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Maximizing Clinical Flexibility with
Inclusive ® TRS Open Platform
Dr. Tarun Agarwal
Page 17
Implant Considerations in the
Esthetic Zone
Dr. Siamak Abai
Page 25
Implant-Retained Overdenture:
Diagnosis to Delivery
Dr. David Little
Page 39
Restoring the Edentulous Maxilla
Using CBCT Technology
Dr. Timothy Kosinski
Page 55
COLUMNS
Inclusive
Restorative Driven Implant Solutions Vol. 4, Issue 1
A Multimedia Publication of Glidewell Laboratories • www.inclusivemagazine.com
‘My First Implant’
From Russia with Love
Dr. Russell Baer
Recalls His
First Implant Case
Page 11
Implant Q&A:
Dr. Curtis Jansen
Monterey, Calif.
Page 47

Check out the latest issue of Inclusive
magazine online or via your smartphone at
www.inclusivemagazine.com
– www.inclusivemagazine.com –
On the Web
Here’s a sneak peek at additional
Inclusive magazine content available online
ONLINE VIDEO PREsENtAtIONs
■ Glidewell Laboratories Vice President of Sales and Business
Development Dave Casper introduces Dr. Siamak Abai as the
new editor-in-chief and clinical editor of Inclusive magazine.
■ Dr. Siamak Abai summarizes the biological considerations critical to
a predictable and esthetic result when placing and restoring dental
implants in the anterior.
■ Dzevad Ceranic, CDT, explains some of the clinical and financial
advantages to prescribing a CAD/CAM milled bar in lieu of a conventional
cast metal bar in implant denture cases.
■ Dr. Curtis Jansen discusses the prevalence of single-tooth implant
restorations, the significance of intraoral scanning, the practical and
emotional benefits of all-inclusive pricing, the prospects of sameday
dentistry, and risk management for implant treatment in an
interview with contributing editor Dr. Bradley Bockhorst.
■ Dr. Timothy Kosinski outlines the step-by-step process by which an
edentulous arch can be safely and predictably restored via implant
therapy utilizing the latest CBCT technology.
■ Glidewell director of implant R&D and digital manufacturing Grant
Bullis identifies the thread characteristics of dental implants and
examines the mechanical forces exhibited by various thread forms.
ONLINE CE CREDIt
■ Get free CE credit for the material in this issue with each test you
complete and pass. To get started, visit our website and look for
the articles marked with “CE.”
Look for these icons on the pages that follow
for additional content available online

Contents
17
25
39
47
Maximizing Clinical Flexibility with the Open
Platform Inclusive Tooth Replacement Solution
Dr. Tarun agarwal Designed around the clinician’s implant
system of choice, the Open Platform Inclusive Tooth Replacement
Solution provides the clinical flexibility to facilitate an esthetic,
predictable outcome regardless of the chosen treatment protocol.
In a demonstration of these principles, Dr. Tarun Agarwal presents
a case in which he restores a mandibular first molar with the benefit
of a CAD/CAM custom healing abutment and matching custom
impression coping specifically designed for the prescribed Nobel
Biocare implant.
Implant Considerations in the Esthetic Zone
Dr. siamak abai With increasing emphasis on ideal esthetic
outcomes, clinicians require a firm understanding of the biological
considerations needed to produce predictable results. Dr. Siamak Abai
summarizes the peri-implant soft tissue, gingival biotype and other key
characteristics clinicians should account for when treatment planning in
the anterior. He further explains the vital role of proper implant placement,
site preparation and a properly planned provisional in providing
a successful esthetic and functional outcome.
Implant-Retained Overdenture: Diagnosis to Delivery
Dr. DaviD liTTle By providing superior stability, function and
retention, implant-retained dentures are helping to address many
of the challenges faced by edentulous patients. Dr. David Little
explains the advantages of implant-retained prostheses before
outlining a case from initial examination through final restoration.
Along the way, he discusses the ins and outs of treatment planning,
implant placement, impression-taking, try-ins, and the importance
of teamwork and dental laboratories in restoring edentulous cases
with implant therapy.
Implant Q&A: An Interview with Dr. Curtis Jansen
Dr. CurTis Jansen Digital advances are inevitably changing the
way doctors approach restorative solutions. Dr. Curtis Jansen explores
the evolving role of digital scanning, compares various intraoral
scanners and weighs the advantages of same-day dentistry against
traditional laboratory services. He also discusses the preeminence of
single-unit restorations and first molars in implantology; explains the
benefits of single, all-inclusive fees; and emphasizes the importance
of managing risk and patient expectations.
– Contents – 1

– www.inclusivemagazine.com –
PuBLIshER
Jim Glidewell, CDT
EDItOR-IN-ChIEF, CLINICAL EDItOR
Siamak Abai, DDS, MMedSc
INCLusIVE MARkEtINg & EDuCAtION MANAgER
Jennifer Archer
MANAgINg EDItORs
David Casper, Greg Minzenmayer
CREAtIVE DIRECtOR
Rachel Pacillas
CONtRIButINg EDItORs
Bradley C. Bockhorst, DMD; Grant Bullis;
Dzevad Ceranic, CDT; Tim Torbenson;
Keith Peters; Eldon Thompson; Barbara Young
COPy EDItORs
David Frickman, Jennifer Holstein,
Chris Newcomb, Megan Strong
DIgItAL MARkEtINg MANAgER
Kevin Keithley
gRAPhIC DEsIgNERs/WEB DEsIgNERs
Emily Arata, Jamie Austin, Deb Evans, Juan Gallardo,
Kevin Greene, Joel Guerra, Tony Hsiao,
Audrey Kame, Allison Newell, Phil Nguyen,
Kelley Pelton, Melanie Solis, Ty Tran, Makara You
PhOtOgRAPhERs/VIDEOgRAPhERs
Sharon Dowd, Mariela Lopez;
Andrew Lee, James Kwasniewski, Marc Repaire,
Sterling Wright, Maurice Wyble
ILLustRAtOR
Phil Nguyen
COORDINAtORs/AD REPREsENtAtIVEs
Teri Arthur, Vivian Tsang
If you have questions, comments or suggestions, e-mail us at
inclusivemagazine@glidewelldental.com. Your comments may be
featured in an upcoming issue or on our website.
© 2013 Glidewell Laboratories
Neither Inclusive magazine nor any employees involved in its publication
(“publisher”) makes any warranty, express or implied, or assumes any
liability or responsibility for the accuracy, completeness, or usefulness of
any information, apparatus, product, or process disclosed, or represents
that its use would not infringe proprietary rights. Reference herein to
any specific commercial products, process, or services by trade name,
trademark, manufacturer or otherwise does not necessarily constitute
or imply its endorsement, recommendation, or favoring by the publisher.
The views and opinions of authors expressed herein do not necessarily
state or reflect those of the publisher and shall not be used for advertising
or product endorsement purposes. CAUTION: When viewing the
techniques, procedures, theories and materials that are presented, you
must make your own decisions about specific treatment for patients and
exercise personal professional judgment regarding the need for further
clinical testing or education and your own clinical expertise before trying
to implement new procedures.
Inclusive is a registered trademark of Inclusive Dental Solutions.

Contents
ALSO IN THIS ISSUE
8 Trends in Implant Dentistry
Monolithic Implant Crowns
11 My First Implant
Dr. Russell Baer
29 Small Diameter Implants
Choosing the Appropriate
Implant Diameter
33 Lab Sense
Raising the Bar: Inclusive CAD/CAM
Milled Bar Technology
45 Product Spotlight
Inclusive TRS Screw-Retained
Hybrid Denture
65 R&D Corner
Form and Function of Implant
Threads in Cancellous Bone
85 Clinical Tip
Residual Cement Removal, Titanium
Scalers and Successful Restorations
55
71
75
I Have a CBCT Scan — Now What Do I Do?
Restoring the Edentulous Maxilla with Dental Implants
Dr. TimoThy kosinski For clinicians entering the increasingly
popular world of implant dentistry, a full understanding of the
risks, benefits, limitations and anatomic considerations involved is
crucial. To ensure the best result possible, dentists should visualize
the completed restoration up front. Dr. Timothy Kosinski explains
how modern technology is making surgical implant procedures
more predictable and accessible, presenting an edentulous maxillary
case that demonstrates how digital technology is simplifying the
placement, positioning and angulation of implants, putting both
doctors and patients at ease.
Clinical Case Report: Maxillary Esthetic Zone
Restoration with a Monolithic BruxZir Implant Bridge
Dr. ara nazarian Modern dentistry continues to benefit from
clinical advances, giving doctors the tools and materials needed to
treat implant cases with a high degree of precision, customization and
predictability. Dr. Ara Nazarian describes an anterior maxillary case
that was treated with dental implants and a BruxZir Solid Zirconia
bridge to effectively achieve a functional and esthetically pleasing
result. In the process, he explains how monolithic restorations, the
training of soft tissue with patient-specific provisionals and the
precision of the CAD/CAM design process are setting up today’s
implant cases for success.
Use of Cone Beam Computed Tomography in
Implant Dentistry: The ICOI Consensus Report
Dr. erika benaviDes, eT al. In moving beyond the twodimensional
limitations of conventional radiography, Cone Beam
Computed Tomography (CBCT) is having a significant impact on
implant dentistry. Its 3-D imaging offers dentists a powerful tool
in the assessment, diagnosis and treatment planning of implant
cases. Here, the International Congress of Oral Implantologists
(ICOI) reports on the benefits and applications of CBCT scanning,
explaining key aspects such as field of view, scan volume size,
dose considerations and the advantages the technology brings to
digital treatment planning, implant placement, surgical guidance,
anatomical assessment and implant site evaluation.
– Contents – 3

Contributors
■ SIAMAK ABAI, DDS, MMedSc
Dr. Siamak Abai earned his DDS degree from
Columbia University in 2004, followed by two
years of residency in general dentistry. After two
years of general private practice in Huntington
Beach, Calif., he returned to academia and
received an MMedSc degree and a certificate
in prosthodontics from Harvard University.
Dr. Abai brings nearly 10 years of clinical, research and
lecturing experience to his role as director of clinical research
and development for Glidewell Laboratories’ Implant division.
He is also editor-in-chief and clinical editor of Inclusive
magazine. Before joining Glidewell in January 2012, Dr. Abai
practiced at the Wöhrle Dental Implant Clinic in Newport Beach,
Calif. Contact him at inclusivemagazine@glidewelldental.com.
■ 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 Marketing,
Restorative/Zfx for Zimmer Dental. He also
maintains a private practice in Oceanside,
Calif. A member of the CDA, ADA, AO, ICOI
and the AAID, Dr. Bockhorst lectures internationally on an
array of dental implant topics. In this issue of Inclusive magazine,
Dr. Bockhorst serves as guest contributing editor for the
Implant Q&A interview with Dr. Curtis Jansen. Contact him at
760-929-4324 or bradley.bockhorst@zimmer.com.
■ GRANT BULLIS, MBA
Grant Bullis, director of implant R&D and digital
manufacturing at Glidewell Laboratories,
began his dental industry career at Steri-Oss
(now a subsidiary of Nobel Biocare) in 1997.
Since joining the lab in 2007, Grant has been
integral in obtaining FDA 510(k) clearances
for the company’s Inclusive ® Custom Implant
Abutments. In 2010, he was promoted to director and now
oversees all aspects of CAD/CAM, implant product development
and manufacturing. Grant has a degree in mechanical
CAD/CAM from Irvine Valley College and an MBA from
Keller Graduate School of Management. Contact him at
inclusivemagazine@glidewelldental.com.
4
– www.inclusivemagazine.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. He was then promoted to general
manager of the Full-Cast department. In
2008, Dzevad took on the company’s rapidly growing Implant
department, and in 2009 completed an eight-month implants
course at UCLA School of Dentistry. Today, Dzevad leads an
implant team of more than 250 employees at the lab. Contact
him at inclusivemagazine@glidewelldental.com.
■ TARUN AGARWAL, DDS, PA
Dr. Tarun Agarwal is a 1999 graduate of
the University of Missouri-Kansas City. He
maintains a full-time private practice emphasizing
esthetic, restorative and implant
dentistry in Raleigh, N.C., and regularly
presents programs to study clubs and dental
organizations nationally. Through his realworld
approach to dentistry, practice enhancement and
life balance, Dr. Agarwal seeks to motivate dentists and
energize team members to increase productivity and profitability.
His work and practice have been featured in
numerous consumer and dental publications. Contact him at
dra@raleighdentalarts.com or visit www.raleighdentalarts.com.
■ RUSSELL A. BAER, DDS
After teaching implant dentistry and conducting
research in implantology and reconstructive
dentistry at the University of Chicago,
Dr. Russell Baer’s passion led him to the former
Soviet Union, where he founded and serves
as academic director of the Chicago Center
for Advanced Dentistry. With offices in Moscow,
Kiev, Vilnius, Almaty and Mumbai, this training center
gives American dentists the opportunity to teach and practice
implant dentistry abroad. Dr. Baer mentors general dentists on
implantology and does clinical research at University Associates
in Dentistry/Dental Implant Institute of Chicago. An active
AO and ICOI member, he has written numerous articles and
lectures worldwide. Contact him at rabaer@uadchicago.com.

■ ERIKA BENAVIDES, DDS, Ph.D
Dr. Erika Benavides obtained her DDS at the
University of Valle in Cali, Colombia, before
completing a craniofacial genetics externship
program at the Medical University of South Carolina
and a GPR program at the University of
Missouri Kansas City (UMKC) and the Truman
Medical Center. At UMKC, she also received oral
and maxillofacial radiology training and a Ph.D in oral biology
and biomedical engineering. She is a clinical assistant professor
at the University of Michigan School of Dentistry, a Diplomate
of the American Board of Oral and Maxillofacial Radiology,
and she holds dual appointments with the American Academy
of Oral and Maxillofacial Radiology (AAOMR). Her faculty practice
is dedicated to CBCT. Contact her at benavid@umich.edu.
■ SCOTT D. GANZ, DMD
After graduating from the University of Medicine
and Dentistry of New Jersey, Dr. Scott
Ganz completed a three-year specialty program
in Maxillofacial Prosthetics at MD
Anderson Cancer Center in Houston, Texas.
His book, “An Illustrated Guide to Understanding
Dental Implants,” has received wide
acclaim as the standard in patient education texts, and has
sold in more than 15 countries. Dr. Ganz has published more
than 75 articles and has been the featured speaker for numerous
organizations over the past 20 years, including the AO,
ICOI and AAID, among others. Contact him at 201-592-8888
or sdgimplant@aol.com.
■ CURTIS E. JANSEN, DDS
Dr. Curtis Jansen received his dental degree and
a certificate in advanced education in prosthodontics
at the University of Southern California
(USC), where he went on to teach in the
department of restorative dentistry and served
as director of implant dentistry. He practiced
and worked with a dental implant manufacturer
in Florida and was extensively involved in the research,
design and development of a number of patented implant restorative
components used by major manufacturers today.
Dr. Jansen lectures widely and owns a private prosthodontics
practice in Monterey, Calif., with an on-site dental laboratory.
Contact him at cejdds@mac.com or 831-656-9394.
■ TIMOTHY F. KOSINSKI, DDS, MAGD
Dr. Timothy Kosinski graduated from the University
of Detroit Mercy School of Dentistry
and received a Master of Science degree in biochemistry
from Wayne State University School
of Medicine. An adjunct assistant professor
at UDM School of Dentistry, he serves on the
editorial review board of numerous dental
journals and is a Diplomate of the ABOI/ID, ICOI and AO.
Dr. Kosinski is a Fellow of the AAID and received his Mastership
in the AGD, from which he received the 2009 Lifelong Learning
and Service Recognition award. Contact him at 248 -646-8651,
drkosin@aol.com or www.smilecreator.net.
■ DAVID A. LITTLE, DDS
Dr. David Little received his DDS at the
University of Texas Health Science Center
at San Antonio Dental School and now
maintains a multidisciplinary, state-of-the-art
dental practice in San Antonio, Texas. An
accomplished national and international
speaker, professor and author, he also serves
the dental profession as a clinical researcher, focusing on
implants, laser surgery and dental materials. As a professional
consultant, he shares his expertise on emerging restorative
techniques and materials with industry peers. Highly respected
for his proficiency in team motivation, Dr. Little’s vision,
leadership and experience are recognized worldwide. Contact
him at dlittledds@aol.com.
■ MICHAEL McCRACKEN, DDS, Ph.D
Dr. Michael McCracken is co-director of CIRP,
a yearlong comprehensive implant education
institute in Birmingham, Ala. After completing
dental school at University of North Carolina
at Chapel Hill and a prosthodontic residency
at University of Alabama at Birmingham, he
received a Ph.D in biomedical engineering.
Dr. McCracken is a part-time professor at UAB, where he has
served as associate dean for education, director of graduate
prosthodontics and director of the implant training program.
He maintains an active research program within the university
and a private practice focused on implant dentistry. He also
lectures internationally. Contact him at 256-797-1964.
– Contributors – 5

Contributors
■ 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
popular dental publications. Contact him at 248-457-0500
or www.aranazariandds.com.
■ PARESH B. PATEL, DDS
Dr. Paresh Patel is a graduate of the University
of North Carolina at Chapel Hill School of
Dentistry and the Medical College of Georgia/
AAID MaxiCourse. He is cofounder of the
American Academy of Small Diameter Implants
and a clinical instructor at the Reconstructive
Dentistry Institute. Dr. Patel has placed more
than 2,500 small-diameter implants and has worked as a
lecturer and clinical consultant on mini implants for various
companies. He belongs to numerous dental organizations,
including the ADA, North Carolina Dental Society and
AACD. Dr. Patel is also a member and president of the Iredell
County Dental Society in Mooresville, N.C. Contact him at
pareshpateldds2@gmail.com or www.dentalminiimplant.com.
■ HECTOR F. RIOS, DDS, Ph.D
Dr. Hector Rios received his dental degree from
the University of Valle in Cali, Columbia. He
then completed a GPR program in hospital
dentistry at the University of Missouri Kansas
City (UMKC) and the Truman Medical Center.
At UMKC, he also obtained a Ph.D in oral
biology/molecular biology and biochemistry.
Currently, he is a tenure-track assistant professor in the
department of periodontics and oral medicine at the University
of Michigan School of Dentistry in Ann Arbor, and a Diplomate
of the American Board of Periodontology. Dr. Rios maintains
a faculty practice limited to periodontics and dental implants.
Contact him at hrios@umich.edu.
6
– www.inclusivemagazine.com –
■ SUSAN S. WINGROVE, RDH
Susan Wingrove is an international speaker
and practicing dental hygienist, who does
regeneration research as a consultant for
Regena Therapeutics and instrument design
for Paradise Dental Technologies Inc. She
designed the Wingrove Titanium Implant Set,
ACE probes and Queen of Hearts instruments.
A member of the AO, American Dental Hygiene Association
and International Federation of Dental Hygiene, she is also
a published author who has written articles for national and
international journals on implant therapy, regeneration and
advanced instrumentation, as well as the textbook “Peri-
Implant Therapy for the Dental Hygienist: Clinical Guide to
Maintenance and Disease Complications” (Wiley-Blackwell).
Contact her at sswinrdh@gmail.com.
■ TIM TORBENSON
Tim Torbenson has more than three decades
of dental industry experience in the technical,
restorative and surgical aspects of the
field. Since 1986, Tim has been exclusively
involved in implant dentistry, working
in dental laboratories and with dental
implant manufacturers on implant product
development, education and training program development,
management and technical support. He has also lectured
throughout the U.S. on various dental implant-related
topics. Tim joined Glidewell in August 2011 as director of
implant sales and business development. Contact him at
inclusivemagazine@glidewelldental.com.

Letter from the Editor
Glidewell Laboratories has ushered in the new year with many advances in
restorative materials and prosthetic dentistry, as well as a new editor-in-chief of
Inclusive magazine. Since joining the Glidewell clinical research and development
team over a year ago, I feel welcomed to be a part of this quarterly publication.
After finishing my prosthodontics residency in Boston, Mass., I joined the private
practice of world-renowned Dr. Peter Wöhrle in Newport Beach, Calif. My
journey in dentistry led me to Glidewell Laboratories, where I’ve been able to
accentuate my clinical and research training to provide colleagues with thoughtprovoking
articles and information about clinical advances made possible by the
latest dental technology.
In this issue of Inclusive magazine, Dr. Russell Baer details his experiences abroad
as he recounts placing his first implant in Moscow, Russia, almost two decades
ago. His international efforts led to the establishment of implant training programs
in Russia, Kazakhstan and India, among other countries. Garnering international
attention and drawing some of the biggest names in implant dentistry, these
thriving programs continue to enhance the lives of patients around the globe.
The benefits of providing a complete solution to the patient from the treatment
planning phase to the final restoration is highlighted in Dr. Tarun Agarwal’s
article “Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth
Replacement Solution.” Under this treatment option, the concept of complete
patient care is combined with a predictable fee schedule and custom tissue
contouring, resulting in consistent treatment and improved case acceptance.
Articles by Dr. David Little and Dr. Timothy Kosinski highlight the use of technology
in implant prosthodontics, with an emphasis toward improving the standard of
care through the use of cone beam computed tomography and digital treatment
planning. Dr. Kosinski highlights the use of digital technology for the treatment
planning of implant-retained overdentures in the maxillary arch, while Dr. Little
guides us through a mandibular implant-retained overdenture case.
Running throughout this issue is a common theme of utilizing the latest technology
in patient treatment. Dental technology has come a long way in recent
years, and now it is our responsibility as clinicians to maximize its use to raise
the quality of patient treatment. An interview with Dr. Curtis Jansen detailing his
experiences with intraoral scanning and CAD/CAM-produced restorations highlights
this concept.
I look forward to being a part of your journey in prosthodontics and implant
dentistry.
With kind regards,
Dr. Siamak Abai
Editor-in-Chief, Clinical Editor
inclusivemagazine@glidewelldental.com
– Letter from the Editor – 7

Trends in
Implant Dentistry
In 2012, Glidewell Laboratories saw continued growth in the demand for BruxZir ® Solid Zirconia
crowns, which by year’s end surpassed PFMs as the implant restoration of choice. With no porcelain
overlay, monolithic all-ceramic restorations produced from BruxZir zirconia or IPS e.max ® lithium
disilicate (Ivoclar Vivadent; Amherst, N.Y.) have exhibited the ability to better withstand functional
stresses that can result in chipping. The flexural strength of BruxZir Solid Zirconia is significantly
greater than that of a conventional PFM, 1 while its high fracture toughness (KIc value) reflects the
material’s ability to absorb the energy responsible for crack propagation three to six times better than
traditional ceramics. 2,3 Doctors are taking notice, leading to a significant rise in all-ceramic prescriptions
while the demand for coping-based restorations remains flat in comparison.
8
Sales of Implant Crowns at Glidewell Laboratories
January 2012–December 2012
BruxZir ® Solid Zirconia IPS e.max ®
4,000
3,000
2,000
1,000
0
Monolithic Implant Crowns
Coping-Based All-Ceramic
PFM
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12
Data source: Glidewell Laboratories January 2011–December 2012
REFERENCES
1. Guess PC, Att W, Strub JR. Zirconia in fixed implant prosthodontics. Clin Implant Dent Relat Res. 2012 Oct;14(5):633-45.
2. Chiang YT, Birnie D, Kingery WD. Physical ceramics: principles for ceramics science and engineering. John Wiley & Sons. 1997:484.
3. Griffiths AA. The phenomena of rupture and flow in solids. Philosophical Transactions of the Royal Society of London 1920. Series A(221):163-98.
– www.inclusivemagazine.com –

Year-Over-Year Total Sales Increase for
BruxZir Implant Crowns
Clinicians who have switched from PFMs to monolithic all-ceramic restorations
are seeing considerable benefits, including exceptional resistance to
chipping and fracture. At the same time, the precision and predictability
of the CAD/CAM manufacturing process is improving patient acceptance
upon initial seating. This is inspiring increased confidence among clinicians
in the immediate and long-term success of their implant restorations.
– Dzevad Ceranic, CDT
Implant Department General Manager
Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12
Watch here for emerging trends
Check back here for more observations in the next issue.
– Trends in Implant Dentistry: Monolithic Implant Crowns – 9

my first
implant
with Russell A. Baer, DDS
thERE WAs A CERtAIN gLAMOuR to the idea of traveling to
a faraway place like Moscow, replete with caviar, vodka,
beautiful women and characters from the Russian
underworld. What started out as a handful of people
going overseas on a regular basis to teach implant
technology in a government-run polyclinic evolved into
a comprehensive teaching and training program that
drew big names in the dental world. Decades later, the
program is still going strong and has spread to the far
corners of the globe. Dr. Russell Baer shares his story with
Inclusive magazine.
FROM RUSSIA WITH LOVE
I fell into dentistry almost by accident. As a cardiopulmonary
technician, I enjoyed my work in an intensive care unit
and was bound for medical school. But after watching doctors
come to the hospital at all hours of the night, half of
them with failing marriages, I reconsidered my career path
and chose to go to dental school. I still loved the exposure
to surgery, which would be advantageous years later when
I began placing implants.
I graduated from dental school and completed my general
practice residency in the mid-1980s. I went through restorative
training and implants with Danny Sullivan and Steve
Perells. At that time we practiced in a classic model at the
University of Chicago. In 1993, I had the opportunity to give
some lectures in the former Soviet Union and Uzbekistan.
Even though Moscow is only a two-hour flight from Sweden,
they had not had anyone come and speak on modern
implants since Leonard Linkow back in the late 1970s and
early 1980s. This was a great opportunity. So I put together
a training course: we would train the students, do several
cases, then come back and deliver the final restorations
a few months later. Slowly, we turned it over to the local
doctors to teach. I went over for the first time in 1995 to
teach the course and returned every 8 to 12 weeks. I took
a good friend, oral surgeon Rick Balcerak, who performed
the surgeries while I did the restorative work.
ESTABLISHING OUR OWN PRIVATE CLINIC
We encountered our share of challenges initially. We had
to go to a different clinic each time because our local
– My First Implant: Dr. Russell Baer –
doctors were unreliable and never followed through. We
had trouble keeping long-term relationships because they
did not want to teach anyone else, and preferred instead to
remain the local experts. Finally, in 1998, we decided to start
our own clinic in order to establish better follow-through.
We opened a private clinic called the Chicago Center for
Advanced Dentistry, which was set along the main drag
in Moscow near the Kremlin, on Tverskaya — the
Rodeo Drive of that area.
MY VERY FIRST IMPLANT (MOSCOW)
Just before opening our private clinic, when we
were still working in the government clinics, Rick
turned to me and said: “I’m tired of this. You know
what you’re doing. You place the implants.” I had
watched enough surgeries and restored hundreds of
cases up to this point, and it was time to start placing
the implants myself. And with his mentorship,
I did. It was a healed tooth #30 — I had observed
hundreds of these — and I thought,
“I can do it.” Pushing the
lump in my throat aside, I
followed what I had seen to
the letter; I just went in there
and did it. That night, all I
could think of was the implant
falling out of the
patient’s mouth. But
I saw that it worked,
and it elevated my
confidence level. That
first implant solidified
my love of surgery.
After that I had many
opportunities with
our Russian patients
— at times
we would do 50
to 60 procedures
in a
day — and
I got better
and better.

BRINGING IN THE BIG GUNS
Because there was a certain glamorous appeal to a place
like Russia — the vodka, the pretty women, venturing into
new, uncharted waters — it was surprisingly easy to get
fellow doctors to go over to Moscow with me. I brought
some of the biggest names in dentistry at the time: Chuck
Babbush, Paulo Malo, Jean Bedard, Jack Hahn and numerous
others who continued to come over and teach. I was able to
learn from their expertise, and it basically became my own
private implant residency. Jack Hahn was a mentor to me
and influenced the design of my residency. We also offered
every specialty in dentistry and conducted several courses
simultaneously. We might bring in an oral surgeon and do
six or seven sinus lifts on a given weekend, for example,
which was a fantastic way to learn.
A DAY IN THE LIFE
Here was my typical routine: Wednesday after work at the
office here in Chicago, I would board a plane, land in Moscow,
treat patients Thursday afternoon, Friday and Saturday,
teach Saturday evening study club, and then be back home
in Chicago on Sunday by 3:30 p.m. I did that about every
eight weeks.
In Moscow, our day usually started at 9 a.m. and went to
about 9 p.m. We would have a big lunch and a late dinner,
which is more of a European model. In the early days, when
we were teaching in the government clinic, it was normal
to take a big lunch and have borscht, blini and caviar, and
shashlik — a kind of kebab. And it was not unusual for the
doctors to want to do a vodka toast. The hardest thing was
trying to be polite while turning them down, so I said no in
the daytime but imbibed in the evenings so as not to insult
our local partners.
Interestingly, dentistry was able to break away from the
government-run polyclinics, and private clinics started
springing up. These were some of the most modern and
luxurious clinics in the world, owned by organizations like
Gazprom, a massive natural gas conglomerate in Russia.
12
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Baer’s colleague and mentor, Jack Hahn (middle), poses with former students in
2010 at the Chicago Center for Advanced Dentistry in Moscow. Renowned implantologist
Sergey Zorin (left) is now one of the local doctors teaching in the program.
They had digital X-rays, lasers and CEREC ® machines
(Sirona Dental Systems; Charlotte, N.C.) in every operatory,
as if money was no object. Some of these clinics were
just amazing to me. My first introduction to CEREC was
actually in Russia in the mid-1990s. We even ran into a
machine that was like CEREC but would take the tooth
out, scan it and mill an implant the exact same size as the
root. At the time, it was considered a crazy invention, and
it wasn’t widely accepted back in the States.
We didn’t necessarily have more freedom to experiment in
Moscow. We were very straightforward in our approach,
since it was a difficult environment. We were always careful
about pushing the envelope with immediate placement,
immediate loading and function. We were conservative and
wanted to get good results. Yet every time I left, I wondered
if there would be a mob guy waiting for me at the airport
saying, “I don’t like my implant.” Occasionally when a
patient drove up in a black Mercedes with multiple escort
cars, we were a bit leery, as it was not crystal clear whether
they were part of the Russian underworld or government
officials. I remember one patient who, excusing himself
mid-procedure, stepped outside to have a cigarette with his
bodyguard in the middle of having his full lower jaw done!
ONCE UPON A TIME IN MUMBAI
The Chicago Center for Advanced Dentistry was a premiere,
high-end, private-style clinic that we started in Moscow.
But the concept worked so well that we soon expanded
into new areas of the region like Vilnius, Lithuania; Kiev,
Ukraine; and then Almaty, Kazakhstan — which is where I
spent Memorial Day this year placing implants.
We also opened a clinic in Mumbai in 2004 or 2005. I was
there, actually, about six months ago. We had a young
dentist there from Iowa whom we hired out of college in
1999. He also majored in Russian, so we hired him to live in
Moscow and manage the clinic. And he is still managing the
clinic today, but now commutes to Moscow from Mumbai
since marrying a fellow Indian dentist.

In Mumbai, dentistry was more of a public health issue.
The dentists all spoke English and had the technology;
they just needed to convince the patients to take advantage
of this technique.
BACK IN THE USSR
In Russia, on the other hand, you had a growing middle class,
and the patients were eager for treatment. The majority of
the patients we saw were people who had failing full-mouth
dentition, and they weren’t going to tolerate dentures, so
we did a lot of full-arch implant cases. Today, if you were to
ask the big companies like Nobel Biocare and Straumann,
they’d tell you that Russia is one of the fastest growing
implant markets in the world.
From the beginning and throughout the years, we had
corporate partners who helped us supply the facility with
equipment. We had to do some pitching, of course. When
we first went over, we didn’t have any strong partners. We
were using two lines of Stryker brand implants that no
longer exist. Stryker had an implant division back then. We
were also placing a screw-type implant that was eventually
bought out by BioHorizons, and a fin-type implant, which
is now the Bicon implant. I got to know Jack when we
approached Steri-Oss in 1997, and he was the designer
of their Replace implant (Nobel Biocare; Zurich,
Switzerland). Russia was an emerging market, so
what we were doing in Moscow was of interest
to these companies.
Back at home in Chicago, I knew that if it
worked in Russia, it could also work here. But
the bottom line is this: It’s not so much the
implant that matters, but the person who is
putting it in. The education and qualification
of the doctor will always be primary, and the
products secondary. IM
Title of article
Left: Baer with business partner Mridu Sekar (left)
and colleague Paulo Malo (middle) in Yalta, hosting
a symposium sponsored by the Chicago Center for
Advanced Dentistry
Right: Baer featured on a billboard in Almaty,
Kazakhstan
Keeping it ReaL — Similar to the
appeal that drew some of the big names
in dentistry, there was a kind of celebrity
attached to it all. At one point, my wife and
I were traveling in Kazakhstan. Walking
down the streets of Almaty, I said, “Honey,
look.” And there was my face, larger than
life, pasted across a billboard. But with the
cars roaring by and people going about
their busy days, she looked right past it
and continued walking, unfazed,
and said, “What?”

16
– www.inclusivemagazine.com –

Maximizing Clinical Flexibility with the
Open Platform Inclusive ®
Tooth Replacement Solution
by
OsseoSpeed TX
(DENTSPLY Implants)
Tarun Agarwal, DDS, PA
The Inclusive ® Tooth Replacement Solution is touted
as the industry’s first all-in-one, restorative-driven
treatment package, described in simplest terms
as the complete set of components required to replace
a missing tooth. But the true value of this full-service,
patient-specific solution cannot be adequately measured
with a mere list of parts and pieces, no matter how
comprehensive that list may be. The ultimate benefit can
instead be found in the freedom and flexibility inherent in
the solution during all phases of treatment, which serve
to maximize clinical efficiency and facilitate a predictable,
esthetic outcome.
Showcasing the most obvious example of this clinical
flexibility is the Open Platform Inclusive Tooth Replacement
Solution. While the original Inclusive Tooth Replacement
Solution features an internal hex tapered implant of timetested
design, the Open Platform treatment package is
built around the clinician’s implant of choice. A clinician
accustomed to working with any of the major implant
OSSEOTITE ® Certain ®
Tapered Dental Implant
(Biomet 3i)
Brånemark System ®
(Nobel Biocare)
NobelActive
(Nobel Biocare)
systems (Fig. 1) can therefore take full advantage of the
Inclusive Tooth Replacement Solution prosthetic guide,
custom temporary components, custom impression coping
and final CAD/CAM restoration while placing an implant
from his existing inventory.
Whichever implant is used, the principal advantages to be
found in utilizing the Inclusive Tooth Replacement Solution
remain unchanged. With a stent to help direct implant
placement from a prosthetic perspective, custom temporary
components to provide contoured soft tissue management
in the event of immediate provisionalization or conventional
healing and a custom impression coping to fully capture the
resulting gingival contours, the patient is better prepared
to receive the accompanying final restoration with minimal
discomfort and fewer adjustments. By truly beginning with
the end result in mind, the Inclusive Tooth Replacement
Solution streamlines the treatment workflow and alleviates
component and communication issues too often associated
with traditional implant services.
NobelReplace ®
Tapered Groovy ®
(Nobel Biocare)
Bone Level
(Straumann USA, LLC)
Go online for
in-depth content
Tapered
Screw-Vent ®
(Zimmer Dental)
Figure 1: The Open Platform Inclusive Tooth Replacement Solution supports the following implant systems: Astra Tech OsseoSpeed (now DENTSPLY Astra Tech Implant
System ); Biomet 3i Certain ® ; Nobel Biocare Brånemark System ® , NobelActive and NobelReplace ® ; Straumann Bone Level; and Zimmer Screw-Vent ® . All associated
third-party trademarks are the property of their respective owners.
– Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution – 17

Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution
Figure 2: Rx form for the Open Platform Inclusive Tooth Replacement
Solution
Figure 4: A prosthetic guide featured with the Open
Platform Inclusive Tooth Replacement Solution
Flexibility in All Phases
To better examine the Open Platform Inclusive Tooth
Replacement Solution and the options it affords clinicians
during each stage of treatment, it is helpful to break the
package down into four distinct phases.
Phase 1: Treatment Planning
When submitting an Open Platform Inclusive Tooth
Replacement Solution case, clinicians may take either
digital or conventional full-arch impressions, along with
a bite registration, so that the laboratory may accurately
produce articulated study models. The special Rx enables
clinicians to denote the system, diameter and platform
size of the implant to be used, along with the prescribed
tooth shade and soft tissue depth noted in the edentulous
site (Fig. 2). This information enables the laboratory to
properly design custom components with patient-specific
18
– www.inclusivemagazine.com –
Figure 3: Radiograph of an MIS SEVEN ® implant (MIS Implant Technologies;
Fair Lawn, N.J.) placed using the Open Platform Inclusive Tooth Replacement
Solution
Figure 5: A custom healing abutment featured with the Open Platform
Inclusive Tooth Replacement Solution
soft-tissue contours in an effort to provide a more natural
emergence profile than that obtained with conventional
stock components.
Phase 2: Surgical
Courtesy of Robert A. Horowitz, DDS
Placement of the prescribed implant is performed
according to clinician preference, using the system and
instrumentation of choice (Fig. 3). Because implant placement
within the edentulous space is critical to achieving an
optimal restorative outcome, the Open Platform Inclusive
Tooth Replacement Solution features a prosthetic guide
(Fig. 4) with which to prepare the osteotomy in freehand
cases. Anatomical landmarks should be properly accounted
for during treatment planning, as the prosthetic guide does
not take these into consideration. However, use of the guide
will ensure swift, accurate seating of the custom healing

Figure 6: A custom temporary abutment and BioTemps provisional crown
featured with the Open Platform Inclusive Tooth Replacement Solution
Figure 8: Anatomical sulcus following custom healing phase of the Open
Platform Inclusive Tooth Replacement Solution
abutment or custom temporary abutment, and help to
improve the final prosthetic outcome.
Phase 3: Temporization/Healing
Immediately upon implant placement, the clinician may
elect to place the custom healing abutment (Fig. 5) or
provisionalize the case with the custom temporary abutment
and BioTemps ® provisional crown (Fig. 6). Temporization can
also be performed after a period of healing, if indicated. The
custom healing abutment and custom temporary abutment
are each milled from a radiopaque, biocompatible polyether
ether ketone (PEEK) material that is easy to adjust as
needed, while the BioTemps crown milled from poly(methyl
methacrylate) (PMMA) is designed with an internal relief
space to allow for adjustable seating during cementation.
The custom temporary abutment and BioTemps crown
can even be modified and luted together extraorally to
Figure 7: A custom impression coping featured with the Open Platform
Inclusive Tooth Replacement Solution
Figure 9: Inclusive Custom Abutments are available in titanium, all-zirconia
or zirconia with titanium base
create a single-piece screw-retained provisional. Whatever
the indication or preference, patient-specific soft tissue
management can be initiated upon implant placement — in
a fraction of the time it would require to create a custom
component chairside.
Phase 4: Final Restoration
When the time comes for the definitive restoration, a final
impression is taken with the custom impression coping
(Fig. 7). This CAD/CAM component is designed with the
same gingival contours as the custom healing abutment and
custom temporary abutment to precisely capture the final
gingival architecture (Fig. 8) and convey that information
to the laboratory, providing a greater understanding of the
appropriate emergence profile. Along with final full-arch
impressions, the clinician submits a final Rx for the desired
Inclusive ® Custom Abutment (Fig. 9) and final BruxZir ®
– Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution – 19

Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution
Figure 10: Clinicians may prescribe a final crown made from BruxZir Solid
Zirconia or IPS e.max
Figure 12: Radiograph of tooth #19 after endodontic therapy to treat periapical
abscess
Solid Zirconia or IPS e.max ® (Ivoclar Vivadent; Amherst,
N.Y.) monolithic crown (Fig. 10). A screw-retained final
restoration may also be prescribed (Fig. 11). The precise
nature of the manufacturing process used to produce
both the temporary and final custom components helps
to ensure efficient seating of the definitive restoration
upon final delivery, without blanching and with little to no
chairside adjustment.
Clinical Example
The following case report serves to showcase the
advantages and flexibility of the Open Platform Inclusive
20
Figure 11: A BruxZir Solid Zirconia screw-retained crown prescribed as
the final restoration in a case utilizing the Open Platform Inclusive Tooth
Replacement Solution
Figure 13: Periapical radiograph of site #19 post-extraction
Tooth Replacement Solution. This particular case features
placement of a NobelActive implant from Nobel Biocare.
Case Report
– www.inclusivemagazine.com –
Courtesy of Robert A. Horowitz, DDS
Following endodontic therapy to treat a periapical abscess
on tooth #19 (Fig. 12), the patient in this case suffered
recurrent periapical infection requiring extraction of the
compromised mandibular first molar. The patient was
referred to an oral surgeon for drainage and extraction
(Fig. 13), at which time immediate implant placement was
contraindicated by the infection.

Figure 14: Radiograph of NobelActive implant placed in edentulous site #19 Figure 15: Digital design of custom healing abutment
Figure 16: Digital design of custom impression coping Figure 17: Milled custom impression coping (left) with custom healing
abutment (right)
A five-month healing period was observed, after which
the patient returned for diagnostic evaluation for implant
therapy. A 3-D cone beam computed tomography (CBCT)
scan was obtained using a GALILEOS scanner (Sirona
Dental Systems; Charlotte, N.C.). The treatment plan called
for guided placement of an 11.5 mm NobelActive RP implant
in the edentulous space, utilizing all-digital impressions and
a two-stage surgical protocol.
After guided placement of the NobelActive implant (Fig. 14),
an Inclusive ® Scanning Abutment for NobelActive RP was
attached to the implant fixture for the purpose of capturing
the precise location, angulation and connection orientation
of the implant during the intraoral scan. A digital impression
was taken using the CEREC ® Omnicam (Sirona Dental
Systems), and the information submitted to Glidewell
Laboratories for the CAD/CAM production of the custom
healing abutment and custom impression coping featured
with the Open Platform Inclusive Tooth Replacement
Solution (Figs. 15–17).
Following a prescribed healing period, the patient returned for
a second-stage procedure involving exposure of the implant
platform (Figs. 18a, 18b). To account for the shifting of adjacent
teeth during osseointegration, a second digital impression
was taken during this visit, this time utilizing the custom
impression coping (Fig. 19). Use of this custom impression
coping facilitates capture of the patient-specific gingival
– Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution – 21

Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution
Figure 18a: Presentation of edentulous site post-implant placement, following
prescribed healing period
Figure 19: Radiograph to confirm seating of custom impression coping
contours. Once the digital impression was taken (Fig. 20),
the custom healing abutment was placed (Figs. 21a–21c).
Key advantages of the custom healing abutment include the
preservation of keratinized soft tissue and preparation of
that tissue into an ideal form for a more esthetic restoration,
as well as simplified delivery of the definitive restoration.
Having the abutment on hand eliminates tedious creation of
a custom healing abutment chairside.
For the definitive restoration, an IPS e.max screw-retained
crown (Fig. 22) was prescribed and delivered. Due to
Figure 18b: Second-stage exposure of the NobelActive implant platform
Figure 20: Digital impression with custom component in place
Figure 21a: Seating of custom healing abutment Figure 21b: Radiograph to confirm seating of custom healing abutment
22
– www.inclusivemagazine.com –
proper preparation of the site utilizing the custom healing
abutment (Figs. 23a, 23b), the accurate capture of that soft
tissue architecture and the precise nature of the digital
process, the crown seated easily into place. No adjustment
was required.
The use of a custom healing abutment and matching
custom impression coping, combined with the use of digital
impression technology, enabled this case to be completed
in fewer visits, simplified delivery of the final prosthesis
and resulted in a highly esthetic outcome. Both the patient

Figure 21c: Soft tissue sutured into place around custom healing abutment
Figure 23a: Presentation of edentulous site #19 following prescribed healing
period with custom healing abutment
and the practice saved time and money. Given the minimal
cost differential between custom components and generic
ones, an open, patient-specific solution warrants strong
consideration in the planning of any implant treatment
modality.
Summary
Advancements in the techniques and materials associated
with dental implant therapy have served to widen the range
of treatment protocols available to practicing clinicians.
Successfully managing these protocols and the options that
may arise during any individualized procedure can go a long
way toward determining the efficiency and predictability
with which a case is completed. Undue reliance on traditional
components can restrict a clinician’s choices during the
course of treatment or require time-consuming chairside
alternatives to avoid compromised results. The Open
Platform Inclusive Tooth Replacement Solution is designed
to meet this challenge by providing the flexibility needed
to address any clinical situation, in whatever manner the
Figure 22: IPS e.max screw-retained crown
Figure 23b: Presentation of anatomically sculpted soft tissue at edentulous
site #19 following removal of custom healing abutment
clinician feels most comfortable or productive. Beginning
with the implant of choice, those utilizing this solution may
employ a single-stage or two-stage surgical protocol, provide
patient-specific healing or custom provisionalization, take
conventional or digital impressions, and select a definitive
abutment and crown as indicated. Whatever the prescribed
procedure, this adaptable, comprehensive solution aims to
maximize clinical control during every phase of treatment,
resulting in a simplified workflow that reduces chairtime
while contributing to a more esthetic restoration. IM
– Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution – 23

IMPLANT CONSIDERATIONS
IN THE EsthEtIC ZONE
by
Siamak Abai, DDS, MMedSc
Go online for
in-depth content
Successful clinical outcomes for implant placement and integration in the esthetic zone is multifactorial, with the clinician’s
understanding of biological structures and implant biomaterials at the pinnacle of a qualified result. Through
the years, there has been a shift in case outcome acceptance from mere satisfaction with the clinician’s placement
of an implant regardless of position and esthetic result to rejection when there is deviation from the ideal esthetic
outcome. This shift is a result of an increase in the clinician’s knowledge of the biological structures and implant site
preparation prior to implant placement. Regardless of the physical position of the implant, biological considerations such
as gingival biotype, an understanding of the peri-implant soft tissue, and the possibility of immediate implant placement
and provisionalization have to be considered for a predictable outcome. With the advanced tools and technologies available
today, clinicians who take the time to properly assess all relevant restorative factors prior to implant surgery will
find it much easier to achieve an efficient, satisfying result.
– Implant Considerations in the Esthetic Zone – 25

IMPLANT CONSIDERATIONS IN THE ESTHETIC ZONE
Biological Considerations
The predictability of ideal peri-implant
tissue contour involves a number of
clinical parameters and is ultimately
determined by proper implant placement,
periodontal health, gingival
biotype and the clinician’s ability to
manage the different procedures required
for an esthetic outcome. 1 The
position of the soft tissue margin at
the facial aspect of the restoration is
of great importance because it dictates
crown length and cervical form of the
final restoration. 2 A critical step in increasing
successful outcomes is the
utilization of a provisional that facilitates
optimal healing. Furthermore, a
proper provisional restoration can be
used as a guide for the fabrication of
the definitive restoration. 3 The stability
of peri-implant tissue is dependent
on the surgical technique and the
position of the implant fixture, and it
has been suggested that a temporization
period of up to six months may
be required prior to the placement of
a definitive restoration. 4 Implants seated
in dense bone with a high degree
of primary stability might safely be restored
sooner, while a longer healing
period would be recommended for
non-standard cases (e.g., a labial bony
defect that requires bone grafting). Development
of proper tissue contours
and emergence profile also depends
on placement of an implant similar in
cervical diameter to the tooth being
replaced 5 (Fig. 1). Replacement of the
tooth with a larger-diameter implant,
involving less running room between
the implant platform and the gingival
margin, would result in a more apical
positioning of facial papillae, whereas
the use of a smaller-diameter implant
with adequate running room can provide
more restorative options for creating
the proper gingival scalloping.
In all, a global understanding of the
biological basis of tissue management
is critical for a desirable outcome. For
clinicians who would prefer to receive
modifiable custom provisional components
prior to surgery rather than
fabricating them chairside, laboratory
assistance is available (Figs. 2a, 2b).
26
Figure 2a: Custom healing abutment
Implant
Tooth Cross Section
Running Room
Figure 1: Implant with diameter matching cervical
diameter of tooth
Figure 2b: Custom temporary abutment
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Figure 3: Cross section of peri-implant soft tissues
around natural tooth and dental implant
2 mm
1.5 mm
1.5 mm
Figure 4a: Proper implant size and placement to
help maintain biological width
Figure 4b: Proper implant placement matching
neck of implant to crestal bone height

Peri-Implant soft tissue
The peri-implant soft tissue and the
soft tissue surrounding natural teeth
are similar in that they both possess
a junctional epithelium component
and a connective tissue component.
However, the peri-implant connective
tissue component has higher fiber
content as compared to the gingiva
around natural teeth. Peri-implant
collagen fibers are arranged parallel
to the implant surface, while natural
tooth gingival fibers are arranged perpendicular
to the cementum surface
of the root 6 (Fig. 3). Furthermore, studies
have shown various fiber bundles
organized in different fashions to the
titanium surface of implants. 7 In a dog
study, Berglundh and Lindhe demonstrated
that by surgically reducing the
thickness of the gingival flap prior to
suturing, a crestal bone remodeling
occurred. This allowed the biological
width of the peri-implant soft tissue
to develop to its original dimension at
the expense of reduced crestal bone
height, mimicking the surgical crown
lengthening procedure on natural
teeth. 8 It has also been found that, due
to the nature of a reduced vasculature
of peri-implant soft tissue, bacterial invasion
is more destructive around an
implant than a natural tooth. 1 These
findings emphasize the importance of
a constant gingival dimension, or biological
width, around implants, which
can be maintained in part by proper
implant selection and by minimizing
component exchange (Figs. 4a, 4b).
With these considerations, soft tissue
management and maintenance of the
alveolar crest are critical to the final
esthetic outcome, and more easily
achieved if recognized and planned
for prior to implant placement.
gingival Biotype
Gingival morphology and biotype also
play an important role in the treatment
planning and finalization of an esthetic
outcome. Historically, gingival biotype
has been categorized as flat and thick,
or scalloped and thin, with the contour
of the gingiva correlating to the
Figure 5a: Thick, flat gingival biotype
Figure 5b: Thin, scalloped gingival biotype
underlying alveolar bone 9 (Figs. 5a, 5b).
Clinicians have found thin tissue biotype
to be more challenging, as the
prevalence of gingival recession and
periodontal disease is more likely. 10
Conversely, thick tissue biotype has
been associated with successful treatment
outcomes in implant cases. Implant
cases demonstrate that patients
with thin gingival mucosa presented
with more gingival recession, whereas
patients with thick gingival mucosa
presented with the proper maintenance
of the implant papillae height.
The literature also suggests that thin
biotype is less resilient to the stresses
of frequent component swapping,
indicating a treatment protocol that
would minimize the seating and removal
of temporary components.
Regardless, tissue biotype is a significant
factor in the predictability of
treatment outcomes. 11 While definitive
Figure 6a: Periodontal probe masked by thick
gingival biotype
Figure 6b: Periodontal probe visible through thin
gingival biotype
classification can be elusive, assessment
with a periodontal probe has
been shown to be an adequately
reliable and objective method in
evaluating gingival biotype, as compared
to direct measurement using a
tension-free caliper. 12 This is done by
placing the tip of a metal periodontal
probe to depth within the gingival sulcus
on the facial aspect of an incisor.
A thick gingival biotype would tend
to mask the probe, whereas visibility
of the probe through the tissue would
indicate a thin biotype (Figs. 6a, 6b).
Immediate Placement
and Provisionalization
Recent advancements in implant
dentistry have shifted the dogma of
implantology toward the immediate
placement of implants following extraction.
Evidence-based dentistry has
– Implant Considerations in the Esthetic Zone – 27

IMPLANT CONSIDERATIONS IN THE ESTHETIC ZONE
allowed clinicians to predictably place
and temporize implants in order to
help conserve bone following extraction.
However, the integrity of buccal
bone in the first three months following
extraction in the esthetic zone has
provided a challenge to clinicians due
to rapid loss of bone, especially in
cases of delayed implant therapy. It
has been estimated that 23 percent of
bone mass is lost within the first three
months post-extraction, with another
11 percent lost in the two subsequent
years. 13 Because of early bone loss,
which creates a lack of quantity and
contour of keratinized tissue surrounding
implants, clinicians are faced
with esthetically unfavorable or unpredictable
restorative results. This
has contributed to the shift toward
immediate implant placement and
temporization, which serves to preserve
buccal bone volume and allows
for immediate tissue contouring
post-implant placement. Here again is
where a properly planned provisional
can go a long way toward improving
case results from both a functional
and esthetic perspective, increasing
patient satisfaction in both the short
and long term.
summary
While some patients may forgive unesthetic
implant restorations for the
sake of functionality, clinicians today
have the opportunity to truly impress
and gratify their patients by meeting
or exceeding esthetic expectations,
particularly in the anterior. Fortunately,
successful outcomes in the esthetic
zone have become the norm rather
than the exception, due to the clinician’s
understanding of the importance
of treatment planning and the biological
limitations of individual patients.
Whereas gingival shape and thickness
are perhaps less critical in the posterior,
given adequate gingival attachment
around the implant, a thicker gingival
biotype and constant biological width
can be considered prerequisites to a
satisfying result in the esthetic zone.
With ideal implant positioning and
28
custom tissue conditioning — aided
by tools and techniques designed to
provide patient-specific surgical, provisional
and restorative solutions —
today’s clinicians can equip themselves
to predictably plan and efficiently
treat the individual patient’s needs.
Each patient is therefore more likely
to receive a final, implant-borne restoration
that exhibits the natural form
and function they desire. IM
ReFeRences
1. Saadoun AP, Touati B. Soft tissue recession around
implants: Is it still unavoidable? Pract Proced Aesthet
Dent. 2007 Jan-Feb;19(1):55-62, A-H.
2. Palacci P, Nowzari H. Soft tissue enhancement
around dental implants. Periodontology 2000. 2008;
47:113-32.
3. Cho SC, Shetty S, Froum S, Elian N, Tarnow D.
Fixed and removable provisional options for patients
undergoing implant treatment. Compend Contin
Edu Dent. 2007 Nov;28(11):604-9.
4. Touati B, Guez G. Immediate implantation with
provisionalization: from literature to clinical implications.
Pract Proced Aesthet Dent. 2002 Nov-Dec;
14(9):699-707.
5. Kazor CE, Al-Shammari K, Sarment DP, Misch CE,
Wang HL. Implant plastic surgery: a review and
rationale. J Oral Implantol. 2004;30(4):240-54.
6. Berglundh T, Lindhe J, Ericsson I, Marinello CP,
Liljenberg B, Thomsen P. The soft tissue barrier at
implants and teeth. Clin Oral Implants Res. 1991
Apr-Jun;2(2):81–90.
7. Yeung SC. Biological basis for soft tissue management
in implant dentistry. Aust Dent J. 2008 Jun;53
Suppl 1:S39-42.
8. Berglundh T, Lindhe J. Dimension of the periimplant
mucosa. Biological width revisited. J Clin
Periodontol. 1996 Oct;23(10):971-3.
9. Ochsenbein C, Ross S. A reevaluation of osseous
surgery. Dent Clin North Am. 1969 Jan;13(1):
87-102.
10. Claffey N, Shanley D. Relationship of gingival thickness
and bleeding to loss of probing attachment
in shallow sites following nonsurgical periodontal
therapy. J Clin Periodontol. 1986 Aug;13(7):654-7.
11. Fu JH, Yeh CY, Chan HL, Tatarakis N, Leong DJM,
Wang HL. Tissue biotype and its relation to the
underlying bone morphology. J Periodontol. 2010
Apr;81(4):569-74.
12. Kan JY, Morimoto T, Rungcharassaeng K, Roe
P, Smith DH. Gingival biotype assessment in the
esthetic zone: visual versus direct measurement.
Int J Periodontics Restorative Dent. 2010 Jun;
30(3):237-43.
13. Covani U, Cornelini R, Barone A. Bucco-lingual
bone remodeling around implants placed into
immediate extraction sockets: a case series.
J Periodontol. 2003 Feb;74(2):268-73.
– www.inclusivemagazine.com –

Choosing the Appropriate
Implant Diameter
with Paresh B. Patel, DDS
Bicortical StaBilization
Engaging the bone in both directions (labio-lingual) as well
as the inferior and superior plates is important when choosing
the appropriate implant diameter. That is where mini
implants are at their best: placed in thin bone with strong
cortical plates — the ideal environment for a small-diameter
implant to engage and osseointegrate.
availaBility of Bone
Conventional-diameter implants typically require at least
6 mm of width labio-lingually. But most patients who
need denture stabilization lack sufficient bone width for
these larger root-form fixtures, necessitating either a ridge
augmentation procedure or the placement of small-diameter
implants. Mini implants can often be placed in as little as
3 mm of bone, gaining stability by engaging both labial and
lingual cortical plates. Similarly, a mini implant of just 10 mm
in length can be sufficient to achieve bicortical stabilization
along the inferior-superior axis in a resorbed mandible.
smALL DiAmEtEr
implants
Bicortical Stabilization of Inclusive ® Mini Implants in the Labio-Lingual Dimension
– Small Diameter Implants: Choosing the Appropriate Implant Diameter –
29

Quality of Bone
Generally accepted placement protocols suggest that the
widest possible diameter of implant be used based on
the available bone. However, the thread design of various
implant sizes may also be taken into account in relation
to the quality of bone. A thinner ridge often indicates a
higher percentage of cortical bone and associated bone
density. A thicker ridge often indicates a higher percentage
of cancellous interior bone. The increasing thread pitch
associated with successively wider Inclusive ® Mini Implants
reflects an anticipation of the bone density to be encountered
with various ridge sizes.
Naturally, it is incumbent upon the clinician to treatment
plan for the ideal implant size on a case-by-case basis,
based on a complete diagnostic evaluation. The variation
in thread design referenced above is chiefly intended to
facilitate efficient placement in various bone types as commonly
encountered.
The increasing thread pitch
associated with successively
wider Inclusive Mini Implants
reflects an anticipation
of the bone density to be
encountered with
various ridge sizes.
BONE TYPE DESCRIPTION INCLUSIVE MINI IMPLANT THREAD PITCH
D1 Thin/Dense Ø 2.2 mm
D2 Thin/Trabeculated Ø 2.5 mm
D3 Average/Spongy Ø 3.0 mm
Note: The 3.0 Inclusive Mini Implant is used to compress, condense and engage Type D2 bone. Because it is a self-tapping screw, removing the entire volume of bone, as in
the case of a traditional implant with a non-cutting apex, is not necessary.
30

Ø 2.2 mm Inclusive Mini Implant for Types D1 and D2 Bone, Respectively
Ø 2.5 mm Inclusive Mini Implant for Highly Resorbed Premaxilla Bone
– Small Diameter Implants: Choosing the Appropriate Implant Diameter – 31

other factorS for conSideration
■ number of implants – As important as the diameter,
the standard number of mini implants is typically four
in the lower arch and six in the upper arch. If possible,
placing five in the lower and seven in the upper and engaging
additional alveolar bone will lend greater stability.
■ immediate loading – If 35 Ncm of torque can be
achieved, it is generally safe to load the mini implants
with a new denture featuring O-ring attachment housings,
or to pick up the housings in an existing denture
chairside. If achieving 35 Ncm of torque is not possible,
consider a soft reline of the denture and allow for a prescribed
period of osseointegration.
■ Parafunctional habits – Lateral forces can compromise
the success of any implant, so if the patient is a
bruxer or grinder, consider placing the largest diameter
implant possible.
■ occlusion – Whether mini implants are being placed in
the upper or the lower arch, if the opposing arch is natural
dentition and 35 Ncm of torque cannot be achieved for all
implants, consider soft lining the denture for six weeks.
32
Continuing Education
■ a-P spread – The wider the anterior-posterior (A-P)
spread, the more stable the oral environment.
o Upper arch: Maximize the A-P spread by placing the most
distal implants as far back as possible without impinging
on the sinus cavities.
o Lower arch: Try to space posterior implants 5 mm anterior
to the mental foramen.
Serving a changing demographic
As a population, we are simply living longer, and the number
of older people will increase dramatically over the next
few decades. Statistics say 10,000 Americans are turning 65
daily, with 40 million people estimated to be edentulous.*
Clearly, it’s time for us to fully embrace the idea of mini implants
as a viable treatment option for these patients. Bone
resorption is more commonplace among aging patients,
and small-diameter implant placement protocols represent
a minimally invasive, more affordable alternative to conventional-diameter
implant placement. IM
*SOURCE: Federal Interagency Forum on Aging-Related Statistics. Older Americans
2012: Key Indicators of Well-Being. Federal Interagency Forum on Aging-Related
Statistics. Washington, DC: U.S. Government Printing Office. June 2012. Available at
http://www.agingstats.gov.
“effective, Predictable and Profitable Treatment of the edentulous
mandible with small-Diameter implants: a surgical hands-on Course”
glidewell international technology center
June 21–22, 2013
To register or learn more, visit www.glidewellce.com.

LAB
RAIsINg thE BAR
Inclusive ® CAD/CAM Milled Bar Technology
by
Dzevad Ceranic, CDT, Implant Department General Manager
CAst MEtAL BARs have traditionally been used in fixed-removable
implant cases when indicated, as a solution to increase the strength of
the acrylic prosthesis and more evenly distribute load-bearing forces
across the implants. Given these important benefits, bars are often
prescribed by clinicians in full-arch cases unless contraindicated by
limited vertical dimension or inadequate patient finances. Traditional
casting methods, however, can be time-consuming and cost-intensive,
relying heavily on inexact processes that often result in multiple try-in
appointments or structural flaws within the bar. Fortunately, advances
in CAD/CAM technology have brought about communication tools and
production techniques that are faster and more precise, increasing the
efficiency with which implant bars are fabricated and greatly improving
predictability upon seating. Streamlined workflows consisting of proven
processes serve to mitigate human error and reduce the learning curve
for clinicians and lab technicians working together to restore edentulous
cases. The overall process serves to minimize or even eliminate repeat
try-ins, reducing clinician costs. Moreover, the high-quality titanium
alloy from which CAD/CAM bars are milled results in a one-piece
framework that is both lighter and stronger, increasing patient comfort
and confidence.
Go online for
in-depth content
sEnsE
33

34
A PASSIVE FIT
The clearest advantage of utilizing CAD/CAM
technology in the production of implant bars and
frameworks is the superior fit. Traditional casting
methods are imprecise, highly technique sensitive
and costly. To ensure a passive fit during try-in, a cast
metal implant bar is typically delivered in segments,
attached to the individual implants in the patient’s
mouth and luted together intraorally. The united
framework is then picked up in an impression and
returned to a lab, where the segments are laserwelded
together (Fig. 1) for a second try-in.
With Inclusive ® CAD/CAM processes, specialized
software enables the technician to design the bar
in a 3-D virtual environment, exercising precise,
measurable control over its features and parameters.
This digital model is then precisely milled from
a solid block of biocompatible, medical-grade
titanium alloy. The milled bar is delivered for try-in
as a single unit, rather than in segments. Laboratory
statistics for the year 2012 indicate an overwhelming
rate of success in achieving an ideal, passive fit
upon initial seating (Fig. 2). This history suggests a
minimal risk of remakes and fosters a high degree
of confidence for clinicians seeking to predictably
plan these full-arch cases.
A STRONGER PROSTHESIS
The same digital production processes that enable
the precise fit of CAD/CAM milled bars also lend
them superior strength compared to cast gold
implant bars. As a milled, one-piece structure,
there are no solder joints resulting from separate
segments being laser-welded together (Fig. 3).
Nor are there any fractures, cracks or porosities
associated with the lost wax technique by which
cast metal bars are produced. This, combined with
the high-strength material properties of titanium
alloy (Fig. 4), ensures long-term reliability of the
prosthesis. Even in the unlikely event of failure, an
exact replica can be milled from the original digital
design file, facilitating replacement of the prosthesis
without the costly hassle of casting a new bar from
scratch. Also, a bar milled from titanium, though
significantly stronger, weighs less than the same
bar cast in gold (Fig. 5), resulting in a lighter, more
comfortable prosthesis.
Figure 1: Soldering process used to attach cast metal bar segments
Figure 2: Acceptance rate of Inclusive CAD/CAM milled bars in 2012, with
percentage and cause of remakes
Figure 3: A one-piece CAD/CAM milled bar (left) compared to an unfinished
cast metal bar with laser-welded segments
MPa
1000
800
600
400
200
– www.inclusivemagazine.com –
uLtIMAtE tENsILE stRENgth
950 690
Titanium Ti-6AI-4V
(Grade 5), Annealed
J-3 Noble Yellow Type 4
Crown & Bridge Alloy
Figure 4: The ultimate tensile strength of titanium alloy (950 MPa) is superior
to that of gold alloy (690 MPa).

Number of Cases
g/cm3
15
12
9
6
3
12,000
10,000
8,000
6,000
4,000
2,000
Titanium Ti-6AI-4V
(Grade 5), Annealed
DENsIty
4.43 12.9
J-3 Noble Yellow Type 4
Crown & Bridge Alloy
Figure 5: The low density of titanium alloy (4.43 g/cm 3 ) makes it a lightweight
material compared to gold alloy (12.9 g/cm 3 )
FuLLy EDENtuLOus IN ONE OR
BOth JAWs By AgE gROuP
Age Group 25-34 35-44 45-54 55-64 65-74 75-84 85+
1991 2000 2010 2020
Figure 6: Statistical projections indicate a continuing rise in total edentulous
populations (Source: Chester W. Douglass, DMD, Ph.D, et al., The Journal of
Prosthetic Dentistry, January 2002)
Figure 7: An assortment of Inclusive CAD/CAM Milled Bars, featuring a
variety of geometries and attachment configurations
CASE EFFICIENCY
By providing enhanced visibility and superior communication
tools in a virtual setting, CAD/CAM
technology enhances collaboration between the clinician
and laboratory regarding the indications and
treatment options for the best possible outcome.
Digital production techniques also require less time
in the laboratory, resulting in a faster turnaround
time for a CAD/CAM milled bar than for a conventional
cast gold bar, helping to reduce overall
treatment duration. And the elimination of unnecessary
appointments or chairside processes as
described earlier is a sure means of increasing
case efficiency and improving patient satisfaction.
Furthermore, while the material cost of gold and
gold-based alloys continues to climb, titanium remains
relatively inexpensive. Because components
such as UCLA abutments are not required in the production
of CAD/CAM milled bars, labor is reduced.
These and other elements contribute to significant
savings for both the clinician and patient, maximizing
profitability while making a milled bar
prosthesis more affordable for a growing edentulous
population (Fig. 6).
CLINICAL FLExIBILITY
As digital techniques continue to spur exciting
advances within the dental industry, Glidewell
Laboratories maintains its position as a technology
leader. With a firm commitment to the development
of cutting-edge methods and materials, Glidewell
seeks to support clinicians and their patients with
the understanding that any implant treatment
should be restorative-driven and patient-specific,
allowing for maximum clinical flexibility. Inclusive ®
CAD/CAM Milled Bars are compatible with all
major implant systems, and the software allows for
a wide variety of bar geometries and attachment
configurations (Fig. 7). A dedicated specialist works
to carry out each step of the production process for
optimal quality. With a high daily case volume and
a legacy of service spanning more than 42 years,
Glidewell is uniquely positioned to ensure that each
case results in a predictable, satisfying outcome. ❯❯
– Lab Sense: Inclusive CAD/CAM Milled Bar Technology – 35

1 Model
scan
From final impressions verified with an
implant verification jig, the lab produces
a stone model. Inclusive ® Scanning
Abutments for the prescribed implant
system are attached to the individual
implant analogs. The arch is digitally
scanned to produce a 3-D virtual model,
with the scanning abutments providing
the location, angulation and connection
orientation of each implant. Each scanning
abutment is physically measured with
digital calipers and confirmed to align
with master designs contained in the
proprietary software library. The denture
setup is then scanned, and the resulting
3-D image is superimposed over that of
the master model.
Once the final design has been examined
and approved, the design file is converted
to a file type that can be executed by the
milling software. The milling software runs
a preliminary routine that nests the virtual
bar within a titanium blank and maps
out the proper tool path. Once the tool
path has been verified and approved, a
physical titanium blank is attached to a
milling fixture and placed within the highly
precise 5-axis mill. Actual milling time
varies according to the intricacy of the
bar design, but generally requires just a
few hours.
36
3Mill
Production Workflow
Inclusive CAD/CAM Milled Bars
2 Digital
Design
With a complete digital rendering of
the verified patient model and approved
denture setup, a dental technician with
CAD expertise designs the bar in a virtual
environment. Designs are based on
one of the standard bar types available
in the software library, or designed
from scratch. Whichever base design
is chosen, the technician proceeds to
manipulate every aspect of the bar with
a level of precision measured in mere
microns. This enables the technician to
set the height of the bar off the tissue
as prescribed, and to craft the shape of
the bar for maximum strength, optimal
comfort and proper support for the
acrylic buildup.
4 Polish
When the milling process is complete, the
bar undergoes a proprietary treatment
process to ensure maximum flexural
strength. The sprues that hold the bar
within the block are cut and removed.
With implant analogs attached to protect
the connection interfaces, the bar is sent
through a four-stage automatic polishing
process, followed by a final hand polish.
– www.inclusivemagazine.com –
5Final
QC
The bar undergoes a final inspection and
is fitted onto the physical master model to
ensure a passive fit, with no rocking and
no gaps. The approved bar is then processed
into the denture setup (in the case
of screw-retained hybrid dentures) or the
denture setup is relieved to accommodate
the bar (in the case of removable dentures).
A complimentary thermoformed
nightguard is provided with each screw-
retained denture to help ensure long-
lasting esthetics and function. IM

Implant-Retained Overdenture
Diagnosis to Delivery
INTRODUCTION
In the past, patients suffering from tooth loss faced many
challenges and were considered dental cripples. The
average bite force for dentate patients, 150 to 250 psi,
was reduced to 50 psi when they became edentulous. 1 After
15 or more years of wearing dentures, many patients’ bite
force and chewing efficiencies were reduced even further
to 5.6 psi, making simple, functional tasks like eating very
difficult. While the edentulous population is increasing,
so too are treatment options for the edentulous patient.
Today, osseointegrated implant-retained denture prostheses
have eliminated many of the disadvantages associated with
traditional dentures. The emotional impact of edentulism
can be life altering, causing embarrassment, lack of selfesteem,
a negative self-image, dissatisfaction with one’s
facial appearance and emotional insecurity culminating in
social inhibition and difficulty establishing relationships.
by David A. Little, DDS
Go online for
in-depth content
The physical effects of tooth loss include decreased oral
facial support due to the loss of hard and soft tissue; 2 the
look of premature aging in the facial region caused by
bone resorption, a decrease in lip support and facial height;
impaired phonetics and oral function; and pain. 2 These
physical issues contribute to the discomfort and ultimate
instability of conventional removable denture prostheses by
requiring the denture wearer to utilize the lip, tongue and
cheek muscles to hold traditional dentures in place. 3,4
Implant-retained dentures resolve many of these issues. For
instance, patients experience a secure and stable fit, better
comfort, improved biocompatibility, increased support and
decreased bone loss when two to four implants are placed
to support a full-arch prosthesis. 3,5 In addition, improved
material sciences have provided newly developed denture
– Implant-Retained Overdenture: Diagnosis to Delivery – 39

IMPLANT-RETAINED OVERDENTURE: DIAGNOSIS TO DELIVERY
base technology and denture tooth materials that are stronger
and more esthetic. Overall, this type of prosthesis allows
patients to function normally in society and enables them to
eat what they want, instead of only what they can. The preservation
of bone that is noted around root-form implants
also promotes long-term health and prosthetic stability.
This article describes a case in which a team approach was
undertaken to meet the patient’s expectations. By visualizing
the case conceptually, then in wax and ultimately in
the acrylic dentures, the team was able to deliver a highly
esthetic and functional implant-retained prosthesis.
CASE REPORT
Diagnosis and Treatment Planning
A 54-year-old patient presented with ill-fitting upper and
lower removable partial dentures (Figs. 1a, 1b). A comprehensive
examination was performed, including a clinical
exam, digital panoramic radiograph, full-mouth radiographs
and clinical photographs. An oral cancer screening was then
performed, which resulted in negative findings.
In treatment planning the implant-retained overdenture
case, several factors were considered.
Patient expectations
• Functional demands: Is minimal movement of the
denture OK? Or is the patient expecting the new
prosthesis to be very stable? (The latter would
require multiple implants for an implant-supported,
screw-retained restoration or an implant-retained,
soft tissue-supported overdenture.)
• Oral hygiene
• Financial commitment
• Treatment phases/time frame
• Esthetics
• Phonetics
Prosthetic design dependencies
• Patient expectations
• Bone quality/quantity/biomechanical
considerations
• Number of implants
• Position of implants
40
1a
1b
– www.inclusivemagazine.com –
Figures 1a, 1b: Preoperative retracted and extraoral views of patient’s existing
condition
To help the patient make a fully informed financial decision,
it is best to present the patient with a single case fee for the
different treatment modalities: a two-implant overdenture
solution, a four-implant solution, a six-implant fixed solution,
and so forth. In this case, a four-implant overdenture
solution was chosen.
The treatment plan was accomplished in three phases. The
first phase consisted of extracting the remaining teeth and
placing transitional dentures. After healing, a lab-fabricated
radiographic guide was used to show the positions of the
teeth in the CT scan (Figs. 2a, 2b).
A cone beam computed tomography (CBCT) scan was
taken, which is the authors’ standard of care for any patient
considering implant treatment. Using SimPlant ® software
(Materialise Dental; Glen Burnie, Md.), the case was
treatment planned using a team approach. Via an online
meeting, Glidewell Laboratories helped facilitate digital
treatment planning for four implants in the mandible. Care
was taken to place the implants in the best bone, taking into
account the position of the teeth in their correct anatomical
positions and leaving adequate space for the planned
attachments. In this virtual environment, we are able to
visualize the end result before commencing treatment
(Figs. 3a–3e).
The second phase of treatment is placement of the implants.
Four ANKYLOS ® implants (DENTSPLY Friadent; Waltham,
Mass.) were placed in the positions predetermined in the
planning software. The surgical guide helps to ensure that

Figure 2a: Barium sulfate radiographic guide for the edentulous patient
Figure 2b: Radiographic guide seated intraorally prior to CBCT scan
3a 3b
3c
3d 3e
Figures 3a–3e: Preoperative treatment planning with SimPlant planning
software
– Implant-Retained Overdenture: Diagnosis to Delivery –
the implants are parallel (Fig. 4). Healing abutments were
placed, the transitional lower denture was relieved and a
soft liner was used.
The third, restorative phase of treatment involved upper and
lower denture fabrication and the placement of LOCATOR ®
Abutments (Zest Anchors; Escondido, Calif.) on top of the
implants. LOCATOR Attachments (Zest Anchors) serve as
the retentive devices for the mandibular implant-retained,
soft tissue-supported overdenture. These attachments resist
wear and maintain satisfactory retention for up to 56,000
cycles of function.
This system proved appropriate where occlusal clearance
became an issue. The LOCATOR Attachments come in a variety
of retention strengths, from extra light to heavy (Fig. 5).
This type of prosthesis allowed for excellent retention and
stability for this patient.
Figure 4: Surgical guide for optimal implant placement
Figure 5: LOCATOR Abutment, Core Tool and set of LOCATOR Attachments
Implant-retained denture
prostheses have eliminated
many of the disadvantages
associated with
traditional dentures.
41

IMPLANT-RETAINED OVERDENTURE: DIAGNOSIS TO DELIVERY
42
Figure 6a: Periodontal probe used to measure tissue depth
Figure 6b: LOCATOR Abutment in place
Figure 6c: Block-out sleeve in place
Figure 6d: LOCATOR Denture Cap for pick-up
– www.inclusivemagazine.com –
Figure 7: LOCATOR Abutment and abutment-level impression posts seated
and ready for impression taking
Figure 8a: Strong-Massad DenPlant implant overdenture impression tray
(Nobilium, CMP Industries; Albany, N.Y.)
Figure 8b: Final impression
Figure 8c: Model with LOCATOR Analogs

To select the proper abutment height, the healing abutments
were removed and a periodontal probe was used
to measure from the head of each implant to the gingival
crest. The attachments are best positioned supragingivally
to allow for good tissue adaptation and easy maintenance
(Figs. 6a–6d).
A conventional impression was made by seating impression
copings onto the implants (Fig. 7). One of the most critical
steps in the prosthetic procedure is to make a very accurate
impression (Figs. 8a–8c).
The key to a successful overdenture is a well-made denture.
The dental laboratory team accomplished the necessary
fabrication steps prior to the next appointment. First, the
impressions were boxed, poured and trimmed appropriately.
Then, stabilized record bases with wax rims were fabricated.
During the subsequent visit, the record bases and wax rims
were first tried in to ensure proper fit and comfort. Necessary
adjustments were made for form and function, and the
wax rims were contoured to achieve proper lip support,
phonetics and occlusal plane. Once satisfied, a jaw relation
was taken and vertical dimension of occlusion established
at the position previously marked on the patient’s nose and
chin with her existing transitional dentures in place. A bite
registration material was applied between the indexed wax
rims and allowed to set at the proper position. The properly
oriented casts were then sent to the dental laboratory team
for use in setting the teeth.
Once the casts were mounted on an articulator, the teeth
were set in the wax rims and returned to the office. At the
try-in appointment, the proper position of the teeth was
verified for form and function, then returned to the laboratory
for processing on the final cast. Once laboratory
processing was accomplished, the finished dentures were
returned for delivery.
Improved material sciences
have provided newly developed
denture base technology
and denture tooth materials
that are stronger and
more esthetic.
DELIVERY OF THE
ESTHETIC DENTURES
The dentures were tried in to evaluate for proper fit, comfort
and occlusion. With minor adjustments, the mandibular
denture was secured. An intraoral pick-up of the retaining
element was necessary, and the intaglio surface of the
mandibular denture was modified to accommodate the
LOCATOR Attachments (Figs. 9a, 9b). Lingual vent holes were
also placed to aid in the pick-up. Another option would
have been to have the LOCATOR Denture Caps processed
into the overdenture.
Auto-polymerizing acrylic was mixed and placed in the
modified areas of the mandibular denture. The denture was
positioned over the abutment-retained LOCATOR Attachments,
and the patient was instructed to close and hold
in full centric occlusion to allow for complete cure of the
acrylic material. After approximately seven minutes, the
denture was retrieved and inspected for complete pick-up.
Excess acrylic was trimmed to remove any sharp edges.
Finally, the mandibular denture was checked in situ for fit,
and the occlusion verified. The denture was accepted by the
patient, and she was scheduled to return in one week for a
post-delivery check.
Figure 9a: Intraoral occlusal view of the LOCATOR Abutments
Figure 9b: View of LOCATOR Attachments in the overdenture
– Implant-Retained Overdenture: Diagnosis to Delivery – 43

IMPLANT-RETAINED OVERDENTURE: DIAGNOSIS TO DELIVERY
CONCLUSION ReFeRences
Through the use of dental implants and overdenture prostheses,
patients now have options beyond the conventional
dentures of the past. By utilizing a team approach
and advancements in technologies, material sciences
and implant techniques, dentists can provide edentulous
patients with the best in artificial dentition, while treating
the patient as a whole (Figs. 10a–10d). Implant-retained, soft
tissue-supported overdentures can drastically improve the
quality of life for patients who otherwise might be considered
dental cripples. IM
10a
10b
44
10c
10d
Figures 10a–10d: Postoperative photographs of the patient
– www.inclusivemagazine.com –
1. Geckili O, Bilhan H, Mumcu E, Dayan C, Yabul A, Tuncer N. Comparison of
patient satisfaction, quality of life, and bite force between elderly edentulous
patients wearing mandibular two implant-supported overdentures
and conventional complete dentures after 4 years. Spec Care Dentist.
2012 Jul-Aug;32(4):136-41.
2. Henry K. Q&A on the future of implants. Dental Equipment and Materials.
2006 Sept/Oct.
3. Rossein KD. Alternative treatment plans: implant-supported mandibular
dentures. Inside Dentistry. 2006;2(6):42-3.
4. DiMatteo A. Dentures and implants: bringing them together for a winning
combination. Inside Dentistry. 2009;5(1):97-104.
5. Agliardi E, Panigatti S, Clericò M, Villa C, Malò P. Immediate rehabilitation
of the edentulous jaws with full fixed prostheses supported by four
implants: interim results of a single cohort prospective study. Clin Oral
Implants Res. 2010 May;12(5):459-65.

PRODUCT
Inclusive ® TRS Screw-Retained Hybrid Denture
IMPLANt-REtAINED OVERDENtuREs present patients with
sig nificant advantages over traditional dentures, providing
superior retention for improved function, eliminating the
need for denture adhesives and serving to slow or prevent
bone resorption in the edentulous arch. Unfortunately,
the complexity of conventional methods can make such
treatment options unpredictable for the prescribing clinician
and expensive for the patient, limiting the number of
individ uals who might otherwise benefit from an implantretained
prosthesis.
In keeping with its commitment to provide single-source
restorative solutions demonstrating state-of-the-art quality
and high value, Glidewell Laboratories has addressed this
area of patient demand by expanding its all-in-one Inclusive ®
Tooth Replacement Solution concept to include full-arch
indications. A family of fully edentulous treatment packages
is now available from the leaders in digital dentistry,
headlined by the Inclusive ® TRS Screw-Retained Hybrid
Denture. This fixed-removable solution comes complete
with everything needed to complete the case, including:
● 6 x Inclusive ® Tapered Implants
● Final Inclusive ® Surgical Drill
● 6 x titanium healing abutments
● 6 x impression copings
● 6 x analogs
● Model work
● CAD/CAM milled titanium bar
● Final overdenture with premium denture teeth
spOt
Light
To create the bar, a custom acrylic framework is fabricated
on the master model and then scanned. The scanned data
of the framework and the individual implant platforms are
transferred to a digital design station where the one-piece
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– Product Spotlight: Inclusive TRS Screw-Retained Hybrid Denture – 45

IMPLANT
Dr. Bradley Bockhorst: I know you’ve
just spent six hours lecturing at the
California Dental Association (CDA)
meeting, so I appreciate you coming out
here to spend a little time with us. During
your presentation at the Academy of
Osseointegration (AO) Annual Meeting
last March, one of the things you talked
about was the “money tooth.” Can you
expand on that for us?
Dr. Curtis Jansen: I’m always trying
to think how I can motivate and educate
doctors — and there’s no better
way than with money. So many people
are standoffish about the whole concept
of intraoral scanning or sameday
dentistry. Everybody likes to talk
about anterior teeth and how pretty
they are, and how we can achieve esthetic
results. But what drives doctors’
&
Q A:
Go online for
in-depth content
An Interview with Dr. curtis Jansen
Interview of Curtis E. Jansen, DDS
by Contributing Editor Bradley C. Bockhorst, DMD
Dr. Curtis Jansen completed dental school and graduate training in
prosthodontics at the University of Southern California, where he later
served as director of implant dentistry in the department of restorative
dentistry. He went on to Biomet 3i in 1992 and was a primary trainer, edu cator
and researcher. Since 1996, he has maintained a prosthodontics practice
in Monterey, Calif., and lectures extensively. Dr. Jansen recently took the time
to share his thoughts on intraoral scanning, same-day dentistry, model-less
restorations and the importance of managing patient expectations for
implant treatment.
practices, what pays for their mortgages
and their fancy cars, is single-tooth
dentistry. And if we break it down
even more, when we’re talking to the
guys and gals who are doing implants,
it’s lower mandibular molars. For a lot
of the bigger surgeons, it may be as
much as 25 percent of the time that
they pick up a handpiece or put in an
implant that they’re replacing mandibular
molars. For me, if I break up my
practice into single crowns and single
implants, it’s mandibular and maxillary
first molars. I’m either replacing or
restoring first molars. It’s the “money
tooth” — and I love it!
BB: Do you think part of that is that it’s
the first tooth to come in, so it’s the first
tooth to come out?
CJ: Right. I think that it’s the first
tooth that gets the early composite,
or the early alloy, and it may just
break down. Then one thing leads
to another. What’s surprising is that
80 percent of dentistry is “re-dentistry.”
Rarely are we treating a tooth for the
first time, and that tooth is the tooth
that gets beat up first, gets the endo,
so it is the one that comes out first.
I think that holds true for a lot of
implant restorations and a lot of fullcoverage
restorations.
BB: At one point you said that 75 percent
of the cases you evaluated involved
first molars. Is that a true statement?
CJ: Yes and no. I found in talking to
many surgeons placing implants that
about 70 percent of the implants they
– Implant Q&A: An Interview with Dr. Curtis Jansen – 47

place are posterior, either single or
multiple units. About 45 percent are
single posterior implants. When you
get down to mandibular first molars,
they account for about 25 percent of
the posterior implants being placed.
I’d be very curious about what you
guys do here at Glidewell, and on
which restorations you do the most
crowns. You’ve got cases coming in
from many different places, but I bet
you’re keeping pretty good numbers.
BB: After I saw your AO presentation,
I came back to the office and looked
up Glidewell stats for custom implant
abutments: 29 percent of the custom
abutments we do are first molars.
CJ: So it holds true!
BB: Everybody talks like it’s the fullarch
cases, but it’s those single units that
really are the bread and butter.
CJ: It is. That’s why my perspective
is to try to get through to these individuals
who are so highbrow, who
think, “How could you do that?” If
they break it down, they can really
see where their business is. Glidewell
is extremely good at that. That’s how
I try to get through to the stubborn
ones. I say, give me single posteriors,
let us talk about this one area of your
practice, and I think you could utilize
intraoral scanning. You could do a lot
of things to be more productive.
BB: Another thing I’d like to talk to
you about is technology. What do you
see as being the most significant technologies
impacting dentistry right now?
Which ones are you incorporating into
your practice?
CJ: The greatest advancement in dental
technology I see out there — and I
think it’s incredible — is digital, obviously.
If we break down digital into
digital radiographs and things like
that, I think that’s it. But for me right
now, as a restorative doctor, it has to
do with intraoral scanning. I think
there’s a huge misconception out there
and so many doctors are turned off by
same-day dentistry. I call it “SDD” and
48
“NDD,” next-day dentistry. For me,
there is no question about it: The most
significant thing that I’ve incorporated
in my practice is not only intraoral
scanning, but also lab scanning.
Then we get into implants. I like to
do a fair number of implants. I like
to scan abutments. Glidewell has a
very nice abutment. Some of the other
manufacturers have nice abutments. I
can’t tell you how antiquated it is for
me to take off a healing abutment, put
on an impression coping and make
a conventional impression. I’ve only
been doing digital scanning with implant
restorations for about six months
now, but conventional impressions for
The most
significant thing
that I’ve
incorporated in
my practice is
not only intraoral
scanning,
but also lab
scanning.
implants already seem so last year I
just can’t believe it!
BB: I got a kick out of one of your talks
from a couple of years ago when you
said, “People, can we make this any
more complicated?” And now the question
is, “What’s changed?”
CJ: What’s changed? It’s scanning! Intraoral
scanning abutments. But make
no mistake about it, I don’t think it’s
necessarily only intraoral scanning. Nor
do I think conventional impressions
– www.inclusivemagazine.com –
are going away anytime soon. But for
me, intraoral scanning and lab scanning
are a big deal.
Then if you take it even further, what
you guys at Glidewell have done beautifully
is introduce one fee. You talk
about mandibular first molars, and that’s
what is going to drive their practice.
So many doctors are doing single posterior
implants. But many restorative
dentists have a problem, and they want
to make a referral to an oral surgeon
or a periodontist. Often this referral
makes things harder. The patient can
get lost and confused during the referral
process. The patient ought to
be able to just go up to the front desk
and say: “Hey, your doctor just said I
should have an implant. I’m ready to
go. I want to pay for everything, right
here.” But so many times we just screw
it all up during the referral process.
BB: The one-fee philosophy, can you
talk more about that?
CJ: Talking about what’s big for me
practice management-wise — we can
talk parts and pieces, intraoral scanning,
doing it in the lab, doing it
different ways. But from a practice
management philosophy, running the
practice and seeing the patients who
want it white, W-H-I-T-E, and they
want it white now, most patients are
ready to make decisions fast. We’ve got
Netflix, and the 29-minute oil/lube
from Pep Boys — all these things influencing
patient expectations. Patients
want and expect things to happen
quickly, and they’re willing to pay for
it. And they want one fee. They don’t
want to be overwhelmed with, for
example, “Oh, it’s a graft, and it’s this
part, and it’s that part.” They just want
to know what it costs, and they’re
ready to go. The hysterical thing is —
maybe you’ve heard me talk about
this — that doctors think they somehow
have to justify their fees and have
a bunch of appointments. But patients
are paying for perceived value; they’re
not paying for appointments.
BB: Right. And that leads right into our
patients’ perception of the technology

that we’re using. There is the clinical
utility, but also the practice management
aspect of it.
CJ: It’s huge. I think doctors miss
this aspect, which is a very big component
of practice management. Most
dentists — and I’m not claiming to be
one of them — are getting a lot smarter.
But we’re not business people, as
you know.
BB: I want to take a step back and
discuss some of the details of the technology.
You mentioned before that you have
multiple intraoral scanners. Which ones
do you have, why do you have several
and which do you use where?
CJ: Well, I’m a restorative guy, and I’m
a curious guy. I’ve got to have a little
of everything. I’ve got three of the
four widely used digital impression
systems in my office. I tend to use
one more than another — but they’re
apples and oranges. I don’t have to explain
that to you, but I think we have
to explain that to your audience. Two
of these systems have an associated
mill that allows me to do same-day
dentistry. Two are merely impression
material substitutes, and I don’t mean
to degrade those. But to me, that’s all
those really are. I can use those to
make impressions and then I can do
fancy things with them — I can send
the data to you, and I can save twenty
bucks or more on my lab bill. With
the other ones, I can do Invisalign ®
cases (Align Technology; San
Jose, Calif.).
So does the average restorative
doctor need three or four systems
in their office? Absolutely
not. But they have a big decision
to make. They need to
decide, for instance, if they
merely want to have a substitute
for impression materials. If I’m
using Cadent iTero (Align Technology)
or Lava Chairside Oral
Scanner C.O.S. (3M ESPE; St. Paul,
Minn.), they’re both very nice
systems, but I don’t see a model
for three to five days. Now, maybe
I don’t need a model, but I
still like my model. I can do a
rehab in three to five days. I’ve
got E4D ® Dentist (D4D Technologies;
Richardson, Texas)
in the office, and I’ve got an
attached mill. So I can still
do intraoral impressions, I
can do lab impressions; but
I can also fabricate a restoration
on the same day.
E4D is probably my favorite
from that perspective. But
the coolest scanning technology,
I think, is Lava C.O.S.
It’s live, streaming video. The
easiest one that I can do all
by myself, from a scanning
perspective — behind my back,
underneath my leg — is Cadent
iTero. I can do a pirouette on the
tooth with the scanning wand and
the data is good.
There are a lot of things to consider
for restorative doctors, but the biggest
decision is whether they are ready to
do same-day dentistry in their office,
or they want to be able to partner with
a lab like you. I would imagine that
you’re going to start really incentivizing
doctors to do some of this stuff.
BB: We receive a huge number of cases
using various scanners, and we accept
digital scans from all systems that are
out there on the market. So have you
gone model-less yet?
– Implant Q&A: An Interview with Dr. Curtis Jansen – 49

CJ: That’s the tough part. You know,
as much as I’d love to go model-less,
I’m just not there yet. It’s very difficult
for me. I like to check my contacts —
I like a little clacker! But I’m trying.
I’ve been using a digital scanner since
October 2008. I have to say one more
thing, for doctors who are making a
decision about going digital: Try to get
all the information on all the systems,
not just what you hear your buddies
talking about. There are so many cultlike
things in dentistry. You have these
different groups or any one of a number
of different organizations pushing
a particular system, so be careful. But
going model-less, that’s a big deal. I
think we have to start in the dental
schools. What I want to find out is
how I can get a printer from you guys
because I hate making impressions!
But I just can’t wait three to five days
for a model — it’s too long. I like the
idea of printing or milling a model in
my office the same day.
BB: Heading toward model-less is
key for us, too. If you can avoid those
steps that are part of conventional impression-taking,
not only do you avoid
potential errors, but you can obviously
move things along more quickly.
CJ: With the labor and time and effort
that’s involved, a majority of doctors
don’t pour their own impressions.
BB: And the ones I’ve seen that they
have poured make us wish they hadn’t!
CJ: That’s very true. Lee Culp, CDT,
chief technology officer of Digital
Technologies Inc. (DTI) in Dublin,
Calif., has said that 95 percent of
doctors do not pour their own impressions.
To me, that’s a fascinating
statistic. If we can do more intraoral
scanning and then go model-less —
that’s going to be a big deal.
BB: So are you using intraoral scanning
for all of your implant cases?
CJ: When you look at my conventional
dentistry — say I’m doing six
restorations in the anterior, I’ll prep
and provisionalize conventionally, get
50
the provisionals as nice as I can, make
a conventional impression of the patient-approved
provisionals and then
go into the lab and scan everything:
the prep, the model of the provisionals
and the opposing dentition. Those
are all lab scans. Then I will design
and mill the restorations using the
provisionals as a guide. But for my
implants, it’s almost 100 percent intraoral
digital scanning. If I can, I’ll
solely do intraoral scanning with implant
restorations. Then design the
abutment and restoration. It’s just so
much easier with implants. I can justify
the time and the wait because I’m
going to get a model and an abutment
several days later. I’m not just waiting
for a model. I love this concept
of concurrent manufacturing. From
the intraoral scan I design the implant
abutment; from there I send the information
to an abutment manufacturer.
They can then mill the abutment and
print or mill a model of the abutment
and the actual abutment. But I find it
difficult to do that with conventional
dentistry. I have to wait three to five
days just for a model before I can start
any lab work. With implants, it makes
perfect sense for me.
BB: For those implant cases, do you immediately
provisionalize them routinely?
CJ: For my implant cases, I think
one of the biggest new options out
there is the ClearChoice ® model
(ClearChoice Dental Implant Centers;
Greenwood Village, Colo.) with their
same-day restoration option.
ClearChoice works only with
oral surgeons and prosthodontists,
and they advertise
– www.inclusivemagazine.com –
big time. ClearChoice has done more
for prosthodontists with their advertising
than anybody else. But at the same
time, I think they’re the scariest thing
out there, some serious competition. I
want to be like ClearChoice — I want
to try to take them on. They’re doing
a really good job, but I think maybe
I can do better. But for the concept
that they have, this same-day immediate
tooth, my office is too small. I built
the wrong office. I’ll do some sameday
dentistry that’s just conventional
dentistry. But many times I’ll be doing
immediate non-occlusal loading, or
I’ll do an All-on-4 (Nobel Biocare;
Yorba Linda, Calif.) case on implants.
I don’t think there’s anything bigger
in my practice to make patients happier
than allowing them to get rid of
their beat-up, useless mandibular or
maxillary dentition, put in four to five
implants and give them fixed teeth the
same day. Loading the implants the
same day, that’s big.
It will be interesting to see how Glidewell
addresses this because a lot of
doctors don’t know how to do this
type of dentistry. Glidewell is good at
educating doctors on products, and
there is great opportunity to do the
same with procedures. I just think we
need so much help from the laboratory
for these immediate-load implants.
I can do it. But the average guys out
there, they can put in the implants and
get it close, but they don’t know how
to connect a fixed restoration. They
don’t know how to convert
that denture to a fixed

estoration. That’s going to be the difficult
thing. But I think there’s a big
business model there.
BB: That’s exactly one of the projects
we’re really working on. You’re going to
see that package in the near future.
To go back and clarify something for
our audience, ClearChoice is a group of
practices with offices around the country,
and they primarily do All-on-4.
They market to their local communities,
and they’re really drawing in a lot of
patients who had given up on going to
the dentist. At one point, I heard a statistic
that about 60 percent of patients
who go to ClearChoice haven’t been to a
dentist in more than 10 years. So, their
marketing efforts are reaching people.
When ClearChoice first comes into a
market, dentists are often concerned.
But, in actuality, it has really helped
educate a lot of people on procedures
like All-on-4. What they ultimately find
is that the whole market is more educated
about implants. So we end up getting
more business because of it.
CJ: Right. I think it’s a good thing.
BB: What’s your opinion on putting the
abutment in one time, as soon as possible,
and then leaving it there?
CJ: That’s the beauty of what I was
doing initially. After confirming that
the implant could be loaded, I’d really
take my time with the zirconia abutment.
Or I’d use a titanium abutment,
but I’d really take my time with it and
get it perfect, with margins below the
tissue, etc. Then I’d impress it or scan
it and put it in the patient’s mouth.
And people would ask me how I could
determine margin placement at the
time of surgery. I can do that because
I’m working with good surgeons. If a
surgeon takes out a tooth and takes a
whole buccal cortex out with it, they’re
going to warn me not to do that one.
But 9 times out of 10, the tooth is taken
out very atraumatically, the implant
is placed, and we know we’re not going
to have a lot of recession. In those
cases — especially with thin biotypes,
or highly scalloped tissue — I
think it really pays to take as much
time as we can to decrease the number
of what we call “switches,” when
the abutment or the impression coping
comes on and off the implant.
So, if I can leave that abutment on —
fantastic. But that’s where this whole
concept of what I call forecasting
comes in. If I could then scan that and
come back in 12 weeks, people ask,
“How do you get your margins?” Well,
I’ve scanned it outside the mouth.
Then I can scan inside the mouth.
There are enough data points to where
I can merge the two data sets. It’s very
exciting. If we can, we want to limit
the number of switches and transfers
because every time we raise a flap,
every time we take an abutment off, it
sets up a series of consequences, and
we lose hard and soft tissue.
BB: You will be presenting on risk management.
Can you tell us a little bit
about what you’re doing along those
lines, and what recommendations or
suggestions you have for clinicians
out there?
We want to
limit the number
of switches
and transfers
because every
time we raise
a flap, every
time we take an
abutment off...
we lose hard
and soft tissue.
CJ: Right, this is a great course. It’s
something that I’ve done probably the
last six or so years with The Dentists
Insurance Company (TDIC), which is
one of the bigger insurance companies
here in California. They use actual
malpractice cases as examples in the
seminars. I don’t know if you’ve ever
sat through one of those courses, but
you get a 5 percent reduction on your
premium if you do. That’s one reason
why the people are there, but these
seminars are also very helpful. An attorney
and a restorative dentist present
four to five different patient situations
and review various learning points.
We’re going to draw more than 1,000
people over the next three days. One
of the common themes is recordkeeping.
Doctors keep miserable records,
and at times they pay for it because
they can’t defend themselves. We have
so many responsibilities as clinicians,
and at times we may get sloppy with
recordkeeping. What I would recommend
for doctors is consent forms,
which is kind of a given. You can go to
www.thedentists.com and get consent
forms. But for some of these cases, it’s
bigger than just a consent form. You
need certain things in your treatment
notes. If a patient has some type of
potential problem and you’re worried
about, say, a root canal, you’ve
got consent to cover that — but many
times it helps to also write in the chart
that you spoke to the patient about
RBAs (risks, benefits and alternatives)
to proposed treatment.
The other thing that’s very interesting
when we talk about implants and these
big-ticket items is that you’ve got these
piranhas, these ambulance-chasing attorneys
out there. I only work with
what I call the “good guys” — only the
attorneys who defend. But as far as
risk management, I don’t think doctors
can protect themselves enough from
both patients and employees. You can
never be Teflon. But you need to look
at these consent forms. You need to
look at treatment plans. You need to
cover yourself the best that you can.
I cannot tell you how much help
there is with a company like TDIC. It’s
– Implant Q&A: An Interview with Dr. Curtis Jansen – 51

important to discuss informed refusal
on these All-on-4 cases — you’re talking
about a whole different type of
treatment. A lot of people know what
informed consent is, but not informed
refusal. When you tell Mrs. Stieglewitz
that you’re going to take out all of her
teeth, you’re going to give her some
implants and everything is going to be
peaches, if it’s not all peaches, you’ve
altered a significant portion of her
life — it’s like taking away an arm or
a leg. It’s more than just a single-tooth
implant. I don’t think a lot of doctors
get that. When you’re talking in that
realm, and when you’re talking about
that kind of money, then you’ve got
some attorneys who are pretty interested
in that. And Mrs. Stieglewitz has
more of a case to make than that she
just didn’t get her single tooth. She
doesn’t have any teeth!
BB: Even before that legal aspect is
managing patient expectations, which
I’m sure is a huge part of this topic. Can
you expand on that?
CJ: Again, it’s the informed refusal,
informed expectations. You have to
compare all the available treatment
options. If you immediately load some
implants and give the patient a fixed
restoration on the same day, that’s
great if it works. But if it doesn’t, you
have now taken the patient’s teeth out
and they have nothing but a floating
plastic replica of teeth. Oh yeah, and
they don’t get the fixed for at least
12 weeks. Well, some patients are not
going to be too happy with you, so the
topic of patient expectations is huge.
You need to tell them what’s going to
happen if it doesn’t work. So, you hit
the nail on the head. Patient expectations
are a big part of it. And so many
doctors are so eager and so enthusiastic
to get into the treatment that they
forget about that part, if it fails or they
can’t go fixed the same day. If they
don’t cover that with their patients,
it could be a big problem. Suddenly
your records are subpoenaed, and
you’re asked to give a deposition.
BB: Regarding major catastrophes during
implant placement, like injuring a
52
nerve, from your work with the insurance
cases, what are the usual things
people are getting in trouble over?
CJ: The biggest thing is simple informed
consent. Like politics, it’s not
necessarily the damage of the incident;
it’s how it’s handled. And a lot
of doctors don’t handle it well. And
what happens is a second party gets
involved, and that’s when it gets ugly.
Dentists, they just can’t help themselves.
They can do a simple occlusal
alloy, and the guy across the street will
find some fault with it. So, it’s not necessarily
that you see an injured nerve
or an implant that fails. Most of the
lawsuits I see start from a critical second
opinion.
The amazing thing, in my experience,
has been that somehow juries can always
ferret out the truth. I’ve worked
with a lot of attorneys and they have
the utmost confidence in juries figuring
out the truth. And a lot of times,
doctors are less than truthful. What we
do is very difficult, and sometimes we
just have to ante up and tell the patient
that it doesn’t always turn out right. It’s
not going to work right all the time. I
think juries understand that. Patients
should understand that, too. So I don’t
think it’s necessarily the act itself, it’s
how these doctors are responding to
it. Or, unfortunately, not responding to
it, and leaving the patient to their own
means. And that’s when the patient
goes out, finds somebody else and all
heck breaks loose. It’s really unfortunate.
You get paid the big bucks so
you need to pick up the phone and
deal with the problem. You can’t just
hope that it goes away, or assign a
staff member to deal with it.
BB: We’ve talked about a lot here. What
are some of the things on the horizon
that are affecting the future of dentistry?
CJ: I just went on a tour of your facility,
and the things I saw are fascinating.
Talking with Dave Casper [Vice
President of Sales & Business Development],
some of the things that you’re
doing are absolutely amazing. Some of
the biggest things on the horizon are
– www.inclusivemagazine.com –
what you’re doing here at Glidewell
with intraoral scanning. But more than
that, it’s patient management — and
you guys figuring out that it’s about
one fee.
Patients want
and expect
things to
happen quickly,
and they’re
willing to pay
for it. And they
want one fee.
Patients look at everything, as with
anything. If they’re going to buy a
couch, they’re doing it online. And
they don’t want to have to chase
answers. They want to know what
the cost is going to be. So, in terms of
patient convenience, what we’re doing
for patients is the same-day stuff. It’s
about managing one fee. It’s going to
be the coming together of not only
parts and pieces, but like we talked
about — it’s patient management.
And you’re going to need to help
the doctors with that. You’ve already
helped tremendously with your onefee
approach to getting a tooth.
They’re not just getting an implant.
It’s not the implant, it’s not the prep;
it’s the restoration they’re walking out
with. That’s what you guys want to
do, and that’s what patients want. So
I think it’s a coming together of these
technologies: old traditional ways are
going to meet hi-tech. Because, at
the end of the day, it’s about keeping
our patients happy. How do we keep
them happy? They want technology,
and they don’t want things to take
too long. What an exciting time to be
involved in dentistry! IM

I Have a CBCT Scan — Now What Do I Do?
54

I Have a CBCT Scan —
now What Do i Do?
Restoring the Edentulous Maxilla
with Dental Implants
by
Timothy F. Kosinski, DDS, MAGD
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The use of dental implants has become an important method for
restoring missing teeth with function and esthetics. Our patients are
requesting — some even demanding — this type of treatment. Modern
materials and methods have made implant dentistry predictable with long-term
positive prognoses.
Proper placement of dental implants involves a comprehensive understanding
of both the surgical and prosthetic applications. Today, implant dentistry is
prosthetically driven. There must be a clear visualization of the completed
restorative case prior to any surgical intervention. This necessitates careful
discussion of the patient’s desires and expectations. Anatomic considerations must
be understood, including the position of the nerves, sinuses and bone undercuts.
The thickness and angulation of bone must be studied, and the integrity of
the buccal and lingual plates clearly determined. As teeth are lost, bone in the
maxilla tends to shrink apically and palatally. This may compromise lip support
and phonetics. When placing dental implants, the final functional and esthetic
result must be considered. Placing implants too far palatally may result in speech
problems and a facial cantilever of the final implant-retained denture, which may
result in rocking of the prosthesis or breakdown of the bone around the dental
implants — and eventual failure.
Prior to surgical placement of any dental implant, limitations need to be
recognized by the dentist, who may be uncomfortable with certain procedures
or lack confidence in attaining the appropriate final result. These dentists should
– I Have a CBCT Scan — Now What Do I Do? – 55

I Have a CBCT Scan — Now What Do I Do?
embrace the referral process. Complications may arise in any
surgical protocol, so there also needs to be an understanding
of potential postoperative complications such as dehiscence
or fenestration. Minimizing surgical damage with flapless
designs is tissue-friendly; however, flap designs still need to
be available for backup should complications arise. 1
Flapless surgical placement of dental implants has become
more popular with the increasing use of digital radiography,
which allows us to visualize the underlying anatomy
effectively. Regular intraoral and radiographic evaluations
are a necessary part of the total implant experience.
Maintenance is critical to the long-term positive prognosis
of any dental restoration. The prosthesis must be designed
in such a way that the patient can maintain it not only today
but also into the future.
Modern technology makes it possible to predictably place
dental implants using flapless procedures in ideal position,
angulation and depth, considering all emergence profile
and smile design expectations. This technique proves to
be a cost-effective solution to assist the implant dentist in
planning an esthetic final result and minimizing surgical
challenges. Benefits include patients being positively influenced
by the concept of virtual placement because
clinicians can discuss the safety and ease of implant surgery
for a procedure that the patient may psychologically feel is
extremely invasive. Healing time is also reduced, with less
postoperative trauma and discomfort.
Success with dental implants is based on achieving primary
stability and secondary integration of the titanium fixtures,
while also maintaining hard and soft tissue contours for
long-term function and esthetics. Any anatomic irregularities
or limitations need to be addressed prior to implant
placement. 2 Doing the case properly from the start saves the
practitioner considerable time and effort. “Measure twice,
cut once” is a readily accepted statement in dentistry today.
Becoming educated in any dental technique is essential
to achieving positive results. Certainly our dental training
allows the dentist to perform implant surgical procedures,
yet success with these procedures is largely dependent
on the individual practitioner’s level of competence and
confidence. There are several reasons why dentists are not
currently placing dental implants in their practices. Namely,
there is a fear that complications may occur, vital anatomy
may be damaged, or a procedure may be required that they
may not be comfortable performing. There needs to be a
clear understanding of the benefits, risks and techniques
associated with implant dentistry. Confidence with surgical
and prosthetic implant procedures are the result of education
and repetition. It must be understood that, in some situations,
bone grafting procedures may be needed prior to implant
placement. The two-dimensional images provided by
56
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bitewings, periapicals, panoramic X-rays or even traditional
CT (computed tomography) scans may not be sufficient in
diagnosing complicated or challenging situations.
Cone beam computed tomography (CBCT) diagnosis and
preparation of any case can help the practitioner guarantee
success by alleviating most common fears prior to any
surgical intervention. CBCT scanning is a remarkable tool in
the diagnosing of implant position and placement. Scanning
software allows for the fabrication of precise planning and
surgical guides, which help to ensure a positive result.
Communication with the patient concerning this innovative
therapy reduces anxiety of an unknown procedure and
increases treatment acceptance. Reconstruction is made
simpler because implants are ideally placed. The latest
computer software allows us to simulate the placement
of implants accurately without ever touching the patient.
CBCT imaging systems provide the dentist with complete
information on vital anatomy in the areas to be considered
for dental implants by producing a three-dimensional view of
all of the oral structures. 3 This allows us to create an accurate
treatment plan and increases our chances for a predictable
surgical and prosthetic result. The high-resolution volumetric
images give us, for the first time, three-dimensional views
of bone and tooth structure and orientation. 4 Implant
type, size, shape and position are determined prior to any
surgical intervention. Any bone irregularities or deformities
are determined without elongation or magnification of
conventional radiographs. CBCT systems allow us to become
better diagnosticians and surgeons because they generate
volume images from digitized information, resulting in axial,
panoramic and cross-sectional relationships. As there is no
distortion of the images, accurate measurements can be
made directly from the CBCT information. 3
Prior to the CBCT scan, a radiographic guide is fabricated
from a duplication of the patient’s properly fitting and
contoured maxillary complete denture. It is wise to get
patient acceptance of the prosthesis prior to CBCT scanning,
so that information is built from a positive starting point.
The final look of the case will be determined before starting
implant placement, and the patient’s existing prosthesis
aids in the visualization of the optimal prosthetic design.
The radiographic guide is placed in the mouth during the
CBCT scan. 1,5 This allows visualization of the ideal position
of the teeth on a 3-D model. The entire three-dimensional
image is analyzed and the implant planning and simulation
of implant placement completed by computer. The surgical
placement of dental implants can be performed in a
conventional manner using the newly created surgical guide
to help direct the implants into the ideal position. Optimally,
the surgery can be completed without making an incisional
flap. The implants are placed to the desired depth using the
computer software and surgical guide. This software serves

as an ideal aid in evaluating potential implant receptor sites.
Using the CBCT scan and interactive NobelGuide planning
software (Nobel Biocare; Yorba Linda, Calif.) allows for the
case to be restoratively driven and makes surgical placement
predictable and simple. The virtual three-dimensional model
created using the software creates an environment where
not only quantity of bone is determined, but also the quality
of the bone to be invaded. Buccal and cortical thickness
surrounding the trabecular bone is evaluated so that all the
implants are properly positioned. 2,6,7 The tool allows us to
also determine the position and angulation of the abutments
to be used so that the final prosthesis is functioning along
the long axis of the dental implants.
CBCT diagnosis and computer scanning are often done with
the assistance of well-trained professionals in our dental
laboratories. The final approval of all diagnosing is the
responsibility of the treating dentist, but computer experts
help us with the idiosyncrasies of the process. Not every
dental laboratory can provide dental implant prosthetics,
stEP-By-stEP: Computer-Aided Restoration of the
Edentulous Maxilla with an Implant-Retained Overdenture
and some laboratories are better prepared and educated
to provide highly technological products. Visualizing the
finished case prior to any surgical intervention ensures a better
result. How long an implant lasts depends on many factors,
including biomechanical stresses, patient maintenance and
the general health of the patient. Oftentimes, the integrated
dental implant remains intact, but the prosthesis needs to
be reconstructed after years of use. With modern implant
designs, immediate loading has become popular. Of course,
the quality and quantity of available bone and initial stability
need to be considered. Occlusal forces must be minimized
during the initial bone healing phase.
The procedure for placing dental implants today is fairly
straightforward and not overly traumatic to the patient
in most circumstances. It is generally painless and quick.
Following local infiltration of the surgical site, preparation
for the dental implant placement begins. First, a small drill
is used to create angulation and final depth, and then largerdiameter
drills are used to create the osteotomy.
The patient in this case is a 63-year-old white male with no significant medical findings. He takes no medications
and appears to have no medical contraindications or limitations for dental implant therapy. He has been edentulous
in the maxilla for more than 15 years. Although his conventional maxillary complete denture has served him
well, he desires increased function and chewing ability. Over time, the denture also required relining as bone loss
occurred. The increased thickness resulted in a more prevalent gagging reflex.
1 2
Figures 1, 2: Evaluation of the edentulous maxilla intraorally and radiographically appears to demonstrate adequate bone width and height for eventual
dental implant placement and fabrication of a palateless maxillary overdenture. The patient desires a stable, palateless prosthesis, which will reduce the
gagging reflex and improve taste sensation.
– I Have a CBCT Scan — Now What Do I Do? – 57

I Have a CBCT Scan — Now What Do I Do?
58
3 4
Figure 3, 4: The patient’s properly fitting and esthetic conventional maxillary complete denture is duplicated to create a stable radiographic guide. Six to eight
radiopaque gutta-percha markers are positioned in three distinct planes. These gutta-percha markers are important in determining precise virtual placement
of the chosen dental implants using your CBCT scanning software of choice.
Figure 5: The CBCT scan allows for virtual placement of the dental
implants in ideal bone angulation and depth for proper parallelism.
The implant width and length are predetermined prior to any surgical
intervention. The dental laboratory can help with the virtual placement,
but the practicing dentist gives final approval of the positioning.
Figure 7: A surgical guide is designed using CAD software to replicate
how the implant was virtually placed prior to the actual surgical
intervention.
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Figure 6: The CBCT scan allows for visualization of the actual bone
morphology.
Figure 8: A precise acrylic surgical guide with occlusal sleeve openings
will direct the subsequent drill preparation and dental implant placement.

9 10
Figures 9, 10: The surgical guide needs to seat completely and should be anchored to prevent movement during osteotomy preparation. This is done with
the use of stabilizing facial pins that engage the labial aspect of bone approximately 3–5 mm.
Figure 11: The depth of the 2.2 mm diameter pilot drill is precisely
determined using a 2.2 mm diameter drill key, which allows accurate
angulation and depth of this important primary drill.
Figure 13: A tissue punch drill is used to remove soft tissue from the
surgical site, preventing possible contamination of the osteotomy. This
drill does not require a drill key, as the opening in the surgical guide is the
same diameter of the final predetermined implant body.
Figure 12: A 2.8 mm diameter drill key helps guide the subsequent
2.8 mm diameter drill.
Figure 14: The desired implant is ratcheted to the predetermined depth
using the stable surgical guide.
– I Have a CBCT Scan — Now What Do I Do? – 59

I Have a CBCT Scan — Now What Do I Do?
60
Figure 15: All four dental implants are precisely placed based on the
virtual design.
16 17
Modern technology makes
it possible to predictably
place dental implants using
flapless procedures in ideal
position, angulation and depth,
considering all emergence
profile and smile design
expectations.
Figures 16, 17: Evaluation of the maxillary right and left periapical radiographs demonstrates ideal positioning of the four parallel dental implants.
Figure 18: The surgical guide is removed after extracting the stabilizing
pins. Note there is little or no bleeding following implant placement and
labial pin placement.
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Figure 19: A conventional panoramic radiograph illustrates proper
positioning of the dental implants.

Figure 20: Following proper integration of the dental implants after
approximately four months, a conventional polyvinyl siloxane (PVS)
impression is made using impression copings. Radiographs are used to
verify complete seating to the top of the implants.
22 23
Figure 21: An accurate impression made using the indirect technique
exhibits no voids or distortions. Quality impressions provide for an
accurate master cast.
Figures 22, 23: The dental lab (Glidewell Laboratories; Irvine, Calif.) fabricates stable record bases and occlusal rims. Conventional denture techniques are
used to create an esthetic denture.
CBCT diagnosis and preparation of any case
can help the practitioner guarantee success by
alleviating most common fears prior to any
surgical intervention....Scanning software allows for
the fabrication of precise planning and surgical guides,
which help to ensure a positive result.
– I Have a CBCT Scan — Now What Do I Do? – 61

I Have a CBCT Scan — Now What Do I Do?
62
24 25
Figures 24, 25: The metal framework provides reinforcement and resistance to fracture for the horseshoe-shaped implant-retained overdenture.
LOCATOR ® attachments (Zest Anchors; Escondido, Calif.) are used to provide retention of the overdenture.
Figure 26: LOCATOR attachments of the appropriate height are placed
into the master cast. Height is determined by the interocclusal space
and soft tissue thickness.
Figure 28: The retentive male LOCATOR attachments shown here in
the palateless implant-retained maxillary complete denture are available
in different colors indicating different levels of retention. They are easily
changed as needed over time.
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Figure 27: The LOCATOR attachments are torqued to approximately
20 Ncm to ensure adequate tightness and resistance to unthreading.
Becoming educated in
any dental technique is
essential to achieving positive
results...yet success with
these procedures is largely
dependent on the individual
practitioner’s level of
competence and confidence.

29 30
Figures 29, 30: The palateless implant-retained maxillary complete denture is stable and functional. The patient is pleased with the natural-looking final
prosthesis. Quality of life is improved with increased masticatory ability.
Figure 31: The postoperative CBCT scan demonstrates that the dental
implants are indeed in ideal position and mimic the virtual placement of
the implants done prior to any surgical intervention. IM
ReFeRences
1. Arnet EM, Ganz SD. Implant treatment planning using a patient acceptance
prosthesis, radiographic record base, and surgical template. Part 1: Presurgical
phase. Implant Dent. 1997 Fall;6(3):193–7.
2. Ganz SD. Restoratively driven implant dentistry utilizing advanced software
and CBCT: realistic abutments and virtual teeth. Dent Today. 2008 Jul;
27(7):122, 124, 126–7.
3. Iplikçioglu H, Akça K, Cehreli MC. The use of computerized tomography
for diagnosis and treatment planning in implant dentistry. J. Oral Implantol.
2002;28(1):29–36.
4. Geiselhöringer H, Holst S. The new NobelProcera system for clinical success: the
next level of CAD/CAM dentistry. Cosmetic Dent. 2009;3(2):26–31.
How long an implant lasts
depends on many factors
including biomechanical
stresses, patient maintenance
and the general health of
the patient.
5. Kois JC. Predictable single-tooth peri-implant esthetics: five diagnostic keys.
Compend Contin Educ Dent. 2004 Nov;25(11):895–900.
6. 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.
7. Degidi M, Piattelli A. Comparative analysis study of 702 dental implants subjected
to immediate functional loading and immediate nonfunctional loading to traditional
healing periods with a follow-up of up to 24 Months. Int J Oral Maxillofac
Implants. 2005 Jan-Feb;20(1):99–107.
– I Have a CBCT Scan — Now What Do I Do? – 63

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R&D CORNER
Form and Function of
Implant threads in Cancellous Bone
by Grant Bullis, MBA, Director of Implant R&D and Digital Manufacturing
and Siamak Abai, DDS, MMedSc
thE ExtERNAL thREADs ON DENtAL IMPLANts are designed to maximize
initial contact, enhance surface area and facilitate dissipation of stresses at the
bone-implant interface. 1 The geometric characteristics of the thread influence
how stresses are transferred from the implant to the bone. Sufficient initial
contact with surrounding bone is important to facilitate primary stability of
the implant. Macro enhancements to the surface area of the implant from
the thread geometry itself increase potential bone apposition and both the
primary and secondary stability of the implant.
Primary stability is defined as the capacity of the implant to withstand loading
in axial, lateral and rotational directions. 2 Primary stability is influenced
by the mechanical engagement of the implant with the surrounding bone
after insertion, by bone quality and by the drilling protocol. Initial implant
stability obtained after implant insertion is critical to the success of the
implant. 3 At the time of placement, the assessment of primary stability may
also serve as a guide for determining treatment protocol: immediate, early
or delayed loading. 3
Secondary stability refers to the increase in stability due to regeneration
and remodeling of the bone at the implant interface. Adequate primary
stability is a prerequisite for secondary stability. 2
– Form and Function of Implant Threads in Cancellous Bone – 65

Threaded implants convert rotary motion into linear
motion to advance the implant into the osteotomy site.
Dental implants on the market today come in many thread
configurations, which share characteristics common to
screw thread forms (Fig. 1). These characteristics include:
• Crest – The outermost surface joining the two sides of
the thread.
• root – The innermost surface joining the two sides of
the thread.
• helix angle – The angle formed by a point on the side
and the plane perpendicular to the axis of the screw
thread.
Thread ChARACtERIstICs
Pitch
Crest
Root
Helix Angle
Figure 1: Depiction of the thread characteristics of screw-type dental implants, including helix angle, pitch, lead, crest and root
66
One-Start Thread Four-Start Thread
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• Pitch – The distance from a point on one thread to a
corresponding point on the adjacent thread, measured
parallel to the axis.
• lead – The axial distance that the implant advances in
one complete turn.
The thread pitch and lead are the same for one-start
threads. For multiple-start threads, the lead is a multiple of
the pitch. The lead of a two-start thread is twice the pitch;
the lead of a three-start thread is three times the pitch, etc.
Pitch
Helix Angle
Lead

Thread FORMs
Most dental implant thread forms can be classified as
variations of threads developed for fastening and power
transmission applications. Some of the thread forms used
for screw-type dental implants are V-shaped threads,
buttress and reverse buttress threads, and square threads.
V-shaped threads were originally developed for fastening
applications and to repeatedly translate machine parts
against heavy loads 4 (Fig. 2).
For example:
V-Thread
• Brånemark System ® (Nobel Biocare)
• Screw-Vent ® (Zimmer Dental)
• Certain ® (Biomet 3i)
Square
Thread
For example:
• External Implant System
(BioHorizons)
All associated third-party trademarks are the property of their respective owners.
Figure 2: Depiction of the basic classifications of thread forms for screw-type dental implants
Most dental implant
thread forms can be
classified as variations
of threads developed
for fastening and power
transmission applications.
Buttress
Thread
For example:
• Inclusive ® Tapered Implant
(Glidewell Laboratories)
• Straumann ® Standard
(Straumann USA, LLC)
For example:
Reverse
Buttress
Thread
• NobelReplace ® (Nobel Biocare)
– Form and Function of Implant Threads in Cancellous Bone – 67

Threads are effective at increasing the initial contact with
the surrounding bone and contributing to primary stability.
However, they exhibit differences in how they transmit
loads to the adjacent bone.
Three primary types of loads are generated at the boneimplant
interface: compressive, tensile and shear forces.
Studies have shown that compressive forces lead to
increased bone density and strength. 5 Tensile and shear
forces have been shown to result in weaker bone, with
shear forces being the least beneficial. 5 The amount of shear
force increases as the thread face angle increases. 5
Figure 3: Depiction of the direction of forces
applied by V-form screw threads
68
Direction of FORCES
Tension Compression Shear
V-Thread Buttress Thread Square Thread
Figure 4: Depiction of the direction of forces
applied by buttress-form screw threads
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V-shaped screw threads have symmetrical sides inclined at
equal angles. They are easy to manufacture and are widely
used for mass-produced threaded fasteners (Fig. 3).
Buttress threads have non-symmetrical sides and are very
efficient in transmitting forces in a single direction along
the axis of the screw head (Fig. 4).
Square-form threads have symmetrical sides perpendicular
to the axis of the screw head. They are very efficient at
transmitting forces in both directions along the axis of the
screw thread (Fig. 5).
Figure 5: Depiction of the direction of forces
applied by square-form screw threads

Multi-stARt
In addition to the thread form, the thread lead and pitch are
important thread characteristics that affect bone-implant
contact, stress distribution and primary stability.
Some manufacturers have introduced multiple-threaded
implants where two or more threads run parallel, one to
the other (Fig. 6). These multiple-threaded implants allow
for faster insertion; but, according to one FEA (finite
element analysis) study, the most favorable configuration in
terms of implant stability appeared to be the single-lead
threaded implant, followed by the double-lead threaded
implant. The triple-lead threaded implant was found to be
the least stable. 6
V-threads, square threads and buttress threads are dental
implant thread forms with a long history of successful use.
These threads serve to dissipate occlusal loads into the
bone surrounding the implant; however, they differ in form,
inherent strength and in how they transmit forces. The multistart
iterations of threaded implants facilitate faster insertions
at the apparent sacrifice of some primary stability. More
research is needed to examine the interaction of primary
stability and thread lead with single-start and multiple-start
threads. V-threads are strong, but they transmit more shear
forces to the surrounding bone. Square-thread forms transmit
Figure 6: Depiction of the difference between single-thread and multiple-thread dental implants
occlusal forces with less shear forces than V-threads, though
they are not as strong as V- and buttress-thread forms due to
their smaller cross-section at the base of the thread. Buttress
threads are the strongest thread form for a given size because
of their larger base cross-section, and because they minimize
shear forces in a manner similar to square threads. They
combine excellent primary stability with the best features of
both V- and square-thread forms. IM
ReFeRences
1. Steigenga JT, al-Shammari KF, Nociti FH, Misch CE, Wang HL. Dental implant
design and its relationship to long-term implant success. Implant Dent. 2003;
12(4):306–17.
2. Sennerby L, Meredith N. Implant stability measurements using resonance frequency
analysis: biological and biomechanical aspects and clinical implications.
Periodontol 2000. 2008;47:51-66.
3. Vidyasagar L, Salms G, Apse P, Teibe U. Dental implant stability at Stage I and II
surgery as measured using resonance frequency analysis. Stomatologija. Baltic
Dental and Maxillofacial Journal. 2004;6:67-72.
4. Oberg E, Jones F, Horton H, Ryffel H, Green R, McCauley C. Machinery’s Handbook
(25th Edition). 1996. Industrial Press Inc. New York, NY.
5. Strong JT, Misch CE, Bidez MW, Nalluri P. Functional surface area: thread-form
parameter optimization for implant body design. Compend Contin Educ Dent
1998;19(special):4-9.
6. Ma P, Liu HC, Li DH, Lin S, Shi Z, Peng QJ. Influence of helix angle and density on
primary stability of immediately loaded dental implants: three-dimensional finite
element analysis. Zhonghua Kou Qiang Yi Xue Za Zhi. 2007 Oct;42(10):618-21.
One-Start Two-Start Three-Start
Four-Start
– Form and Function of Implant Threads in Cancellous Bone – 69

Clinical Case Report
Maxillary Esthetic Zone Restoration with a
Monolithic BruxZir ® Implant Bridge
by
Ara Nazarian, DDS, DICOI
dvances in clinical techniques and materials continue to revolutionize dentistry, enabling clinicians to practice
with a greater degree of predictability and confidence than ever before. With increasingly affordable dental
implants, more and more patients are opting for crown & bridge services that preserve natural tooth structure
and underlying ridge width. Custom, prefabricated provisional appliances provide the patient with a more natural
and highly functional temporary prosthesis during the healing phase. Monolithic CAD/CAM restorations provide
a superior combination of strength and esthetics — and a precise fit — at a fraction of the cost of noble metals.
Clinicians taking advantage of these solutions, particularly in combination, are reporting reduced chairtime and
increased patient satisfaction — the principal ingredients of a thriving practice in this modern age of dentistry.
Case Description
The patient in this case presented with a complaint of
constant throbbing pain on tooth #7, which served as an
abutment tooth for an anterior maxillary bridge spanning
teeth #7–10 (Fig. 1). Moreover, the patient expressed
displeasure with the overall appearance of his smile in the
esthetic zone, noting the discoloration of his canines. Upon
clinical examination, it was discovered that tooth #11 had
undergone endodontic therapy within the prior three years
and required full coverage. For tooth #7, a probing depth
of about 11 mm was discovered. In addition, the tooth
demonstrated significant mobility and increased pain on
biting. These symptoms indicated a vertical fracture in this
abutment tooth.
Figure 1: Preoperative retracted view of the maxillary anterior
– Maxillary Esthetic Zone Restoration with a Monolithic BruxZir Implant Bridge – 71

CLINICAL CASE REPORT
After careful evaluation of the patient’s requests and needs, a
treatment plan was created. The plan consisted of extracting
and grafting tooth #7 and #10, with consecutive socket
preservation utilizing grafting material. For the healing
phase, the patient would receive a BioTemps ® provisional
bridge (Glidewell Laboratories; Newport Beach, Calif.), so
that he would not have to wear a flipper. Upon sufficient
healing of the ridge and socket grafts, Inclusive ® Tapered
Implants would be placed in the areas of tooth #7 and #10,
followed by a period of osseointegration and, ultimately,
the delivery of two Inclusive ® Custom Abutments (Glidewell
Laboratories) and a four-unit monolithic BruxZir ® Solid
Zirconia bridge (Glidewell Laboratories). Finally, tooth #6
and #11 would be restored with individual BruxZir crowns.
Atraumatic extraction of tooth #7 and #10 proceeded as
planned (Fig. 2), and grafting was performed to establish
the necessary bone quantity for eventual implant placement.
Tooth #6 and #11 were each prepared for an eventual
BruxZir crown. The strength of the BruxZir material
allows for a conservative, feather-edge preparation similar
to that used for cast gold, requiring as little as 0.5 mm
occlusal clearance. Before leaving the office, the patient
was fitted with his custom BioTemps bridge (Fig. 3), which
was digitally prefabricated from conventional diagnostic
impressions. Among the advantages of the BioTemps bridge
is that it is designed to seat passively over the ridge, affixing
in this case to tooth #6 and #11, and is cemented (or screwretained,
according to preference) to feel and function more
like natural teeth. A BioTemps bridge or crown also helps to
sculpt the soft tissue for a more natural emergence profile
and serves as a preview of the final restoration (Fig. 4).
Computer-aided design helps to ensure a precise fit, while
the biocompatible poly(methyl methacrylate) (PMMA)
material can easily be modified if necessary. Having this
provisional on hand, pre-milled for the day of surgery,
eliminates chairtime that would otherwise be required to
create a custom temporary.
The strength of the
BruxZir material allows for
a conservative, feather-edge
preparation similar to that used
for cast gold, requiring as little
as 0.5 mm occlusal clearance.
72
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Figure 2: Atraumatic extraction of tooth #7 & #10
Figure 3: BioTemps provisional bridge spanning teeth #6–11
Figure 4: BioTemps provisional seated with TempBond ® Clear with Triclosan
(Kerr Corporation; Orange, Calif.)
Figure 5: Inclusive Tapered Implant (3.7 mm x 13 mm)

A period of nearly five months was allowed for the bone
grafts to heal, after which time the patient returned for
placement of two Inclusive Tapered Implants. The Inclusive
Tapered Implant (Fig. 5) is machined from high-grade
titanium alloy and features industry-standard properties
such as an anatomically tapered body, RBM surface
treatment and an internal hex prosthetic connection for
ease of placement and reliable long-term function. The
prescribed length of each implant (13 mm) was based on
the radiographic location of the nasal cavities, while the
prescribed diameter (3.7 mm) was based on the available
bone width. Implants were placed as planned in the areas
of tooth #7 and #10 using the convenient hand carrier
(Fig. 6), and seated to depth using a torque wrench with
a final torque value of 35 Ncm, indicating good primary
stability. To eliminate the need for a second surgery when
taking impressions, collared 5 mm tall healing abutments
were placed and later removed, creating nice emergence
profiles. The BioTemps bridge was cemented back into
place to serve as a provisional restoration during the
osseointegration period.
The prescribed length of
each implant was based on
the radiographic location of
the nasal cavities, while the
prescribed diameter was
based on the available bone.
Approximately four months later, the patient returned for
evaluation and final impressions. The BioTemps bridge was
removed and adequate implant fixation verified using an
Osstell ® ISQ implant stability meter (Osstell; Linthicum,
Md.), which uses resonance frequency analysis as a method
of measurement (Fig. 7). Full-arch, implant-level impressions
were taken using the appropriate Inclusive ® Closed-Tray
Transfer copings (Glidewell Laboratories) (Fig. 8) and
Capture ® PVS impression material (Glidewell Laboratories).
The impressions and bite registration were submitted to the
laboratory along with a prescription for the final custom
abutments, final crowns and final four-unit bridge.
The Inclusive ® Titanium Custom Abutments were received
on a stone model with soft tissue mask (Fig. 9). The
abutments were securely seated on tooth #7 and #10, with
the abutment screws tightened to 35 Ncm and the screw
Figure 6: Preliminary placement of Inclusive Tapered Implant in the area of
tooth #10
Figure 7: Osstell ISQ reading of 76 indicating solid osseointegration
Figure 8: Inclusive Closed-Tray Transfer copings affixed to implants for the final
impression
Figure 9: Inclusive Custom Abutments on stone model with soft tissue mask
– Maxillary Esthetic Zone Restoration with a Monolithic BruxZir Implant Bridge – 73

CLINICAL CASE REPORT
access holes (Fig. 10) were filled with two cotton pellets
and TempoSIL ® (Coltène Whaledent; Cuyahoga Falls, Ohio)
and covered with Premise universal nanohybrid composite
(Kerr Corporation). Due to the patient-specific design of the
abutments, minimal blanching was observed. Final seating
of the 4-unit anterior BruxZir bridge over the custom
abutments was followed by final seating and cementation of
the individual BruxZir crowns on the natural preps of tooth
#6 and #11 (Fig. 11). The precise CAD/CAM techniques
by which BruxZir restorations are produced resulted in
a precise fit requiring minimal chairside adjustment. And
the material itself, a monolithic, tooth-shaded ceramic
uniquely processed to exhibit high translucency while
maintaining its class-leading strength, resulted in a pleasing
esthetic outcome.
summary
Today’s clinicians have at their disposal a wealth of tools
designed to increase the efficiency and predictability of
their treatment offerings, using methods and materials that
serve to lower costs while improving patient results. Highquality
dental implants are becoming ever more affordable,
making them an attractive option to patients who might
otherwise sacrifice healthy teeth to conventional crown
& bridge treatment, or resort to using removable or fixed
partial dentures. A BioTemps provisional appliance provides
the patient with an immediate, custom temporary that is
both functional and esthetic, helping guide the case toward
a predictable conclusion. Custom implant abutments can be
precisely designed to provide ideal support of the restoration
and underlying soft tissue, while all-ceramic crowns &
bridges milled from BruxZir Solid Zirconia, boasting a
flexural strength far greater than layered porcelain, now
exhibit sufficient esthetics for use in the anterior. The
CAD/CAM technology inherent in the production of these
restorations not only reduces their costs, but also limits the
need for adjustments or remakes, resulting in less chairtime
per patient.
While conventional materials and techniques continue to
serve as they have for decades, most clinicians today are
seeking to maximize both the potential of their practice
and the satisfaction of their patients. Those failing to take
advantage of the benefits that advanced dental technology
has to offer are missing out on a key opportunity. IM
74
– www.inclusivemagazine.com –
Figure 10: Intraoral seating of Inclusive Custom Abutments
Figure 11: Final BruxZir crowns on tooth #6 & #11 and BruxZir bridge for teeth
#7–10

Use of
Cone Beam Computed
tomography in Implant Dentistry
The International Congress of Oral Implantologists Consensus Report
by
Erika Benavides, DDS, Ph.D; * Hector F. Rios, DDS, Ph.D; † Scott D. Ganz, DMD; ‡
Chang-Hyeon An, DDS, Ph.D; § Randolph Resnik, DMD, MDS; II Gayle Tieszen Reardon, DDS, MS; Steven J. Feldman, DDS; # James K. Mah, DDS, MSc, DMSc; **
David Hatcher, DDS, MS; †† Myung-Jin Kim, DDS, MSD, Ph.D; ‡‡ Dong-Seok Sohn, DDS, Ph.D; §§ Ady Palti, DMD; IIII Morton L. Perel, DDS, MScD;
Kenneth W.M. Judy, DDS, Ph.D (HC); ## Carl E. Misch, DDS, MDS; *** and Hom-Lay Wang, DDS, MSD, Ph.D †††
PuRPOsE: The International Congress of Oral Implantologists has supported the development
of this consensus report involving the use of Cone Beam Computed Tomography
(CBCT) in implant dentistry with the intent of providing scientifically based guidance to
clinicians regarding its use as an adjunct to traditional imaging modalities.
MAtERIALs AND MEthODs: The literature regarding CBCT and implant dentistry
was systematically reviewed. A PubMed search that included studies published between
Jan. 1, 2000, and July 31, 2011, was conducted. Oral presentations, in conjunction
with these studies, were given by Dr. Erika Benavides, Dr. Scott Ganz, Dr. James Mah,
Dr. Myung-Jin Kim and Dr. David Hatcher at a meeting of the International Congress
of Oral Implantologists in Seoul, Korea, on Oct. 6–8, 2011.
REsuLts: The studies published could be divided into four main groups: diagnostics,
implant planning, surgical guidance and postimplant evaluation.
CONCLusIONs: The literature supports the use of CBCT in dental implant treatment
planning, particularly in regards to linear measurements, three-dimensional
evaluation of alveolar ridge topography, proximity to vital anatomical structures and
fabrication of surgical guides. Areas such as CBCT-derived bone density measurements,
CBCT-aided surgical navigation and postimplant CBCT artifacts need further research.
ICOI RECOMMENDAtIONs: All CBCT examinations, as all other radiographic
examinations, must be justified on an individualized needs basis. The benefits to the
patient for each CBCT scan must outweigh the potential risks. CBCT scans should not be
taken without initially obtaining thorough medical and dental histories and performing
a comprehensive clinical examination. CBCT should be considered as an imaging
alternative in cases where the projected implant receptor or bone augmentation sites are
suspect, and conventional radiography may not be able to assess the true regional threedimensional
anatomical presentation. The smallest possible field of view should be used,
and the entire image volume should be interpreted. (Implant Dent 2012;21:78–86)
It is generally accepted that partial
or complete edentulism adversely
affects an individual’s quality of
life and can negatively contribute to
the maintenance of optimal health. 1–3
Structural and functional adaptations
of the soft and mineralized tissues of
the maxilla and mandible occur over
time after tooth extraction and can
directly influence the therapeutic alternatives.
4 Because mineralized tissue
changes may not be clinically apparent,
radiographic imaging analysis is paramount
for successful diagnosis and
treatment planning in dental implantology
and directly contributes to the
implant’s long-term success. 5
Until recently, the most common diagnostic
radiographic modalities used
to assist clinicians during implant
treatment planning were limited to
intraoral periapical and panoramic
radiography. 5 These radiographic modalities
only provide two-dimensional
*Clinical Assistant Professor, Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Mich. † Assistant Professor, Department
of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Mich. ‡ Private Practice, Prosthodontics, Maxillofacial Prosthetics & Implant
Dentistry, Fort Lee, N.J. § Associate Professor, Department of Oral and Maxillofacial Radiology, School of Dentistry, Kyungpook National University, Daegu, Republic of
Korea. II Clinical Professor, Department of Periodontology and Implantology, Temple University, Philadelphia, Pa.; Private Practice, Pittsburgh, Pa. Private Practice, Sioux
Falls, S.D. # Chairman and CEO, XCPT Communication Technologies LLC, Sarasota, Fla. **Associate Professor, University of Nevada, Las Vegas, Nev.; Private Practice,
Advanced Dental Imaging LLC, Las Vegas, Nev. †† Clinical Professor, Roseman University of Health Sciences, Henderson, Nev.; Adjunct Associate Clinical Professor,
University of Pacific, San Francisco, Calif.; Private Practice, Diagnostic Digital Imaging, Sacramento, Calif. ‡‡ Professor, College of Dentistry, Seoul National University, Seoul,
Republic of Korea. §§ Professor and Chairman, Department of Dentistry and Oral and Maxillofacial Surgery, Catholic University Hospital of Daegu, Nam-Gu, Adegu, Republic
of Korea. IIII Private Practice, Baden-Baden, Germany; Clinical Professor, New York University, College of Dentistry, New York, N.Y. Editor-in-Chief, Implant Dentistry.
## Clinical Professor, Department of Periodontology and Implantology, Temple University, Philadelphia, Pa. ***Clinical Professor and Director of Oral Implantology, Temple
University, School of Dentistry, Philadelphia, Pa.; Private Practice, Beverly Hills, Mich., and Chicago, Ill. ††† Professor and Director of Graduate Periodontics, Department of
Periodontics & Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Mich.
– Use of Cone Beam Computed Tomography in Implant Dentistry – 75

Use of Cone Beam Computed Tomography in Implant Dentistry
Table 1 – Advantages and Limitations of CBCT
Advantages of CBCT Limitations of CBCT
(2-D) representations of three-dimensional
(3-D) structures. In an effort to
overcome this limitation, the use of
medical computed tomography (CT)
for dental implant applications became
available in the mid 1980s; however,
this practice received some criticism
due to the level of radiation exposure
during image acquisition. The
introduction of Cone Beam Computed
Tomography (CBCT) in the late 1990s
represented an unparalleled advancement
in the field of dental and maxillofacial
radiology because it greatly
reduced the radiation exposure to
patients undergoing scans. 6,7 The 3-D
information generated by this technique
offers the potential of improved
diagnosis and treatment planning for
a wide range of clinical applications
in implant dentistry. 8,9 The goal of this
consensus report is to discuss key elements
needed for the sound, scientifically
based use of CBCT in the area of
dental implantology.
■ CONE BEAM COMPutED
tOMOgRAPhy
CBCT is an advanced digital imaging
technique that allows the operator to
generate multiplanar slices of a region
of interest and to reconstruct a 3-D
image of these structures of interest
by using a cone-shaped rotating X-ray
beam via a series of mathematical algorithms.
6 The advent of CBCT has
76
• Mutiplanar reconstruction
• Significantly less radiation compared with other 3-D
advanced imaging modalities (i.e., medical CT)
• Fast, efficient, in-office modality
• Interactive treatment planning
• Adequate for bone grafting assessment
• Computer-aided surgery
• Limited soft tissue visualization
made it possible to visualize the dentition,
the maxillofacial skeleton and
the relationship of anatomical structures
in three dimensions. 6 The use
of CBCT in the dental profession is
increasing exponentially due to an
increase of equipment manufacturers
and the growing acceptance of this
imaging modality. 8
Field of view. The size of the field of
view (FOV) describes the scan volume
of a particular CBCT machine and is
dependent on the detector size and
shape, the beam projection geometry,
and the ability to collimate the beam
which differs from manufacturer to
manufacturer. Beam collimation limits
the patient’s ionizing radiation exposure
to the region of interest and
ensures that an appropriate FOV can
be selected based on the specific case.
In general, CBCT units can be classified
into small, medium and large
volume based on the size of their FOV.
Small volume CBCT machines are
used to scan from a sextant or a quadrant
to one jaw only. They generally
offer higher image resolution because
X-ray scattering (noise) is reduced as
the FOV decreases. Medium volume
CBCT machines are used to scan both
jaws while large FOV machines allow
the visualization of the entire head
that is commonly used in orthodontic
and orthognathic surgery treatment
– www.inclusivemagazine.com –
• Some CBCT machines produce an increased
radiation exposure compared with selected intraoral
and panoramic radiographs
• Limited bone density measurements
• Artifacts created by metal subjects (e.g., PFM
crowns, dental implants), costly
• Third-party software applications and 3-D models are
an additional expense
• Liability, extra cost
planning. The main limitation of
large FOV CBCT units is the size of
the field irradiated. Unless the smallest
voxel size is selected in the larger FOV
machines, there is a reduction in image
resolution as compared with intraoral
radiographs or small FOV CBCT machines
with inherent small voxel sizes.
Limiting the scan volume should be
based on the clinician’s judgment
for the particular situation. For most
dental implant applications, small or
medium FOV is sufficient to visualize
the region of interest. Small volume
CBCT machines are becoming more
popular and provide the following
advantages over larger volume CBCT:
1. Increased spatial resolution
2. Decreased radiation exposure to
the patient
3. Smaller volume to be interpreted
4. Less expensive machines
■ ADVANtAgEs AND
LIMItAtIONs OF CBCt
CBCT has made it possible for clinicians
to directly visualize the dentition
including the maxillofacial skeleton
in 3-D as opposed to “imaging” it two
dimensionally. The advantages of CBCT
are the weaknesses of 2-D intraoral
periapical and panoramic radiographic
representations. The ability to visualize
the complete geometric shape of the area
of interest and avoid superimposition

or planar viewing permits accurate
radiographic interpretation without
assumption (Table 1).
Therefore, spatial proximity of vital
structures such as the inferior alveolar
nerve, the incisive canal, the mental
foramen and inherent concavities
can be accurately assessed and measured.
However, the quality of the
interpretation is based on the clinician’s
diagnostic ability, thoroughness,
utilization of native and third-party
treatment planning software, and determination
of the appropriate FOV for
each particular case. There are several
CBCT equipment manufacturers in the
dental imaging field. This has resulted
in significant variability in radiation
dose, scanning times, ease of use, image
resolution and software dynamics
among CBCT machines.
CBCT has limitations similar to all
interpretive technologies. The most
significant limitations of CBCT are
the lack of accurate representation of
the internal structure of soft tissues
such as the muscles, salivary glands
and soft-tissue lesions; the limited
correlation to Hounsfield units for
standardized quantification of bone
density; and the various types of
artifacts produced mainly by metal
restorations that can interfere with
the diagnostic process by masking
underlying structures (Table 1). To
improve visualization of the contour
and thickness of the gingival soft
tissues, techniques such as the use
of a cotton roll or air to separate
the lip from the vestibule have been
described and proven successful. 9
A large number of commercial thirdparty
software packages are available
to import and analyze CBCT data exported
in a DICOM format (Digital Imaging
and Communication in Medicine).
The most differentiating aspects of the
available software applications include
their ease of navigation, cost, quantity
and quality of available diagnostic
tools, and their implant planning mod-
ules. Advanced software applications
can significantly reduce the “scatter”
effect or artifact so that an accurate
diagnosis can be established, thus helping
to mitigate one potential limitation
of this imaging modality.
■ DOsE CONsIDERAtIONs
As it is well known, the main concern
of exposure to dental X-rays in
general is the risk of potential stochastic
effects, which are those effects
that can be caused regardless of how
small the radiation exposure might be
and include radiation-induced cancer
and hereditable effects. Risks versus
benefits decisions are made daily in
a dental office. As with any surgical
procedure, conventional dental and
CBCT imaging require similar types
of decisions.
This risk is age-dependent, being
highest for the young and least for the
elderly. Published estimated risks are
given for the adult patient at 30 years
of age that represent averages for both
genders. At all ages, risks for females
are slightly higher than those for
males. To calculate individual risks,
these estimates should be modified
using the appropriate multiplication
factors derived from the International
Commission on Radiologic Protection
report published in 2007. 10,11 The
NCRP report No. 145 published in
2003 provides guidelines to help minimize
radiation risks from common
dental radiographic examinations. 12
There are multiple CBCT radiation
dosimetry studies in the literature
(Table 2). Based on these reports, it can
be concluded that a significant variation
in effective dose exists among
CBCT machines; however, when
compared to medical CT, CBCT can
be recommended as a dose-reducing
technique for dental implant applications.
13–17 The effective dose from CBCT
examinations ranges from 13 µSv
with the 3-D Accuitomo CBCT machine
using the 4 x 4 cm FOV to 479 µSv
with the CB MercuRay CBCT machine
(Table 2). For comparison, the effective
dose from one panoramic radiograph
is approximately 10–14 µSv and that
of a complete series of radiographs
can range from 34.9 µSv (when using
PSP plates or F-speed film and the use
of a rectangular collimator) to 388 µSv
(when using D-speed film and a round
collimator). 14 Furthermore, the exposure
from a maxillomandibular medical
CT ranges from 474–1,160 µSv. 18
The average background radiation in
the U.S. is 3,000 µSv (3 mSv) per year
or 8 µSv per day (Table 2).
As with any other dental imaging
modality, CBCT examinations must
be justified on an individual basis by
demonstrating that the benefits to the
patients outweigh the potential risks.
CBCT examinations should potentially
add significant new information
to aid in the patient’s management.
CBCT must not be selected unless
a review of the medical and dental
histories and a thorough clinical examination
has been performed.
It is important to understand that every
effort must be made to reduce the
effective radiation dose to the patient.
By using the smallest possible FOV,
the lowest mA setting, the shortest
exposure time and a pulsed exposure
mode of acquisition, it is possible to
accomplish effective dose reduction to
the patient. 19 If visualization of structures
beyond the region of interest for
implant placement is required, imaging
made with the appropriate larger
FOV protocol should be selected on a
case-by-case basis.
■ CBCt IN IMPLANt
DENtIstRy
The use of 3-D information in the areas
of diagnosis and treatment planning
has been greatly enhanced through
the availability of CBCT. Its application
in the area of implant dentistry assists
the clinician in assessing individual
patient anatomy in 3-D. This analysis
can be made through native software
that initially reconstructs the CBCT
– Use of Cone Beam Computed Tomography in Implant Dentistry – 77

Use of Cone Beam Computed Tomography in Implant Dentistry
CBCT
Scanner FOV (cm)
Effective Dose
(µSv)
Digital Panoramic
Equivalent (14 µSv)
No. of Days of Annual
per Capita Background
(3 µSv = 3000 µSv) References
i-CAT classic 22/13 (40 s)/13 (10 s) 82/77/48 5.9/5.5/3.4 10/9.4/5.8 Loubele et al. 18
i-CAT next
generation
6 min. (low resolution/
high resolution)
6 max. (low resolution/
high resolution)
96.2/118.5 6.9/8.5 11.7/14.4 Hatcher 20
58.9/93.3 4.2/6.6 7.2/11 Hatcher 20
22/13 206.2/133.9 14.7/9.6 25/16 Hatcher 20
13 61.1 4.4 7.4 Silva et al. 21
23 x 17 74 5.3 9
16 x 13 (19 mAs) 87 6.2 10.6
Ludlow and
Ivanovic 15
Ludlow and
Ivanovic 15
16 x 13 (18.5 mAs) 83 5.9 10.2 Pauwels et al. 22
16 x 16 45 3.2 5.5 Pauwels et al. 22
Newtom 9000 23 56.2 4 6.9 Silva et al. 21
Newtom 3G
12 in (male/female) 93/95 6.6/6.8 11.3/11.6
19 68 4.9 8.3
Coppenrath
et al. 23
Ludlow and
Ivanovic 15
6 in/12 in 57/30 4/2.1 6.9/3.7 Loubele et al. 18
Newtom VG 15 x 10 83 5.9 10.2 Pauwels et al. 22
Newtom VGi 15 x 15 194 6.7 23.9 Pauwels et al. 22
High resolution
scan (12 x 8)
265 18.9 32.6 Pauwels et al. 22
CB MercuRay 100 kVp 19/15/10 479/402/369 34/29/26 58/49/45 Ludlow et al. 14
ProMax 3D
Picasso-Trio
120 kVp 19/15/10 761/680/603 54/49/40 93/83/73 Ludlow et al. 14
10 510.6 36.5 62 Okano et al. 16
19 (max./stand)/15/10
1073/569/
560/407
77/41/40/20 131/69/68/50
8 x 8 (72 mAs/96 mAs) 488/652 35/47 59/79
8 x 8 (169 mAs/19.9
mAs)
12 x 7 (127
mAs/91mAs)
Ludlow and
Ivanovic 15
Ludlow and
Ivanovic 15
122/28 8.7/2 15/1.7 Pauwels et al. 22
123/81 8.8/5.8 15.1/10 Pauwels et al. 22
Pax-Uni3D 5 x 5 max. 44 3.1 5.4 Pauwels et al. 22
Kodak 9000 3D Max. ant./min. post. 19/40 1.4/2.9 2.3/4.9 Pauwels et al. 22
Kodak 9500 3D 20 x 18 92 Pauwels et al. 22
78
Table 2 – CBCT Machines
15 x 9 136 Pauwels et al. 22
20 x 18 (small/
medium/large adult)
15 x 9 (small/medium/
large adult)
76/98/166 5.4/7.0/11.9 9.3/12.1/20.4 Ludlow 24
93/163/260 6.6/11.6/18.6 11.4/20.1/32.0 Ludlow 24
28 mAs 84 6 10.3 Pauwels et al. 22
– www.inclusivemagazine.com –

CBCT
Scanner FOV (cm)
data after acquisition and through
advanced third-party software applications
that can aid in the determination
of dental implant receptor sites and
related procedures. The ideal receptor
site for dental implant placement
can be defined as one with adequate
bone quality and volume where an
osteotomy can be prepared and the
implant can be stabilized in a favorable
position whereby the prosthetic goals
can be achieved. The 3-D visualization
and evaluation of the structures of interest
during the treatment planning
phase allows for the analysis of the
following parameters:
1. Determination of available bone
height, width and relative quality.
2. Determination of the 3-D topogra-
Effective Dose
(µSv)
phy of the alveolar ridge.
Digital Panoramic
Equivalent
(14 µSv)
3. Identification and localization of
vital anatomical structures such as
the inferior alveolar nerve, mental
foramen, incisive canal, maxillary
sinus, ostium and floor of the nasal
cavity.
4. Identification and 3-D evaluation of
possible incidental pathology.
5. Fabrication of CBCT-derived implant
surgical guides.
6. Communication of the diagnostic
and treatment planning info to all
members of the implant team.
7. Evaluation of prosthetic/restorative
options through implant software
applications.
8. In addition, the CBCT scan in combi-
No. of Days of Annual
per Capita Background
(3 µSv = 3000 µSv) References
SCANORA 3D 14.5 x 13 68 4.9 8.4 Pauwels et al. 22
10 x 7.5 46 3.3 5.7 Pauwels et al. 22
SkyView 17 x 17 87 6.2 10.7 Pauwels et al. 22
ILUMA 19 x 19 (20
mAs/152mAs)
98/498 7/35.6 11.9/60.6
Ludlow and
Ivanovic15 20.5 x14 (76 mAs) 368 26.3 45.3 Pauwels et al. 22
3D Accuitomo 4 x 4/6 x 6 49.9/101.5 3.6/7.3 6/12.4 Okano et al.
FPD
16
Ant. (4 x 4/6 x 6) 20/43.3 1.4/3.1 2.5/5.2 Hirsch et al. 25
Max. ant. (4 x 4/6 x 6) 21–26/52–63 1.5–1.9/3.7–4.5 2.6–3.2/6.4–7.8
Min. pm (4 x 4/6 x 6) 21–31/57–69 1.5–2.2/4.1–4.9 2.6–3.8/7.0–8.5
Min. 3rd (4 x 4/6 x 6) 21–29/52–77 1.5–2.1/3.7–5.5 2.6–3.6/6.4–9.5
Lofthag-Hansen
et al. 26
Lofthag-Hansen
et al. 26
Lofthag-Hansen
et al. 26
3D Accuitomo 4 x 3 29.6 2.1 3.6 Okano et al. 16
Max. (ant./pm/mol) 29/44/29 2/3.2/2 3.5/5.3/3.5 Loubele et al. 18
Min. (ant./pm/mol) 13/22/29 0.9/1.6/2 1.6/2.7/3.5 Loubele et al. 18
Max. ant/Mn. pm/Min. 21–25/
1.5–1.8/
2.6–3.1/ Lofthag-Hansen
3rd
11–25/11–27 0.8–1.8/0.8–1.9 1.4–3.1/1.4–3.3
et al. 26
3D Accuitomo
10 x 5 54 3.9 6.6 Pauwels et al.
170
22
4 x 4 43 3.1 5.3 Pauwels et al. 22
Veraviewepocs
3D
Ant. (4 x 4/8 x 4/pan
4 x 4)
30.2/39.9/
29.8
2.2/2.9/2.1 3.8/4.9/3.6 Hirsch et al. 25
8 x 8 73 5.2 9 Pauwels et al. 22
Prexion 3D
Standard (19 s)/high
resolution (37 s)
189/388 13.5/27.7 23/47
Ludlow and
Ivanovic15 nation with software modeling can
be used as a virtual treatment planning
platform to simulate the ideal
implant placement with consideration
of surgical, prosthetic and
occlusal factors.
■ REVIEW OF
thE LItERAtuRE
The literature regarding CBCT and
implant dentistry was systematically
reviewed. A PubMed search that included
studies published between
Jan. 1, 2000, and July 31, 2011, was
conducted.
The use and potential of CBCT have
been reported in a number of scientific
papers for a number of purposes.
– Use of Cone Beam Computed Tomography in Implant Dentistry – 79

Use of Cone Beam Computed Tomography in Implant Dentistry
The most commonly cited uses include
the following: (1) identifying the 3-D
characteristics of individual patient
anatomy, (2) identifying potential
risks of intrusion into vital anatomical
structures including nerves,
blood vessels and impacted or supernumerary
teeth, (3) ancillary bone
grafting procedures including sinus
augmentations, (4) assessing bone
quality including facial and lingual cortical
plates and intermedullary bone,
(5) assessing potential dental implant
receptor sites for the placement of
standard, narrow-diameter and zygomatic
implants, (6) the fabrication of
surgical guides/templates and prostheses,
and (7) postoperative assessment
of grafting procedures.
Level of evidence and other considerations.
More than 40 percent of the
published studies between 2000 and
2011 represent laboratory trials which
include ex-vivo (i.e., cadaver) studies
and other types of models. Approximately
30 percent of the published
studies are randomized clinical trials,
and more than 20 percent represent
case reports.
It is also important to keep in mind
that published research that applies to
one CBCT machine may not apply to
other equipment because the image
quality and resolution varies among
machines and there are more than 30
CBCT machines currently available in
the market.
Based on the currently available literature,
the adjunctive use of CBCT in
implant dentistry can be divided into
four main categories:
1. Diagnostics
2. Implant planning
3. Surgical guidance
4. Postimplant and/or post-grafting
evaluation
■ CBCt AND DIAgNOstICs
CBCT is an excellent diagnostic modality
in implant dentistry that should
be used for the evaluation of the
proposed implant site to exclude the
80
presence of occult pathology, foreign
bodies, and/or defects, and to determine
the suitability of the site in
terms of 3-D morphology and proximity
to vital anatomical structures.
■ CBCt AND IMPLANt
PLANNINg
In dental implant treatment planning,
one of the most frequently reported
applications of CBCT is linear measurement
of the ridge. CBCT images have
been found to provide reliable bone
quantity information for preoperative
implant planning in different areas
of the maxilla and mandible both in
clinical and experimental studies. 27–31 It
has been shown that magnification of
CBCT-obtained linear measurements
does not occur and measurements have
been found to be more accurate than
those obtained with medical CT. 32,33
Furthermore, dental metallic artifacts
do not alter the accuracy of linear measurements
obtained with CBCT. 34
Another important advantage of CBCT
in preimplant treatment planning is
the ability to evaluate the ridge topography
and proximity to vital anatomical
structures three-dimensionally to
determine whether advanced grafting
is necessary for appropriate implant
site development. CBCT images have
proven to be superior in this regard
compared with other 2-D imaging
modalities. 35–38 CBCT can accurately
assess the thickness of cortical bone
such as the facial/buccal and lingual/
palatal cortical plates, the floor of the
nasal cavity, and the medial and lateral
walls of the maxillary sinuses.
Evaluation of bone density has also
been an area of increasing interest.
Because of the volumetric data acquisition
and reconstruction of CBCT
data, linear attenuation coefficients
and true Hounsfield units which
originated from medical CT scans are
challenging to calculate from CBCT
scans. To date, it has been possible to
obtain only relative bone quality information.
However, several research
studies have been done to assess the
– www.inclusivemagazine.com –
reliability of bone density measurements
obtained with CBCT in an effort
to overcome this limitation and provide
a method to standardize imaging
variables to better estimate true tissue
density. 39 Some studies have found
that CBCT might hold potential with
regard to the structural analysis of trabecular
bone and that bone quality
evaluated by CBCT shows a high correlation
with the primary stability of
dental implants. 40–43 Furthermore, the
use of the quantitative CBCT (QCBCT)
method holds promise as an alternative
diagnostic tool for preoperative
bone density evaluation. 44
In addition to implant planning, the use
of CBCT has been found to be effective
in locating blood vessels in the lateral
wall of the maxillary sinus — which
should be appreciated before sinus
augmentation procedures. Significant
vessels also reside in the mandibular
symphysis region that can cause
life-threatening events if perforated
during implant surgery. CBCT can
aid clinicians in identifying these important
anatomical features to avoid
potential serious complications.
■ CBCt AND suRgICAL
guIDANCE
CBCT-aided implant surgery can be
divided into the following: passive,
semi-active and active.
1. Passive CBCT-aided implant surgery
refers to the use of CBCT
information such as linear measurements,
relative bone quality,
3-D evaluation of ridge topography
and proximity to vital anatomical
structures to help in the implant
treatment planning process. Passive
CBCT-aided implant surgery can
be accomplished with or without
third-party interactive treatment
planning software.
2. Semi-active CBCT-aided implant surgery
includes the use of CBCT data
imported into third-party interactive
treatment planning software where
virtual implants are simulated as

a precursor to the fabrication of
surgical guides that will be used at
the time of implant placement. Depending
on the software application’s
protocol to relate implant position to
the underlying bone and restorative
needs of the patient, a scanning
template may need to be fabricated
before the scan acquisition. The
scanning template can be made
with a radiopaque material (barium
sulfate) and contain gutta-percha
markers, or other specific fiduciary
markers that aid in the fabrication
of the surgical guide. The scanning
template is positioned intraorally,
and the CBCT scan is acquired. The
data from the scan is then imported
into the interactive treatment planning
software for implant planning.
Surgical guides can be fabricated by
several different methods, based on
the particular software application
and are not all equally accurate. The
use of stereolithography or rapid
prototyping has been successful in
the ability to reconstruct the patient’s
bony anatomy, and facilitates
the fabrication of CBCT-derived surgical
guides. This process can be
completed with or without a scanning
appliance worn during the
CBCT scan acquisition. Other methods
involve laboratory-drilled templates
that require registration of the
scanning template to the CBCT data.
Each type of template contains metal
cylinders that correspond to the diameter
of the osteotomy drills specific
to the implants to be placed. The
registration of 3-D surface data has
been found to be reliable and sufficiently
accurate for dental implant
planning. Thereby, in certain situations
and with certain software applications,
barium-sulfate scanning
templates can be avoided and dental
implant planning can be accomplished
fully virtual. 45 The process
to perform virtual implant treatment
planning involves the use of thirdparty
software to decide the most appropriate
location and orientation of
the proposed implant. 27,46 Moreover,
the use of surgical guides facilitates
flapless implant placement. 47,48 The
use of CBCT-derived surgical guides
has been enhanced to allow for implants
to be placed directly through
the surgical template with manufacturer
specific hardware to control
depth and rotation of the implants.
Therefore, extra equipment and cost
is associated with these protocols.
CBCT-generated surgical guides
and the integration of CAD/CAM
and CBCT to determine the appropriate
restorative modality have
been found to be precise27,49,50 and
will continue to evolve as a link between
the treatment planning and
the restorative processes.
3. Active CBCT-aided implant surgery
refers to the use of CBCT data
and surgical navigation systems to
perform fully computer-guided implant
placement. The accuracy of
navigation systems has been tested
in some studies; however, more
research is need in this area. 51
■ CBCt AND POstIMPLANt/
POstgRAFtINg
EVALuAtION
The usefulness of CBCT for postimplant
evaluation has also been studied.
One of the main concerns of postimplant
evaluation with CBCT is the
presence of beam hardening and partial
volume artifacts around implants,
which in some cases prevent the
visualization of the bone-implant interface.
However, scattering artifacts
caused by metal are significantly less
with CBCT as compared with medical
CT. In 2010, Naitoh et al. 52 evaluated
the rate of bone-to-implant contact in
a clinical study and reported that the
bone configuration surrounding anterior
dental implants with and without
bone grafting can be adequately assessed
using CBCT. Similar findings
have also been obtained in human
skulls. 31 However, controversial results
are also found in the literature
using other animal models where the
evaluation of peri-implant bone defect
regeneration by means of CBCT was
not accurate for sites providing bone
width of

Use of Cone Beam Computed Tomography in Implant Dentistry
These incidental findings may include,
but are not limited to, osseous
or sinus pathology, intracranial
or vascular calcifications and airway
asymmetry. The likelihood of
seeing these types of findings increases
with a larger FOV where a
larger head volume is included in the
82
scan. There is no informed consent
process or signature of waiver that
allows the clinician to interpret only
a specific area of an image volume.
Therefore, the clinician may be considered
liable for a missed diagnosis,
even if it is outside of their area
of practice. 54 If questions regarding
image data interpretation occur,
prompt referral to a specialist in oral
and maxillofacial or medical radiology
is recommended. If incidental findings
are considered clinically significant,
appropriate referral for medical
consultation should follow.
RECOMMENDATIONS
The decision to order a CBCT scan must be based on the patient’s history and clinical examination, and justified on
an individualized needs basis that demonstrates that the benefits to the patient outweigh the potential risks of the patient’s
exposure to ionizing radiation, especially in the case of children or young adults and large FOV scans. Because
the 3-D information obtained with CBCT cannot be obtained with other 2-D imaging modalities, it is virtually impossible
to predict which treatment cases would not benefit from having this additional information before obtaining it.
Based on the available evidence and the type of information acquired with 3-D imaging modalities, the consensus
panel suggests that use of CBCT should be considered as an imaging alternative before cases where the proposed
implant receptor or bone augmentation sites are suspect, and conventional radiography may not be able to assess the
true regional 3-D anatomical presentation as indicated below:
■ Computer-aided implant planning and placement
including flapless techniques (e.g., interactive
treatment planning software applications, surgical
guides and navigation systems)
■ Implant placement in a highly esthetic zone or
where concavities, ridge inclination, inadequate
bone volume or quality, undeterminable proximity
to vital structures and insufficient interradicular
spacing is suspected
■ Pre- and post-advanced bone grafting evaluation
(e.g., sinus lift, ridge splitting, block grafting)
■ History or suspected trauma to the jaws, foreign
bodies, maxillofacial lesions and/or developmental
defects
■ Evaluation of postimplant complications
(e.g., postoperative neurosensory impairment,
osteomyelitis, acute rhinosinusitis)
It is important to keep in mind that the smallest possible FOV should be used and the entire image volume should
be interpreted.
ADDITIONAL RECOMMENDATIONS
Education. The use of CBCT requires a specific skill set that, until recently, has not been taught in dental schools at
either the undergraduate or postgraduate levels. Therefore, it is also recommended that clinicians who are providing
dental implant procedures for their patients become knowledgeable in 3-D diagnosis and treatment planning concepts,
and become familiar with interactive treatment planning software applications.
Protocols. 3-D imaging technology does not supersede sound surgical and restorative/prosthetic fundamentals.
Clinicians should understand that the scan process often starts before the scan itself. Diagnostic wax-ups, mounted
articulated study casts and the use of scanning templates help to improve the diagnostic accuracy of the CBCT data as
it relates to the desired implant placement or ancillary grafting procedure. The use of scanning and surgical templates
helps to improve surgical accuracy, reduce postoperative morbidity and aid in the restorative phase of treatment. IM
Coming soon to the pages of Inclusive
Dr. Ganz will publish a follow-up article in a future issue of Inclusive magazine on advances in CBCT technology and restoratively driven implant dentistry.
– www.inclusivemagazine.com –

acKnOWLeDgMents
This work was supported by the International Congress
of Oral Implantologists (ICOI).
aDDenDUM
The American Association of Physicists in Medicine,
whose members continually strive to improve medical
imaging by lowering radiation levels and maximizing
benefits of imaging procedures involving ionizing radiation,
issued a Position Statement on radiation risks
from medical imaging procedures on Dec. 13, 2011.
In part, it reads “predictions of hypothetical cancer
incidents and deaths in patient populations exposed
to such low doses are highly speculative and should
be discouraged. These predictions are harmful because
they lead to sensationalistic articles in the public
media.” Readers are urged to go to the website of
the American Association of Physicists in Medicine
(www.aapm.org) to read this statement in its entirety.
ReFeRences
1. Kuboki T, Okamoto S, Suzuki H, et al. Quality of life
assessment of bone-anchored fixed partial denture
patients with unilateral mandibular distal-extension
edentulism. J Prosthet Dent. 1999;82:182–87.
2. Ozhayat EB, Stoltze K, Elverdam B, et al. A method
for assessment of quality of life in relation to prosthodontics.
Partial edentulism and removable partial
dentures. J Oral Rehabil. 2007;34:336–44.
3. Kimura A, Arakawa H, Noda K, et al. Response shift
in oral health-related quality of life measurement
in patients with partial edentulism. J Oral Rehabil.
2012;39:44–54.
4. Akca K, Iplikcioglu H. Evaluation of the effect of the
residual bone angulation on implant-supported fixed
prostheses in mandibular posterior edentulism. Part
I: Spiral computed tomography study. Implant Dent.
2001;10:216–22.
5. Chan HL, Misch K, Wang HL. Dental imaging
in implant treatment planning. Implant Dent.
2010;19:288–98.
6. Sukovic P. Cone beam computed tomography
in craniofacial imaging. Orthod Craniofac Res.
2003;6(suppl 1):31– 36, discussion 179–82.
7. Tsiklakis K, Donta C, Gavala S, et al. Dose reduction
in maxillofacial imaging using low dose Cone beam
CT. Eur J Radiol. 2005;56:413–7.
8. Scarfe WC, Farman AG, Sukovic P. Clinical applications
of cone-beam computed tomography in
dental practice. J Can Dent Assoc. 2006;72:75–80.
9. Ganz SD. Cone beam computed tomographyassisted
treatment planning concepts. Dent Clin
North Am. 2011;55: 515–36, viii.
10. Ludlow JB, Davies-Ludlow LE, White SC. Patient
risk related to common dental radiographic examinations:
The impact of 2007 International Commission
on Radiological Protection recommendations
regarding dose calculation. J Am Dent Assoc.
2008;139:1,237–43.
11. The 2007 Recommendations of the International
Commission on Radiological Protection. ICRP
publication 103. Ann ICRP. 2007;37:1–332.
12. Miles DA, Langlais RP. NCRP report No. 145: New
dental X-ray guidelines: Their potential impact on
your dental practice. Dent Today. 2004;23:128,
130, 132 passim; quiz 134.
13. Ludlow JB, Davies-Ludlow LE, Brooks SL. Dosimetry
of two extraoral direct digital imaging
devices: NewTom cone beam CT and Orthophos
Plus DS panoramic unit. Dentomaxillofac Radiol.
2003;32:229–34.
14. Ludlow JB, Davies-Ludlow LE, Brooks SL, et
al. Dosimetry of 3 CBCT devices for oral and
maxillofacial radiology: CB Mercuray, NewTom
3G and i-CAT. Dentomaxillofac Radiol. 2006;35:
219–26.
15. Ludlow JB, Ivanovic M. Comparative dosimetry of
dental CBCT devices and 64-slice CT for oral and
maxillofacial radiology. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2008;106:106–14.
16. Okano T, Harata Y, Sugihara Y, et al. Absorbed and
effective doses from cone beam volumetric imaging
for implant planning. Dentomaxillofac Radiol.
2009; 38:79–85.
17. Qu XM, Li G, Ludlow JB, et al. Effective radiation
dose of ProMax 3D cone-beam computerized tomography
scanner with different dental protocols.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2010;110:770–6.
18. Loubele M, Bogaerts R, Van Dijck E, et al. Comparison
between effective radiation dose of CBCT
and MSCT scanners for dentomaxillofacial applications.
Eur J Radiol. 2009;71:461–8.
19. Sur J, Seki K, Koizumi H, et al. Effects of tube
current on cone-beam computerized tomography
image quality for presurgical implant planning in
vitro. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2010;110(3):e29–33.
20. Hatcher DC. Operational principles for conebeam
computed tomography. J Am Dent Assoc.
2010;141(suppl 3): 3S–6S.
21. Silva MA, Wolf U, Heinicke F, et al. Cone-beam
computed tomography for routine orthodontic
treatment planning: A radiation dose evaluation. Am
J Orthod Dentofacial Orthop. 2008;133:640.e1–5.
22. Pauwels R, Beinsberger J, Collaert B, et al. Effective
dose range for dental cone beam computed
tomography scanners. Eur J Radiol. 2010;81:
267–71.
23. Coppenrath E, Draenert F, Lechel U, et al. [Crosssectional
imaging in dentomaxillofacial diagnostics:
Dose comparison of dental MSCT and
NewTom 9000 DVT]. Rofo. 2008;180:396–401.
24. Ludlow JB. A manufacturer’s role in reducing the
dose of cone beam computed tomography examinations:
Effect of beam filtration. Dentomaxillofac
Radiol. 2011;40:115–22.
25. Hirsch E, Wolf U, Heinicke F, et al. Dosimetry of
the cone beam computed tomography Veraviewepocs
3D compared with the 3D Accuitomo
in different fields of view. Dentomaxillofac Radiol.
2008;37:268–73.
26. Lofthag-Hansen S, Thilander- Klang A, Ekestubbe
A, et al. Calculating effective dose on a cone beam
computed tomography device: 3D Accuitomo
and 3D Accuitomo FPD. Dentomaxillofac Radiol.
2008;37:72–9.
27. Dreiseidler T, Neugebauer J, Ritter L, et al. Accuracy
of a newly developed integrated system for
dental implant planning. Clin Oral Implants Res.
2009;20:1,191–9.
28. Madrigal C, Ortega R, Meniz C, et al. Study of
available bone for interforaminal implant treatment
using cone-beam computed tomography. Med
Oral Patol Oral Cir Bucal. 2008;13:E307–E312.
29. Suomalainen A, Vehmas T, Kortesniemi M, et al.
Accuracy of linear measurements using dental
cone beam and conventional multislice computed
tomography. Dentomaxillofac Radiol. 2008; 37:
10–7.
30. Veyre-Goulet S, Fortin T, Thierry A. Accuracy of
linear measurement provided by cone beam computed
tomography to assess bone quantity in the
posterior maxilla: A human cadaver study. Clin
Implant Dent Relat Res. 2008;10:226–30.
31. Shiratori LN, Marotti J, Yamanouchi J, et al. Measurement
of buccal bone volume of dental implants
by means of cone-beam computed tomography.
Clin Oral Implants Res. 2011; Epub ahead of print.
32. Al-Ekrish AA, Ekram M. A comparative study of the
accuracy and reliability of multidetector computed
tomography and cone beam computed tomography
in the assessment of dental implant site dimensions.
Dentomaxillofac Radiol. 2011;40:67–75.
33. Yim JH, Ryu DM, Lee BS, et al. Analysis of digitalized
panorama and CBCT image distortion for
the diagnosis of dental implant surgery. J Craniofac
Surg. 2011;22:669–73.
34. Cremonini CC, Dumas M, Pannuti CM, et al. Assessment
of linear measurements of bone for
implant sites in the presence of metallic artifacts
using cone beam computed tomography and multislice
computed tomography. Int J Oral Maxillofac
Surg. 2011;40:845–50.
35. Angelopoulos C, Thomas SL, Hechler S, et al.
Comparison between digital panoramic radiography
and cone-beam computed tomography for
the identification of the mandibular canal as part
of presurgical dental implant assessment. J Oral
Maxillofac Surg. 2008;66(10):2,130–5.
36. Bornstein MM, Balsiger R, Sendi P, et al. Morphology
of the nasopalatine canal and dental implant
surgery: A radiographic analysis of 100 consecutive
patients using limited cone-beam computed
tomography. Clin Oral Implants Res. 2011;22:
295–301.
37. Chan HL, Brooks SL, Fu JH, et al. Cross-sectional
analysis of the mandibular lingual concavity using
cone beam computed tomography. Clin Oral
Implants Res. 2011;22:201–6.
38. Lofthag-Hansen S, Grondahl K, Ekestubbe A.
Cone-beam CT for preoperative implant planning
in the posterior mandible: Visibility of anatomic
landmarks. Clin Implant Dent Relat Res.
2009;11:246–55.
39. Mah P, Reeves TE, McDavid WD. Deriving Hounsfield
units using grey levels in CBCT. Dentomaxillofac
Radiol. 2010;39:323–5.
40. Corpas Ldos S, Jacobs R, Quirynen M, et al.
Peri-implant bone tissue assessment by comparing
the outcome of intraoral radiograph and
cone beam computed tomography analyses to
the histological standard. Clin Oral Implants Res.
2011;22:492–9.
41. Isoda K, Ayukawa Y, Tsukiyama Y, et al. Relationship
between the bone density estimated by CBCT
and the primary stability of dental implants. Clin
Oral Implants Res. 2011; Epub ahead of print.
42. Naitoh M, Hirukawa A, Katsumata A, et al. Prospective
study to estimate mandibular cancellous
bone density using large-volume cone-beam computed
tomography. Clin Oral Implants Res. 2010;
21:1,309–13.
43. Song YD, Jun SH, Kwon JJ. Correlation between
bone quality evaluated by cone-beam computerized
tomography and implant primary stability.
Int J Oral Maxillofac Implants. 2009;24:59–64.
– Use of Cone Beam Computed Tomography in Implant Dentistry – 83

Use of Cone Beam Computed Tomography in Implant Dentistry
44. Aranyarachkul P, Caruso J, Gantes B, et al. Bone
density assessments of dental implant sites: 2.
Quantitative cone-beam computerized tomography.
Int J Oral Maxillofac Implants. 2005;20:
416–24.
45. Ritter L, Reiz SD, Rothamel D, et al. Registration
accuracy of three-dimensional surface and cone
beam computed tomography data for virtual implant
planning. Clin Oral Implants Res. 2011; Epub
ahead of print
46. Worthington P, Rubenstein J, Hatcher DC. The role
of cone-beam computed tomography in the planning
and placement of implants. J Am Dent Assoc
2010;141(suppl 3):19S–24S.
47. Fornell J, Johansson LA, Bolin A, et al. Flapless,
CBCT-guided osteotome sinus floor elevation with
simultaneous implant installation. I: Radiographic
examination and surgical technique. A prospective
1-year follow-up. Clin Oral Implants Res.
2012;23:28–34.
84
48. Nickenig HJ, Eitner S. Reliability of implant
placement after virtual planning of implant positions
using cone beam CT data and surgical
(guide) templates. J Craniomaxillofac Surg. 2007;
35:207–11.
49. Murat S, Kamburoglu K, Ozen T. Accuracy of a
newly developed CBCT-aided surgical guidance
system for dental implant placement: An ex vivo
study. J Oral Implantol. 2011; Epub ahead of print.
50. Patel N. Integrating three-dimensional digital technologies
for comprehensive implant dentistry.
J Am Dent Assoc. 2010;141(suppl 2):20S–24S.
51. Heiland M, Pohlenz P, Blessmann M, et al. Navigated
implantation after microsurgical bone transfer
using intraoperatively acquired cone-beam computed
tomography data sets. Int J Oral Maxillofac
Surg. 2008;37:70–5.
52. Naitoh M, Nabeshima H, Hayashi H, et al. Postoperative
assessment of incisor dental implants using
cone-beam computed tomography. J Oral Implantol.
2010;36:377–84.
53. Schulze RK, Berndt D, d’Hoedt B. On cone beam
computed tomography artifacts induced by titanium
implants. Clin Oral Implants Res. 2010;21:
100–7.
54. Carter L, Farman AG, Geist J, et al. American academy
of oral and maxillofacial radiology executive
opinion statement on performing and interpreting
diagnostic cone beam computed tomography.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2008;106:561–2.
Reprinted with permission from Wolters Kluwer Health.
Benavides E, Rios HF, Ganz SD, et al. Use of cone
beam computed tomography in implant dentistry:
the International Congress of Oral Implantologists
consensus report. Implant Dent. 2012;21(2):78–86.
Copyright © 2012 by Lippincott Williams & Wilkins

Residual Cement Removal, Titanium Scalers
and Successful Restorations
with Susan S. Wingrove, RDH
thE PLACEMENt OF CEMENt-REtAINED CROWNs, though
popular, may leave behind residual cement that can be
difficult to remove from subgingival areas. The effective
removal of residual subgingival cement can help prevent
soft tissue inflammation, gingival bleeding, crestal bone
loss and peri-implant disease. Because implant restorations
can greatly benefit from the timely identification and
removal of cement residue, a firm understanding of the
latest methods and tools for detecting and eliminating it
is useful.
Detecting residual cement early on offers the best chance
of correcting a problem before it can compromise bone
Figure 1: Inspecting for cement residue with dental tape floss
Courtesy of Dr. Peter Fritz
CLINICAL
tip
and soft tissue healing. When inspecting subgingivally for
cement residue, use dental tape floss. Insert the floss so it
contacts both sides of the implant and wraps around in a
circle, crisscrossed at the front (Fig. 1). Switch hands and
move the floss in a shoe-shine motion in the peri-implant
crevice. Check the floss — if it is frayed or roughened, then
cement or calculus is present.
In addition to physically inspecting around the implant with
dental tape floss or a titanium scaler, a radiograph should
be taken to check for the presence of cement residue
(Fig. 2). 1 However, many cements are not radiopaque, making
them difficult to detect via radiograph. This emphasizes
Figure 2: Radiograph showing presence of residual cement
Courtesy of Dr. John Remien
– Clinical Tip: Residual Cement Removal, Titanium Scalers and Successful Restorations – 85

the importance of physically inspecting around the implant
and using an opaque cement that can be detected via periapical
radiograph.
The removal of cement residue will increase the likelihood
of a complication-free implant. When residual cement is
present, it may be necessary to anesthetize the patient in the
affected area with topical or local anesthetic so the cement
can be effectively scaled away. Debriding is accomplished
by using a titanium implant scaler to dislodge the cement
using short horizontal strokes (Fig. 3) and curetting any
granulation tissue. 2 Great care should be taken when
removing residual cement to minimize trauma to the periimplant
tissue.
The advantages of biocompatible titanium scalers in the
removal of residual cement are substantial. 3 The use of
graphite or plastic cleaning instruments can leave tracings
of plastic and graphite embedded in the rougher surfaces
of modern implants, which can lead to peri-implantitis. 4
Titanium implant scalers fabricated from medical grade
23 titanium are strong enough to remove the hardest
cements. At the same time, titanium implant scalers should
have a low-enough Rockwell hardness to avoid scratching
the surfaces of modern and older implants.
Re-evaluate three to six weeks after residual cement has
been removed for inflammation, which might indicate that
residual cement is still present.
The healing of bone and soft tissue is crucial to the success
of implant restorations, and the importance of detecting
and removing cement residue cannot be overstated.
Residual cement must be eliminated in a timely manner
to help ensure the best possible outcome for the implant
restoration. 3 Areas around the implant should be inspected
following placement of the crown and closely monitored
in follow-up appointments. By utilizing the tools and
technology available to modern dentistry, the threat that
residual cement poses to implant restorations can be
confidently and effectively mitigated. IM
ReFeRences
1. Wadhwani C, Hess T, Faber T, Piñeyro A, Chen CS. A descriptive study of the
radiographic density of implant restorative cements. J Prosthet Dent. 2010 May;
103(5):295-302.
2. Wingrove S. Peri-implant therapy for the dental hygienist: clinical guide to maintenance
and disease complications. Wiley-Blackwell. 2013.
3. Wadhwani CP, Piñeyro AF. Implant cementation: clinical problems and solutions.
Dent Today. 2012 Jan;31(1):56, 58, 60-2.
4. Fox SC, Moriarty JD, Kusy RP. The effects of scaling a titanium implant surface
with metal and plastic instruments: an in vitro study. J Periodontol. 1990 Aug;
61(8):485-90.
86
– www.inclusivemagazine.com –
The removal of cement residue
will increase the likelihood of
a complication-free implant....
Great care should be taken
when removing residual
cement to minimize trauma
to the peri-implant tissue.
Courtesy of Dr. Alfonso Piñeyro
Figure 3: Removal of hard cement residue with a titanium scaler

Intraoral Scanning
for Accurate
Optical Impressions by Michael McCracken, DDS, Ph.D
When I made my first optical
impression for an implant
crown using an Inclusive ®
Scanning Abutment from Glidewell
Laboratories, I remember thinking
how wonderful it would be if this
technique turned out to be as good
as my regular technique. No impression
material, no stone casts, no bite
registration, not even a pen. It never
occurred to me that the digital impression
technique might be better. But
after trying it, I am convinced that it is.
The standard implant impression involves
putting a machined abutment
on the implant, and capturing the
position and location of the implant
with an elastomeric material, such
as polyvinyl siloxane (PVS). The lab
pours the cast in stone with an analog,
articulates an opposing cast, and fabricates
a crown. However, each clinical
step introduces the possibility of error.
No PVS material is perfect. It may distort
a bit during the chemical reaction
upon setting, even more when you
remove it from the mouth — especially
if you have an implant with a
bit of facial angulation. There is the
potential for error in the setting of
the stone, and in the opposing alginate
impression your assistant makes.
The most difficult step is the centric
jaw relation record, which must be
88
Coming soon to the pages of Inclusive
carefully recorded, trimmed and used
for an accurate relationship. All of this
combines to give us a crown that may
require a bit of adjustment upon seating,
such as lightly modifying the
proximal contacts or the occlusion to
get it to fit. Deemed “clinically acceptable,”
we proceed to polish the crown
and send the patient home.
I find, though, that when I use the
optical impression technique for my
implant crowns, my crowns fit much
better. In fact, of my last two dozen
implant crown insertions made with
an optical technique, I only had to
adjust two of them. Not bad for routine
clinical dentistry! It saves me a lot
of time, and I preserve the esthetics
and finish of the crown.
I am now realizing that making optical
impressions is more accurate than
traditional techniques. There is very
little error in the scan, so my proximals
are perfect. Instead of using a bite
registration material, I am capturing the
relationship with a digital scan, so the
occlusion is more accurate. Altogether,
I feel like I am delivering better quality
and more efficient dentistry, which is a
beautiful thing.
Here is how you do it. First, order an
Inclusive Scanning Abutment from
Glidewell. These are made for every
major implant platform and are
available in long (anterior) or short
(posterior) varieties. I typically use the
short one, as it is better suited to the
vertical limitations encountered in the
oral environment.
Attach the abutment onto the implant
using the abutment’s internal screw,
and make sure it is fully seated with a
radiograph. Next, scan the abutment to
make your digital impression. I usually
just scan the quadrant if I have only one
implant. I like using the IOS FastScan ®
(IOS Technologies; San Diego, Calif.)
for this because it has a large scan field,
but other scanners can also be used.
Finally, scan the interocclusal relationship
with the patient closed. If the
patient hits the scanning abutment
when closing, simply remove it and
scan the teeth adjacent to the edentulous
space with the patient in centric.
That’s it!
I then fill out the digital prescription on
the computer, and the file is e-mailed
directly to Glidewell. In a few days, I
get a milled titanium custom abutment
and an all-ceramic crown in a small
box from the lab. It feels a bit odd at
first — no stone model, no analog, no
little implant bits floating around in the
box. But once you try it in, you’ll be
hooked on a more accurate and efficient
way to make implant crowns. IM
Dr. McCracken is currently compiling data in a prospective clinical trial that compares the digital impression technique to conventional implant im pression techniques.
Look for his article, “Optical and Conventional Implant Impression Techniques: A Comparison” in a future issue of Inclusive magazine.
– www.inclusivemagazine.com –