical decisions to be made concern the

choice of whether to follow the soft or dense bone protocol

for a given case, and whether to utilize a bone tap drill. The

goal is to achieve high primary stability, at least 35 Ncm,

at the time of implant placement. This will also impact the

decision whether to immediately provisionalize the case.

As with most things implant-related, assessment of the

preoperative bone quality and quantity is critical to planning

the osteotomy. If using conventional radiography, such as

periapicals and panoramics, evaluation of the trabecular

pattern of the bone, the amount of cortical versus cancellous

bone, and the vertical height of the bone can often indicate

the likely density of the underlying bone. The use of cone

beam computed tomography (CBCT) and digital treatment

planning software can provide an even clearer preoperative

assessment of the bone to be drilled, by allowing the surgeon

to examine the bone three dimensionally, and providing a

Hounsfield or relative density scale of a planned osteotomy

site (Fig. 1). By carefully considering all of these factors, the

surgeon often has a sense of which drilling protocol will be

– Clinical Tip: Bone Quality Based Drilling Protocol – 35

used before the patient even presents for the surgery. As is

often the case, however, many surgical decisions are made

intraoperatively. In essence, sometimes even the best-laid

plans need modification.

A good rule of thumb in osteotomy preparation is to start

small and advance as needed. In other words, drill to the

manufacturer’s recommendations for your specific implant

system for soft bone. Once you have done so, if you feel

that the bone was particularly difficult to penetrate with the

drills, or, when you attempt to place the implant, it does not

easily advance to full depth, then it is typically advisable

to enlarge the osteotomy diameter with the dense bone

drill. The potential dangers in not having an adequately

sized osteotomy include: damaging the implant connection

during placement, not fully seating and properly positioning

the implant in the bone, and creating excess pressure on the

surrounding bone. All of these are detrimental to the longterm

success of the implant and restoration. Some surgeons

advocate drilling to the dense bone diameter in all cases.

This is certainly an option, but the risk is that you could

compromise the amount of initial stability that you achieve

and that the drill or the implant could be displaced into an

unfavorable location due to loss of resistance and torque.

So, again, it is at the discretion of the surgeon.

Screw taps are used in cases of extremely dense bone,

Type I and perhaps Type II. Essentially, the screw taps

precisely mimic the thread patterns of the proposed implant.

Therefore, by tapping the bone with these specialized drills,

the internal configuration of the osteotomy is identical to

that of the threads of the planned implant. This allows for

a more passive, complete placement of the implant with

less insertional torque, and is therefore gentler to the

surrounding bone. Many implants today purport to be

self-threading or tapping, often eliminating the need for

the screw tap. But in those instances where the bone is

particularly dense, screw taps are useful. The screw tap

may be used as an alternative to, or in conjunction with, the

dense bone drill.

There is a great deal of latitude in the choice of whether to

utilize the soft or dense bone protocol, as well as whether

to use a screw tap (Fig. 2). From pre- and intraoperative

evaluation of the bone quality and density, to the decision to

precisely shape the internal anatomy of the osteotomy site

with a screw tap, a variety of factors must be considered to

create the ideal osteotomy and achieve good implant primary

stability. But the extra time and attention to detail needed to

make that informed decision will be rewarded with simpler

surgeries and long-term restorative success. IM

Figure 2: Drill sequence for 4.7 mm x 11.5 mm

Inclusive Tapered Implant. The dense bone drill

and screw tap are optional. Note: Drill charts for

3.7 mm and 5.2 mm Inclusive Tapered Implants

are also available.





16 mm

13 mm

11.5 mm

10 mm

8 mm

Ø1.5 mm

Lance Drill

Ø2.3/2.0 mm

Pilot Drill

Ø2.8/2.3 mm

Surgical Drill

Ø3.4/2.8 mm

Surgical Drill

Final Drill

Soft Bone

Ø3.8/3.4 mm

Surgical Drill

Final Drill

Dense Bone

Ø4.4/3.8 mm

Surgical Drill


Dense Bone

Ø4.7 mm

Screw Tap

Ø4.7 mm


Tapered Implant


– www.inclusivemagazine.com –


Q A:

Go online for

in-depth content

An Interview with Dr. David Little

Interview of David A. Little, DDS

by Bradley C. Bockhorst, DMD

Dr. David Little maintains a multidisciplinary, state-of-the-art

dental practice in San Antonio, Texas, where he dedicates himself

to developing and refining his knowledge skills — as well as those

of his colleagues and peers — through extensive continuing

education and product research. As a clinical researcher

focusing on implants, restorative materials, and technology,

Dr. Little develops predictable procedures for successful

functional and esthetic outcomes. His passion for helping others

drives him to share this expertise in emerging restorative

techniques and materials, as evident in the following interview.

Dr. Bradley Bockhorst: Your practice

is a little different from the typical practice

out there. Tell us how you’re set up.

Dr. David Little: My practice is in a little

town called China Grove, which the

Doobie Brothers made famous. It’s a

sleepy little town around San Antone,

but you can see downtown from my

office. I built the office around a lake,

so all the treatment rooms look out on

the water. One half of the office is a

specialty wing. I have a fully equipped

surgical suite and orthodontic bay,

and every specialist in dentistry rotates

through my practice. We have

CBCT technology, intraoral scanners,

lab support — just about everything

under one roof. And they’re not part

of my practice, they just rent from me.

Together we provide many services.

BB: So you can refer a case and still

keep it in-house?

DL: Exactly.

BB: You’re a general dentist. You place

and restore implants. How do you decide

which ones you’re going to place

and those you’re going to refer out?

– Implant Q&A: An Interview with Dr. David Little – 39

BB: Sounds like it’s a truly interdisciplinary


DL: Absolutely. We’re really blessed to

be able to jump in and take care of

things, especially trauma cases.

BB: You mentioned medical considerations

as a determining factor when deciding

what you might refer out. What

are red flags for you when you’re looking

at a patient’s medical history?

Figure 1: Digital treatment plan

Figure 2: Surgical guide

Figure 3: Denture-modified surgical stent

The key to

success is


planning from

the restoration


DL: First of all, you look at medical

history. Also, in our office, we can do

everything from just local anesthesia

all the way to IV sedation, depending

on what patients want along those

lines. Then, the key is to determine

the factors necessary for success: Is

it great bone? Is it good occlusion? Is

everything set up to make it successful?

If so, then it’s one that I’m going to do.

If the patient needs a sinus lift or bone

augmentation, I’m going to refer it. We

do really well referring together. The

oral surgeon will do the bone grafts,

we’ll do the implants, or if we need

periodontal plastic surgery, we’ll bring

in the periodontist. It actually works

very well.

DL: Uncontrolled diabetes, blood disorders,

the use of bisphosphonates —

those are things that we shy away

from. Essentially anything that makes

us uncomfortable. If I wouldn’t do an

extraction, then I’m probably not going

to do an implant on them. So, I use

that as my guideline.

BB: Do you have any advice for aspiring

implantologists — how they should

get started, and what they should look

for in first cases?

DL: First of all, I think you need to

have an eye for implants. I think you

have to start looking for cases where

implants will be the best solution for

the patient. Second, get educated.

Go out and really learn your craft.

And then use mentors. Mentors are a

really good thing. Today, by using a

team approach, you can work with a

laboratory like Glidewell, and sit down

and plan out the case, looking at it

from the restorative aspect backward,

so that everything is planned out. By

using CBCT and surgical guides, you

can do it very predictably and get

great results. The bottom line is: It’s

better for our patients.

BB: You mentioned earlier that you have

a cone beam scanner in your office.

DL: I do. Even before I had one, I

would send it out to get that done

because I think it’s really valuable information.

Sometimes all you need is

a scan to say, “Yes, OK, I’ve got this

much bone — great.” Sometimes I

look at it and go: “Wow, I’m glad I did

that. I didn’t want to do that case.”


– www.inclusivemagazine.com –

But the real key is not just the CBCT.

It’s putting it in the software and being

able to manipulate it. I call it virtual

planning. I want to be able to show

my patient that I’m going to put in

this size implant, and this is why, and

this is how it’s going to be contoured

and shaped, all the way to the final

restoration. Because I think the key to

success is treatment planning from the

restoration backward.

BB: What is your favorite planning software?

There are several on the market.

DL: I use SimPlant ® (Materialise Dental

Inc.; Glen Burnie, Md.), mostly

because you can use every implant

system. But with whatever implant

you’re using, there is going to be a

system that will work with you. So,

again, I think you’ve got to look at the

total picture.

BB: We’ve had the same experience. We

do a lot of SimPlant cases here because it

has an open architecture. Let’s talk about

guided surgery and level of guidance.

DL: Obviously, you can have the lab

make a guide for you from a wax-up.

That will kind of give you the position,

but it doesn’t really give you the angle,

doesn’t give you the depth. It just gives

you a guide to stay within that area.

Or you can go all the way to where

you can actually control depth, angle,

and position; you can even place the

implant through the guide (Figs. 1, 2).

Everything is planned out. I like that

the best because it gives me the perfect

emergence profile. The software helps

me establish what my abutment is

going to be like, so the laboratory can

work with me to create a provisional

that stays in that same position —

everything is worked through.

I’ll also say that using even the

patient’s denture as a guide is huge

because that makes sure that you keep

those implants in the neutral zone,

and you’re going to get a great result

as well (Fig. 3). There are a lot of guide

techniques, but I like using the one

that controls all of it, if I can.

BB: At the California Dental Association

(CDA) meeting in Anaheim last

May, you spoke on the topic of overdentures.

Can you talk a little bit about how

you approach your edentulous patients?

DL: A lot of denture patients are dental

cripples. They really can’t function

and they can’t eat. So, one of the

things I do is I ask them, “Do you want

to eat what you want, or eat only what

you can?” Then I talk about what the

different solutions are. I ask questions

like, “At the end of this, would you just

like it that your denture stays in a little

better, or are you looking for something

that you never have to take out?”

Their answers will tell you the direction

they want to go. Then I look at

implant-retained, soft tissue-supported

as a solution. You can do that with

mini implants, or you can do that with

two or four conventional implants,

with different attachments such as O-

rings and Locator ® attachments (Zest

Anchors; Escondido, Calif.) (Figs. 4, 5).

Or, you could go to implant-retained,

implant-supported. The ANKYLOS ®

SynCone ® (DENTSPLY Friadent) is what

I use for that particular one. It is implant-retained

and implant-supported,

but still removable. And, finally, we

have the option to go screw it in and

either use processed denture teeth,

which are very esthetic today, or make

it out of porcelain.

So, you have that whole range of solutions.

And I really like what Glidewell

has done in establishing one fee. If you

ask a dentist how much an implant

costs, they know the surgical fee off the

top of their head. But if you ask them

how much a crown is, they go: “Uh, it

depends.” On what? Well, it depends

on abutments, etc. So it’s having a

solution — a two-implant solution, a

four-implant solution. If you include

everything in that, it’s just a whole lot

better when you present it to patients.

BB: And you understand all your costs

as a dentist. Talking about the edentulous

patient, how do you make that

decision between a screw-retained denture

and a crown & bridge procedure?

Figure 4: Locator attachments and overdenture

Figure 5: Restored overdenture case

DL: I look at the situation and treat

it four ways: First, I look at it and

treat it in my mind. Second, I wax it

up so I can see if what I’m thinking

can work. Then I sit down with the

lab and we discuss how this is going

to work out. Then we ask the patient

because they’re most important. That’s

who we’re doing it for. Do they want it

fixed? Hopefully, if they want it fixed,

they have enough bone to do it. That’s

usually what we have to deal with. If

they do have enough bone, then I tell

them, “Look, if you have a lower denture,

you’re eating at about 10 percent

efficiency.” If I put in two or four implants

— implant-retained, soft-tissue

supported — you’ll be at about 40 to

60 percent. But if you really want to

– Implant Q&A: An Interview with Dr. David Little – 41

Figure 6: Double-cord tissue retraction and laser

troughing tissue management

get back to the way you were chewing,

we can do this screw-retained, or

porcelain, and then I can get you back

to functioning even better than you

were before. So, those are the things

I look at. And I really ask that question

of my patients: “Do you want to

eat what you want, or eat only what

you can?”

BB: Regarding screw-retained dentures

versus porcelain, how do you make a

decision on which way to go?

DL: That’s a good question. What do

patients think? They all think porcelain

is better. Well, porcelain is better

if you have the space for it. And

lip support is the number one thing.

You’ve got to do a wax rim and make

sure your lip support is proper because

I think you can do a better job

with acrylic a lot of times. So, it’s all

in the diagnosis — looking at it and

seeing what is best for that individual

patient. Because the cost on those is

not as much as you’d think, when you

get to that point. A lot of factors are involved,

but really, listen to the patient.

I think that’s the main thing.

BB: A suggestion I’ve heard you give in

When I talk to

young dentists

who are coming

out of dental

school, I tell

them, “Don’t

biopsy wallets.”

... Always do

what’s best.

a past presentation is, “Treat the patient

as you’d treat yourself.” Can you expand

on that treatment approach?

DL: When I talk to young dentists

who are coming out of dental school,

I tell them, “Don’t biopsy wallets.”

Treatment plan what you would do

for yourself, for your mom. Don’t

make value judgments. Tell them what

you’d recommend. You can always

back off and sequence it, but always

do what’s best. They want what’s right.

I think that’s my best advice: Don’t

biopsy wallets.

BB: I also know you’re a big proponent

of education and the importance of

educating the team. What are your

thoughts along those lines?

DL: Here’s the truth: As dentists, we

spend more time with our team than

we do with our family during waking

hours, so we’ve got to be on the

same page. So many times you go to

a seminar and you’re all fired up, but

when you come back to the office, after

a couple weeks, things are back

to normal. Unless you take it back

and implement it, nothing happens.

And the key to that is, when you do

bring implants into your practice, you

have to have systems, strategies, and

everybody talking the same language

because the very first part of case acceptance

is the phone call. Sometimes

I’ll actually do random care calls. I’ll

call offices and say, “I need implants,”

and see what they say because everybody

needs to be on the same page.

BB: We were talking about different

technologies — guided surgery, cone

beam scanning. Another is intraoral

scanning. Are you involved in that?

DL: Absolutely, and I’ve been involved

with that from the beginning. Looking

at the different technologies out there,

I definitely get better fits when I use

an intraoral scanning device. I definitely

get less chairtime when I seat

them, so that’s the real value for the

dentist. There’s also that wow factor.

Patients love it, there’s no gagging. But

I really think it also makes you a better

dentist. If we take an impression

and look at it and go, “It looks pretty

good, the lab will make that work”

versus blowing it up and looking at it

and saying, “Wow, I can’t see that,” it

really makes us prepare teeth better,

and see things more accurately. Key,

though, is still tissue management.

Figure 7: Temporary abutment and provisional crown


– www.inclusivemagazine.com –

The holy grail would be when we can

scan it and that’s no longer a factor.

But I think that’s going to be the future

of dentistry, where we’re headed.

I’m a big believer of doing the scanning

yourself and letting the lab do

the work. That’s just not my type of

practice, where I’d plan it and mill it

right there in the office. I think it’s a

great service and a great technology,

but I prefer to use the lab because my

chairtime is more valuable to me.

BB: Regarding tissue management with

intraoral scanning, do you have a particular

technique that you like to use?

DL: Tried and true, the gold standard

is still the double-cord technique —

I can teach that all day long — and

I’ve gotten into diode (AMD) and CO 2

(DEKA) soft tissue lasers . I think lasers

have really made a big difference

in being able to manage tissue. And

there are lots of products out there

that help that. I think doing whatever

you need to do to be able to see that

margin is the key.

BB: As far as the different materials

that are out there right now, is there

anything you’re experimenting with or

starting to work with?

DL: We’ve seen a growth in monolithic

restorations, which is probably the

biggest thing happening right now.

When we first thought about that, we

said: “Oh my goodness, that material

is so hard. How is it going to wear

the opposing?” Concerns like that. But

there are companies out there, like

Glidewell, that have done all the tests,

and I now know it’s not going to wear

the opposing enamel. And you’re not

going to have to worry about it breaking.

Also, the esthetics continue to get

better and better. That goes back to

CAD/CAM, and using that technology

to its finest. But I don’t think there’s a

single perfect solution for every case.

You’ve got to evaluate each case individually.

Lithium disilicate is good in

some areas, zirconia is good in other

areas. I think you need to look at the

case and the technologies available

and make the best decision.

BB: Going back to implant placement,

are you immediately provisionalizing

your cases?

DL: I’m very conservative in that respect.

There are a lot of things I look

at to make sure I can do that. Let’s

look at single-tooth for a minute, upper

anterior (Fig. 7). If I can get the

tooth out atraumatically, that’s number

one. I have to have the buccal plate

solid and in good shape. Two is if I

can place the implant and get a little

bit of bone apical. So if I have apical

stability, place it a little bit more

toward the palate to get a little palatal

stability. And the most important

thing is that I can have it in disclusion

so there’s no pressure on it.

Doing that, our success rate in our

office — and we track everything —

is just as good as if we don’t provisionalize.

And our papillae are better.

So, I’m seeing great results doing that.

But if those things don’t match, I don’t

do it. There are some great provisional

techniques we can apply to wait out

that healing period.

Now, let’s talk full arch. There’s a

big trend, especially among baby

boomers, where they want it now.

They don’t want to wait. So, if we can

extract, place the implants, and seat an

immediate screw-retained provisional,

I think that’s a beautiful service for

patients. Patients are really enjoying

that (Fig. 8).

BB: And are you doing everything in

one surgery?

DL: We are. But again, not for every

case. We don’t promise it, either. I always

start out with a full denture. And

if it’s not the bone that I want to see,

if I don’t have the torque I want, then

we just reline it. But I usually know

because I’ve used the planning CBCT,

and I know exactly what I have. I’ve

measured my vertical. I know every

detail about it. So we are doing cases

where we’re doing upper and lower

immediate extractions and immediate

placement and immediate screwretained

provisionalization, and then

coming back later with CAD/CAM

Figure 8: Immediate screw-retained provisional restoration

and building the final prosthesis. And

that’s a great service to patients.

BB: Have you worked much with Allon-4

(Nobel Biocare; Yorba Linda, Calif.)

when you’re doing screw-retained restorations?

DL: I have. That’s been around now

for 10 years, so we’ve got some track

record to look at. And for patients

who don’t have adequate bone, that’s

a great solution. Honestly, if I have a

choice, I’d rather have six straight. But

a lot of times I can’t. So, in situations

where you don’t want to do bone

grafts and other things, it is a solution.

We mentioned SynCone earlier. One

of the things I like about SynCone in

the lower is that I can put four implants

in between the mental foramen,

– Implant Q&A: An Interview with Dr. David Little – 43

It’s a great

time to be in

dentistry. And

the best thing is,

the people who

benefit the most

are our patients.

I can load that immediately, and the

costs are a lot less, so it opens that

treatment solution up to more patients.

Sometimes I even use that as

a provisional technique, and then

graft and come back later in the other

areas. Again, you’ve got to look at

what is best for the patient and make

the diagnosis.

BB: Going back to single teeth and

immediately provisionalizing, in what

percentage of your cases do you think

you’re actually doing that?

DL: If I do that in that upper anterior

area, I plan on doing it every time I

can. Now, the truth is, that’s probably

only about 80 percent of the time because

there are some times when we

just don’t. We always have the lab fabricate

some type of provisional for me.

BB: Have that flipper ready.

DL: Always have that ready. Like an

Essix ® appliance (Raintree Essix Inc.;

Wilmington, Del.) or something that

I can put in there so that we have

something for the patient to wear

without any worry and without compromising

their care. And, obviously,

patients want it now. If you can do it

now, patient acceptance goes up. With

the technology we have today, we can

do that.

BB: Once you provisionalize at the time

of placement, how long are you waiting

until you do the final restoration?

DL: There are a lot of different opinions

on that, a lot of different research

out there. I’m still waiting three

months. Truthfully, if they’re in a good

provisional that looks great and you

have to wait longer, it’s not a problem.

They’re happy. So, it’s not as big an

issue from that standpoint.

BB: How about full-arch cases? If you

immediately provisionalize, how long

are you waiting?

DL: With those cases we’re actually

waiting a little bit longer — about four

months on most of those cases. It depends.

When wI put that in, I can tell

right then how long it’s going to be. If

I have any concerns, I’ll wait longer.

There’s no rush because you have a

good provisional for them to work with.

It goes back to working with the lab

and having everything in proper order.

It’s to the point now where we’ve become

so good at the provisionals that

we can use that as part of our diagnostics

for our final, and even eliminate

some appointments. The more planning

you do, the better your results

are going to be.

BB: Right. It gives you that ideal prototype

to work from. Are there any future

technologies you see coming to the fore

in dentistry?

DL: I think implants are going to

continue to grow. More dentists

are going to be able to get into that

technology, and more patients are

going to be able to afford it. In our

practice, it’s one of the most successful

things that we do, so there’s a bright

future for that. As I said before, a lot

of people who are edentulous are

dental cripples, and we can really help

with the use of implant overdentures.

Those treatment options are going to

become more and more popular.

Scanning technologies are also going

to change things, even if it’s just with

diagnostic impressions. We’re going to

be able to do more and more things

digitally, and anything we can do

digitally, I think, is going to help us

all the way through a given procedure

to final restoration. We’re looking at

doing dentures digitally now, which

is something else becoming more

prevalent in our field and that will

continue to evolve. It’s a great time to

be in dentistry. And the best thing is,

the people who benefit the most are

our patients. IM


– www.inclusivemagazine.com –

Go online for

in-depth content

Coming Soon…


Inclusive Tooth Replacement Solution

Open Platform



The Inclusive ® Tooth Replacement Solution, released

in March of this year, is the first all-in-one

treatment package for a missing tooth, featuring

implant, surgical drills, custom temporary components

for patient-specific soft tissue management, and the final

CAD/CAM restoration. The complete solution is available

for one low price, with no hidden fees. With this solution,

the ease of re-creating a natural emergence profile and

natural esthetics for a predictable outcome is an attainable

reality, both for specialists and general dentists alike.

Inclusive Implant Solutions

Compatibility Chart

In response to the dental implant market embracing the

importance of soft tissue contouring and its benefits to the

surgeon, the restorative doctor, and the patient, Glidewell’s

Implant department has now expanded the solution to

accommodate all implant systems compatible with the

Inclusive ® Custom Implant Abutment product line. This

creates the opportunity for more clinicians to offer their

patients the advantages of the tissue contouring system

contained within the Inclusive Tooth Replacement Solution.

Whatever implant system you use, you and your patients

can now benefit from the tremendous effects of training

tissue from the time of implant placement, establishing the

clinical advantages of a stable tissue bed. IM

AstraTech Dental # OsseoSpeed #

Certain #

Biomet 3i #

External Hex


Brånemark System #

Nobel Biocare # NobelActive #

NobelReplace #

Straumann # Bone Level #

Zimmer Dental # Screw-Vent #

AstraTech OsseoSpeed is now Dentsply Astra Tech Implant System.

# Not a trademark of Glidewell Laboratories

– Product Spotlight: Inclusive Tooth Replacement Solution — Open Platform – 47



Go online for

in-depth content

Obtaining Accurate Occlusal Records in

Kennedy Class I and Class II Implant Cases


Bradley C. Bockhorst, DMD

One of the challenges when restoring distal free-end

cases, also referred to as Kennedy Class I and Class

II cases, is obtaining accurate occlusal records.

Clinicians will typically use bite registration material

between the remaining teeth or attempt to inject enough

bite registration material to fill the edentulous space. This

may not be adequate to obtain an accurate articulation,

however. In these situations, utilizing a simple bite block

while obtaining occlusal records can be a tremendous help.

The result of inaccurate records is that the case is then

articulated incorrectly. This further compounds the occlusal

discrepancies in the final prosthesis. To minimize this

potential occlusal anomaly, an occlusal verification jig can be

fabricated by the laboratory. To fabricate the jig, an implantlevel

impression, bite registration, and opposing model or

impression are made and forwarded to the laboratory.


A soft tissue model is poured and the case articulated.

Inclusive ® Custom Implant Abutments are fabricated and

mounted on the implant analogs. An acrylic custom jig is

fabricated to seat securely over the abutments and extended

to function as an occlusal index. This appliance is then sent

to the clinician’s office.

Clinical Procedure

When the patient returns for their CR/VDO (centric relation/

vertical dimension of occlusion) record verification, the

abutments are mounted on the implants and the abutment

screws tightened (Figs. 1a, 1b). The occlusal verification

jigs are then seated on the abutments (Fig. 2), and the bite

is checked.


1b 2

Figures 1a, 1b: Abutments mounted on implants

Figure 2: Jigs seated on the abutments

– Clinical Tip: Obtaining Accurate Occlusal Records in Kennedy Class I and Class II Implant Cases – 49

If it is not repeatable and verifiable,

a new bite should be made (Fig. 3).

This is done by trimming the jigs until

there are no occlusal contacts from the

opposing dentition (Figs. 4a–4c).


Figure 3: Note open posterior bite




Figures 4a–4c: Adjusted jigs completely out of occlusion


– www.inclusivemagazine.com –


Figures 5a, 5b: A new bite registration is made

Then an accurate bite registration

is made (Figs. 5a, 5b). The new bite

registration should be verified and



– Clinical Tip: Obtaining Accurate Occlusal Records in Kennedy Class I and Class II Implant Cases – 51

The bite registration, incorporating the

jigs, is carefully removed and returned

to the laboratory (Figs. 6a, 6b).


Figures 6a, 6b: The bite registration, incorporating

the jigs, is returned with the case for completion.

Case completion

The case is remounted and should

proceed in the usual manner to

completion, with greater certainty of

an accurate occlusal relationship. Use

of the occlusal verification jig will help

minimize adjustments and remakes for

distal free-end cases. IM



– www.inclusivemagazine.com –

Photo Essay:

Immediate and Post-Placement

Utilization of the Inclusive

Tooth Replacement Solution

Go online for

in-depth content


Darrin M. Wiederhold, DMD, MS

and Bradley C. Bockhorst, DMD

The Inclusive ® Tooth Replacement Solution provides clinicians the armamentarium to place

and immediately temporize single-unit implants in edentulous spaces. The components

further assist the restorative dentist by immediately beginning to guide the soft tissue

development around the implant. However, there are also cases in which the implant has

already been placed. The Inclusive Tooth Replacement Solution line offers the versatility to

address these post-placement cases as well, with the difference being that the custom temporary

components are designed and milled based on an implant-level impression. The following pair

of case reports demonstrates both situations. The first illustrates the use of the Inclusive Tooth

Replacement Solution to replace a missing maxillary right second premolar at the time of surgery.

The second illustrates the introduction of the Inclusive Tooth Replacement Solution during the

healing phase, post-implant placement.

– Photo Essay: Immediate and Post-Placement Utilization of the Inclusive Tooth Replacement Solution – 53

Case #1: Implant Placement and Immediate Non-Functional Temporization

The patient is a 46-year-old female who initially presented

to our office with a chief complaint of: “I have a brokendown

tooth that I would like to have extracted and replaced

with an implant.” After evaluation of the patient, the crown

of tooth #4 was found to be fractured, and decay was noted

subgingivally. The tooth was determined to be nonrestorable,

and was atraumatically extracted under local anesthesia,

with care taken to preserve the buccal plate. The socket

was gently currettaged and Puros ® Cortico-Cancellous Particulate

Allograft material (Zimmer Dental; Carlsbad, Calif.)

was placed in the extraction site for socket preservation and

covered with a BioMend ® Absorbable Collagen Membrane

(Zimmer Dental). The membrane was then secured using

4-0 Vicryl ® suture (Ethicon Inc; Somerville, N.J.).

After four months, the patient returned to our office for

evaluation, during which the extraction site and graft were

determined to have adequately matured to proceed with

implant placement. After reviewing the CBCT scan in the

In2Guide implant planning software (Cybermed Inc.;

Irvine, Calif.), the decision was made to place a 3.7 mm x

10 mm Inclusive ® Tapered Implant.


The requisite polyvinyl siloxane impressions were taken, as well as an accurate bite registration and preoperative intraoral

photographs, including selection of the shade for the BioTemps ® provisional crown.



The diagnostic records were submitted,

along with a completed Inclusive Tooth

Replacement Solution digital Rx, to

Glidewell Laboratories for fabrication

of the Inclusive Tooth Replacement

Solution components. Upon receipt of the

patient’s diagnostic records and digital

Rx, the Inclusive Tooth Replacement

Solution components were fabricated

and forwarded to our office for implant

placement and temporization.

James Smith



123 Main Street Suite #1 Anywhere, USA



4 A3

Please fabricate components for replacement of #4.

J Smith



✔ Shade photos


– www.inclusivemagazine.com –


On the day of surgery, the risks and benefits of the

planned implant surgery were reviewed thoroughly with

the patient, and her verbal and written informed consent

was obtained. The patient was then draped in the

usual sterile fashion for implant surgery, and instructed

to swish preoperatively with 0.12% chlorhexidine gluconate

oral rinse for one minute. The surgical area was

anesthetized using 4% Septocaine ® with epinephrine

1:100,000 (Septodont; Lancaster, Pa.), buccally and

palatally. A full thickness mucoperiosteal flap was then

reflected between the mesial of tooth #3 and the distal

of tooth #5 to allow visualization of the alveolus.


The fit of the Inclusive Tooth Replacement Solution

prosthetic guide was confirmed, and the proposed

location of the osteotomy site verified using a periodontal

probe. With the prosthetic guide in place,

the planned site was marked using the Inclusive ®

Lance Drill.


The prosthetic guide was then removed and the pilot

hole made utilizing the 2.3 mm/2.0 mm diameter surgical

drill to a depth of 10 mm.


– Photo Essay: Immediate and Post-Placement Utilization of the Inclusive Tooth Replacement Solution – 55


The location and angulation of the osteotomy were confirmed with a digital periapical digital, with the 2.3 mm/

2.0 mm surgical drill in place.


7 8

Once the proper angulation and location were confirmed,

the osteotomy was completed, ending with

the 2.8 mm/2.3 mm diameter surgical drill due to

the relatively soft bone in the area.

A 3.7 mm x 10 mm Inclusive ® Tapered Implant was

delivered to the site and advanced initially by hand with

the plastic carrier.


– www.inclusivemagazine.com –

With the implant securely hand-threaded into the

osteotomy, the Handpiece Hex Driver was attached

to the handpiece and used to rotate the implant

to depth.


Final seating of the implant was accomplished with

the Torque/Ratchet Wrench, achieving a torque

value of 40 Ncm.


Because the custom temporary components are

fabricated with one of the implant hexes aligned to

the direct buccal, it is imperative that the implant

be rotated to the proper orientation at the time

of surgery. This was accomplished and confirmed

with the Implant Driver attached to the Torque/

Ratchet Wrench.


It is imperative

that the implant

be rotated to

the proper

orientation at

the time

of surgery.

– Photo Essay: Immediate and Post-Placement Utilization of the Inclusive Tooth Replacement Solution – 57


As sufficient initial implant stability was achieved in this case (35–40 Ncm), the decision was made to immediately

temporize the implant with the custom temporary abutment and BioTemps crown.



Both the custom abutment and BioTemps crown

exhibited excellent fit and orientation in all dimensions.

It was further confirmed that the BioTemps

crown was out of occlusion by 1.5 mm, which is

desirable for immediate temporization so as to

avoid any lateral micromotion on the neophyte

implant that might compromise its osseointegration.

The patient tolerated the procedure

very well, and there were no operative complications.

Postoperative home care instructions were

reviewed thoroughly with her, and she was

appointed in one month for follow-up.


A three-month postoperative checkup revealed

excellent healing of the soft tissues. Final

impressions were scheduled to follow one

month later.


– www.inclusivemagazine.com –

Case #2: Post-Placement Utilization of the

Inclusive Tooth Replacement Solution

A 41-year-old male presented with a chief complaint of:

“I had my molar taken out over 10 years ago, and I would

like an implant to replace it.” Following appropriate workup,

a 5.2 mm x 8 mm Inclusive Tapered Implant was placed

without complication in the edentulous area #19. The

5.2 mm diameter implant features a platform-switching

design that utilizes 4.5 mm diameter prosthetic components.

A flaring Inclusive ® Healing Abutment 4.5 mm x 5.7 mm x

3 mm was tightened to 15 Ncm into the implant in a singlestage


To ensure proper tissue management specific to his anatomy,

in the interest of gingival health and natural esthetics, the

patient elected to take advantage of the custom healing

features of the post-placement Tooth Replacement Solution.

An advantage of the post-placement solution is that the

custom temporary components are designed and milled

based on an implant-level impression, mitigating or even

eliminating any need for chairside adjustment of the custom

components upon delivery. Continued on page 62

Upon return to the office post-implant placement,

the patient exhibited excellent soft tissue healing

around the standard titanium healing abutment.

The resulting tissue formation, however, is of a

generic, round geometry commonly encountered

with stock components, rather than being optimized

for the anatomy of the edentulous space.


The stock healing abutment was removed so that

a closed-tray impression coping could be seated

on the implant and the closed-tray screw handtightened.


– Photo Essay: Immediate and Post-Placement Utilization of the Inclusive Tooth Replacement Solution – 59

3 4

A periapical radiograph was taken to verify complete

seating of the custom impression coping.

A standard closed-tray impression was taken. The

impression coping was then removed and the healing

abutment replaced. The impression, an opposing model,

bite registration, and prescribed shade of BioTemps

provisional crown were sent to Glidewell Laboratories

with the Tooth Replacement Solution Rx.


Upon receipt of the Tooth Replacement Solution components, the stock healing abutment was removed

and replaced with a custom healing abutment. This patient-specific abutment is anatomically

contoured, unlike standard, round components. The abutment screw was tightened to 15 Ncm and

the access opening sealed with a piece of Teflon tape, covered with flowable composite. Had the

patient desired a temporary restoration in this posterior space, the custom temporary abutment

and BioTemps provisional crown could have been delivered in lieu of the custom healing abutment,

with the same emphasis on sculpting the desired soft tissue contours.



– www.inclusivemagazine.com –


Once an appropriate osseointegration period had

passed, the case was ready for final impressions.

The matching custom impression coping allows the

transfer of the final soft tissue contours and implant

position to the master cast.


The resulting impression, complete with the custom impression

coping, opposing model, bite registration, and prescribed

shade of final restoration were submitted to the lab

on the pre-populated Tooth Replacement Solution Rx. In this

case, a BruxZir ® Solid Zirconia screw-retained crown was



The custom healing abutment was removed,

so that the custom impression coping could be

seated on the implant and the abutment screw

hand-tightened. A periapical radiograph was

taken to confirm complete seating of the custom

impression coping. The top of the screw access

opening was then blocked out with soft wax to

prevent impression material from flowing inside the

coping. A closed-tray impression was taken.


– Photo Essay: Immediate and Post-Placement Utilization of the Inclusive Tooth Replacement Solution – 63



Delivery of the final prosthesis involved

removing the custom healing abutment

and then seating the one-piece BruxZir

screw-retained crown. The abutment screw

was tightened to 35 Ncm and a periapical

radiograph taken to verify final seating.


Once the interproximal and occlusal contacts

had been checked, the occlusal screw access

opening was sealed with a piece of Teflon

tape and composite, bringing the case to a

successful conclusion.

A Road Map for Surgical and Restorative Success

The Inclusive Tooth Replacement Solution is designed to

address communication and component issues known to

complicate implant treatment and too often compromise

the final result. By planning the case from the restorative

perspective prior to implant placement, and taking advantage

of custom temporary components for patient-specific soft

tissue management, clinicians are finding it much easier

to achieve the desired, esthetic outcome. These case

presentations highlight the simplified, predictable process

by which this versatile, one-of-a-kind solution addresses

implant placement and soft tissue healing in a manner that

will help pave the path to a superior final restoration. IM


– www.inclusivemagazine.com –



When a Flapless Approach Makes Sense


Michael McCracken, DDS, Ph.D

For many dentists who place

implants, the lure of the “perfect

surgery” is almost irresistible.

Picture it in your mind. It starts

with a flapless approach, continues

with a flawless six-minute implant

placement, and ends with the stunned

appreciation of the patient and a

satisfied smile on the face of the

dentist. The fact is, however, that

flapless surgery can present serious

challenges to the beginning surgeon.

In the university residency setting,

a flapless surgery is automatically

categorized as a minimum of 3 on a

4-point scale, just because it is flapless.

These surgeries can be difficult!

I have seen more than one experienced

and proficient surgeon become

embarrassed when demonstrating a

flapless surgical approach.

Clinicians disagree on whether keratinized

tissue is critical for implant

longevity. There is no doubt, however,

that keratinized tissue is generally desirable

because it improves esthetics

Figure 2: Favorable bone architecture

When is a flapless approach reasonable?

Look for three things:

n Abundant keratinized tissue (Fig. 1)

n Favorable bone architecture (Fig. 2)

n Easy access to treatment planning technology (Fig. 3)

Figure 1: Abundant keratinized tissue

– Clinical Tip: When a Flapless Approach Makes Sense – 65

The Benefits of Digital Treatment Planning

and Guided Surgery in Conjunction with

Small-Diameter Implants

n 3-D view to determine the quality and quantity of bone

as well as identify critical structures


n Minimally invasive procedure through a flapless


n Accurate transfer of the digital plan to the clinical

setting utilizing a pilot surgical guide

Criteria for Flapless Approach

u ≥7 mm keratinized gingiva

u Adequate bone to encase


u Appropriate diagnostic

work-up (e.g., CBCT)

Benefits of Flapless

u Minimally invasive

u Less potential for bone loss

as there is no disruption of

blood supply

and frequently aids in patient comfort.

If keratinized tissue is minimal, I

prefer to raise a flap to preserve what

tissue is there. If less than 3 mm of

keratinized tissue is present, incise

lingually to the band and leave it on

the facial of the implant. If more than

3 mm of keratinized tissue exists, split

the band, putting some on each side

of the implant. If you leave a small

gap in the surgical margins around

the implant at closure, this gap will

fill in with keratinized tissue, actually

increasing its width.

If the bone architecture is not ideal,

laying a flap is often necessary to

correct the situation. This may require

alveoplasty to broaden and flatten

the ridge, or grafting to increase the

ridge width. These procedures may be

impossible without a flap.

Finally, use technology to make your

flapless approach successful and accurate.

CBCT scans are present in most

dental communities, and laboratory

support is readily available to facilitate

guide fabrication. This takes the

guesswork out of implant placement.

Although I am reluctant to admit it,

some of my most esthetic implants

have been placed with a surgical guide

based on CBCT analysis.

So when you have all three —

abundant keratinized tissue, favorable

bone architecture, and prior 3-D

planning — go for it! There is nothing

like that satisfied smile, especially

when it’s yours. IM

If the bone architecture

is not ideal, laying a flap

is often necessary to

correct the situation.

Benefits of Flapped

u Direct visualization

u Ancillary procedures

(e.g., grafting)

Figure 3: 3-D treatment planning technology


– www.inclusivemagazine.com –



Go online for

in-depth content



Inclusive Custom


Dzevad Ceranic, CDT, Implant Department General Manager

and Grant Bullis, Director of Implant R&D and Digital Manufacturing

OVER THE PAST FIVE YEARS, the Implant department at

Glidewell Laboratories has witnessed a tremendous rate

of growth in the demand for its line of Inclusive ® Custom

Abutments (Fig. 1). By pioneering advance ments in the

computer-aided design and manufacturing techniques used

to produce these patient-specific restorations, the laboratory

has developed and refined processes that are far more

predictable, more precise, 1 and more efficient than traditional

waxing and casting techniques. The end result is a custom

solution at or near the cost of a generic, prefabricated

abutment, making it the first choice of a growing number

of clinicians.

Digital Abutment Units

Nov 09

Jan 10

Mar 10

May 10

July 10

Sept 10

Nov 10

Jan 11

Mar 11

May 11

July 11

Sept 11

Nov 11

Jan 12

Mar 12

May 12

Figure 1: Graph charting growth in demand for digitally designed Inclusive Custom Abutments at Glidewell Laboratories. The last three years have seen average monthly

prescriptions increase by nearly 3,000 percent.

– Lab Sense: Inclusive Custom Abutments – 67

Figure 2a: Clinical image of an Inclusive Custom Abutment with delivery jig

Figure 2b: Clinical image of a custom abutment, freshly seated, demonstrating

proper soft tissue support

Custom Abutments or

Stock Abutments

The clinical benefits of patient-specific

implant abutments have been well

documented in the dental literature. A

prefabricated “stock” abutment lacks

the flexibility in form to address the

unique challenges, individual complexities,

and esthetic demands of a given

case. In the majority of implant cases,

the patient is best served by an abutment

specifically tailored to the natural

emergence profile of the tooth being

replaced, the morphology of adjacent

and opposing dentition, the presence

of defects, and proper support of the

eventual restoration, among other factors.

2 To provide optimal function and

esthetics, stock abutments must often

be modified by the lab to establish

suitable height, margins, and path of

insertion, which can vary, depending

on the location and angulation of implant

placement. Not only does this

modification process provide a less

than ideal emergence profile, but the

cost is often as much or more than the

cost of a custom abutment.

through proper support and management

of the soft tissue with a properly

placed margin, which facilitates

cement removal during delivery of the

final restoration (Fig. 3).

Digital Custom Abutments or

UCLA Abutments

Since its introduction in 1987, the

universal clearance-limited abutment

(UCLA) has enabled technicians to

create the wax-up of a custom abutment

by hand, allowing them to design

abutments that adapt to conditions

of restricted occlusal and interproximal

clearance. While suitable in most

clinical situations, the UCLA process

can be tedious, time-consuming, and

less precise 3 for both the clinician and

laboratory. Given the high cost of noble

metals, and the intensive laboratory

procedures required to fabricate

the final solution, an overwhelming

number of clinicians are switching

from UCLA abutments to digital custom

abutments (Fig. 4).

Digital Inclusive Custom

Abutments or Other Digital

Custom Abutments

With a greater number of clinicians

choosing the esthetics, function, and

Glidewell provides an acrylic jig with

each Inclusive Custom Abutment to

help ensure swift, accurate seating,

thereby minimizing chairtime and patient

discomfort (Figs. 2a, 2b). Once

delivered, these patient-specific abutments

promote peri-implant health

Figure 3: Illustration depicting the subgingival location of the cement junction found on a typical stock abutment,

in comparison to the tissue-level cement junction found on an Inclusive Custom Abutment


– www.inclusivemagazine.com –

Digitally (CAD) Designed vs. Waxed Units























Custom Abutments


Custom Abutments




Custom Abutments



Custom Abutments

Figure 4: Comparative percentages of digitally designed Inclusive Custom Abutments versus conventionally waxed Inclusive Custom Abutments ordered from Glidewell

Laboratories in 2009 and 2012

efficiency of CAD/CAM custom abutments,

it bears looking at some of

the industry-leading options available

today. Dedicated to providing

the highest-quality implant prosthetics

possible, Glidewell Laboratories

continuously improves the technologies,

materials, and processes used to

design and manufacture its Inclusive

line of products. Recently, the lab’s research

and development department

conducted a same-case, microscopic

comparison of an Inclusive Titanium

Custom Abutment alongside patientspecific

titanium abutments from two

other leading manufacturers. Scanning

electron microscopy (SEM) images

provide an up-close look at the critical

implant-abutment interface of these

competing solutions (Fig. 5).

Seen from this highly magnified view,

the Inclusive Custom Abutment presents

favorably in relation to its peers.

The Inclusive abutment exhibits

smooth transitions between features,

an absence of burs or tooling marks,

and an excellent finish of the mating

surface. The second sample lacks a

smooth transition between features,

displays more pronounced roughness

of the mating surface, and exhibits an

inconsistent blend line in the gingival

portion of the abutment. The third

sample exhibits burs on and around

the mating surface and connection

geometry, and a tri-lobe interface with

geometry that differs from the implant’s

prosthetic connection. The clinical

relevance of these defects could

include an increased potential for

micro-leakage 4 between implant and

abutment, and a higher risk of screw

loosening 5 caused by a less intimate fit

around the connection.

The fit and finish displayed in these images

are indicative of the commitment

at Glidewell Laboratories to achieve

and maintain an unsurpassed level of

quality. As the world’s largest dental

implant laboratory, Glidewell leverages

the expertise of dozens of certified

dental technicians in the design of its

prosthetic components. The abutment

manufacturing division is ISO 13485

Figure 5: SEM images comparing an Inclusive Titanium Custom Abutment (left) to same-case samples from a pair of leading custom abutment manufacturers

– Lab Sense: Inclusive Custom Abutments – 69

Figure 6: Inclusive Titanium Custom Abutment Figure 7: Inclusive All-Zirconia Custom Abutment Figure 8: Inclusive Zirconia with Titanium Base Custom


certified, and operates under FDA

Current Good Manufacturing Practices

(CGMPs). The lab’s abutments are produced

on high-precision Swiss lathes

and multi-axis milling machines. As

the leader in digital dentistry, Glidewell

employs an experienced staff of

engineers and machinists to ensure

that each abutment they produce is

one that clinicians and their patients

can rely on.

Inclusive Custom

Abutment Options

Inclusive Custom Abutments are available

in titanium, all-zirconia, or hybrid

(zirconia with titanium base) options. A

titanium abutment (Fig. 6) is the most

frequently prescribed, particularly in

the posterior. An all-zirconia abutment

(Fig. 7), favored for its more natural esthetics,

is indicated for all areas of the

mouth, and is a popular choice for anterior

restorations. A hybrid abutment

(Fig. 8) combines the esthetics of a zirconia

coping with a titanium abutment

connection, resulting in a all-titanium

implant-abutment interface. All three

varieties are compatible with a number

of popular implant systems (Fig. 9),

in addition to their compatibility with

the Inclusive ® Tapered Implant System.

While other custom abutment manufacturers

can accept digital files from a

few dental scanners, Glidewell Laboratories

accepts and works with files from

almost any digital scanner or design

software, providing industry-leading

flexibility for both clinicians and laboratories

(Fig. 10).

Inclusive Tooth

Replacement Solution

The Inclusive ® Tooth Replacement Solution,

is a comprehensive, restorativedriven

treatment package with patientspecific

temporary components that

begin sculpting the soft tissue from

the moment of implant placement. It

features a matching custom impression

coping for transferring the final

soft tissue architecture to the laboratory.

Taking advantage of these tissue

contouring components ensures that

the patient’s soft tissue is ideally prepared

to provide a natural emergence

profile (Figs. 11a, 11b). This helps to

Inclusive Custom Abutments Compatibility Chart

Astra Tech # Biomet 3i Keystone




Nobel Biocare # Straumann # # Neoss# Dental #

OsseoSpeed # Certain # External Hex


PrimaConnex # Neoss # Brånemark

System # NobelActive # NobelReplace # Bone Level # Screw-Vent #

Titanium 3 3 3 3 3 3 3 3 3 3

Zirconia w/ Ti-Base 3 3 3 3 3 3 3 3 3 3

All-Zirconia 3 3 3

#Not a trademark of Glidewell Laboratories

Figure 9: Inclusive Custom Abutments are compatible with most major implant systems, in addition to the Inclusive Tapered Implant System.


– www.inclusivemagazine.com –

mitigate the painful and disruptive

blanching often associated with seating

a final abutment through tissue

that has been left to form around a

stock healing abutment.


A prefabricated implant abutment is

often viewed as the most immediate,

least expensive option for restoring

implant cases. But a patient-specific

abutment that takes into consideration

the unique anatomical qualities of

the patient’s edentulous space will, in

most situations, provide more reliable

function and more natural esthetics,

maximizing long-term health and performance.

As technological advancements

decrease the costs associated

with the design and manufacture of

digital custom solutions, clinician demand

for traditional cast and stock

abutments is rapidly waning in favor

of CAD/CAM precision and efficiency.

Available for most major implant systems,

Inclusive Custom Abutments

consistently deliver the high quality

that clinicians expect. IM


1. Castillo de Oyagüe R, Sánchez-Jorge MI, Sánchez

Turrión A, Monticelli F, Toledano M, Osorio R.

Influence of CAM vs. CAD/CAM scanning methods

and finish line of tooth preparation in the vertical

misfit of zirconia bridge structures. Am J Dent. 2009


2. Kerstein RB, Castellucci F, Osorio J. Ideal gingival

form with computer-generated permanent healing

abutments. Compend Contin Educ Dent. 2000 Oct;

21(10):793-7, 800-1; quiz 802.

3. Lewis SG, Llamas D, Avera S. The UCLA abutment:

a four-year review. J Prosthet Dent. 1992 Apr;

67(4):509-15. Review.

4. Silva-Neto JP, Nobilo MA, Penatti MP, Simamoto PC

Jr, Neves FD. Influence of methodologic aspects on

the results of implant-abutment interface microleakage

tests: a critical review of in vitro studies. Int J

Oral Maxillofac Implants. 2012 Jul;27(4):793-800.

5. Kano SC, Binon P, Bonfante G, Curtis DA. Effect

of casting procedures on screw loosening in UCLAtype

abutments. J Prosthodont. 2006 Mar-Apr;15(2):


Dental Scanning Systems


3Shape Dental System

(3Shape) 3


(exocad America) 3


(Dental Wings) 3


(Delcam) 3

Lava C.O.S.

(3M ESPE) 3

Optimet Dental CAD/CAM Scanner

(Optical Metrology) 3



(Align Technology) 3


(Sirona Dental Systems) 3

Lava C.O.S.

(3M ESPE) 3

E4D Dentist

(D4D Technologies) 3

IOS FastScan

(IOS Technologies) 3

Dental Software

3Shape Dental Designer (3Shape) 3

DentalCAD (exocad America) 3

DWOS (Dental Wings) 3

DentCAD (Delcam) 3

Figure 10: Digital scanning systems and design software formats supported by Glidewell Laboratories

Figure 11a: Representation of the soft tissue architecture

resulting from the use of a custom healing

component featured with the Inclusive Tooth Replacement


Figure 11b: Representation of the final Inclusive

Custom Abutment, easily seated in the anatomically

contoured sulcus

– Lab Sense: Inclusive Custom Abutments – 71

Production Workflow

The following overview presents an insider’s look at how Inclusive

Custom Abutments are fabricated at Glidewell Laboratories.




A soft tissue study model is created from an implant-level

impression. A scanning abutment attached to the implant

analog serves to capture the implant angulation, position,

and abutment connection orientation. The scanning abutment

is then removed and the arch is scanned a second

time, with the soft tissue mask in place. A scan of the

opposing model, followed by a scan of the fully articulated

casts enables the design software to construct and properly

align a complete 3-D model.




Once the fully articulated case exists in a virtual environment,

the abutment can be digitally designed using software

that contains a proprietary library of morphology.

The technician adjusts the soft tissue margins to create

an optimal emergence profile, then adjusts the angle (up

to 20 degrees) to account for implant angulation and to

avoid undercuts. The dimensions of the abutment are precisely

modified to ensure proper support for the eventual

restoration, including appropriate interproximal and occlusal




Once the digital restoration is complete, the electronic file

is forwarded to a top-of-the-line Haas 5-axis CNC milling

station (Haas Automation; Oxnard, Calif.) for precision milling

from either a titanium blank or BruxZir ® zirconia block.

An M-series FANUC robot arm (FANUC Robotics; Rochester

Hills, Mich.) assists with 24/7 loading of titanium

blanks to help the laboratory meet increasing demand.


Once milled, each abutment is forwarded to a quality

control technician, where a comprehensive inspection is

conducted to ensure accurate fit and design.

Final QC


As a final addition, each Inclusive Custom Abutment —

whether titanium, zirconia, or zirconia with titanium base —

includes an acrylic jig used at the time of delivery to

ensure and maintain complete, accurate seating while the

abutment screw is inserted and tightened.




– www.inclusivemagazine.com –

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A Clinical Conversation

with Dr. Christopher Travis

Interview of Christopher P. Travis, DDS

by Bradley C. Bockhorst, DMD

Dr. Christopher Travis is a practicing prosthodontist in South Orange County, Calif. We spoke

the other day about one of the problems we face in practice: treating patients who suffer

from xerostomia, or dry mouth. I was intrigued to discover that up to one-third of his patients

deal with this condition to some degree. Implant prostheses are a good option for xerostomia

patients who are wearing full or partial dentures.

Dr. Bradley Bockhorst: What are the causes of xerostomia,

and how do you treat it? What are the complications? How has

it impacted your practice?

Dr. Christopher Travis: Xerostomia is abnormal dryness

in the mouth caused by dysfunction in the salivary gland.

There are many causes. Probably the major cause is the

many medications we are using nowadays. They can be

as innocuous as antihistamines, decongestants, and antidiuretics

to more prescription-oriented medications for

anxiety or depression, possibly for cancer therapy — they

can cause a lot of problems with salivary gland function.

BB: When we are talking about cancer patients, it’s not just

medications for chemotherapy we’re referring to, it’s also from

the radiation.

CT: If the cancer is in the head and neck area, you’re

definitely going to be affected by the radiation. Also, aging

seems to be correlated with saliva flow, but that’s not quite

accurate. Aging itself is not really the problem. The problem

is when health is compromised as people get a bit older

and they’re taking more medications. Those two go hand in

hand with the possibility of the lack of salivary flow from

the salivary glands.

Another problem can be with HIV patients who are taking

antiviral drugs. Others are Sjögren’s syndrome, which is

an autoimmune disease. A lot of the autoimmune diseases,

like lupus erythematosus, erythema multiforme, von Recklinghausen’s

disease and Sjögren’s, can cause salivary flow

dysfunction, and the drugs used to treat these diseases can

cause it as well.

– Treating Xerostomia Patients: A Clinical Conversation with Dr. Christopher Travis – 75

Treating Xerostomia Patients


at a glance

Dryness of the mouth resulting from diminished

or arrested salivary secretion. Several factors,

both natural and induced, can lead to the

occurrence of xerostomia.


• Lipstick on teeth caused by lack of salivary


• Thick, ropey, mucous-like saliva

• Dry mouth

• Sore, thick throats and difficulty talking

• Malodor or bad breath

• Candida albicans – fungus normally present on the

skin and in mucous membranes such as the vagina,

mouth, or rectum. Becomes an infectious agent

when there is some change in the body environment

that allows it to grow out of control

• Oral candidiasis (thrush) or vaginal candidiasis

(vaginitis) – fungal infection commonly referred to as

a yeast infection

BB: I also read on the Sjögren’s Syndrome Foundation website

that they estimate there are 4 million Sjögren’s patients out

there, and that 9 out of 10 are women —

CT: — who are post-menopausal. That’s right. I’ve been in

practice almost 31 years, and I would say about half of the

women in my practice, which would be about a third or

more of my practice, have a Sjögren’s type of symptom,

including sialoliths, which are salivary gland stones. Of

course, that can be checked out by sialography, and can be

dealt with in that respect.

BB: I read on the foundation’s website that, on average, it takes

seven years to be diagnosed with Sjögren’s. So as dentists serving

our patients, we can be on the forefront of diagnosis. If we have

patients who come in with dry mouth or dry eyes, those types

of things should be red flags that we should automatically pick

up on. Have you ever been the primary clinician spotting that?

CT: I have. I’ve told a patient that she may have Sjögren’s

syndrome, and she was tested and — boom! — she had

it. And one of the reasons is because a lot of the time, the

physician will not test for Sjögren’s specifically. But once

the patient tests positive for Sjögren’s, they can be treated

properly and not necessarily shotgunned with a whole lot

of drugs.

Smoking and chewing tobacco, especially, can hamper

salivary flow terribly. And, of course, smoking and chewing

isn’t good for the mouth anyway — you can develop cancer.

Another thing is snoring and wearing a sleep apnea

appliance. Of course that can be a yin and a yang: you want

to stop snoring so you wear an appliance, yet it can also

lead to salivary flow dysfunction.

BB: They’re breathing through their mouths all night, so

obviously there are going to be potential complications.

CT: That’s right. People with strokes can get it because they

lose their nervous input into the salivary glands. Also, Bell’s

palsy from the facial nerve can be a problem, as well as

other little palsies. So, neuromas and so on can cause issues

as well.

BB: You named off general categories of pharmaceuticals. Are

there particular drugs that, when you’re looking at a patient’s

chart, almost pop out at you as being related to xerostomia?

CT: Yes, especially antidepressants, anti-anxiety drugs:

ZOCOR ® (Merck & Co. Inc; Whitehouse Station, N.J.),

Xanax ® (Pfizer; New York, N.Y.) — you’ve got some of those

medications that you have to be careful with, especially if

the patient does have a lack of salivary flow. And if some

of the diagnostics include periodontal disease and caries,

along with the lack of the salivary flow, then we have to be

careful. A lot of times the patient can’t get off the meds, so

we have to do a sort of palliative treatment. Really, in the

last decade there has not been a lot of research in this area.

One of the reasons is that the scientists who want to do

research want to make money and get grants. Well, there’s

not a lot of money in salivary dysfunction. But there should

be because it affects a lot of things.

BB: I wanted to talk a little bit more about aging. It’s not

aging, per se, that can cause the potential for xerostomia. Can

you expand on that?

CT: Usually, aging has a tendency to go hand in hand with

patients’ limited health issues, and the medications they

may have to take regarding some of their health issues —

high blood pressure, for instance. Also, antihistamines and

decongestants, because people tend to get more allergic to

things as they get older. Another is anti-diuretics. People

become incontinent and sometimes have to be treated as

well. That seems to go hand in hand, but aging in itself is

not the criteria for salivary gland dysfunction.


– www.inclusivemagazine.com –

BB: For the sake of our audience, can you do a quick anatomy


CT: Absolutely.

We’re just going to go through three major sets of salivary

glands surrounding the mouth. The first set we’ll talk about

is the parotid glands. There is one large parotid gland on

either side, usually located just below the zygomatic arch,

and just outside of the coronoid process of the mandible.

The parotid duct goes into the molar area, where sometimes

patients bite. It’s that duct that goes into the mouth with

their molars, and it’s on either side.

The second set of salivary glands are the sublingual glands.

They go just posterior to the synthesis of the mandible. You

can see the sublingual fossa, sometimes called clefts. And

this is where the salivary glands are housed. A Wharton’s

duct comes right into the floor of the mouth, and that’s where

sometimes when you’re doing dentistry you occasionally

get spit on.

Anatomical view of the parotid gland

Courtesy of Primal Pictures Ltd.


Anatomical view of the sublingual gland

Courtesy of Primal Pictures Ltd.


Anatomical view of the parotid duct

Courtesy of Primal Pictures Ltd.


Anatomical view of the submandibular gland

Courtesy of Primal Pictures Ltd.


– Treating Xerostomia Patients: A Clinical Conversation with Dr. Christopher Travis – 77

Treating Xerostomia Patients


to salivary flow dysfunction

• Sjögren-Larsson syndrome – systemic

autoimmune disease; immune cells attack and

destroy the exocrine glands that produce tears

and saliva. Pronounced SHOW-grins, this disease

is common in those with fibromyalgia and chronic

fatigue syndrome.

• Lupus – collection of autoimmune diseases;

a hyperactive immune system attacks normal,

healthy tissues and can affect the joints, skin,

kidneys, blood cells, heart, and lungs

• Erythema multiforme – condition of the skin and

oral mucous membrane ranging from a mild rash

to life-threatening rash. Usually follows an infection

or drug exposure. Peak incidence occurs in the

second and third decades of life.

• Von Recklinghausen’s disease

(neurofibromatosis) – genetic disease in

which patients develop multiple soft tumors

(neurofibromas). Tumors occur under the skin

sand throughout the nervous system.

• Sialolithiasis – formation of calculus, or stones,

in the salivary glands

• Bell’s palsy – disorder of the nerve that controls

movement of facial muscles. Damage to this nerve

causes weakness or paralysis of these muscles.

Cannot use muscles due to paralysis.

• Stroke – rapid loss of brain function due to

disturbance in the blood supply to the brain

The submandibular salivary glands are located in the

submandibular fossa of the mandible, or cleft, on both sides.

Their ducts go into the ventral side of the oral cavity on

either side of the mouth. It is very important for the surgeon

who places implants not to drill their osteotomy into this

area. Of course we’re using guided surgery with CT scans

now, so those things are definitely less of an occurrence.

All three sets of salivary glands are the main salivary glands

that allow us to chew our food in our mouth. There are

minor ones, too, some of which are called molar glands, but

these are the three sets of two that are the most important.

BB: We’ve talked about the causes of xerostomia, and we just

reviewed the anatomy of the three sets of salivary glands. Can

you tell us a little bit about the ways of diagnosing xerostomia?

CT: That’s very important because you have to treat the

patient who has xerostomia a little differently — a lot of

the diagnoses come from the patients’ symptoms. One of

the most important things, especially with women, is that

they come in with lipstick on their teeth. Women who have

lipstick on their teeth usually are experiencing a lack of

salivary flow — there is no saliva there to rinse the lipstick

off their teeth. That’s one of the first things I notice.

The next thing I notice obviously is a dry mouth. Maybe

thick and ropey saliva, almost a mucous-like saliva. Sore

throats. Difficulty talking. Sometimes they’ll complain about

a tongue that’s really sore all the time, and feeling thick —

those kind of symptoms. And I ask specific questions in the

initial consultation when the patient is sitting in my chair.

Lots of them — especially, again, postmenopausal women —

say they have a lot of these symptoms. It’s a tough nut

to crack.

BB: Are there other things you can detect from your patients,

such as taste, or a malodor?

CT: That’s correct. A lot of times there are specific causes

of bad breath. Now, obviously, bad breath can be the result

of periodontal disease or caries caused by salivary gland

dysfunction. Because the saliva has certain bactericidal

properties, bad breath, malodor, and a bad taste in their

mouth can be symptoms of gland dysfunction.

BB: And then you mentioned caries, lack of salivary flow can

obviously affect that, right?

CT: Tremendously, especially near the gingival tissues and

the areas of the CEJ (cementoenamel junction) of the teeth.

They become rampant caries, and it can be very difficult to

treat. You have to go with certain preventive measures, such

as using PreviDent ® (Colgate; New York, N.Y.) or some kind

of fluoride rinse, drink water a lot, and so forth.

BB: So if they have cervical lesions, does that become part of

the differential diagnosis as to what’s causing that?

CT: Correct. That is definitely one of the major pop-up


BB: As far as developing fungal and other infections, you

mentioned the bactericidal properties of saliva. What are some

other things that can show up?

CT: It isn’t necessarily specifically from salivary gland

dysfunction, but those people who have autoimmune

problems or who are taking medications can have candida

problems all throughout their body, especially the ladies. So

what happens is they get candidiasis in their mouths, and

a lot of the people I treat have to wear prostheses — either

fixed or removable prostheses — and that can be a problem

when you do get candida because it’s tough to keep treating

it with Nystatin or Monistat ® (Insight Pharmaceuticals;


– www.inclusivemagazine.com –

A lot of times, having the prosthesis off the mucosa

is something the patient can tolerate really well.

And, of course, implants don’t have caries.

Ways Sjögren’s Syndrome may affect the body

Neurological problems,


(brain fog)

Dry eyes,

corneal ulcerations,

and infections

Dry nose, recurrent

sinusitis, nose bleeds

Difficulty swallowing,

heartburn, reflux


Dry mouth, mouth sores,

dental decay: difficulty with

chewing, speech, taste, and


Recurrent bronchitis,

pneumonia, interstitial

lung disease

Dry skin, vasculitis,

Raynaud’s phenomenon

Arthritis, muscle pain

Stomach upset,


autoimmune pancreatitis

Abnormal liver function

tests, chronic active

autoimmune hepatitis,

primary biliary cirrhosis

Peripheral neuropathy

(numbness and tingling in

the extremities)

Vaginal dryness,

painful intercourse

Diagram of the many effects of Sjögren’s syndrome on the body, including symptoms that can contribute to xerostomia

Courtesy of Sjögren’s Syndrome Foundation, www.sjogrens.org

– Treating Xerostomia Patients: A Clinical Conversation with Dr. Christopher Travis – 79

Treating Xerostomia Patients


INHIBIT salivary flow

• Smoking

• Chewing tobacco

• Wearing sleep apnea appliances

• Postmenopausal stage of life (women)

• Aging



• Over-the-counter medications – antihistamines,

decongestants, anti-diuretics

• Prescription medications for anxiety or depression,

cancer therapy, radiation therapy

• Antiviral drugs for HIV

Trevose, Pa.) or something similar, to get rid of it, because

it’s a continuous infective condition, and it’s a tough call.

BB: What are some of the complications patients suffer through

when they have dry mouth or xerostomia?

CT: Oh, it makes it very difficult. They can’t eat very well.

The complications are systemic in nature, sometimes — they

don’t want to eat because they can’t, and they can’t chew

their food well. It’s the first stage of digestion, so these

people have systemic problems from eating improperly.

They have problems wearing dentures — sometimes they

can’t wear them at all. Of course other complications are

periodontal disease or cervical caries that have to be treated

in a little different fashion.

Many times, as I said previously, the patient with complications

can get candida albicans, or candidiasis, which

makes it very difficult to wear dentures. And then the

tongue can get very painful and enlarged. Sometimes the

taste buds on the tongue don’t perform properly and don’t

give off a good taste. Those types of complications can

come about, and you need to be familiar with those so you

can symptomatically treat them, if possible.

BB: Earlier we were talking about dry mouth caused by sleep

apnea appliances, but can dry mouth also exacerbate this?

CT: It can. The tongue has the tendency to get sticky, so it

will stick to the soft palate of the throat and keep people

from breathing properly through their nose. They start

snoring, and might actually stop breathing for a certain

period of time. That’s when the sleep apnea symptoms start.

BB: We’ve talked about the causes and the complications. How

are you treating the xerostomia patients in your practice?

CT: Initially we start with palliative treatment. We want

them to brush their teeth and floss properly — make sure

everything is really clean. Fluoride pastes like PreviDent

are very important to keep caries down to a minimum.

Another thing is to be able to buy products like Biotène ®

(GlaxoSmithKline; Philadelphia, Pa.) or Spry ® (Xlear; Orem,

Utah), or Thayers ® Dry Mouth Spray (Thayers; Westport,

Conn.), or any of those products that contain carboxymethyl

cellulose. It allows a sort of lubrication in the mouth. I

really like using Biotène in my practice. Also, Omni used to

have TheraSpray. It’s the same kind of product, containing

carboxymethyl cellulose that allows for more lubrication in

the mouth, and actually helps in caries prevention as well.

Other products can be a little bit more gutsy — you can

take medications like pilocarpine, or cevimeline, which is a

cholinergic agonist, and those medications can help create

more saliva flow. However, they do have side effects. Other

salivary-stimulating drugs would be anetholtrithione. It’s a

good drug, but it has the tendency to cause flatulence. So

you’ve got to watch that; the side effects are not necessarily

pleasant. But I like some of those, and I will go ahead and

prescribe a pilocarpine every once in a while if indicated. We

have to know what kind of medical history a given patient

has, because if the patient has glaucoma, for example, you

certainly don’t want to give them pilocarpine because that

could exacerbate their problem.

BB: You’ve named off some over-the-counter-products, sprays,

and lozenges, and you’ve gone into pharmaceuticals. So maybe

you can go into more specifics regarding the over-the-counter

products. When you’re prescribing these to your patients, what

instructions are you giving them?

CT: I usually go PRN, because if you buy the Thayers

products or the Spry or the Salese (Nuvora; Santa Clara,

Calif.) or the Biotène — and I like Biotène — I just tell

them, “Take it with you in your purse” — they’re mainly

women. They can of course brush their teeth at home with

all of the salivary stimulating products, but I like them to

use them as needed. If they start feeling a dry mouth, then

they can go ahead and spray their mouth. Maybe before

lunch, maybe before breakfast and before dinner they can

use the products — and at bedtime.

BB: OK, those are the artificial salivas. How often are you

actually prescribing pharmaceuticals?

CT: Not as often as I do the palliative agents for nonprescription

drugs. Again, pilocarpine and cevimeline do

have side effects so you have to be careful with respect to

the health history of the patient. And I might do that for a

patient who just has no saliva, cannot eat, and is in pain all


– www.inclusivemagazine.com –

the time, and then I will prescribe those agents.

BB: And do you typically do that in coordination with the

patient’s physician?

CT: Always. In fact, I call the patient’s physician and tell them

that I would like to prescribe this kind of medication, and

then we’ll go over the list together. Of course, I usually have

a list a mile long of the medications the patient is already

taking, and if I see some conflict, then I will definitely call

the physician.

BB: What this leads into, depending on how the patient

presents, is that this could dictate or affect the type of denture

or prosthesis you’re going to use when restoring that patient.

Can you talk about what you do with these patients? Obviously,

dentures are very problematic for them. How do you treat them

and when might implants be appropriate?


Products that help relieve dry mouth:

• Oral rinses and sprays that contain carboxymethyl


• Prescription-strength fluoride toothpaste

• Antifungal agents

Salivary-stimulating drugs/products:

• Pilocarpione or cevimeline – cholinergic agonists that

help to create saliva flow

• Anetholetrithione – drug that stimulates saliva flow

CT: I’ll start with natural teeth that have carious prevalence

due to a lack of salivary gland function. With extensive

cervical caries, I would probably do full-coverage restorations

to make sure the margins are in the sulcus of the

teeth, because the bug that creates the cervical caries

really doesn’t get into the sulcus. The sulcus has its own

bactericidal effects so you don’t have that problem in the

sulcular areas.

BB: When you’re prepping those teeth, how far subgingival are

you placing that margin?

CT: One millimeter. You don’t want to get involved with the

biological width. You don’t want to get too involved with

the emergence profile and angle. You really want it perfect

so you don’t have any periodontal problems. If the caries

is not extensive, then I will probably do some composite

bondings and make sure that the patient uses PreviDent

every evening, brushes it on their teeth and just spits out

the excess and goes to bed — no rinsing. When using

PreviDent or any of these fluoride rinses or pastes, it’s very

important not to rinse it out, just spit out the excess.

Now, if the patient has partial or full anodontia, removable

prostheses can be a problem because the dentures

themselves can actually hamper the salivary gland flow.

They stop salivary gland flow.

A lot of times, having the prosthesis off the mucosa is

something the patient can tolerate really well. And, of

course, implants don’t have caries, and they don’t have the

periodontal applications in the same way that salivary gland

dysfunction goes hand in hand with periodontal disease. So,

that’s when we would do a hybrid prosthesis either through

a guided type of restoration, or create a bar overdenture

that may be off the ridge a little bit more.

– Treating Xerostomia Patients: A Clinical Conversation with Dr. Christopher Travis – 81

Treating Xerostomia Patients

BB: To recap, if a patient is partially edentulous, could you

possibly place a couple of implants and put them in a bridge,

and that way get them out of the partial?

CT: You could do a fixed partial prosthesis in the

posterior area, and that patient would have neither caries

involvement, nor would there be any problem with the

mucosal involvement.

BB: And then with the fully edentulous patients, as you

mentioned, it could be an overdenture or a bar-supported

prosthesis off the tissue, right? Or, even better, it might be

heading into a screw-retained denture or a fixed type of

prosthesis where you’re actually up off the tissue.

A screw-retained denture to replace a removable denture (palatal view)

CT: That would be ideal, a fixed prosthesis — the old standard

Brånemark hybrid is the most successful restoration

in the history of dentistry, and that’s something that works

really well with the lack of saliva flow. IM

Bilateral posterior implant-borne bridges to replace a partial denture

(occlusal view)

The old standard Brånemark hybrid is the most successful

restoration in the history of dentistry, and that’s something

that works really well with the lack of saliva flow.


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Creating Surgical Guides Using

CBCT and Intraoral Scanning


Perry E. Jones, DDS, FAGD



of the recent advances in the use of the iTero

optical scanner (Align Technology; San Jose, Calif.)

has been the use of generic STL files to allow the

creation of very precise surgical guides. CBCT DICOM files

can be merged with iTero STL files to create 3-D renderings

that support virtual planning of prosthetic restorations and

“crown down” planning of hard tissue considerations. Soft

tissue-borne surgical guides have been used for several years;

however, limitations of CBCT DICOM data has restricted

the development of tooth-borne surgical guides. This article

will demonstrate the merging of CBCT DICOM and iTero

STL files, virtual wax-up with case planning in the 3-D

environment, CAD/CAM processing of the surgical guide,

and clinical application consisting of implant placement

and the fabrication of final, model-less implant restorations

through the use of dedicated scanning abutments.

Dental History

A 50-year-old Caucasian male in good health presented with

multiple missing teeth amid otherwise healthy dentition

(Fig. 1). The patient reported he had several congenitally

Figure 1: Mandibular occlusal view demonstrating healthy dentition, with

edentulous sites #29 and #30 planned for implant restoration

– Creating Surgical Guides Using CBCT and Intraoral Scanning – 83

Creating Surgical Guides Using CBCT and Intraoral Scanning

“missing” teeth, and had also lost a number of teeth after

failed endodontic procedures. The patient was first seen

by the Department of Oral and Maxillofacial Surgery of

Virginia Commonwealth University’s School of Dentistry,

with a stated desire for using dental implants to restore

the missing teeth. The patient was referred to my private

practice for an evaluation of his restorative needs.

Treatment Plan

After a discussion of the alternatives, benefits, and complications

of treatment options, the patient stated that

he wished to receive implant restorations. Following a

discussion of financial considerations, it was agreed that

the treatment plan would be divided into several phases.

Phase one would be to place two implant fixtures in the

area of tooth #29 and tooth #30. It was agreed that a custom

surgical guide would be created using CBCT and digital

scanning technology, for the ultimate purpose of facilitating

guided placement of the dental implants.

Scan Procedure

A full-arch optical scan of both maxillary and mandibular

arches with a centric record of the teeth in maximum

intercuspation was taken using the iTero intraoral scanning

unit. The resultant generic STL data files, the standard

CAD/CAM file format, were exported directly from this

user’s “MyAligntech” account. A CBCT scan was taken with

a NewTom CBCT scanner (ImageWorks; Elmsford, N.Y.) and

the resultant DICOM data files exported to the In2Guide

(Cybermed; Irvine, Calif.) software. The DICOM and STL

files types were then merged via the In2Guide software to

produce a 3-D rendering.

Virtual Planning

Using the principles of “crown down” planning, a virtual waxup

added the crown morphology to represent a mandibular

right second bicuspid (tooth #29) and a mandibular right

first molar (tooth #30) (Fig. 2). Using the implant placement

planning features of the In2Guide software, an optimized

position for each of the implant fixtures was developed.

This case demonstrates the value of virtual planning, as

there were several anatomical and dental issues requiring

close attention to fixture placement detail. The mandibular

second molar is mesial-tipped, presenting a clearance

and path of insertion issue for the prosthetic restoration

of the implant fixture. Further, the hard tissue anatomy

exhibits limited freedom of placement, given the position

of the inferior alveolar canal, mental foramen, and lingual

Figure 2: In2Guide planning software with virtual wax-up of tooth #29 and


mylohyoid concavity. With the virtual planning complete,

the completed implant fixture placement was submitted for

CAD processing.

Surgical guide

In a 100 percent digital environment, a model-less printed

surgical guide was produced by the Cybermed In2Guide

manufacturing process. The surgical guide was delivered in

a sealed package for patient try-in. Planned visual cutouts

allowed verification of proper seating of the surgical guide

(Fig. 3). Prior to the surgical appointment, the surgical guide

was trial fitted to the mandibular dentition (Fig. 4), and

optimal fit confirmed (Fig. 5).

Surgical Procedure

After a review of the patient’s health history, including

basic vital signs such as blood pressure and pulse, informed

consent was received. The patient was given two 1.7 ml

carpules of Lidocaine Hydrochloride 2% with 1:100,000

Epinephrine. Upon profound local anesthesia, with the

surgical guide in place, a single disposable tissue punch

(Fig. 6) was used to remove a precise cylinder of tissue to

access the mandibular ridge of bone at the planned implant

surgical site. NobelGuide drill guides and guided drills

(Nobel Biocare; Yorba Linda, Calif.) were used to perform

the surgical procedure. The drill series consisted of an

initial “flare” drill (Guided Start Drill) (Fig. 7), a 2 mm depth

drill (Guided 2.0 Twist Drill) used with a precise drill guide

(Fig. 8), and sequential full-depth drills (Guided Tapered


– www.inclusivemagazine.com –

Figure 3: In2Guide surgical guide created with cutouts to verify full seating

Figure 6: Disposable tissue punch used with surgical guide in place

Figure 4: Intraoral occlusal view of In2Guide surgical guide during try-in. Note

the seating verification cut-outs.

Figure 7: First sequence flare drill used to perform the surgical drill procedure

Figure 5: Occlusal view of In2Guide surgical guide. Note full seating and

excellent retention.

Figure 8: In2Guide with collimator for the 2 mm surgical drill

– Creating Surgical Guides Using CBCT and Intraoral Scanning – 85

Creating Surgical Guides Using CBCT and Intraoral Scanning

Figure 9: Full-depth surgical drill placed in metal guide holes of the surgical


Figure 10: Implant delivery tool on the handpiece

Drills) to match the implant fixture shape (Fig. 9). These

drills were used to precisely create the osteotomy in all

dimensions of space, including depth. Both implant sites

were drilled to the precise depth and shape for planned

implant placement.

An 8 mm long NobelReplace ® Tapered RP implant (Nobel

Biocare) was placed at the site of tooth #29, and a 10 mm

long NobelReplace Tapered RP implant was placed at the

site of tooth #30. Using the guided implant mount, the two

respective implant fixtures were carried with the implant

driver (Fig. 10) and rotated to a position just short of full

depth (Fig. 11). Using a manual torque wrench, the implants

were rotated into place such that the shoulder of the implant

holder mated with the surgical guide at a torque value of

35 Ncm (Figs. 12, 13). The guided mount and surgical guide

were removed and 5 mm RP Healing Abutments (Nobel

Biocare) were rotated into the NobelReplace Tapered RP

implant (Figs. 14, 15). There were no complications, and

in fact, the patient reported this was the easiest dental

procedure performed on him to date.

Figure 11: Placement of implant with the delivery tool with full depth held

back approximately 1 mm

Implant Restoration

After four months of healing, the patient returned for

restoration of the two implants. The healing abutments were

removed (Fig. 16) and an Osstell ® ISQ implant stability meter

with SmartPeg attachments (Osstell Inc. USA; Linthicum,

Md.) was used to check the level of relative implant osseous

integration (Fig. 17). A SmartPeg attachment was placed in

each implant fixture and a reading of 85 was recorded for

each implant. Further, a “reverse” torque test was performed

using a manual torque wrench, with no movement

at 35 Ncm. The implants were deemed satisfactory for

restoration and functional occlusal loading.

Figure 12: Manual torque wrench used for final seating of the implants to

35 Ncm


– www.inclusivemagazine.com –

Figure 13: Implants torqued to full-depth position with surgical guide in place

Figure 16: Healing abutments removed with excellent tissue health four

months post-op

Figure 14: Soft tissue view immediately after implant placement

Figure 17: Osstell ISQ with SmartPeg used to help gauge level of osseous


Figure 15: Healing abutment in place. Note minimal tissue trauma.

The merging of CBCT

DICOM files with iTero STL

files to create surgical guides

provides clinicians a higher

level of confidence when

placing implants.

– Creating Surgical Guides Using CBCT and Intraoral Scanning – 87

Creating Surgical Guides Using CBCT and Intraoral Scanning

Figure 18: Inclusive Scanning Abutments used for the iTero scan process

Figure 20: BruxZir screw-retained crowns, consisting of titanium base and

monolithic body

Figure 19: iTero scan software demonstrating Inclusive Scanning Abutments

at site #29 and #30

Figure 21: BruxZir screw-retained crowns with access openings revealing

titanium retention screws tightened into place

Posterior Inclusive ® Scanning Abutments for NobelReplace

RP were secured at fixture level on each NobelReplace

implant, by way of internal titanium retention screws (Fig.

18). A radiograph was taken to verify that the scanning

abutments were properly seated on the implant fixtures,

and to further aid in confirmation of osseous integration.

A mandibular full-arch scan, maxillary full-arch scan, and a

centric position of maximum intercuspation were recorded

with the iTero digital scan technology (Fig. 19). The STL

files were sent directly to Glidewell Laboratories. Using

the Abutment Designer software program (3Shape; New

Providence, N.J.) and a proprietary design library, the

virtual design of the implant crowns was completed. Two

model-less, custom-milled, screw-retained crowns were

fabricated (Fig. 20). The screw-retained crowns were made

with a titanium base to allow a titanium-to-titanium interface

between the crown and implant connection. The body of

these crowns were milled from BruxZir ® Solid Zirconia,

a high-strength monolithic ceramic material. Milling took

place in a 100 percent digital environment, without models.

The screw-retained crowns were delivered for evaluation,

and the patient was seen for try-in and delivery. The healing

abutments were removed so that the restorations could be

seated and then tightened into place (Fig. 21) using the

supplied titanium retention screws and a standard Nobel

Biocare abutment driver. A manual torque wrench was used

to tighten the titanium retention screw of implant crown #29

and crown #30 to a value of 35 Ncm. The occlusal access

holes were filled with Teflon plumber’s tape (Fig. 22) and

the access holes sealed with TPH ® 3 universal composite

resin (Dentsply Caulk; Milford, Del.) (Fig. 23). A routine

periapical radiograph confirmed an excellent interface


– www.inclusivemagazine.com –

Figure 22: Teflon plumber’s tape used to protect titanium screws

Figure 24: Radiograph to verify proper seating of restoration to implant

Figure 23: Composite resin placed to seal the screw access holes

Figure 25: Buccal view demonstrating excellent tissue adaptation

between the crown’s titanium base and the implant (Fig. 24).

The occlusion was checked in various functional positions

as well as maximum intercuspation, with an objective to

minimize lateral occlusal forces transmitted to the implant.

The occlusal composite was checked in occlusal function

and deemed to be satisfactory. The final BruxZir implant

restorations on tooth #29 and tooth #30 can be seen from

buccal (Fig. 25) and occlusal views (Fig. 26). The patient was

seen for a post crown insertion visit after two weeks to

reevaluate the crowns, and they were deemed to have an

excellent fit and occlusal relationship.


Software development now enables the merging of CBCT

DICOM files with Align Technology’s iTero STL files. The

Figure 26: Occlusal view of final restorations

– Creating Surgical Guides Using CBCT and Intraoral Scanning – 89

Creating Surgical Guides Using CBCT and Intraoral Scanning

generic STL files may be exported directly from the iTero

user’s account to planning software available to various

services such as Cybermed’s In2Guide. Virtual wax-up

and planning may be done to create surgical guides, with

simultaneous consideration of hard tissue and optimal

restoration location, providing clinicians a higher level of

confidence when placing implants. Final implant restoration

may be done with digital scanning systems such as iTero

using dedicated Inclusive Scanning Abutments, which are

available for a number of the most popular implant systems.

Remarkable advances in implant crown manufacture allow

Glidewell Laboratories to create screw-retained crowns in

a 100 percent digital environment without conventional

models. The clinical example presented in this article

showcases the use of scanning technology to plan implant

placement, create a precise surgical guide in an all-digital

environment, place implant fixtures, and restore these

implants with digital scanning technology and highly

precise all-digital manufacturing technology — all without

the use of a conventional analog model. The promises of

the digital future of dentistry are now here. IM

General References

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tomography (CT) and cone-beam CT (CBCT) for computer-aided implant

placement. Part II: reliability of mucosa-supported stereolithographic guides.

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Epub ahead of print.

• Miles DA. CBCT: facilitating comprehensive, high-tech diagnostics. Compend

Contin Educ Dent. 2011 Nov-Dec;32 Spec No 4:14-5. No abstract available.

• Jacobs R. Dental cone beam CT and its justified use in oral health care. JBR-BTR.

2011 Sep-Oct;94(5):254-65. Review.

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2011 Oct;20(5):512-6.

• Behneke A, Burwinkel M, Behneke N. Factors influencing transfer accuracy of

cone beam CT-derived template-based implant placement. Clin Oral Implants

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• Noh H, Nabha W, Cho JH, Hwang HS. Registration accuracy in the integration of

laser-scanned dental images into maxillofacial cone-beam computed tomography

images. Am J Orthod Dentofacial Orthop. 2011 Oct;140(4):585-91.

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dental measurements taken from CBCT models and those taken from a digital

method. Eur J Orthod. 2011 Mar 22. Epub ahead of print.

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author reply 249-50. No abstract available.

• Schwartz AI. Improving precision with CBCT imaging. Dent Today. 2011 Jan;30(1):

168-71. No abstract available.

• Al-Ekrish AA, Ekram M. A comparative study of the accuracy and reliability of multidetector

computed tomography and cone beam computed tomography in the

assessment of dental implant site dimensions. Dentomaxillofac Radiol. 2011 Feb;


• Worthington P, Rubenstein J, Hatcher DC. The role of cone-beam computed tomography

in the planning and placement of implants. J Am Dent Assoc. 2010 Oct;

141 Suppl 3:19S-24S.

• Maret D, Molinier F, Braga J, Peters OA, Telmon N, Treil J, Inglèse JM, Cossié A,

Kahn JL, Sixou M. Accuracy of 3D reconstructions based on cone beam computed

tomography. J Dent Res. 2010 Dec;89(12):1465-9. Epub 2010 Oct 7.

• Chan HL, Misch K, Wang HL. Dental imaging in implant treatment planning.

Implant Dent. 2010 Aug;19(4):288-98.

• Hassan B, Couto Souza P, Jacobs R, de Azambuja Berti S, van der Stelt P. Influence

of scanning and reconstruction parameters on quality of three-dimensional

surface models of the dental arches from cone beam computed tomography.

Clin Oral Investig. 2010 Jun;14(3):303-10. Epub 2009 Jun 9.

• Scarfe WC, Farman AG. What is cone-beam CT and how does it work? Dent Clin

North Am. 2008 Oct;52(4):707-30, v.

• D’souza KM, Aras MA. Types of implant surgical guides in dentistry: A review.

J Oral Implantol. 2011 Sep 9. Epub ahead of print.

• Cassetta M, Giansanti M, Di Mambro A, Calasso S, Barbato E. Accuracy of two

stereolithographic surgical templates: A retrospective study. Clin Implant Dent

Relat Res. 2011 Jul 11. doi: 10.1111/j.1708-8208.2011.00369.x. Epub ahead of


• Nokar S, Moslehifard E, Bahman T, Bayanzadeh M, Nasirpouri F, Nokar A.

Accuracy of implant placement using a CAD/CAM surgical guide: an in vitro study.

Int J Oral Maxillofac Implants. 2011 May-Jun;26(3):520-6.

• Frisardi G, Chessa G, Barone S, Paoli A, Razionale A, Frisardi F. Integration of 3D

anatomical data obtained by CT imaging and 3D optical scanning for computer

aided implant surgery. BMC Med Imaging. 2011 Feb 21;11:5.

• Al-Harbi SA, Sun AY. Implant placement accuracy when using stereolithographic

template as a surgical guide: preliminary results. Implant Dent. 2009 Feb;18(1):


• van der Zel JM. Implant planning and placement using optical scanning and cone

beam CT technology. J Prosthodont. 2008 Aug;17(6):476-81. Epub 2008 May 9.

• Jones PE. The iTero optical scanner for use with Invisalign: A descriptive

review. Dental Economics. 2012 Feb 7 [cited 2012 Feb 7]. Available from:


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• Jones PE. Cadent iTero optical scanning digital impressions for restorative and Invisalign.

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• Jones PE. From intraoral scan to final custom implant restoration. Inclusive.

Fall 2011 Vol. 2 Issue 4: 6-13.

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Available from: http://www.cadentinc.com/open/files/inc/1517604459.pdf.


– www.inclusivemagazine.com –

“Rules of 10”

Guidelines for Successful Planning and Treatment

of Mandibular Edentulism Using Dental Implants


Lyndon F. Cooper, DDS, Ph.D;

Bryan M. Limmer, DMD; and W. Day Gates III, DDS, MS

The treatment of mandibular edentulism

using dental implants is now well

established as a biologically sound

treatment option. More than 40 years

after Swedish orthopedic surgeon

Per-Ingvar Brånemark intro duced the

process of transforming oral function

in the edentulous patient using endosseous

dental implants, a picture

of success has emerged that is recognized

worldwide. The use of one or

two implants to retain a mandibular

overdenture and the use of four or

more implants to support and retain

a fixed dental prosthesis is widely

known to provide improved function

and increased satisfaction in the

edentulous patient when compared to

conventional denture therapy. 1-6

The three “Rules of 10” for treatment planning dental implant therapy

in the edentulous mandible are designed to improve the success of both the

endosseous implants and the prosthesis. These “rules” acknowledge and

provide a method to control the mechanical environment, addressing factors

affecting implant and prosthesis longevity, including magnitude of forces,

resistance of the prosthesis against these forces, and the biology of bone and

its ability to respond to loading environments. The rules specify that for any

implant-retained overdenture (IRO) or implant-supported fixed prosthesis (ISFP),

there must be a minimum of 10 mm of alveolar dimension (inferior/superior)

and a minimum of 10 mm of interocclusal (restorative) dimension measured

from the soft tissue ridge crest to the occlusal plane. Additionally, for an ISFP, the

anterior/posterior distribution of implants must be greater than 10 mm. This

article provides support in the literature for these rules and illustrates their

application in the treatment of mandibular edentulism.

The contemporary literature demonstrates

a high degree of survival

over the 10- to 20-year time horizon

when implants are placed in the

parasymphyseal mandible and restored

with an IRO or with an ISFP. 7-10

These studies invoke inclusion and

exclusion criteria that favor success,

benefit from the local factors of

mandibular bone quality and quantity,

and commonly employ the use of an

opposing maxillary denture. However,

all the studies indicate high

and lasting rates of implant survival.

Less well documented and perhaps

equally significant is the quality

of the prosthesis, its longevity and

maintenance requirements, and the

related issues of patient-perceived

satisfaction. There is also a history

– “Rules of 10” — Guidelines for Successful Planning and Treatment of Mandibular Edentulism Using Dental Implants – 91


Figure 1: Failure of fixed and removable implant prosthesis

(acrylic fracture)

Figure 2: Failure of fixed and removable implant prosthesis

(framework fracture)

of common limitations associated

with dental implant therapy for the

edentulous mandible.

The commonly prescribed IRO and

ISFP prostheses are based upon denture

fabrication techniques that utilize

methyl methacrylate “acrylic”

resin chemistry and cross-linked denture

teeth. These materials serve as

the functional substrate and esthetic

foundation of the implant-based

prostheses for the edentulous mandible.

Support for the acrylic-veneered

prosthesis has commonly been provided

by gold-based dental alloy frameworks

and, more recently, computer

numeric controlled (CNC)-milled titanium

or chromium-cobalt frameworks.

The functional stresses — impact and

imposed bending — endured by the

esthetic veneer must be supported by

and transmitted through the framework

and the components to the supporting

implants. The data for IRO

and ISFP prostheses suggests that

the incidence of complications with

these prosthetic components is greater

than the failure of the implants 11

(Figs. 1, 2). The materials, designs, and

techniques used in the production of

implant-supported prostheses for the

treatment of mandibular edentulism

require further consideration.

One hypothesis to explain the

prosthetic failures and complications

associated with the IRO and ISFP is

that the mechanical environment

established by implant placement

is inadequate to permit proper construction

of a robust and resilient IRO

or ISFP prosthesis. Three different

factors are essential to defining this

mechanical environment (Fig. 3). One

is the magnitude of forces — specifically,

bending moments, which are

dependent on the magnitude of the

load and the length of any cantilever.

The second is the resistance of the

prosthesis (of a defined material)

against these relatively high and

repetitive loads. The third factor is the

biology of bone and its innate ability

to respond to loading environments.

The aim of this report is to provide

simple rules for treatment planning

dental implant therapy in the edentulous

mandible that both acknowledge

and control the mechanical environment.

This ultimately influences the

success of both the endosseous dental

implants and the prosthesis, and can

offer lasting success for treatment of

mandibular edentulism.

In order to provide a conceptual

framework to manage the treatment

of mandibular edentulism using dental

implants, the three aforementioned

factors affecting implant and prosthesis

longevity have been addressed

and are embodied in three “rules” for

treatment planning. For any IRO or

ISFP, there must be a minimum of

10 mm of alveolar dimension (inferior/

superior) and a minimum of 10 mm of

interocclusal (restorative) dimension

measured from the soft tissue ridge

crest to the occlusal plane. Additionally,

for an ISFP, the anterior/posterior

distribution of implants (commonly

referred to as “A-P spread”) must be

greater than 10 mm. Together, these

three rules are referred to as the “Rules

of 10.” This report will provide the rationale

to support these general rules

and illustrate their application in the

treatment of mandibular edentulism.

Rule No. 1: Inferior/superior

dimension of the mandible must

be ≥10 mm

This rule states that the minimum alveolar

dimension sufficient to support

an IRO or ISFP must be equal to that

required to use implants of approximately

10 mm in length.

The use of implants of 10 mm or less

in length for ISFP is well defined and

successful. More than a decade ago,

Brånemark and co-workers 12 compared

the outcome of ISFP treatment using

implants of greater than 10 mm and

less than 10 mm after 10 years. The

outcome with different lengths of

3.75 mm machined surface implants

revealed no difference in implant

survival after 10 years. In a more

recent 5-year prospective evaluation,

Gallucci and others 13 confirmed a

high (100 percent) implant survival

rate associated with treatment of

mandibular edentulism using ISFP

supported with four, five, or six

implants of between 8 mm and 16 mm.

In all cases, implant failures occurred

before loading. A recent evaluation of

119 patients rehabilitated with four

implants to support mandibular ISFP

revealed a 99.1 percent success rate. 14

There is little information that indicates

the use of longer implants improves

the survival of implants placed in the

parasymphyseal edentulous mandible.

It has also been suggested that

longer implants may be required to

resist the function of long cantilever

prostheses. There is little clinical data

to support or refute this notion. A

three-dimensional (3-D) finite element

model demonstrated that implant

length had no appreciable effect on

stress distribution at the bone/implant

interfaces when loaded by a cantilever

prosthesis, suggesting that implant

length does not dictate survival. 15


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Some added concern is focused on

the IRO. One evaluation revealed a

93.9 percent success rate for implants

supporting an IRO, and the authors

concluded that implant-retained overdentures

are an established treatment

modality, with implant success rates

that are very similar to the results obtained

with implant-supported fixed

prostheses. 16 A long-term examination

of a two-implant mandibular IRO

specifically considered the impact of

implant length as one variable affecting

implant survival. A high survival

rate (95.5 percent) was recorded after

20 years of loading. Although 21 percent

of implants were 8.5 mm or shorter,

implant length and bone quality

did not affect implant survival. 17 The

conclusions that may be drawn are

that implants of approximately 10 mm

have equally high survival in the parasymphyseal

mandible for both IRO

and ISFP, and that increasing implant

length beyond 10 mm does not improve

biologic outcomes in the ISFP

with an appropriately designed cantilever.

Thus, a mandible of 10 mm

height, or inferior-to-superior dimension,

is sufficient for an IRO or ISFP.

Conventional concepts for planning

implant therapy have focused on bone

quality and quantity. 18 However, when

considering the parasymphyseal mandible,

rarely is type III and type IV bone

encountered. Further, ridge resorption

frequently results in a tall mandible

that displays narrow buccolingual

dimension (5 mm) and ensures that the osseous

crest is at least 10 mm to 12 mm

inferior to the planned occlusal plane

(Rule No. 2). Paradoxically, ISFP or

IRO treatment is facilitated by marked

alveolar resorption. Thus, more favorable

prosthetic scenarios involve residual

mandibles of 10 mm to 15 mm

in height, while the more challenging

prosthetic scenarios are associated with

large residual alveolar ridges (e.g., after

extraction). Infrequently, mandibles

of less than 10 mm superior-to-inferior

dimension are encountered. When four

implants of 10 mm cannot be placed

in a severely resorbed mandible, additional

implants of shorter dimension

may be considered. For example, in an

8 mm mandible, the use of 8 mm or

9 mm implants might be considered

if additional implants are included.

Mandibular fracture is not common,

but is recognized as a serious potential

complication among high-risk individuals.


Rule No. 2: Interocclusal

(restorative) dimension measured

from ridge crest to occlusal plane

must be ≥10 mm

The interocclusal dimension directly

impacts the quality and integrity

of both an IRO and an ISFP. Both

overdentures and fixed prostheses

require a minimal dimension to provide

structural integrity and to permit

the establishment of proper contours

in support of comfort, mastication,

and speech.

When planning for implant placement,

it is essential to first understand the

planned position of the prosthetic

teeth. In other words, plan down from

the occlusal plane and not up from

the osseous crest. This assures better

control of the restorative dimension.

The location of the occlusal plane

is defined by proper denture construction

at the appropriate vertical

dimension of occlusion. While it is

beyond the scope of this discussion,

widely accepted anthropomorphic

averages suggest that the distance

from the mandibular incisal edge to

the reflection of the buccal vestibule

is approximately 18 mm. 20 Therefore,

if an existing denture measures less

than 15 mm to 16 mm from the incisal

edge to the buccal flange, there may

be cause to reconsider the vertical

dimension of occlusion and/or the

placement of the occlusal plane.

This concept of restorative dimension

was initially addressed by Phillips and

Wong 21 and reiterated by Lee and Agar 22 ;

however, there is little data in support

Figure 3: Conceptualization of stresses and strains

encountered for a mandibular prosthesis supported

by dental implants. High magnitude masticatory forces

(i.) are enacted through long lever arms (ii.), creating

bending moments and force magnification in the

components (iii.). The forces cause deformation in the

prosthesis and challenge the integrity of the implantabutment

interface. The transmitted forces are further

encountered at the implant-bone interface (iv.).

Figure 4: The mandible must be at least 10 mm in

superior-inferior dimension. Rarely are mandibles of

less than 10 mm observed clinically.

of this inferior-superior dimension for

planning of a mandibular IRO or ISFP.

Practically, the restorative dimension

for any implant prosthesis includes

four key components, each with

its own minimum dimension. They

are: 1) the transmucosal dimension

(biologic width) of approximately

2 mm; 2) a supramucosal abutment

height (0 mm to 2 mm) that permits

hygiene; 3) a framework or attachment

height between 3 mm and 5 mm; and

4) acrylic veneer thickness greater

than 2 mm (Fig. 5). It must also be

acknowledged that the replacement

mandibular teeth should accommodate

their full contours. The average

height of mandibular anterior teeth is

approximately 10 mm. 23 A minimum

10 mm of restorative space places

– “Rules of 10” — Guidelines for Successful Planning and Treatment of Mandibular Edentulism Using Dental Implants – 93


Figure 5: Accounting for a minimal restorative

dimension. A fixed or removable mandibular prosthesis

must allow for placement of: (i.) the transmucosal

abutment; (ii.) adequate room and access for periimplant

mucosal hygiene; (iii.) restorative components,

abutment, and bridge screws; and (iv.) an

esthetic and phonetically accepted veneer.

Figure 6: Defining the depth of implant placement.

Implant placement may be at the osseous crest if

there is sufficient buccolingual width at that location

and sufficient restorative dimension (from the crest

to the occlusal plane). However, if these requirements

are not met, implant placement is planned in

a subcrestal location with a need for accompanying


Figure 7: A-P spread in clinical situation. Providing

a single premolar and a single molar (16.5 mm

in length) in the distal cantilever requires approximately

10 mm A-P spread (X) to maintain a 1.5:1


average-size mandibular prosthetic

teeth precisely at the soft tissue crest

with only a minimal dimension for the

prosthetic components.

It becomes evident that the planning

of an implant-supported or implantretained

prosthesis for the edentulous

mandible begins with defining a superior-inferior

reference, namely, the

occlusal plane. Space accommodation

for the dimension and location of

teeth, frameworks, attachments, retaining

abutments (balls, bars, etc.), and

biologic width will direct planning of

implant position.

Finally, the location of the osseous

crest in relationship to the planned

implant position dictates the extent

of the alveolectomy required (Fig. 6).

Jensen and colleagues provide an

excellent review of the surgical and

prosthetic considerations for the proposed

alveolectomy and describe it

as the creation of a mandibular

“shelf.” In addition to establishing

restorative space and alveolar width,

the shelf design facilitates visualization

of the inferior alveolar nerve,

inspection of any lingual concavities,

and collection of bone stock for any

secondary grafting. 24

This approach differs from the evaluation

of bone as a primary step in the

planning of mandibular implant prostheses.

This second rule is essential for

providing a robust and lasting fixed

or removable prosthesis supported or

retained by dental implants.

Rule No. 3: Anterior/posterior

distribution of implants must be

at least 10 mm for the ISFP

The ISFP was originally envisioned for

treatment of mandibular edentulism by

using the abundant bone of the mandibular

parasymphysis. A cantilever

design of the ISFP was inherent to the

solution, using multiple anterior implants.

The implants must be able to

support functional loads at the posterior

occlusal contacts via the cantilever.

These loads, however, are magnified

within the framework and components,

and potentially at the implant-bone interface.

In the early conceptualization

of this therapy, the anterior-posterior

distribution of dental implants was

recognized as a key factor affecting

the incidence of complications in the

cantilevered mandibular ISFP. To counteract

the imposed bending moments

of the loaded cantilever, maximum

distribution of implants was recommended.

This anterior-posterior distribution

of implants is referred to as the

“A-P spread.” Clinicians were quick to

point out that there were anatomic constraints

for implant placement in the

parasymphyseal mandible. Com pared

to curved or V-shaped mandibles,

square-shaped mandibles often provide

little anterior-posterior dimension

anterior to the inferior alveolar nerve

(Figs. 7–9). Additionally, anatomic variations

in the inferior alveolar nerve (e.g.,

anterior loop) are not uncommon 25 and

can reduce the available A-P spread.

A number of different models have

been used to estimate the proper

cantilever length in relationship to

the A-P spread. These approaches

include the use of photoelastic models,

piezoelectric strain sensors, and finite

element models. The results are diverse

and the majority examined the stresses

that accumulate at the implant-bone

interface. Interestingly, the focus on

the implant, per se, does not match

the clinical situation where implant

failures are infrequent and prosthesis

complications are more prevalent.

Any discussion of cantilever length

requires that: 1) the position of the

distal-most implant be anticipated; and

2) the number of teeth to be provided

distal to that implant be defined.

For the purposes of establishing a

concept that meets the needs of most

patients, the goal is to have the distal

implant in the distal-most location

that does not impose on the inferior

alveolar nerve, which is generally

located in the canine or first premolar

region. Further, distal inclination of

the posterior implants may place the

prosthetic interface even more distal

in the first premolar region. 26


– www.inclusivemagazine.com –

The all-on-four concept generally

requires that posterior teeth beyond

the first premolar are supported

by a cantilever. Efforts to reduce or

eliminate the cantilever by distal

orientation of terminal implants are

advocated. Bridge screws emerging

at the first premolar or molar position

can be achieved in this way. Malo

has reported that this approach is

associated with high implant and

prosthesis survival over 10 years. 26 In

2011, Malo reported on 245 patients in

whom 980 implants were placed and

immediately loaded. The cumulative

patient-related and implant-related

success rates were 94.8 percent and

98.1 percent, respectively, at five years,

and 93.8 percent and 94.9 percent,

respectively, at 10 years. 26

One other key factor contributing to

the overloading of these components

is prosthesis misfit. However, the accuracy

of contemporary impression

materials and the introduction of precision-milled

frameworks for the ISFP

reduce the prevalence of prosthetic

misfit and its impact on the therapeutic

outcome. The geometric distribution

of the implant-abutment and the abutment-prosthesis

interfaces remain the

significant features of ISFP therapy

that can be clinically managed to reduce


When considering the number of teeth

to be provided distal to the canine or

first premolar site, the minimal provision

of one additional premolar and

one molar is sufficient to meet the

esthetic and functional requirements

of most individuals. 27 These general

guidelines can be converted to linear

measurements. The average dimension

of a mandibular premolar is

approximately 6 mm, and that of the

mandibular first molar is approximately

10 mm. 23 Thus, a cantilever of

16 mm can suffice to provide function

and esthetics. The functional relationship

between the cantilever length

and the A-P spread has been debated

(Figs. 7–9). More than 30 years of opinion,

experimentation, and calculation

have generated an array of suggested

Figure 8: A-P spread in clinical situation. The parallel

placement of the implants resulted in approximately

4 mm to 5 mm of A-P spread.

solutions. To provide the broadest

range of success for the largest set of

patients, a conservative estimate of

this functional relationship should be

selected. For a mandible with no more

than four implants to be restored with

a rigid framework, utilizing a cantilever

length to A-P spread ratio of 1.5:1

has been advised. 28 Thus, for the ideal

situation of four implants placed in

the parasymphyseal mandible with

the distal-most implants located in the

first premolar region, a cantilever of

approximately 15 mm (one premolar

and molar tooth) requires 10 mm of

A-P spread. This represents the third

Rule of 10.

Applying the Rules of 10

Several key steps are required for

using the Rules of 10 in the treatment

of mandibular edentulism. The previously

mentioned reference points

(i.e., occlusal plane and osseous crest)

must be firmly established. To assure

accurate measurement, all treatment

should begin with the proper fabrication

of complete dentures and

verification of ideal tooth position

(Figs. 10, 11).

Rule No. 1 requires a volumetric

assessment of the edentulous mandible

with cone-beam computed tomography

(CBCT). However, other

important information can be found

in the radiographic process, and no

radiograph should be made for ISFP

treatment-planning purposes without

the presence of a radiographic stent.

Figure 9: A-P spread in clinical situation. The divergent

placement of the implants resulted in

approximately 10 mm of A-P spread measured at the

abutment/prosthesis interface.

Figure 10: Conventional dentures

Figure 11: Surgical guide

The resultant images should display

the location of the planned prosthesis

in relation to the mandible.

Rule No. 2 requires that the plane of

occlusion is properly located and the

appropriate vertical dimension of occlusion

is defined. If the patient is also

edentulous in the maxilla, this involves

the fabrication of ideal maxillary and

mandibular dentures. The dentures

will define the location of the occlusal

– “Rules of 10” — Guidelines for Successful Planning and Treatment of Mandibular Edentulism Using Dental Implants – 95


plane and mandibular tooth position,

where the mandibular denture can

be duplicated in radiopaque acrylic

for a radiographic stent. The amount

of alveolectomy needed can then be

determined from the CBCT images.

Rule No. 3 requires an understanding

of the anatomy of the edentulous

mandible in relationship to the location

of the planned prosthetic teeth, as

well as the ability to translate this

information to the implant placement,

generally via a surgical guide. This can

be accomplished practically in one

of two ways. One method involves

evaluation of the CBCT images using

3-D planning software (e.g., Simplant ®

[Materialise Dental; Glen Burnie, Md.] or

NobelClinician [Nobel Biocare; Yorba

Linda, Calif.]) and then modifying a

duplicate denture made from clear

acrylic (Figs. 10, 11). The other involves

use of a third-party company to

fabricate a digital surgical guide.


Dental implant therapy for the edentulous

mandible has been successful. Data

concerning implant survival is high

and reflects the quality and quantity

of bone available for osseo-integrated

implant function. The complications

associated with both removable and

fixed dental implant prostheses reflect

the constraints of current materials and

design limitations. The Rules of 10 assure

that there is: 1) adequate bone

for osseointegration and its long-term

success; 2) sufficient dimension for

fabrication of an esthetic, comfortable,

and robust prosthesis; and 3) proper

distribution of imposed forces from occlusal

function within the prosthesis, at

the implant-abutment screw interfaces,

and at the implant-bone interfaces. Following

these simple geometric and linear

guidelines to treatment planning

enables proper implant placement

decisions that underscore robust and

lasting prosthesis construction. IM


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Originally published in: Cooper LF, Limmer BM,

Gates WD. “Rules of 10” — Guidelines for Successful

Planning and Treatment of Mandibular Edentulism

Using Dental Implants. Compend Contin Educ Dent.


Copyright © 2012 to AEGIS Publications, LLC. All

rights reserved. Reprinted with permission from the



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