Restorative Driven Implant Solutions Vol. 3, Issue 1
A Multimedia Publication of Glidewell Laboratories • www.inclusivemagazine.com
Introducing the Inclusive ®
Dr. Darrin Wiederhold and
Dr. Bradley Bockhorst
Digital Design of Custom
Dzevad Ceranic, CDT
Building a Healthy
Dr. Robert Horowitz
Recession Relief: Are Dental
Implants the Answer?
Dr. Ara Nazarian
Technology’s Impact on
Restorative Implant Treatment
Dr. Timothy Kosinski
Darrin Wiederhold, DMD, MS
Implant Division, Glidewell Laboratories
How Many Implants?
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
• 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
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
ALSO IN THIS ISSUE
14 Clinical Tip: Implant Orientation for
Inclusive Tooth Replacement Solution
17 Lab Sense: Virtual Design of
Inclusive Custom Temporary
40 Clinical Tip: Placing Custom
52 Restorative Driven Implant
Treatment: From Immediate
Temporization to Final Restoration
56 Inclusive Contest:
How Many Implants?
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
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
Dr. Bradley C. Bockhorst
Editor-in-Chief, Clinical Editor
– Letter from the Editor – 3
Jim Glidewell, CDT
Editor-in-Chief and clinical editor
Bradley C. Bockhorst, DMD
Jim Shuck; Mike Cash, CDT
Greg Minzenmayer; Dzevad Ceranic, CDT;
David Casper; Tim Torbenson
Eldon Thompson, Barbara Young,
Megan Affleck, David Frickman, Jennifer Holstein
digital marketing manager
Graphic Designers/Web Designers
Jamie Austin, Deb Evans, Joel Guerra,
Audrey Kame, Lindsey Lauria, Phil Nguyen,
Kelley Pelton, Melanie Solis, Ty Tran, Makara You
Sharon Dowd, Mariela Lopez
James Kwasniewski, Marc Repaire, Sterling Wright
Teri Arthur, Vivian Tsang
If you have questions, comments or suggestions, e-mail us at
firstname.lastname@example.org. Your comments may
be featured in an upcoming issue or on our website.
© 2012 Glidewell Laboratories
Neither Inclusive magazine nor any employees involved in its publication
(“publisher”) makes any warranty, express or implied, or assumes
any liability or responsibility for the accuracy, completeness, or usefulness
of any information, apparatus, product, or process disclosed, or
represents that its use would not infringe proprietary rights. Reference
herein to any specific commercial products, process, or services by
trade name, trademark, manufacturer or otherwise does not necessarily
constitute or imply its endorsement, recommendation, or favoring
by the publisher. The views and opinions of authors expressed
herein do not necessarily state or reflect those of the publisher and
shall not be used for advertising or product endorsement purposes.
CAUTION: When viewing the techniques, procedures, theories and
materials that are presented, you must make your own decisions
about specific treatment for patients and exercise personal professional
judgment regarding the need for further clinical testing or education
and your own clinical expertise before trying to implement new
Inclusive is a registered trademark of Inclusive Dental Solutions.
■ 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 email@example.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
■ 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
– 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, firstname.lastname@example.org or www.
■ 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
■ 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 email@example.com or
– Contributors – 5
Clinical Benefits of the
Inclusive ® Tooth Replacement Solution
Go online for
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
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.
– www.inclusivemagazine.com –
Inclusive Tooth Replacement Solution
Conventional Procedure – Single Tooth
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
Design and fabricate Inclusive Tooth
Replacement Solution components
(7 days in lab):
• Prosthetic guide
• Custom healing abutment
• Custom impression coping
• Custom temporary abutment and
• Inclusive implant
• Disposable surgical drills
• 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.
• 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
Design and mill final restorative
components (13 days in lab):
• Inclusive Custom Abutment
(titanium or zirconia)
• BruxZir Solid Zirconia or IPS e.max
• 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
• 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
1. Implant Consultation and
2. Day of Surgery Protocol
3. Healing Phase
4. Restorative Phase:
5. Delivery of Final Prosthesis
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
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
3.BioTemps ® provisional crown
(Glidewell Laboratories) (Fig. 1a)
4. Custom healing abutment
5. Custom impression coping
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
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.
– 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
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
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
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
Figure 13: Abutment screw tightened to 15 Ncm,
with access opening sealed and flap sutured back
Figure 15: Custom impression coping and screw
access opening sealed with soft wax
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
– 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.
contours of the
coping match those
of the custom healing
abutment or custom
it is simple to
remove the custom
abutment, seat the
coping and take
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)
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.
– www.inclusivemagazine.com –
Go online for
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
– www.inclusivemagazine.com –
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
Virtual Design of Inclusive®
Custom Temporary Components
Go online for
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.
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
•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
– www.inclusivemagazine.com –
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
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.
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
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
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
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
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.
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
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.
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
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.
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
– www.inclusivemagazine.com –
An Interview with
Dr. Darrin Wiederhold
Go online for
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.
want to take a
going to ... allow
you to do some
– 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
You want to
make sure that
the first few
cases you do
are what you
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
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.
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.
start to finish —
restoration — is
optimal in terms
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
specialists alike to
with us to improve
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.
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
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
– www.inclusivemagazine.com –
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
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
Incorporating Dental Implants
into Your Daily Practice
Go online for
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
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
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
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
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
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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Placing Custom Healing Abutments
Go online for
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
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
– 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.
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.
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.
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.
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.
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
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
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
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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
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.
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
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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
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.
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
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
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
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
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
The following case illustrates use of the Inclusive Tooth
Replacement Solution to replace a patient’s maxillary premolar,
employing conventional diagnostic methods.
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
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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.
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
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).
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
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
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
3. Misch C. Progressive bone loading. Dent Today. 1995 Jan;14(1):80-3.
– www.inclusivemagazine.com –
Congratulations, Inclusive Image Contest Winners!
and abutment connection
Vents are unique.
Body shape and
thread pattern will
lead to the answer.
Thread pattern is
The neck gives it
Threads and apical
design are the
No clues are
Can’t miss that
No internal threads
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:
Attn: Inclusive magazine
4141 MacArthur Blvd.
Newport Beach, CA 92660
Or scan your entry and e-mail it to
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
– www.inclusivemagazine.com –