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Inclusive

Restorative Driven Implant Solutions Vol. 3, Issue 1

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

Introducing the Inclusive ®

Tooth Replacement

Solution

Dr. Darrin Wiederhold and

Dr. Bradley Bockhorst

Page 6

Digital Design of Custom

Temporary Components

Dzevad Ceranic, CDT

Page 17

Building a Healthy

Referral Network

Dr. Robert Horowitz

Page 22

Recession Relief: Are Dental

Implants the Answer?

Dr. Ara Nazarian

Page 34

Technology’s Impact on

Restorative Implant Treatment

Dr. Timothy Kosinski

Page 43

Implant Q&A:

Darrin Wiederhold, DMD, MS

Implant Division, Glidewell Laboratories

Page 26

Inclusive Contest:

How Many Implants?

Page 56


On the Web

Here’s a sneak peek at additional

Inclusive magazine content available online

ONLINE Video Presentations

• Dr. Darrin Wiederhold introduces the Inclusive ® Tooth Replacement

Solution, a comprehensive package for predictably placing

and restoring dental implants.

• The Glidewell Laboratories Implant Department staff outlines

the lab’s process of designing and milling custom temporary

components.

• Dr. Wiederhold discusses his experience with the Inclusive Tooth

Replacement Solution and shares his vision for upcoming educational

courses at the Glidewell International Technology Center.

• Dr. Timothy Kosinski explores the role of new technologies in

simplifying and improving implant treatment services.

• Dr. Bradley Bockhorst discusses specific guidelines when working

with the Inclusive Tooth Replacement Solution, including

proper implant orientation and seating of custom components.

Check out the latest issue of Inclusive

magazine online or via your smartphone at

www.inclusivemagazine.com

gIDE LECTURE-ON-DEMAND PREVIEW

• Dr. Stefan Paul discusses a vital component for long-term implant

success in this gIDE video lecture, “Restorative Excellence —

Occlusion on Implant-Retained Restorations.”

ONLINE CE credit

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

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

the articles marked with “CE.”

Look for these icons on the pages that follow

for additional content available online


Contents

ALSO IN THIS ISSUE

14 Clinical Tip: Implant Orientation for

Inclusive Tooth Replacement Solution

Components

17 Lab Sense: Virtual Design of

Inclusive Custom Temporary

Components

40 Clinical Tip: Placing Custom

Healing Abutments

52 Restorative Driven Implant

Treatment: From Immediate

Temporization to Final Restoration

56 Inclusive Contest:

How Many Implants?

6

22

26

34

43

Benefits of the Inclusive ® Tooth Replacement Solution

Complex treatment modalities can make it difficult to treat implant

patients efficiently while still maintaining quality of care. With

their in-depth look at the Inclusive ® Tooth Replacement Solution,

Drs. Darrin Wiederhold and Bradley Bockhorst address this

challenge by utilizing predesigned custom temporary components

to provide patient-specific temporization and contoured healing.

Building a Restorative Driven Referral Network

A thriving surgical practice is largely dependent on the success of

the restorative dentists, laboratory technicians and other co-treating

professionals who help carry an implant case to completion. Experienced

periodontist Dr. Robert Horowitz identifies some of the most

common areas of miscommunication in the treatment progression

and looks at how implant specialists might help to maximize

patient satisfaction and profitability for their referring doctors.

Implant Q&A: An Interview with Dr. Darrin Wiederhold

For some clinicians, venturing into the realm of dental implants is

a daunting prospect. In his first published interview as a member

of the Glidewell Laboratories clinical team, accomplished dentist

Dr. Darrin Wiederhold outlines some of the practical steps a clinician

can take to gain the knowledge, confidence and experience required

to successfully join the ranks of implant professionals.

Incorporating Implants into Your Daily Practice

A dentist feeling the pinch in a difficult economy is apt to seek

more efficient ways to provide services, or to take on new services

typically referred to another provider. Dr. Ara Nazarian addresses

the difficulties of traditional implant treatment and explains how a

restorative-driven approach simplifies the process, making it more

convenient and affordable for both the dentist and the patient.

Implant Solutions Utilizing the Latest Technology

Dentists today stand to benefit from technological innovations that

make procedures more predictable and less invasive. Dr. Timothy

Kosinski showcases the use of digital treatment planning to promote

safe and simple guided implant delivery, followed by the placement

of prefabricated custom temporary components that allow

for unprecedented versatility at the time of surgery.

– Contents – 1


Letter from the Editor

Clinicians are faced with many challenges when restoring dental implants. One of these is

sculpting the soft tissue into the optimal contours, and then transferring those contours to

the master cast to allow for fabrication of the final restoration. In the past, various attempts

to achieve this goal ranged from modifying healing abutments to adding composite to stock

impression copings. These procedures were often cumbersome and did not offer a simple,

complete solution. With advances in virtual design and CAD/CAM technologies, an array of

prosthetic components can now be custom made — pre- or post-surgically — to address

these issues.

Glidewell Laboratories receives more than 200 implant cases a day, and we routinely see

impressions where a narrow impression coping was utilized. The challenge in these cases

is to create a restoration that has a natural emergence profile. This problem, coupled with

our experience designing and milling custom abutments, led to the development of the

Inclusive ® Tooth Replacement Solution.

At the core of the Inclusive Tooth Replacement Solution is an anatomically shaped transgingival

section that is virtually designed over the proposed implant site. This base design

is then used to create a custom healing abutment or a custom temporary abutment and a

provisional crown. A matching custom impression coping allows for the soft tissue contours

to be transferred to the master cast, resulting in a superior final restoration.

The solution offers flexibility in that the case can be immediately temporized, if appropriate,

or the alternate custom healing abutment can be delivered. The components can easily be

adjusted or modified as needed.

The goal of the Inclusive Tooth Replacement Solution is to provide the clinician with a

complete, restorative-driven solution for a missing tooth, from treatment planning to final

prosthesis, with all of the necessary components and tools, including the implant. This issue

of Inclusive magazine was conceived to introduce you to our laboratory’s new conventionaldiameter

implant system and tooth replacement solution. Eager for your feedback, we

invite you to read the articles and check out the multimedia content available online at

www.inclusivemagazine.com.

Dr. Bradley C. Bockhorst

Editor-in-Chief, Clinical Editor

inclusivemagazine@glidewelldental.com

– Letter from the Editor – 3


Publisher

Jim Glidewell, CDT

Editor-in-Chief and clinical editor

Bradley C. Bockhorst, DMD

Managing Editors

Jim Shuck; Mike Cash, CDT

Creative Director

Rachel Pacillas

Contributing editors

Greg Minzenmayer; Dzevad Ceranic, CDT;

David Casper; Tim Torbenson

copy editors

Eldon Thompson, Barbara Young,

Megan Affleck, David Frickman, Jennifer Holstein

digital marketing manager

Kevin Keithley

Graphic Designers/Web Designers

Jamie Austin, Deb Evans, Joel Guerra,

Audrey Kame, Lindsey Lauria, Phil Nguyen,

Kelley Pelton, Melanie Solis, Ty Tran, Makara You

Photographers/Clinical Videographers

Sharon Dowd, Mariela Lopez

James Kwasniewski, Marc Repaire, Sterling Wright

Illustrator

Phil Nguyen

coordinatorS/AD Representatives

Teri Arthur, Vivian Tsang

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

inclusivemagazine@glidewelldental.com. Your comments may

be featured in an upcoming issue or on our website.

© 2012 Glidewell Laboratories

Neither Inclusive magazine nor any employees involved in its publication

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

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

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

represents that its use would not infringe proprietary rights. Reference

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

trade name, trademark, manufacturer or otherwise does not necessarily

constitute or imply its endorsement, recommendation, or favoring

by the publisher. The views and opinions of authors expressed

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

shall not be used for advertising or product endorsement purposes.

CAUTION: When viewing the techniques, procedures, theories and

materials that are presented, you must make your own decisions

about specific treatment for patients and exercise personal professional

judgment regarding the need for further clinical testing or education

and your own clinical expertise before trying to implement new

procedures.

Inclusive is a registered trademark of Inclusive Dental Solutions.

Contributors

■ Bradley C. Bockhorst, DMD

After receiving his dental degree from Washington

University School of Dental Medicine,

Dr. Bradley Bockhorst served as a Navy Dental

Officer. Dr. Bockhorst is director of clinical

technologies at Glidewell Laboratories, where he

oversees Inclusive ® Digital Implant Treatment

Planning services and is editor-in-chief and

clinical editor of Inclusive magazine. A member of the CDA,

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

on an array of dental implant topics. Contact him at

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

■ DZEVAD CERANIC, CDT

Dzevad Ceranic began his career at Glidewell

Laboratories while attending Pasadena

City College’s dental laboratory technology

program. In 1999, Dzevad began working

at Glidewell as a waxer and metal finisher,

then as a ceramist. After being promoted to

general manager of the Full-Cast department,

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

In June 2008, Dzevad took on the company’s rapidly growing

Implant department, and in 2009 completed an eight-month

implants course at UCLA School of Dentistry. Today, Dzevad

leads a team of 220 people at the lab and continues to implement

cutting-edge technology throughout his department. Contact him

at inclusivemagazine@glidewelldental.com.

■ ROBERT A. HOROWITZ, DDS

Dr. Robert Horowitz graduated from Columbia

University School of Dental and Oral Surgery

in 1982. After a one-year general practice

residency, he finished a two-year specialty

training program in periodontics at New York

University and the Manhattan VA Hospital.

In 1996, Dr. Horowitz completed a two-year

fellowship program in Implant Surgery at NYU, focusing on

bone grafting procedures. He is a clinical assistant professor

in the department of periodontology and implant dentistry at

NYU College of Dentistry, where he teaches and conducts

research in bone grafting. He is also on faculty and conducts

research in the departments of oral surgery, biomaterials

and biomimetics, and oral diagnosis. Dr. Horowitz has

lectured nationally and internationally and published more

than 40 scientific articles and case studies. Contact him at

inclusivemagazine@glidewelldental.com.

4

– www.inclusivemagazine.com –


■ TIMOTHY F. KOSINSKI, DDS, MAGD

Dr. Timothy Kosinski graduated from the

University of Detroit Mercy School of Dentistry

and received a Master of Science degree in

biochemistry from Wayne State University School

of Medicine. An adjunct assistant professor at

UDM School of Dentistry, he serves on the editorial

review board of numerous dental journals and is

a Diplomate of the ABOI/ID, ICOI and AO. Dr. Kosinski is a Fellow

of the AAID and received his Mastership in the AGD, from which

he received the 2009 Lifelong Learning and Service Recognition

award. Contact him at 248-646-8651, drkosin@aol.com or www.

smilecreator.net.

■ Darrin M. Wiederhold, DMD, MS

Dr. Darrin Wiederhold received his DMD in

1997 from Temple University School of Dentistry

and a master’s degree in oral biology in 2006

from the Medical University of Ohio at Toledo.

Before joining Glidewell in August 2011, he

worked in several private practices and as a

staff dentist for the U.S. Navy. As staff dentist

in Glidewell’s Implant division, he performs implant and

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

facility, and helps support the lab’s digital treatment planning

and guided surgery services. An integral part of the lab’s Implant

Research & Development group, he is also involved in training

and education on implant surgery and prosthetics. Contact him

at inclusivemagazine@glidewelldental.com.

■ ARA NAZARIAN, DDS, DICOI

Dr. Ara Nazarian maintains a private practice in

Troy, Mich., with an emphasis on comprehensive

and restorative care. He is the director of the

Reconstructive Dentistry Institute, a Diplomate

of the ICOI, and has conducted lectures and

hands-on workshops on esthetic materials and

dental implants throughout the U.S., Europe,

New Zealand and Australia. Dr. Nazarian is also the creator of

the DemoDent patient education model system. His articles have

been published in many of today’s popular dental publications.

Contact him at 248-457-0500 or www.aranazariandds.com.

■ PAresh B. Patel, DDS

Dr. Patel is a graduate of the University of North

Carolina at Chapel Hill School of Dentistry

and the Medical College of Georgia/AAID

MaxiCourse. He is cofounder of the American

Academy of Small Diameter Implants and

a clinical instructor at the Reconstructive

Dentistry Institute. Dr. Patel has placed more

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

and clinical consultant on mini implants for various companies.

He belongs to numerous dental organizations, including the

ADA, North Carolina Dental Society and AACD. Dr. Patel is also

a member and president of the Iredell County Dental Society in

Mooresville, N.C. Contact him at pareshpateldds2@gmail.com or

www.dentalminiimplant.com.

– Contributors – 5


Clinical Benefits of the

Inclusive ® Tooth Replacement Solution

Go online for

in-depth content

by Darrin W. Wiederhold, DMD, MS and Bradley C. Bockhorst, DMD

We live in a society of 60-second fast-food drive-thrus, global news

delivered instantly on our smartphones and bundled cable packages.

We demand ever-faster results and increasingly streamlined efficiency. Even dentists are

powerless against the current of progress and the need to accomplish more in less time.

A hallmark of the most successful modern clinicians is the ability to strike a balance

between a daily load of 12 to 16 patients and maintaining the same high standard of

care. No easy task, to be sure — particularly when it comes to treatment involving

dental implants.

Current protocols for implant patients are compartmentalized. The implant manufacturer

is responsible for the components, and the dental laboratory is responsible for

the restoration — after the clinical situation has been determined. From the restorative

perspective, this is equivalent to erecting a house upon an existing foundation, limiting

the builder to what is already there. Developing proper esthetics in an implant case

involves soft tissue contouring that begins at a foundational level, the moment the

implant is placed. Stock components do not allow for this, which means the doctor must

spend valuable chairtime developing custom components or forgo their use altogether,

forcing a choice between quantity of cases or quality of individual patient care.

With the advent of the Inclusive ® Tooth Replacement Solution from Glidewell Laboratories,

practitioners no longer have to choose one or the other. Specially designed custom

temporary components allow for immediate provisionalization specific to the needs of

each patient, and a matching custom impression coping communicates the final gingival

architecture to the dental laboratory. Add to this the implant, surgical drills, a prosthetic

guide, final custom abutment and final BruxZir ® Solid Zirconia restoration (Glidewell

Laboratories), and the clinician receives, in a single box, all the components needed to

place, provisionalize and restore the implant up front. In addition to providing the physical

components (Figs. 1a, 1b), the Inclusive Tooth Replacement Solution supports an easyto-follow

workflow that helps ensure predictability and long-term success, streamlining

the entire process for maximum efficiency. Armed with a clear sense of the endgame and

the tools and road map to get there, experienced and novice clinicians alike can place and

restore dental implants with greater confidence and ease.

6

– www.inclusivemagazine.com –


Inclusive Tooth Replacement Solution

Conventional Procedure – Single Tooth

Step-by-Step

Clinician

Glidewell Laboratories

Appointment

1

Consultation Data Collection

• Complete Inclusive Tooth Replacement Solution Rx

indicating desired implant size, drill preference, tooth #,

required shade for BioTemps provisional crown and any

special design instructions.

• Take PVS impressions.

• Take bite registration.

• Take photos.

• Send Rx to Glidewell with impressions, bite registration

and photos.

Design and fabricate Inclusive Tooth

Replacement Solution components

(7 days in lab):

• Prosthetic guide

• Custom healing abutment

• Custom impression coping

• Custom temporary abutment and

BioTemps crown

• Inclusive implant

• Disposable surgical drills

Appointment

2

Surgery

• Try in prosthetic guide.

• Place implant.

• Deliver custom healing abutment or custom temporary

abutment and BioTemps provisional crown.

• Set post-op recall schedule.

• Keep custom impression coping in patient’s chart or

forward to restorative dentist.

Appointment

3

Final Impressions

• Remove custom temporary components and seat custom

impression coping. Tighten coping screw. Take a PA film to

verify seating, if necessary.

• Take a full-arch impression, opposing impression and bite

registration, as well as a shade.

• Replace the impression coping with the temporary

restoration or healing abutment.

• Complete Inclusive Tooth Replacement Solution Rx,

indicating choice of Inclusive Custom Abutment (titanium

or zirconia) and final shade.

• Send Rx to Glidewell with the impressions and bite

registration.

Design and mill final restorative

components (13 days in lab):

• Inclusive Custom Abutment

(titanium or zirconia)

• BruxZir Solid Zirconia or IPS e.max

crown

Appointment Final

4

Delivery

• Remove custom temporary components for the implant

and irrigate thoroughly.

• Seat final abutment and tighten abutment screw to

35 Ncm. Take a PA to verify seating, if necessary.

• Try in crown. Adjust interproximal and occlusal contacts

as needed.

• Cement crown. Ensure all excess cement is removed.

• Set recall schedule.

– Clinical Benefits of the Inclusive Tooth Replacement Solution – 7


Inclusive Tooth Replacement

Solution Implant Treatment

Workflow

1. Implant Consultation and

Data Collection

2. Day of Surgery Protocol

3. Healing Phase

4. Restorative Phase:

Final Impressions

5. Delivery of Final Prosthesis

Implant Consultation

and Data Collection

As with any larger, more complex

dental case, the taking of preoperative

records and thorough treatment

planning are of paramount importance

when implants are prescribed —

whether it be a single-tooth replacement

or full-mouth rehabilitation. A

truly comprehensive treatment plan

consists of the following:

1. Full-arch upper and lower impressions

(preferably PVS) for the

fabrication of study models

2. An accurate bite registration

3. Full-mouth radiographs, including

a panoramic and CBCT scan (as

needed)

NOTE: If you do not have a CBCT scanner

in your office, the patient can be referred

to an imaging center.

4. Shade match of the existing dentition

5. Preoperative patient photos

While obtaining the aforementioned

records will minimize risk and optimize

the chances of success, the issue

of cost can be a limiting factor, particularly

when dealing with a CBCT scan.

If necessary, explain to the patient the

rationale for the expense of the CBCT

scan by detailing the advantages of

this technology over conventional radiography.

In instances where the cost

is prohibitive, single-tooth implant

cases can still be undertaken with

a high degree of predictability using

conventional radiography alone. Success

in such cases is largely dependent

on the experience level of the clinician,

so an honest assessment of your own

comfort level and abilities will be invaluable

in avoiding potential pitfalls.

Once you have collected the various

data mentioned above and selected

a diameter and length of implant,

forward the appropriate diagnostic

materials (i.e., impressions, models,

bite registration, shade selection and

implant size) to Glidewell Laboratories

for fabrication of the Inclusive Tooth

Replacement Solution components.

Upon receipt, the laboratory will pour

and articulate the models, then assemble

the following components:

1. Prosthetic guide (Fig. 1a)

2.Custom temporary abutment

(Fig. 1a)

3.BioTemps ® provisional crown

(Glidewell Laboratories) (Fig. 1a)

4. Custom healing abutment

(Fig. 1a)

5. Custom impression coping

(Fig. 1a)

6. Surgical drills (Fig. 1b)

7. Inclusive ® Tapered Implant

(Glidewell Laboratories) (Fig. 1b)

The complete set of necessary items

will be delivered to you in one convenient,

all-inclusive box (Fig. 2).


Figure 1a: Prosthetic guide, custom temporary abutment,

BioTemps provisional crown, custom healing

abutment, custom impression coping

Figure 1b: Inclusive Tapered Implant and disposable

surgical drills

Figure 2: Inclusive Tooth Replacement Solution

Developing proper esthetics in an implant

case involves soft tissue contouring

that begins at a foundational level,

the moment the implant is placed.


8

– www.inclusivemagazine.com –


Day of Surgery Protocol

On the day of the implant surgery,

remove the contents of the box and

place them alongside your usual surgical

armamentarium. Confirm the fit

of the prosthetic guide prior to beginning

the procedure (Fig. 3). Make

sure the guide fits snugly around the

teeth, and that there is no rocking or

displacement. Be sure also to visually

confirm that the proposed location of

the implant osteotomy correlates with

your planned location.

Once the implant has been placed

(Figs. 4–11), the decision is made —

based on the level of primary stability

— to place either the custom healing

abutment or the custom temporary

abutment and accompanying Bio-

Temps crown. Either option affords

the opportunity to begin sculpting

the soft tissue architecture around the

implant and developing the future

emergence profile.

To ensure the optimal soft tissue

response and facilitate complete seating

of either the custom healing abutment

or custom temporary abutment and

BioTemps crown, it is recommended

that a tissue punch, or other surgical

means, be utilized to remove the

soft tissue over the osteotomy site.

Note also that the margin of the

custom temporary abutment is set

at approximately 2 mm. Depending

on the thickness of the patient’s soft

tissue, the abutment can be adjusted

and the BioTemps crown relined as

needed. It is critical that the custom

healing abutment or BioTemps crown

be 1–1.5 mm out of occlusion to avoid

any occlusal stresses on the implant as

it osseointegrates (Figs. 12–14).

Once the appropriate custom abutment

has been placed, the implant is

allowed to osseointegrate as normal.

The custom impression coping should

be stored with the patient’s chart to

be used when the implant is ready

to be restored.

Figure 3: Prosthetic guide try-in

Figure 4: 2.3/2.0 mm pilot drill through prosthetic

guide

Figure 6: 2.3/2.0 mm pilot drill to depth

Figure 8: Implant on carrier

Figure 5: Periapical radiograph to verify position

Figure 7: Completed osteotomy following use of the

2.8/2.3 mm surgical drill

Figure 9: Final seating of implant with torque wrench

– Clinical Benefits of the Inclusive Tooth Replacement Solution – 9


Healing Phase

As with any implant treatment protocol,

it is generally advisable that the

patient return for monthly follow-up

appointments to ensure osseointegration

is proceeding well and to adjust

the provisional restoration as needed.

Figure 10: Flat oriented toward the facial

Figure 12: Custom temporary abutment seated

Figure 14: BioTemps crown temporarily cemented

Figure 11: Periapical radiograph to verify implant

position

Figure 13: Abutment screw tightened to 15 Ncm,

with access opening sealed and flap sutured back

into place

Figure 15: Custom impression coping and screw

access opening sealed with soft wax

Restorative Phase:

Final Impressions

When an adequate amount of time has

elapsed and successful osseointegration

of the implant has been confirmed,

the restorative phase begins. Fortunately,

because the contours of the custom

impression coping match those of the

custom healing abutment or custom

temporary abutment, it is simple to

remove the custom abutment, seat the

custom impression coping (Fig. 15)

and take an accurate final impression

(Fig. 16). Either a closed-tray or opentray

technique may be used, but it

should be a full-arch impression. A

full-arch opposing impression and

bite registration are also required.

You then complete a simple prescription

form included with the original

solution components, selecting

your choice of final custom abutment

(titanium or zirconia) and indicating

the final shade for your BruxZir

or IPS e.max ® (Ivoclar Vivadent; Amherst,

N.Y.) restoration. There are no

additional laboratory fees at this point

because the cost of these final restorative

components is included in the

price of the solution. Simply forward

the final impressions and bite registration

along with the completed prescription

to Glidewell Laboratories for

fabrication of the definitive restoration.

Figure 16: Final impression

10

– www.inclusivemagazine.com –


Delivery of Final Prosthesis

The final step in the process is delivery

of the final prosthesis (Figs. 17–23). On

the day of delivery, the custom temporary

abutment is once again removed

and all debris cleaned from inside and

around the implant. The final Inclusive

® Custom Abutment (Glidewell Laboratories)

and BruxZir crown are tried in,

and the contours, contacts and occlusion

checked and adjusted as needed.

Final occlusion should be light on the

implant-retained crown, with forces

directed as much as possible along the

long axis, minimizing lateral forces.

The abutment screw is tightened to

35 Ncm, the head of the abutment screw

is covered and the crown cemented. It

is imperative to meticulously remove

all excess cement. Home care instructions

are given to the patient, and a

recall schedule is set.


Because the

contours of the

custom impression

coping match those

of the custom healing

abutment or custom

temporary abutment,

it is simple to

remove the custom

abutment, seat the

custom impression

coping and take

an accurate

final impression.


Figure 17: Delivery of Inclusive Zirconia Custom Abutment

Figure 18: Abutment screw tightened to 35 Ncm Figure 19: Access opening sealed

Figure 20: Interproximal and occlusal contacts checked

– Clinical Benefits of the Inclusive Tooth Replacement Solution – 11


Figure 21: BruxZir crown cemented in place and all excess cement removed

Figure 22: Final restoration (buccal view)

Figure 23: Final restoration (occlusal view)


Conclusion

Implants can be a rewarding, profitable

addition to any practice. As our

patient population becomes more

dental savvy, the demand for clinicians

who are adept at placing and

restoring dental implants continues

to grow exponentially. Dental implant

treatment is very much the future of

dentistry as a solution to partial or

total edentulism, and it should be part

of any discussion with patients regarding

the restoration of missing teeth.

A key challenge lies in treating a maximum

number of patients in a minimum

amount of time — without sacrificing

the quality of treatment. An excellent

way to address this is by providing

patient-specific temporization and

contoured healing through the use of

predesigned custom temporary components.

Temporization sets the tone

for the final esthetic outcome, the parameters

for which are unique to each

patient. So why treat them all with the

same stock temporary components?

As the demand for implants grows,

so does the need for cost- and timeeffective

ways to provide this service.

The Inclusive Tooth Replacement

Solution provides a highly efficient,

predictable and affordable method

of both placing and restoring dental

implants. In conjunction with the

clinician’s experience and skill, it is

designed to equip dentists with the

tools to provide this service in a single,

comprehensive package. IM

A key challenge lies in treating a maximum number of patients

in a minimum amount of time — without sacrificing the quality

of treatment. An excellent way to address this is by providing

patient-specific temporization and contoured healing through

the use of predesigned custom temporary components.


12

– www.inclusivemagazine.com –


Clinical Tip:

Go online for

in-depth content

Implant Orientation for Inclusive® Tooth

Replacement Solution Components

by Bradley C. Bockhorst, DMD and

Darrin M. Wiederhold, DMD, MS

The Inclusive ® Tooth Replacement

Solution from Glidewell Laboratories

features custom temporary components

designed to guide soft tissue

contours during the healing phase.

Whether you utilize the custom temporary

abutment or custom healing

abutment, the following guidelines

can help to ensure a smooth delivery

at the time of surgery.

Aligning the Abutment Connection

The custom temporary components

of the Inclusive Tooth Replacement

Solution are designed, presurgically,

with one flat of the internal

hex positioned toward the

facial. During surgery, the final

position of the implant should match

this orientation. This is accomplished

by aligning one of the flats on the implant

driver to the facial (Figs. 1–3). If

the seated abutment is rotated slightly,

it can be removed and minor adjustments

made to the rotational position

of the implant.

Seating the Custom Abutment

Assuming there is adequate attached

gingiva and no grafting is planned,

flapless surgery can minimize postoperative

discomfort and swelling,

leading to higher patient satisfaction.

Also, because the periosteum is not reflected,

the blood supply to the bone

is not disrupted, reducing potential resorption.

With the growing popularity

of minimally invasive surgery, the use

of a tissue punch (or other tools, such

as a laser) can make it much simpler

to seat anatomically contoured abutments

during a flapless procedure

(Figs. 4–9). Once adequate tissue has

been removed, the custom temporary

abutment is seated and the abutment

screw tightened to 15 Ncm. A periapical

film should be taken, if necessary,

to verify complete seating. The screw

opening is sealed and the BioTemps ®

provisional crown (Glidewell Laboratories)

is seated with provisional

cement. It is absolutely critical that all

excess cement be removed and the

temporary taken out of occlusion.

In flapped cases, the abutment can be

delivered and the complete seating

visualized directly. The soft tissue can

then be reapproximated and sutured

around the abutment (Figs. 10–12). IM

Figure 1: Flat to facial in flapped case

Figure 2: Flat to facial in flapless case

Figure 3: Final implant position

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Case 1: Tissue Punch

Figure 4: Tissue punch Figure 5: Custom temporary abutment seated Figure 6: BioTemps crown cemented into place

Case 2: Laser (Case courtesy of Dr. Dean Saiki, Oceanside, Calif.)

Figure 7: Laser-assisted gingivoplasty Figure 8: Custom temporary abutment seated Figure 9: BioTemps crown cemented into place

Case 3: Flapped

Figure 10: Custom temporary abutment seated

Figure 11: Flap sutured around abutment

Figure 12: BioTemps crown cemented into place

– Clinical Tip: Implant Orientation for Inclusive Tooth Replacement Solution Components – 15


Lab Sense:

Virtual Design of Inclusive®

Custom Temporary Components

Go online for

in-depth content

by Dzevad Ceranic, CDT

In processing restorations for more than 160,000 implant cases, the Implant

Department at Glidewell Laboratories has accumulated a unique understanding

of the industry as a whole, observing everything from shifting trends to emerging techniques

to common difficulties experienced by practicing clinicians. In this column, we endeavor to

share some of the insights we have obtained, in hopes of improving the quality and efficiency

of cases everywhere.

The esthetic result of any crown & bridge restoration is greatly dependent on the gingival

contours from which that restoration emerges. Implant restorations pose greater difficulty

given the collapse of soft tissue that typically occurs in the edentulous site, and stock abutments

employed during the healing phase may not provide suitable tissue support to achieve the

desired gingival anatomy. A custom temporary abutment and provisional restoration give

the clinician greater control over papillae development and gingival contours, but even if

the desired anatomy is developed intraorally, how does one accurately convey the final soft

tissue architecture to the laboratory using a traditional impression post? To better assist the

technician in designing the most natural emergence profile, a custom impression coping

is required to properly replicate the soft tissue anatomy during the impression procedure.

Yet, the majority of cases received here at Glidewell Laboratories suggest that methods for

developing a custom impression coping chairside are either too tedious or time-consuming

for most clinicians to trouble with, outside of the most demanding anterior situations.

Drawing on our experience with CAD/CAM technology, however, it is now possible to provide

a complete custom temporary solution consisting of a custom BioTemps ® provisional crown

(Glidewell Laboratories) over a custom temporary abutment, an optional custom healing

abutment (for cases in which immediate loading may be contraindicated) and a matching

custom impression coping. Use of these components allows the restorative clinician to

shape and support the soft tissue as desired during the healing phase, and maintain and

capture that carefully contoured gingival anatomy during the impression procedure. Given

this information, the laboratory technician has an accurate understanding of the gingival

architecture from which to design a natural emergence profile for the most predictable and

pleasing esthetic result.

17


Digital Manufacturing Process

The process by which Glidewell Laboratories

designs and mills its custom temporary components

is much the same as that it uses to produce

its Inclusive ® Custom Implant Abutments. Using

this proven CAD/CAM technology, our laboratory

has successfully manufactured more than 160,000

custom abutments.

•Step 1: Model Scan

For conventional cases, the process begins with

articulated, presurgical study models, in which the

proposed implant location is indexed with the aid

of the prosthetic guide. A scanning abutment is then

placed in the proposed implant site. The purpose of

the scanning abutment is to capture the implant’s

angulation, its location relative to the adjacent dentition,

and the abutment connection orientation,

all of which is translated to the design software

when the model undergoes three-dimensional optical

scanning (Fig. 1).

•Step 2: Design of Custom Components

Once a virtual model is created (Fig. 2), complete

with a virtual analog demonstrating the proposed

implant location (Fig. 3), the custom temporary

abutment, custom BioTemps crown, custom healing

abutment and custom impression coping are

Figure 1: Model placed into optical scanner

Figure 2: Scanned model with opposing

Figure 3: Virtual analog placement

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designed using a proprietary add-on software module

developed for the DentalDesigner system from

3Shape (New Providence, N.J.). The computer software

allows the digital technician to manipulate the

size and shape of the component using precise measurements

(Figs. 4–7).

Such precision is critical in implant cases, where

contacts and occlusion help to determine the

functional load to be placed on the implant. To allow

for discrepancies in implant placement following

surgery, the BioTemps provisional is designed with

extra relief space within the cement space (Fig. 8),

providing an internal offset in the area between the

temporary crown and custom temporary abutment.

Figure 4: Custom healing abutment designed

Figure 5: Custom impression coping designed

Figure 6: Custom temporary abutment designed

Figure 7: BioTemps crown designed

Figure 8: BioTemps crown designed with internal relief space

– Lab Sense: Virtual Design of Inclusive Custom Temporary Components – 19


•Step 3: Milling of Custom Components

Once the digital design of each component

has been finalized, the files are transferred to a

state-of-the-art computer-aided milling station. The

custom impression coping, custom temporary

abutment and custom healing abutment are all

milled from polyether ether ketone (PEEK), an

organic polymer thermoplastic (Figs. 9, 10).

The BioTemps provisional crown is milled from

poly(methyl methacrylate) (PMMA), a transparent

thermoplastic sometimes referred to as acrylic glass

(Figs. 11, 12). After seating is confirmed, the custom

temporary crown is stained according to the shade

prescribed by the clinician, then glazed before a

final quality inspection is performed.

Figure 9: PEEK abutment blank ready for milling

Figure 10: Milled PEEK abutment

Figure 11: Close-up of PMMA milling

Figure 12: PMMA block after milling

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Figure 12: PMMA block after milling

Figure 12: PMMA block after milling

Inclusive ® Tooth Replacement Solution

The finished custom temporary components

(Fig. 13), along with the physical models and

prosthetic guide, are sent to the clinician as part of

the newly launched Inclusive ® Tooth Replacement

Solution. One of the goals of this solution, which

also includes an Inclusive ® Tapered Implant and

the appropriate surgical drills (Fig. 14), is to provide

clinicians with everything they need to provisionalize

the case at the time of implant placement. This way,

the patient can leave the office with an esthetic

restoration in place. These custom temporary

components not only serve to manage and maintain

the desired gingival contours critical to a natural

emergence profile, but also give the clinician and

patient a chance to preview the ultimate result —

providing valuable preliminary information and

increasing the likelihood of acceptance upon

delivery of the final restorative components

(Inclusive Custom Abutment and BruxZir ® Solid

Zirconia crown [Glidewell Laboratories]) that

complete the Inclusive Tooth Replacement Solution.

Summary

Without proper communication of the desired

gingival architecture, a laboratory technician must

rely on model manipulation and guesswork when

designing a patient’s final implant restoration.

Such techniques tend to be less predictable and

may compromise the esthetic outcome. Custom

temporary components designed and milled using

proven CAD/CAM techniques enable clinicians to

guide soft tissue contours during the healing phase,

and a matching custom impression coping serves

to accurately preserve and capture these contours

during the impression procedure. The overall

result of this custom temporary solution is a clear

translation of the desired gingival anatomy to the

lab technician for use in designing the optimal

emergence profile, greatly increasing the esthetic

predictability of the final restorative result. IM

Custom temporary components ... enable clinicians to guide soft tissue contours

during the healing phase, and a matching custom impression coping serves to

accurately preserve and capture these contours during the impression procedure.

Figure 13: Inclusive Tooth Replacement Solution custom temporary components

Figure 14: Inclusive Tapered Implant with surgical drills

– Lab Sense: Virtual Design of Inclusive Custom Temporary Components – 21


Building a Referral Network Through

Restorative Driven Implant Concepts

by Robert A. Horowitz, DDS

Introduction

One might argue that the outcome of any implant case

begins with a successful surgery. Most patients are less

concerned with root-form placement, however, than

they are with the esthetics and functionality of the final

restoration. The success of any surgical practice is therefore

highly dependent on the success of its referral network —

the restorative dentists, laboratory technicians and other

co-treating professionals who help to carry an implant case

to completion.

that have been known to complicate implant cases between

the surgical and restorative phases. Intended to promote

an effective, streamlined process resulting in a predictable

outcome, this all-in-one, restorative-based solution (Fig. 1)

offers a number of advantages for the team of providers

working together to ensure each patient receives the best

possible care.

Fortunately, the factors that drive growth for a specialist

practice are the same as those that drive growth for a

general practice or laboratory, chiefly patient satisfaction

and profitability — factors that derive from proper planning,

efficient treatment and minimal complications. Treatment

planning each case to include restorative considerations

from the outset and ensuring proper collaboration and

communication among all members of the team will greatly

enhance the likelihood of a successful outcome and the

efficiency with which it is achieved.

The Inclusive ® Tooth Replacement Solution from Glidewell

Laboratories represents an intriguing new tool in the effort

to address planning, communication and component issues

Figure 1: Temporary, impression and final phases of the patient-specific Inclusive

Tooth Replacement Solution

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Restorative Treatment Planning

To obtain an ideal surgical outcome, a full diagnosis must

be completed before the initiation of treatment. The final

prosthetic design should also be considered. The more

comprehensive the diagnosis, the better the final restoration

will be. Clinical photographs and radiographs, periodontal

evaluation, esthetic evaluation, diagnostic casts on an

adjustable articulator with a wax-up of the teeth (present

and missing) in ideal functional and esthetic locations, and

a cone beam volumetric tomogram taken with a radioopaque

stent are all helpful tools for accomplishing this.

The laboratory technician is forced to approximate the

design of the restorative components. In many cases, this

results in an abutment or crown that does not quite fit

properly, causes tissue blanching or looks less than natural

where it emerges from the gingiva. Adjustments or even a

remake may be required, costing the clinician and patient

valuable chairtime.

It is tempting for some surgical specialists to take prosthetic

diagnosis and soft tissue sculpting for granted. They might

think these are concerns chiefly for the restorative dentist.

Why should a specialist take time to do general work? The

truth is, these are foundational components that help lay

the groundwork for the definitive restoration. Extra time

spent in the planning stages can be rewarded tenfold in

terms of time saved addressing complications that may

otherwise result later in the case. Making the restorative

clinician’s job easier is pleasing to both the clinician and the

patient, fostering goodwill and leading to a greater number

of future referrals.

The Inclusive Tooth Replacement Solution places a great

degree of emphasis on the preplanning of each case from

a restorative perspective. Implant and case-specific surgical

drills are provided according to the surgeon’s prescription,

along with a prosthetic guide — fabricated from an initial

impression — to help ensure proper implant placement

(Fig. 2). Laboratory technicians then utilize digital technology

to design and mill a custom temporary abutment and

provisional restoration (Fig. 3), making them available at

the time of surgery. For clinical flexibility, a custom healing

abutment is also provided (Fig. 3). The purpose of these

custom temporary components is to begin sculpting the

gingiva on the day the implant is inserted. Rather than

ignoring the soft tissue contours or leaving them to chance,

they are guided during the healing phase to prepare for

an ideal emergence profile of the final restoration. And

because the components are pre-milled, the chairside

time that might otherwise be spent crafting a provisional

restoration is eliminated.

Figure 2: The Inclusive Tooth Replacement Solution includes a prosthetic guide

to help ensure proper implant placement.

Restorative Communication

Upon completion of the healing phase, the patient

returns to the referring restorative clinician, who takes

the impression for the lab. The typical challenge with

implant cases is that a stock, cylindrical impression

coping cannot properly capture the gingival architecture.

Figure 3: The Inclusive Tooth Replacement Solution also includes a custom temporary

abutment, a provisional restoration, and a custom healing abutment.

– Building a Referral Network Through Restorative Driven Implant Concepts – 23


Figure 4: A custom impression coping (right) is designed to match the gingival

architecture sculpted by the custom temporary abutment (center) and custom

healing abutment (left). The custom impression coping would be forwarded to the

restorative dentist.

The Inclusive Tooth Replacement Solution addresses this

issue from the outset with a custom impression coping

(Fig. 4) designed to match the gingival architecture sculpted

by the custom temporary abutment. When the patient

returns to the referring doctor, the doctor simply removes

the temporary, places the custom impression coping, takes

the impression and sends it to the lab. The full gingival

architecture is precisely captured for lab use, without the

need to create a custom impression coping chairside.

Restorative Outcome

When utilizing the Inclusive Tooth Replacement Solution,

restorative dentists get the benefit of a laboratory that

has restored more than 160,000 implant cases. They can

therefore expect precise, quality restorations without

any unnecessary complications. A custom abutment and

monolithic crown are milled to precisely match the digital

design files used in the creation of the custom temporary

components. Because of this, the abutment and crown

should seat easily with a precise fit. Any adjustments should

be minimal, allowing the patient to leave the office with a

natural-looking definitive restoration requiring no further

corrective appointments.

Laboratory Support

To maximize the number of successful referrals, an implant

specialist needs to offer support to less-experienced

restorative providers. An important ancillary benefit to

Glidewell’s Inclusive Tooth Replacement Solution is that

each case incorporates patient-specific custom components,

simplifying treatment steps for less-experienced restorative

clinicians. Further, the solution includes the customer

support of a highly experienced team of technical advisors

who can assist the restorative doctor with any questions or

concerns that arise. This frees up the specialist staff to focus

on specialized procedures, while still providing the referring

doctor with answers to any questions or concerns. Users

of the Inclusive Tooth Replacement Solution also benefit

from a significant cost savings over the price of individual

components. As the laboratory manufactures the implants

and all other components on site at its state-of-the-art

U.S. facility, vendor markups are reduced. A single price

covers the entire cost of the solution, eliminating the

guesswork often associated with determining treatment fees

for the placement and restoration of implants.

Summary

The success of those who specialize in the placement of

dental implants is determined in no small measure by

the success of their restorative teams. A specialist who

demonstrates an appreciation for the concerns of his cotreating

professionals stands a better chance of achieving

a positive outcome for the patient in the most efficient,

predictable manner possible. With the Inclusive Tooth

Replacement Solution, many of the communication gaps

that traditionally interrupt the treatment chain are avoided.

Soft tissue architecture is carefully managed from the outset

and communicated effectively to the restorative team.

Parts produced with CAD/CAM technology demonstrate

precise fit and proper occlusion. The restorative process is

simplified, encouraging referrals from clinicians who might

otherwise be reluctant to prescribe implants, considering

them too complex or time-consuming. By maximizing the

patient satisfaction and profitability of referring doctors, the

specialist practice will ultimately benefit. IM

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Implant Q&A:

An Interview with

Dr. Darrin Wiederhold

Go online for

in-depth content

Interview of Darrin M. Wiederhold, DMD, MS

by Bradley C. Bockhorst, DMD

Dr. Darrin Wiederhold is an accomplished dentist and a

new member of the Glidewell Laboratories clinical team. In this

exclusive interview, he outlines the preparatory steps a clinician

can take to successfully incorporate implant dentistry

into their practice. He also discusses his experience

with the new Inclusive ® Tapered Implant System and

Inclusive ® Tooth Replacement Solution, and shares

his vision for upcoming educational courses at the

Glidewell International Technology Center.

Dr. Bradley Bockhorst: Today we will spend some time talking with the

newest member of the Glidewell clinical team, Dr. Darrin Wiederhold, about

some of the projects and technologies we’ve been working on here at the laboratory.

Darrin, can you tell the Inclusive audience a little bit about yourself?

Dr. Darrin Wiederhold: Sure, I’d be happy to. I’m originally from the East Coast;

a Pennsylvania boy. My dad worked for the CIA, so I had an opportunity to

travel throughout my childhood and live in or visit six of the seven continents.

I haven’t made it to Antarctica yet, but being a lover of the sun, I don’t see

myself heading that way anytime soon. When I graduated from high school in

Indonesia, I came back to Pennsylvania, went to college up in University Park

and then to Temple University School of Dentistry down in Philadelphia.

When I finished dental school, I had already started to get some experience

with implants. I became interested in surgery during dental school, so I

started to take some courses to prepare for possibly placing implants

as a restorative dentist or, ultimately, as an oral surgeon. I was about

99 percent sure I wanted to do oral surgery when I got out, but I wanted

to be 100 percent sure before I made that commitment, so I enrolled in a

GPR program up in Buffalo, New York, that had an extensive oral surgery

component. I got a chance to do a lot of trauma cases and even got some

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early exposure to implants there. I decided that it was absolutely what I wanted

to do. So, I applied and was admitted into an oral surgery residency program at

the University of Kentucky at Lexington. I was there a year and had just finished

my intern year when, for personal reasons, I had to withdraw from the program

and take some time off. Two years later, I came back and did a second year of

GPR down in Kentucky as their chief resident. So I had an opportunity to do

about three years of additional training after dental school.

BB: That brings up an interesting question. There’s a lot of interest among general

dentists in starting to place implants. I think just like doing any other kind of

procedure, whether it is wisdom teeth extractions, root canals or ortho, you have

to make sure you’re well trained, confident and competent before you start doing

it. Now, they don’t necessarily have to go through two GPRs and an oral surgery

residency, but what are your thoughts as far as what general dentists should do in

preparation for starting to place implants?

DW: I don’t know that they need all of that additional training, but you do

want more than just a weekend course. You really want to take a comprehensive

course that’s going to expose you to bone physiology, make sure you’re familiar

with all the terminology, allow you to do some live surgeries and develop your

treatment planning skills. You want to become proficient in those aspects and

work as much as you can.

You really

want to take a

comprehensive

course that’s

going to ... allow

you to do some

live surgeries

and develop

your treatment

planning skills.

– Implant Q&A: An Interview with Dr. Darrin Wiederhold – 27


BB: There are some excellent implant courses out there, such as those at the Misch

International Implant Institute and the AAID MaxiCourses ® . The Implants A-to-Z

course at UCLA with Drs. Sascha Jovanovic and George Perri is also a great course.

DW: Absolutely. If you have the opportunity and can invest in one of the yearlong

courses, do it. Essentially, you can’t get enough education. That’s the takeaway

here. Gaining understanding of the fundamentals is crucial. You really want to

be proficient beyond just having a good sense of your surgical skills, the bone

morphology and the anatomy in that area.

Beyond that, though, I would say, managing cases postoperatively is imperative.

You hope every case you do is going to be flawless, but complications can arise,

and the more cases you do, it’s inevitable that you are going to encounter some

challenges and difficulties. It’s important to work at becoming increasingly

proficient and minimizing those complications, so when they do arise, you’ll

have a good sense of how you’re going to handle the situation and can keep

levelheaded during the surgery if you do encounter a problem. If you have a

solid foundation to draw from and something unexpected comes up, you’ll have

fewer sleepless nights.

BB: So the key is knowing how to manage complications. Or, even better, how to

avoid them by recognizing them ahead of time. Another recommendation might be

to have a mentor.

DW: Sure, if you have the opportunity to shadow someone — an oral surgeon,

a periodontist or a general dentist who has extensive experience placing

implants — you can shadow them in their office, watch them, and have them

with you while you’re doing several of your cases.

Additionally, I would say the number one thing would be case selection. You

want to make sure that the first few cases you do are what you would consider

“the ideal.” These cases are going to be the most straightforward, and will,

hopefully, present you with the least challenges so that you can develop your

skills, confidence and competence. Having that safety net in place, with a mentor

or someone you can shadow, makes the process a lot easier.

The number one

thing would be

case selection.

You want to

make sure that

the first few

cases you do

are what you

would consider

“the ideal.”

BB: OK, so we’ve got the correct amount of education. We’ve found a mentor

and those ideal cases. Now what? What’s the ideal first case a clinician should be

looking for?

DW: I would say a maxillary first premolar. It affords all the surgical challenges

that come with the maxilla, whether it be the sinus or avoiding the adjacent

teeth. It allows you to work in the less dense bone, so it’s less forgiving and

you have to be more proficient with it, but it gives you easy access without the

esthetic challenges of an anterior tooth. So, if you can round up a good number

of maxillary premolar cases out of the gate, really get your hands wet, then

repetition is the key. If it seems like they’re getting too easy — that’s a good sign.

It means you’re developing your skills and comfort level. Once you get that true

sense of confidence in yourself and your cases are going well, then it might be

time to branch out to an anterior tooth or a molar. You really can’t put a number

on it, but the more “straightforward” cases you can do will really go a long way

toward increasing your chances for success.

BB: I think that goes back to a key point: having a mentor who can provide surgical

backup. It’s about knowing what cases you’re comfortable with and what you should

refer out. That way, if you run into a problem, you’ve got somebody who has your

back as far as helping you through those cases.

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DW: Right. The thing that you gain most from those experiences is the ability to

recognize when you’re in over your head a little bit, perhaps. There are people

out there who are great at it, who have a natural instinct for it and can take

right to it. But every day someone runs into a challenge that they either haven’t

experienced before or they’re a little uncomfortable handing, or it’s something

that they just would rather not deal with. So, when you are presented with a case

that’s too challenging, there’s no shame in referring it out. Anyone out there who

has had that experience and feels comfortable handling those challenges only

got that way by having gone through it themselves. There’s no reason to feel that

this is a knock against you as a surgeon in any way. It’s just recognizing that you

haven’t seen this before, and figuring out how you’re going to handle it.

BB: It’s part of your learning curve.

DW: Absolutely.

BB: One of the main things that you’ve been doing since you joined us is placing

Inclusive ® Tapered Implants. Can you tell us a little bit about what you think of that

system compared to other ones you have worked with in the past?

DW: Sure. The system has all the advantages that the test of time has proven

with implants of old — the internal hex being the most popular connection out

there in dentistry. It’s got a thread design that maximizes your initial stability and

helps promote osseointegration. It’s intuitively very easy to use. Anyone who

has had experience with any of the large systems out there is going to be very

comfortable using it and is going to be able to transition into Inclusive Tapered

Implants very easily.

The entire

process from

start to finish —

from implant

placement to

the definitive

restoration — is

controlled, very

predictable and

optimal in terms

of improving

your chances

of success.

BB: It’s a system put together by a very experienced team. We have a lot of engineers

and technicians who actually came from the implant industry. Key to being the first

laboratory to introduce an implant system, though, is that we can encompass a full

package. We can help with everything from planning the case to the final restoration,

which leads into one of the major projects we’ve been working on, which is the

Inclusive ® Tooth Replacement Solution. Can you tell us a little bit about that?

DW: It’s basically a comprehensive package that has the full Glidewell expertise

and experience behind it. In addition to the implant, the dentist receives up front

a prosthetic guide, a custom healing abutment, a custom temporary abutment

and BioTemps ® provisional crown (Glidewell Laboratories) to provide early

contouring of the soft tissue, a matching custom impression coping, as well as

the final prosthesis. So, the entire process from start to finish — from implant

placement to the definitive restoration — is controlled, very predictable and

optimal in terms of improving your chances of success. It’s a comprehensive

package that you have laid out before you, before you ever get started. I think

clinicians are really going to take to it.

BB: Right. I think core to this solution is versatility. At implant placement, you’ll

have a custom healing abutment that was made for you pre-surgery, a custom

temporary abutment, a BioTemps crown and a matching impression coping. A

surgical specialist who has a restorative-driven surgical practice can start

sculpting those soft tissues correctly, making it easier for his restorative dentist.

He can then either immediately provisionalize it, or he can put the healing abutment

on it. And later, he can send that custom impression coping to the restorative

dentist, who can then transfer those contours correctly to the laboratory. One of

the biggest challenges for the lab is clinicians using narrow, round impression

copings, and then trying to make an anatomically shaped tooth. This issue is core

to the Inclusive Tooth Replacement Solution, so maybe you can expand on that.

– Implant Q&A: An Interview with Dr. Darrin Wiederhold – 29


We’re excited about

all the upcoming

courses, and how

we can gear them

toward general

practitioners and

specialists alike to

work hand-in-hand

with us to improve

their efficacy

and efficiency.

DW: Sure. For general practitioners who are doing both the surgery and the

restorative procedures, it’s certainly a comprehensive package. If you are a surgical

specialist looking to develop your referral base, then you have the advantage of

being able to communicate to your general practitioner: “I’m not only going to

place the implant for you, I’m going to start the restorative process. I’m going

to place the healing abutment for you, so it can begin the soft tissue contour, to

make your life much easier down the road — predictably.” It is something that

can be easily reproduced. And the additional components can be forwarded to

the restorative dentist, as you mentioned. When the time comes, they can place

the custom impression coping that matches that emergence profile that’s been

developed. So, there’s predictability and a great sense of continuity there. It’s

also a great builder for a referral base for specialists who want to help out in the

process beyond just placing implants.

BB: And then, ultimately, it provides the final restoration — a superior restoration —

which means better patient care.

DW: Absolutely.

BB: Let’s move on to other technologies: guided surgery. Can you tell us what your

background was before and what you’re doing now with digital treatment planning

and guided surgery?

DW: I’ve been doing guided surgery for about six months now, since coming to

Glidewell. Prior to that, I was doing freehand almost exclusively — reflecting a

flap, going in there and eyeballing it, and performing the surgeries. The guided

surgery is great, though. Not only does it allow you to take advantage of Cone

Beam CT scanning capabilities, but it also allows you to anticipate if there’s

going to be a need for a graft, whether you have enough available bone, or if

there are any structures you need to avoid. So, the guided surgery has been

very useful as far as minimizing flaps when necessary, as it virtually eliminates

flaps. The postoperative healing period is certainly much better. It gives you

peace of mind that is unparalleled. If you have the knowledge, going in, of

where the structures are, where the adjacent roots are, the apices, the sinus, the

alveolar nerve — whatever it might be — it’s just an extra tool that gives you

that confidence.

BB: Right. It provides something not only for the person new to placing implants,

but also for the experienced surgical specialist who is using that three-dimensional

view and planning everything so they don’t have those surprises when they go into it.

Digital treatment planning is one of those things we can offer with our service, and

it ties in with CBCT.

There are other technologies we’ve been working with as well. Can you tell us a little

bit about intraoral scanning?

DW: You know, one of the greatest things about working at Glidewell is that we

get the opportunity to play with all of the latest and greatest technologies. CBCT

technology is a big component of those recent developments. We have a PreXion

3D unit that we use. Intraoral scanners, I think, are also going to be a standard

in the future. We’re certainly moving toward a digital era, and if we can eliminate

the need for impression material, it cuts down on costs. If we have the ability

to communicate and upload the images to the Glidewell laboratory right away

to get started on the prosthesis, it reduces the turnaround time. It’s just a much

more comfortable experience for the patient overall, and helps to ensure the

best possible product for the dentist and, ultimately, for the patient, which is

most important.

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BB: A colleague of mine refers to Glidewell as a Dental Disneyland because of all

the technologies we have here. Any technology that’s on the market is, literally, in

production here — and in production in a big way — so you can get an education

here quickly.

To wrap things up, another large role you’re going to have with us is running courses

at the Glidewell International Technology Center. Can you talk about how we’re

going to use these technologies to show dentists how they can easily incorporate them

into their private practices?

DW: Absolutely. We offer the opportunity to take courses on the lab’s premises.

These are not courses designed to make a novice into an expert implantologist

— again, you want to make sure you get those comprehensive, extended courses

prior to coming in — but they’re an adjunct, something they can build on. For

those who feel comfortable doing implants already, this is a way of streamlining

everything for them, to make things easier for them and the patient.

We’re going to be doing courses that address specifically the Inclusive Tooth

Replacement Solution program. That certainly is going to help doctors down the

road. Alternatively, we’re hoping to offer courses in both mini implants and our

conventional-diameter implants that we’re launching. These courses are intended

to familiarize clinicians and staff with the Inclusive system, and how it can benefit

them in their practices. We’re going to have some courses on CBCT technology,

offering the opportunity for folks who may not have access to that technology,

or who are on the fence about it, to come in and see the benefits it can provide

them. I know you are going to be doing digital treatment planning programs to

expose folks to that technology. So, we’re excited about all the upcoming courses,

and how we can gear them toward general practitioners and specialists alike

to work hand-in-hand with us to improve their efficacy and efficiency — and

ultimately perform better dentistry for their patients.

BB: Very good. I sure appreciate having you here. Welcome aboard! IM

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Recession Relief:

Incorporating Dental Implants

into Your Daily Practice

Go online for

in-depth content

by Ara Nazarian DDS, DICO

Challenging economic circumstances create a

number of consequences for dentists. More

patients put off getting care when they need it, some

don’t want to take time off from work to attend dental

appointments and others feel more urgent needs require their

limited funds. Many show up for care only when they can

no longer tolerate the pain caused by their deteriorating

oral condition or when infection threatens their overall

health. By that point, they often have multiple problems,

requiring any number of separate therapeutic procedures.

A crucial way for any general dentist to recession-proof

their practice is to provide patients with as many types of

services as possible under one roof. Even if the prescribed

service requires placement of an implant, this should be

no exception. While many general dentists have avoided

placing implants for various reasons, instrumentation and

protocols have evolved to the degree that it is now possible

for more dentists than ever to offer this standard of care.

Among the newest breakthroughs is the convenient Inclusive

® Tooth Replacement Solution introduced by Glidewell

Laboratories. For one inclusive price, dentists looking to

offer a single-tooth replacement

service receive virtually everything

that is needed to provide the patient

with a safe, predictable and highly

esthetic implant restoration. But the

“tooth-in-a-box” concept behind the

Inclusive Tooth Replacement Solution

goes well beyond the initial

cost advantages of a bundled implant

solution, benefitting greatly

from a restorative-driven focus one

might expect of a world-class dental

lab. Initially, the dentist receives

A crucial way for any

general dentist to recessionproof

their practice is

to provide patients with as

many types of services

as possible under one roof.

a prosthetic guide that enables fast and simple drilling, disposable

drills, a state-of-the-art implant, a custom (patientspecific)

healing abutment, a custom temporary abutment,

a BioTemps ® provisional crown (Glidewell Laboratories),

and a custom impression coping. After healing is complete,

the dentist also receives a custom CAD/CAM final abutment

and BruxZir ® Solid Zirconia crown (Glidewell Laboratories).

The use of a prosthetic guide offers more than one benefit.

By simplifying creation of the implant osteotomy, it takes

significantly less time to place the implant. Even more

importantly, the general dentist gains control, ensuring that

placement occurs in the best location to support an optimal

final restoration.

If high primary stability is obtained, the dentist may choose

to deliver the custom temporary abutment and BioTemps

crown at the time of implant placement. Alternately, the

custom healing abutment may be placed and the implant

allowed to heal. Either way, the anatomical shape of

the custom healing component serves to guide the soft

tissue contours during osseointegration, and the custom

impression coping — designed with

the same anatomical contours —

serves to precisely capture the final

gingival architecture for the lab, thus

increasing the likelihood that an ideal

emergence profile will be achieved.

The following case report presents a

situation where the Inclusive Tooth

Replacement Solution simplified the

planning, placement and restoration

of a posterior tooth, resulting in a

high level of patient satisfaction.

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Among the newest breakthroughs

is the convenient Inclusive ®

Tooth Replacement Solution. ... For one

inclusive price, dentists looking to offer a

single-tooth replacement service receive

virtually everything that is needed to provide

the patient with a safe, predictable and

highly esthetic implant restoration.

Figure 1: Clinical view of edentulous area #3

Figure 2: Preoperative X-ray of edentulous area #3

Case Report

The 33-year-old female patient presented with concerns

about her missing maxillary first molar (Figs. 1, 2). She

wondered about the potential for the adjacent teeth

shifting, and she also worried that the missing tooth might

compromise her job-hunting prospects. The patient’s medical

history was non-contributory, and she was in excellent

health. The tooth had been endodontically treated and

subsequently removed due to a vertical fracture that had

occurred five months earlier. Upon clinical examination, it

was evident that the ridge was sufficient to accommodate

a traditional-sized dental implant to restore the area to

proper esthetics, form and function. After all the risks

and benefits of the various treatment alternatives were

reviewed with the patient, she chose to have an implant

placed in the area of the missing first molar.

In order to plan for this implant and restoration, an

Figure 3: Prosthetic guide with gutta-percha

impression of the upper and lower arches was taken,

along with a bite registration, and forwarded to Glidewell

Laboratories. Radiography and clinical evaluation led to the

prescription of an Inclusive ® Tapered Implant (Glidewell

Laboratories), 5.2 mm in diameter and 11.5 mm in length.

Based on information from the models and radiograph, the

laboratory fabricated a clear prosthetic guide that identified

the parameters for ideal implant placement. A custom

polyether ether ketone (PEEK) healing abutment, a custom

PEEK temporary abutment, a custom impression coping and

a BioTemps provisional crown were designed and milled.

All items — including the implant and related drills — were

delivered from Glidewell in a single, convenient package.

The first molar area was anesthetized using 1.8 ml 4%

Septocaine with 1:100,000 epinephrine. The prosthetic

guide was placed on the adjacent teeth, and a gutta-percha

point was positioned in the access hole (Fig. 3). A radiograph

– Recession Relief: Incorporating Dental Implants into Your Daily Practice – 35


was taken; however, because the gutta-percha point was

radiopaque, its position on the radiograph was used to

confirm the proper drilling angle, relative to the surrounding

structures (Fig. 4).

Once the drilling angle was

confirmed, the 2.3/2.0 mm pilot

drill was used to drill through

the prosthetic guide and the soft

tissue into the underlying bone,

using copious amounts of sterile

saline. The prosthetic guide

ensured that the osteotomy was

centered buccolingually, as well as

mesiodistally. A paralleling pin was placed into the osteotomy

(Fig. 5), and another X-ray was taken to verify the pin’s

angulation. The osteotomy was then further extended to the

recommended length for the selected implant. Using a rotary

tissue punch, a 5 mm outline was created over the initial

osteotomy (Fig. 6), and the tissue plug was removed with a

curette. Drills of increasing size

were sequentially utilized until

the desired width was achieved.

The implant was torqued to its

final depth, reaching a torque level

of 45 Ncm with one of the

internal hex flats facing buccally.

Once the osteotomy was

completed, the implant (Fig. 7)

was placed in the osteotomy

using the accompanying carrier

(Fig. 8) and initially handtightened.

The torque wrench

was then connected to the

implant driver (Fig. 9), and the implant was torqued to its

final depth (Fig. 10), reaching a torque level of 45 Ncm with

one of the internal hex flats facing buccally. This is important,

Figure 4: X-ray of gutta-percha

Figure 5: Paralleling pin placed in osteotomy

Figure 6: Tissue punch over the initial osteotomy

Figure 7: Inclusive Tapered Implant

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as all patient-specific temporary components were fabricated

assuming the final connection orientation.

A periapical radiograph was taken to confirm the position

of the implant (Fig. 11). Use of an Osstell ® ISQ implant

stability meter (Osstell Inc. USA; Linthicum, Md.) showed

values of 72/68. (According to the manufacturer, a reading

above 55 indicates excellent primary stability.) Because the

implant was not in the esthetic zone, it was not immediately

provisionalized. Instead, the custom healing abutment was

connected to the implant (Fig. 12).

Four months later, the patient returned for impressions for

the final abutment and crown restoration. Using the custom

impression coping and a polyvinyl siloxane impression

material (Capture ® PVS, Glidewell Laboratories), a full-arch

impression was taken of the upper arch, along with the

Figure 8: Finger driver and implant

Figure 9: Implant placed with torque driver

Figure 10: Implant seated at final depth

Figure 11: X-ray verifying implant placement

Figure 12: Custom healing abutment connected to the implant

– Recession Relief: Incorporating Dental Implants into Your Daily Practice – 37


opposing arch impression and bite registration. The

prefabricated custom temporary abutment and provisional

crown were placed during the two-week period while the

final restoration was being fabricated. The custom temporary

abutment was hand-tightened (Fig. 13), and the BioTemps

crown (Fig. 14) was cemented with TempBond ® Clear

with Triclosan temporary crown & bridge cement (Kerr

Corporation; Orange, Calif.).

Two weeks later, the patient returned for the placement of

the final Inclusive ® Titanium Custom Abutment (Fig. 15) and

BruxZir Solid Zirconia restoration (Glidewell Laboratories)

(Fig 16). As the laboratory fee for the final abutment and

crown was included in the price of the Inclusive Tooth

Replacement Solution, there were no additional charges at

this stage, further simplifying the treatment process from a

business standpoint.

Conclusion

A key tactic for any dentist feeling the pinch in a difficult

economy is to seek more efficient ways to provide service

offerings, or to take on new services previously outsourced

to another provider. While traditional implant treatment can

be difficult, costly and time-consuming, the restorative-driven

Inclusive Tooth Replacement Solution serves to simplify the

process of placing and restoring dental implants, making

it more convenient and affordable for both the dentist and

the patient.

In the case presented here, initial implant placement was

completed in just 20 minutes, with subsequent delivery of the

custom temporary abutment and temporary crown requiring

even less time. The patient was extremely pleased to be able

to have her missing tooth replaced and her compromised

appearance addressed with a high-quality provisional in such

a short amount of time, and the custom healing components

and custom impression coping helped ensure an optimal

emergence profile for her definitive restoration. With minimal

hassle, an esthetic final result and built-in savings, the “toothin-a-box”

concept behind the Inclusive Tooth Replacement

Solution gives dentists of any experience level another worthy

option for strengthening their practice in today’s recessionaddled

marketplace. IM

Figure 13: Custom temporary abutment in place

Figure 14: BioTemps crown in place

Figure 15: Final Inclusive Titanium Custom Abutment in place

Figure 16: Final BruxZir crown in place

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Clinical Tip:

Placing Custom Healing Abutments

Go online for

in-depth content

by Bradley C. Bockhorst, DMD

For some cases, delivering a restoration on

an implant that has a standard, round healing

abutment can literally be the equivalent of putting a square

or triangular peg in a round hole. Integral to the Glidewell

Laboratories Inclusive ® Tooth Replacement Solution are the

components that help sculpt the peri-implant soft tissues.

Utilizing an anatomically shaped custom healing abutment

not only sets the stage for a superior restoration, but also

simplifies the restorative process, allowing for easier, complete

seating of the prosthetic components.

Custom healing abutments provide a superior option

to standard, round healing abutments if the case is not

going to be immediately provisionalized. The abutments

are fabricated from polyether ether ketone (PEEK), and

can be modified as needed. In cases where the soft tissue

is reflected, complete seating can be visualized and the

flap reapproximated and sutured into place around the

abutment. In flapless cases, the sulcus can be created

by various surgical means, such as a tissue punch of

appropriate diameter, a scalpel or a bur. In this case, a CO 2

laser was used. The model was used as a guide to remove

the tissue in the approximate transgingival shape of the

healing abutment. Complete seating can be confirmed with

a periapical radiograph.

When placing a custom healing abutment, the abutment

screw should be tightened to 12–15 Ncm. If space allows,

the screw access opening should be sealed to prevent food

and debris from accumulating in the screw access hole.

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

or gutta-percha. Seal the opening with composite, acrylic or

a light-cure resin cement, as is demonstrated in this case.

For the final impressions, the screw can easily be uncovered,

and the custom healing abutment removed and replaced

with the matching custom impression coping.

The following case, courtesy of Dr. Dean Saiki, Oceanside,

Calif., illustrates this technique. IM

Figure 1: Custom healing abutment in place on the model

Figure 2: Laser-assisted gingivectomy prior to implant placement

Figure 3: Implant in situ

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Figure 4: Custom healing abutment in place in the patient’s mouth

Figure 5: Abutment screw tightened to 15 Ncm

Figure 6: Cotton pellet placed over head of screw

Figure 7: Access opening sealed with Maxcem Elite self-etch/self-adhesive resin

cement (Kerr Corporation; Orange, Calif.)

Figure 8a: One week post-op (occlusal view)

Figure 8b: One week post-op (buccal view)

– Clinical Tip: Placing Custom Healing Abutments – 41


Restorative Driven Implant Solutions

Utilizing the Latest Technology

Go online for

in-depth content

by Timothy F. Kosinski, DDS, MAGD

As a general dentist who has placed nearly 7,000 dental implants, I have come to understand the importance

of planning from day one for the implant placement and soft tissue healing that will help me achieve my prosthetic

goals for the patient. Being able to visualize the finished case prior to starting is even more relevant today, given

patient expectations with regard to efficiency and outcome. Due to recent advancements in dental technology, this is easier

than ever before.

With CBCT-aided diagnoses and treatment planning, for example, we are able to predictably and virtually place implants

using the latest computer software. The use of surgical guides based on a virtual plan has made procedures predictable and

less invasive for the patient. 1 Often, flapless surgical procedures can be used, which further minimizes healing time and

patient discomfort.

– Restorative Driven Implant Solutions Utilizing the Latest Technology – 43


Meanwhile, the next generation of CAD technology affords us the ability not only to determine implant positioning in bone,

but also to determine soft tissue contours utilizing custom, patient-specific transitional appliances: custom-milled healing

abutments for maximizing final tissue contours, custom-milled transitional or temporary abutments for supporting the transitional

prosthetic appliance, and custom-milled impression copings that match the tissue contours created by the healing

abutment or transitional abutment. The utilization of these appliances allows the tissue to heal properly in the best position

possible, the patient and dentist to visualize the emergence profile of the transitional restoration, and the laboratory technician

to ultimately understand tissue health, contour and ideal esthetics.

Despite such technological innovations, many general dentists still avoid placing implants, demonstrating a seeming lack

of interest in providing what is a progressive, predictable treatment in an exciting field of dentistry. Some express a lack

of confidence in the surgical applications and the fear of damaging a nerve or sinus. Others worry that they will not be

able to anticipate all the costs involved in order to deliver their services profitably. Traditionally, implant dentists have had

to maintain complicated inventories of drills, implants and related components. Laboratory fees and other costs have not

always been predictable either. For these and other reasons, the adoption of implant treatment services by many general

practitioners remains a daunting prospect.

However, the introduction of the Inclusive ® Tooth Replacement Solution from Glidewell Laboratories represents a significant

breakthrough. With all of the necessary components provided for a single, fixed price, concerns about cost control are

eliminated from the outset. Moreover, users can routinely offer their patients implant solutions that are restorative-driven at

every step of the treatment. Rather than wait until the implant has healed to learn whether an esthetic final restoration can

be created, the dentist can feel confident in advance that it will be.

Planning Phase

While the Inclusive Tooth Replacement Solution does not require use of a CT scan, a scan can provide accurate anatomical

information that would be otherwise inaccessible, eliminating risks and simplifying the surgery. Virtually placing an implant

prior to ever touching the patient is a logical treatment step. Most patients seem to understand this and are willing to invest

in a CT diagnosis.

After the CT scan, the scan data and impressions are sent to Glidewell Laboratories, where the model is fabricated and

optically scanned. The scan of the model and CT scan of the patient are imported into planning software. A Web-based

teleconference is then conducted with the treating dentist to finalize the plan. The surgical guide and a 3-D model are

printed. The custom healing abutment, custom temporary abutment, BioTemps ® provisional crown (Glidewell Laboratories)

and matching impression coping are designed and milled. All of these customized components, along with the desired

implant and related drills, are delivered to the practice approximately one week later in a single box.

Surgical Phase

For implant placement, the optimal implant positioning is directed through use of either a prosthetic guide, which is provided

when stone models are used for diagnosis, or a surgical guide based on a CT scan. This guide not only helps to ensure

a safe and predictable path of insertion, but also positions the implant and prosthetic platform in an optimal orientation for

placement of the transitional (and later, final) restorative components.

Through placement of a custom-milled temporary abutment, sculpting of the soft tissue begins as soon as the implant is sufficiently

stable, either at the time of surgery or after initial healing. In my experience, if an implant can be torqued into place

in the initial osteotomy site to 35 Ncm or more, it can be predictably loaded with a transitional crown, as long as excursive

contacts are removed and there is no excessive occlusal force placed. 2,3 CT planning ensures that implants and crowns

are ideally situated, so that forces are maintained along the long axis of the implant. If the implant is torqued to less than

35 Ncm, the custom healing abutment at the level of the soft tissue can be used. With either component, soft tissue

sculpting commences immediately post-surgery.

Restorative Phase

Upon successful osseointegration and appropriate soft tissue healing, a final impression is made using a custom impression

coping. Milled to replicate the gingival architecture created during the healing phase, the custom impression coping

captures the exact soft tissue contours formed by the custom temporary abutment. This can be of tremendous assistance to

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the laboratory in the creation of an ideal final prosthesis, as it provides a clearer image of the definitive emergence profile,

which is critical to the esthetic outcome. A traditional stock impression coping does not accurately convey the soft tissue

architecture around the margin, thus making the laboratory’s job more difficult and the final restoration less predictable.

While techniques exist for the fabrication of a custom impression coping chairside, clinicians seeking to maximize clinical

efficiencies and reduce chairtime will appreciate the convenience of having this custom component prepackaged for initiation

of the restorative phase.

Case Reports

For the cases that follow, a CT scan was done with the patients’ bite open at least 5 mm. You do not want the patient to be

scanned in a fully occluded state, as this could create overlap and inaccuracies. The laboratory can provide various surgical

guide options to help you with this important step. Here, a single surgical guide compatible with Universal SurgiGuide ®

Drill Keys (Materialise Dental Inc.; Glen Burnie, Md.) was used for each case. Keys based on the drill diameters to be used

were placed in the sleeves of the surgical guide to direct each drill precisely. Based on the virtual plan and clinical determination

that there was adequate attached gingiva, the cases were done following a flapless procedure.

CASE ONE:

Figure 1: Edentulous anterior maxilla. The patient lost her maxillary central and

lateral incisors following an accident.

Figure 2: The patient had worn an RPD appliance for more than eight months.

As her quality of life was remarkably diminished, she requested a permanent, fixed

restoration.

Figure 3: A CT scan was done, and the implant placement virtually planned.

Figure 4: A surgical guide was fabricated with sleeves to accommodate drill keys

for each drill.

– Restorative Driven Implant Solutions Utilizing the Latest Technology – 45


Figure 5: A 2.3 mm diameter key was inserted into the sleeve of the surgical

guide, and the 2.3/2.0 mm pilot drill was used to create the initial osteotomy to

the predetermined depth.

Figure 6: A 2.8 mm diameter key was used for the 2.8/2.3 mm surgical drill.

Figure 7: Based on the patient’s bone density, the 3.4/2.8 mm surgical drill was

used to create the final width of the osteotomy to accept the 3.7 mm diameter

Inclusive ® Tapered Implant (Glidewell Laboratories). A 3.5 mm key was used in this

case to provide proper guidance.

Figure 8: The surgical guide was removed from the mouth and the implant

inserted.

Figure 9: The implant driver was utilized with the torque wrench for final seating

of the implant. One flat on the internal hex of the implant should face the labial,

matching the orientation of the implant analog in the model.

Figure 10: Immediate placement of the implants in the maxillary right and left

lateral incisor areas showed little to no bleeding. The flapless procedure was relatively

noninvasive.

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a

b

Figures 11a, 11b: Digital radiograph of the implants ideally positioned per the

CT planning software and final CT illustrating position of the implants, which mimics

the pre-surgical virtual determination

Figure 12: The Inclusive Tooth Replacement Solution for this case includes: custom

temporary abutments used if the implants are torqued to a minimum of 35 Ncm;

a BioTemps bridge #7–10; custom healing abutments approximating ideal tissue

contours; and custom impression copings to be used after integration and tissue

healing. All are custom-fabricated to assist in developing the ideal soft tissue contours

and emergence profiles.

Figure 13: Because the implants were torqued to over 35 Ncm, custom temporary

abutments were positioned to accept the premade provisional bridge. Tissue

contours were established immediately following surgical placement of the implants.

Figure 14: The transitional bridge was seated over the custom temporary abutments

immediately at implant placement.

Figure 15: With the transitional bridge in place, the patient exhibited a Class II

relationship with no anterior occlusion.

Figure 16: Occlusal view of the transitional bridge

– Restorative Driven Implant Solutions Utilizing the Latest Technology – 47


a

b

Figure 17: The final impression was made using the custom impression copings.

This enabled the laboratory to begin fabrication of the final zirconia abutments and

bridge while the patient was healing. Note that the impression components capture

the exact soft tissue contours formed by the custom temporary abutments, assisting

the laboratory in creating an ideal final prosthesis.

Figures 18a, 18b: The impression was made and the impression copings snapped

into the impression for the laboratory to fabricate the master cast.

CASE TWO:

Figure 1: Preoperative view of periodontally involved maxillary left central incisor

Figure 2: Digital radiograph of periodontally involved tooth #9

Figure 3: CT-based virtual plan of maxillary left central incisor, indicating where the

implant will be placed at the time of extraction

Figure 4: A computer-generated model was fabricated once virtual placement was

completed.

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Figure 5: A surgical guide was then created to position the implant correctly.

Figure 6: Using the Inclusive Tooth Replacement Solution, a custom temporary

abutment and BioTemps provisional crown, custom healing abutment, and custom

impression coping were fabricated.

Figure 7: Planning for the possibility of low insertion torque and the patient’s desire

for a provisional restoration at the time of surgery, a removable partial denture

was also fabricated.

Figure 8: The tooth was atraumatically extracted using Physics ® Forceps (Golden

Dental Solutions Inc.; Detroit, Mich.).

Figure 9: The surgical guide was positioned over the osteotomy site.

Figure 10: A 2.4 mm diameter key was used to guide the 2.3/2.0 mm pilot drill.

– Restorative Driven Implant Solutions Utilizing the Latest Technology – 49


Figure 11: A 3.9 mm diameter key was used to guide the 3.8/3.4 mm surgical

drill.

Figure 12: The osteotomy was completed with the 4.4/3.8 mm surgical drill.

Figure 13: To maintain sterility, the 4.7 mm Inclusive Tapered Implant was carried

to the osteotomy site using the attached carrier.

Figure 14: The implant was advanced using the attached carrier as a finger driver.

Figure 15: A torque wrench was used for final seating, positioning the implant with

one of the internal hex flats to the facial, matching the orientation in the model as

closely as possible. Final insertion torque did not exceed 35 Ncm.

Figure 16: Digital radiograph of implant positioned, approximating the cementoenamel

junction (CEJ) of the adjacent roots

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Figure 17: Due to the lower-than-requisite final torque value, the decision was

made to place the custom healing abutment and seat the RPD appliance, rather

than load the implant with the custom temporary abutment and provisional crown.

Figure 18: With the RPD appliance in place, integration was allowed to progress

predictably, with minimal stress on the implant site.

Discussion

Success with implant dentistry is based on the need to achieve primary stabilization and secondary integration of the implant,

while maintaining hard and soft tissue contours to create long-term function and esthetics. 4,5 Just as CT scanning

software is changing the way we practice implant surgery, CAD/CAM technology is changing the restorative aspects of our

practices. These improved, patient-specific materials and techniques are fast becoming preferential to conventional components.

Precise, biocompatible materials with great mechanical strength and esthetics are constantly improving the fabrication

of our prostheses, making them more predictable.

A striking feature of the Inclusive Tooth Replacement Solution is that it allows for substantial treatment versatility, enabling

excellent soft tissue contouring regardless of the choices made. If the dentist finds it impossible to torque an implant to at

least 35 Ncm, the included custom healing abutment can be utilized and the soft tissue around the implant trained to an

ideal contour.

After osseointegration has been achieved, the custom healing abutment can be replaced with the custom temporary abutment,

which duplicates the tissue contours of the healing abutment. Because the contours of the temporary abutment mimic

those of the patient’s original tooth root, the soft tissue healing that occurs around it sets the stage for an optimal emergence

profile when the final abutment and restoration are delivered. Alternately, if a torque of greater than 35 Ncm is achieved

when the implant is placed, the custom temporary abutment and BioTemps crown can be placed immediately. 6

Summary

Within just the past few years, advances in diagnostic technology and surgical protocols have made dental implant treatment

substantially simpler, safer and faster. The introduction of the Inclusive Tooth Replacement Solution takes that simplification

even further, as it eliminates the biggest barriers to placing implants and provides all the tools necessary to work from the

very onset of treatment toward achieving the most esthetic restoration possible. As dentists, don’t we have an obligation to

provide our patients with the most innovative, proven techniques available? IM

references

1. Ganz SD. Restoratively driven implant dentistry utilizing advanced software and CBCT: realistic abutments and virtual teeth. Dent Today. 2008;27:122–27.

2. Lee CY. Immediate load protocol for anterior maxilla with cortical bone from mandibular ramus. Implant Dent. 2006 Jun;15(2):153–59.

3. Balshi SF, Wolfinger GJ, Balshi TJ. A prospective study of immediate functional loading following the Teeth in a Day protocol: a case series of 55 consecutive edentulous

maxillas. Clin Implant Dent Relat Res. 2005;7(1):24–31.

4. van Steenberghe D, Glauser R, Blombäck U, et al. A computed tomographic scan-derived customized surgical template and fixed prosthesis for flapless surgery and immediate

loading of implants in fully edentulous maxillae: a prospective multicenter study. Clin Implant Dent Relat Res. 2005;7 Suppl 1:111–20.

5. Glauser R, Rée A, Lundgren A, et al. Immediate occlusal loading of Brånemark implants applied in various jaw bone regions: a prospective, 1-year study. Clin Implant Dent

Relat Res. 2001;3(4):204–13.

6. Locante WM. Single-tooth replacements in the esthetic zone with an immediate function implant: a preliminary report. J Oral Implantol. 2004;30(6):369–75.

– Restorative Driven Implant Solutions Utilizing the Latest Technology – 51


Restorative Driven Implant Treatment:

From Immediate Temporization

to Final Restoration

Go online for

in-depth content

by Paresh B. Patel, DDS

When dentists place implants, a decision is

typically made — depending on the quality

of the bone encountered during osteotomy preparation

and the degree of primary stability obtained — to immediately

load the implant with a temporary abutment

and provisional crown, or to place a healing abutment

on the implant to better protect it from occlusal forces.

Stock components for either approach typically have the

disadvantage of being round; thus, as the soft tissue heals

around them, the ground is laid for an unnaturally shaped

emergence profile on which a final restoration with

less-than-optimal esthetics must be created. While the

development of CAD/CAM techniques made possible the

creation of custom, anatomically shaped components,

their use has been reserved for producing the definitive

abutment, and doing so introduced uncertainties about

the total cost of treatment — until now.

The introduction of the Inclusive ® Tooth Replacement

Solution from Glidewell Laboratories changes this substantially.

Ingenious in its simplicity, the “tooth-in-a-box”

concept behind this solution makes it easier to place an

implant that will support the best possible final crown,

while maximizing treatment options and eliminating all

uncertainty about total cost. For a single price, the dentist

receives an implant and all of the components necessary

to sculpt the soft tissue and shape the final emergence

profile, no matter what conditions are encountered during

implant placement.

The following case illustrates use of the Inclusive Tooth

Replacement Solution to replace a patient’s maxillary premolar,

employing conventional diagnostic methods.

Case Report

A 42-year-old female patient presented with an unremarkable

medical and dental history. Her chief complaint was a

missing maxillary left premolar, which she lost after failed

root canal treatment. No socket preservation was done

upon removal of the tooth more than nine months earlier.

Since then, the patient had been functioning without any

prosthesis. She wanted to replace the missing tooth with

an implant, and stated she was willing to continue living

without a temporary crown if implant primary stability

could not be achieved.

Thorough clinical examination — including diagnostic

impressions, bone sounding and a panoramic radiograph

— revealed adequate width and height of bone at the

premolar site. Although some collapse of the buccal bone

was evident, it was determined that a sufficient amount

was present to proceed with implant therapy. Soft tissue

examination revealed that the attached gingival volume

was adequate and the tissue was healthy. Because more

than 7 mm of space existed between the two adjacent

Figure 1a: Custom healing abutment, custom temporary abutment, BioTemps

provisional crown, custom impression coping

52

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teeth, placement of a 3.7 mm diameter implant would leave

more than 1.5 mm of space between the implant and each

adjoining tooth, a distance generally acknowledged as

sufficient to reduce marginal bone loss and the resultant

negative loss of papillae. 1,2

Figure 1b: Prosthetic guide

The optimal treatment plan called for using the custom

temporary abutment if 35 Ncm of torque could be obtained.

The patient would then have to comply with a soft diet during

the progression of healing from primary to secondary

stability. If primary stability could not be achieved, the

custom healing abutment included as part of the Inclusive

Tooth Replacement Solution would be placed.

Clinical Procedure

Figure 2: Prosthetic guide seated

Figure 3: Initial osteotomy

Figure 4: Custom healing abutment seated

Figure 5: Custom temporary (occlusal view)

A full-arch polyvinyl siloxane impression using Capture ®

PVS impression material (Glidewell Laboratories) was taken,

along with a bite registration. A shade selection was made

and a digital photograph was taken. All of these were sent

to Glidewell Laboratories, along with an Inclusive Tooth

Replacement Solution prescription form. There, the information

was used to pour a stone model of both arches to

create the diagnostic study models for the Inclusive Tooth

Replacement Solution process.

Following scanning, the digital study models were used to

fabricate a custom healing abutment, custom temporary

abutment and custom impression coping — all with matching

gingival contours — along with a BioTemps ® provisional

crown (Glidewell Laboratories) (Fig. 1a). These items, as

well as a prosthetic guide (Fig. 1b) that communicated to the

dentist the optimal osteotomy position in order to ensure

creation of an esthetic final crown, were all delivered from

Glidewell prior to treatment.

On the day of implant placement, the prosthetic guide was

seated securely into place (Fig. 2). A flapless osteotomy was

created (Fig. 3), beginning with a pilot drill, followed by a

tissue punch and, finally, sequential widening of the osteotomy

using the disposable drills packaged with the Inclusive

Tooth Replacement Solution. A 3.7 mm x 13 mm Inclusive ®

Tapered Implant was then placed. However, only 30 Ncm of

torque was achieved. Because it was not possible to tighten

the implant more than 35 Ncm, the custom healing abutment

was utilized (Fig. 4).

Five weeks later, the patient returned, the healing abutment

was removed and the implant was found to be stable and

healing uneventfully. The custom impression coping was

connected to the implant and an impression was taken.

Careful inspection of the custom impression coping confirmed

that it featured the same gingival contours as the

custom healing abutment, ensuring all minute details of the

carefully sculpted soft tissue would be properly communicated

to the laboratory. The custom temporary abutment

– Restorative Driven Implant Treatment: From Immediate Temporization to Final Restoration – 53


and BioTemps crown were then seated (Figs. 5, 6). No adjustment

was necessary, as the crown was just slightly out of

occlusion and slightly under the gingival tissue.

Figure 6: Custom temporary (buccal view)

Figure 7a: Inclusive Titanium Custom Abutment on laboratory

model

Figure 7b: BruxZir Solid Zirconia crown on laboratory model

The impression was sent to Glidewell Laboratories for fabrication

of the final Inclusive ® Titanium Custom Abutment

(Fig. 7a) and BruxZir ® Solid Zirconia crown (Fig. 7b). Two

weeks later, the patient returned for delivery of the final

restoration (Figs. 8a, 8b).

Discussion

Although it was not possible in this case to place the custom

temporary abutment and provisional crown at the time of

implant placement, the custom healing abutment still offered

the advantage of sculpting the soft tissue to conform to the

eventual final crown contours. When the healing abutment was

replaced by the custom temporary abutment and BioTemps

crown at the impression appointment, this further improved the

esthetic outcome for the patient and enabled controlled, progressive

loading of the implant, which is believed to accelerate

bone remodeling and eventual peri-implant density. 3

It should be noted that while the prosthetic guide provided

in the Inclusive Tooth Replacement Solution directs the position

of the osteotomy, the angulation is less constrained than

it would be by a surgical guide created from a CT scan and

three-dimensional computer model. If, during osteotomy creation,

the dentist fails to encounter bone where it is expected,

small adjustments can be made to the prosthetic guide to alter

the drilling angulation. It should also be noted that if the custom

temporary abutment and provisional crown had not fit

perfectly and been in the optimal prosthetic position as they

were in this case, they too could have been easily modified or

reshaped chairside.

Conclusion

Figure 8a: Final Inclusive Titanium Custom Abutment in place

The Inclusive Tooth Replacement Solution is the first complete,

fully restorative-driven implant solution, where patient-specific

custom temporary components are fabricated and delivered —

with the implant — prior to treatment. The concept and functionality

of this treatment package help dentists achieve exceptional,

cost-effective results while simplifying otherwise complex and

time-consuming procedures. IM

References

Figure 8b: Final BruxZir crown in place

1. Van Oosterwyck H, Duyck J, Vander Sloten J, et al. The influence of bone mechanical

properties and implant fixation upon bone loading around oral implants. Clin Oral

Implants Res. 1998 Dec;9(6):407-18.

2. Esposito M, Ekestubbe A, Gröndahl K. Radiological evaluation of marginal bone

loss at tooth surfaces facing single Brånemark implants. Clin Oral Implant Res. 1993

Sep;4(3):151-7.

3. Misch C. Progressive bone loading. Dent Today. 1995 Jan;14(1):80-3.

54

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Congratulations, Inclusive Image Contest Winners!

The microgrooves

and abutment connection

are clues.

Vents are unique.

Body shape and

thread pattern will

lead to the answer.

Thread pattern is

the giveaway.

The neck gives it

away.

Threads and apical

design are the

telling features.

No clues are

needed.

Can’t miss that

thread pattern.

No internal threads

are present.

Press-fit with

coronal grooves.

A. NobelActive - internal connection (Nobel Biocare)

B. Hexed-Head Press Fit Spike Universal (3M ESPE)

C. Sustain Cylinder External Hex (Keystone Dental)

D. Core-Vent (Zimmer Dental)

E. Tapered Internal (BioHorizons)

F. OsseoSpeed (Astra Tech Dental)

G. Hollow Cylinder (Straumann)

H. NanoTite Tapered Prevail (Biomet 3i)

I. NobelReplace Tapered (Nobel Biocare)

J. Screw-Vent (Zimmer Dental)

Great job to the dentists who correctly identified all 10 implants. We were impressed by your implant

knowledge! The winners were each awarded $100 in Glidewell credit, good toward any implant-related

product or service.

Sorry you missed out on “Name That Implant”? Turn the page and make a guess in this issue’s “How Many

Implants?” challenge. Good luck!

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

– Contest Results – 55


Inclusive Contest: How Many Implants?

Can you guess how many implants are in this beaker? Use the implant specification clues below to estimate the

number of implants for your chance to win an Inclusive ® Custom Abutment of your choice. Write your answer on

the beaker in the white frosted area.

Bonus Question: How much water would this 100 ml beaker hold with these implants inside? Answer correctly

and win a BruxZir ® Solid Zirconia crown. Answer:

Length: 13 mm

Diameter: 3.7 mm

Mass: 0.29 g

Surface Area: 319.14 mm 2

Surface Roughness Average (Ra): 1.5 μ

Center of Mass: Y = -6.52 mm

Nitrogen Content (max.): 0.05%

Oxygen Content (max.): 0.130%

Internal Hex Depth: 2.0 mm

To submit your answers, tear out this page and send it to:

Glidewell Laboratories

Attn: Inclusive magazine

4141 MacArthur Blvd.

Newport Beach, CA 92660

Or scan your entry and e-mail it to

inclusive@glidewelldental.com

The first 100 closest guesses to the actual number of implants will each receive one free Inclusive Custom Abutment.

The first 100 entries to correctly answer the Bonus Question will each receive one free BruxZir Solid Zirconia crown.

(Yes, you could win an abutment, a crown or both!)

Entries must be received by April 30, 2012. The results will be announced in the spring issue of Inclusive magazine. One entry per office.

Participation grants Inclusive magazine permission to print your name in a future issue and/or on its website.

________________________________________ _________________________________________ __________________________

Name City, State of Practice Phone

56

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