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Inclusive®
Restorative Driven Implant Solutions
Vol. 1, Issue 2
A Mulitimedia Publication of Glidewell Laboratories
Hygiene and the
Implant Patient:
A Preventive
Perspective (Page 32)
Optimizing Implant
Placement and
Aesthetics: Technology
to the Rescue by
Dr. Timothy Kosinski (Page 6)
Dr. Bradley Bockhorst
The Importance of the
Scan Appliance (Page 20)
Dr. John Kois on
Predictable Peri-Implant
Esthetic Outcome (Page 11)
CAD/CAM Custom
Abutments Using
3-D Virtual Design (page 28)

inclusivemagazine.com
Here’s some of what you’ll find online at inclusivemagazine.com:
– Original clinical videos
“Optimizing Implant Placement and
Aesthetics: Technology to the Rescue!”
by Dr. Timothy Kosinski
– Exclusive video lectures
Watch Glidewell Director of Business Development Greg
Minzenmayer walk you through the process of fabricating
an Inclusive ® Custom Abutment using 3-D virtual design.
– Photo Essays
Dr. John Kois illustrates a case demonstrating
the five diagnostic keys for predictable
single-tooth peri-implant esthetics.
– Free CE credit
Log on to take short tests
worth 2 CE credits, at no charge to you.
– Plus…
Inclusive magazine’s editor-in-chief looks at
the importance of the scan appliance.
When you see this icon at the end of an article, it means we have even more information on that topic
available online. Take advantage of Inclusive magazine’s interactivity by logging on for in-depth coverage.
Check out
inclusivemagazine.com
to see what the implant
industry is buzzing about.

Contents
Features
26 R&D Corner:
A Tightening Technique to Minimize
Loosening of Prosthetic Screws
by Grant Bullis
31 Product Spotlight:
BioTemps ® Over Implants
by Robert Rosen, CDT
6
11
20
28
32
Optimizing Implant Placement and Aesthetics:
Technology to the Rescue!
Dr. Timothy Kosinski presents a case study, utilizing digital treatment
planning and guided surgery, for a maxillary anterior reconstruction.
Included is extraction and immediate implant placement
and temporization through delivery of the final restorations.
Predictable Single-Tooth Peri-Implant Esthetics:
Five Diagnostic Keys
Dr. John Kois presents a discussion on diagnostic factors such as
relative tooth position, form of the periodontium, biotype of the
periodontium, tooth shape and position of the osseous crest in his
article on accurately predicting the peri-implant esthetic outcome
before removal of a failing tooth.
Digital Implant Treatment Planning:
The Importance of the Scan Appliance
Editor-in-Chief Dr. Bradley Bockhorst offers an overview of the
critical role of the scan appliance in digital treatment planning
and guided implant surgery. This article is designed to aid the
clinician’s understanding of the benefits as well as the proper use
of the scan appliance.
Inclusive ® Custom Abutments Using 3-D Virtual
Design
Greg Minzenmayer, Director of Business Development for Implants
at Glidewell Laboratories, offers an introduction to the lab’s
line of precision-milled CAD/CAM custom abutments. He discusses
the results provided thanks to the use of a 3-D virtual design
process. Read the overview here and be sure to watch Greg’s full
demonstration at inclusivemagazine.com.
Hygiene and the Implant Patient:
A Preventive Perspective
Ann Drewenski, RDH, stresses the role hygiene plays in the success
of implant restorations. She advocates that routine evaluation,
regular maintenance and patient education and commitment will
help implants last a lifetime.
– Contents – 1

Letter from the Editor
Welcome to the second issue of Inclusive. On behalf of everyone on the Inclusive team,
I’d like to thank you for your kind feedback on the inaugural issue. Hopefully you all
had a chance to visit inclusivemagazine.com and view the expanded articles, videos and
CE opportunities. Our second issue contains an equal variety of information, from how
to prevent prosthetic screw loosening to how to maintain your implants once they have
been restored.
As part of our services, we will include milestone articles that have been published previously.
One of these is Dr. John Kois’ article on predictable single-tooth peri-implant
esthetics. This is a must-read article for any dentist considering restoring implants in the
esthetic zone.
Speaking of esthetics, we also have a case report from Dr. Timothy Kosinski that involves
extraction, immediate implant placement and provisionalization of the maxillary incisors
utilizing digital treatment planning and guided surgery. Online you will find video footage
of the procedure, as well as a wonderful patient testimonial.
The dental world has gone CAD/CAM, and Glidewell Laboratories has incorporated
many of these technologies to provide you with a more precise, consistent product. Greg
Minzenmayer, Director of Business Development, walks you through the virtual design
and milling of Inclusive ® Custom Implant Abutments and explains how they can benefit
you and your patients.
Another technology that has generated a tremendous amount of interest and continues
to gain popularity is digital treatment planning of implant cases utilizing CT or CBCT
scans. A key to making the most out of this technology is the scan appliance. The proper
fabrication and use of this appliance is critical, as it presents the ideal positions of the
teeth to be replaced. We have included an overview of the types of scan appliances, as
well as their role in the procedure.
In this issue’s R&D Corner, find out how to accomplish recommended torque to reduce
the occurrence of screw loosening with a simple technique.
As always, we welcome your feedback. We look forward to receiving your questions and
comments, and we are excited to hear what you would like to see in future issues.
Regards,
Dr. Bradley C. Bockhorst
Editor-in-Chief, Clinical Editor
inclusivemagazine@glidewelldental.com
– Letter from the Editor – 3

Publisher
Jim Glidewell, CDT
Editor-in-Chief
Bradley C. Bockhorst, DMD
Managing Editors
Jim Shuck; Mike Cash, CDT
Creative Director
Rachel Pacillas
Clinical Editor
Bradley C. Bockhorst, DMD
Contributing editors
Dzevad Ceranic, Greg Minzenmayer
Copy EditorS
Melissa Manna, Kim Watkins
Magazine/AD Coordinators
Lindsey Lauria, Vivian Tsang
Graphic Designers/Web Designers
Jamie Austin, Deb Evans, Joel Guerra, Lindsey Lauria,
Phil Nguyen, Gary O’Connell, Rachel Pacillas
Staff Photographers/Clinical Images
Jennifer Brunst, RDAEF; Sharon Dowd;
James Kwasniewski
IllustratIONS
Kevin Greene, Phil Nguyen
Ad Representative
Vivian Tsang (vivian.tsang@glidewelldental.com)
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 Web site.
© 2010 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.
Contributors
■ Bradley C. Bockhorst, DMD
After receiving his dental degree from
Washington University School of Dental
Medicine, Dr. Bradley Bockhorst served
as a Navy Dental Officer. Today, Dr. Bockhorst
is Director of Clinical Technologies
at Glidewell Laboratories, where he oversees
Inclusive ® Digital Implant Treatment
Planning Services and is editor-in-chief and clinical
editor of Inclusive magazine. A member of the CDA,
ADA, the Academy of Osseointegration, International Congress
of Oral Implantologists and the American Academy
of Implant Dentistry, Dr. Bockhorst lectures internationally
on an array of dental implant topics. He maintains
a private practice focused on implant prosthetics in Mission
Viejo, Calif. Contact Dr. Bockhorst at 800-521-0576 or
inclusivemagazine@glidewelldental.com.
■ GRANT BULLIS
Grant Bullis, Glidewell Laboratories Research
& Development Department Manager,
began his career in the dental industry
at Steri-Oss in 1997. After Nobel Biocare
acquired Steri-Oss, Grant worked in the
R&D Department, where he was responsible
for the development of implants, prosthetics,
surgical tools and packaging. Grant, who joined
Glidewell Laboratories in 2007, now manages CAD/CAM
and implant product development at the lab. He directs
manufacturing for more than 150 implant laboratory and
prosthetic components. Grant has a degree in mechanical
CAD/CAM from Irvine Valley College in Orange County,
Calif., and an MBA from Keller Graduate School of Management.
To contact Grant, call 800-521-0576 or e-mail
inclusivemagazine@glidewelldental.com.
Inclusive is a registered trademark of Glidewell Laboratories.
4
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■ Dzevad Ceranic, CDT
Dzevad Ceranic, a graduate of Pasadena
City College’s two-year dental technology
program, began at Glidewell in 1999 as
a wax and metal finisher. He quickly was
promoted to the position of ceramist. Later,
Dzevad became manager of the Full-Cast
Department, overseeing a team of more
than 70 employees. In this role, Dzevad was part of the
team that facilitated the lab’s transition to CAD/CAM. In
2008, Dzevad was handpicked to manage Glidewell’s Implant
Department, where he leads a team of 100. Recently,
Dzevad completed an eight-month implants course at
UCLA School of Dentistry. Contact him at 800-521-0576 or
inclusivemagazine@glidewelldental.com.
■ TIMOTHY F. KOSINSKI, DDS, MAGD
Dr. Timothy Kosinski graduated from the
University of Detroit Mercy School of Dentistry
and received an MS degree in biochemistry
from Wayne State University
School of Medicine. He is an adjunct assistant
professor at the Mercy School of Dentistry
and serves on the editorial review board
of numerous dental journals. Dr. Kosinski
is a Diplomate of ABOI/ID, ICOI and AO. He is a Fellow
of the American Academy of Implant Dentistry and
received his Mastership in the AGD, from which he received
the 2009 Lifelong Learning and Service Recognition honor.
Contact Dr. Kosinski at 248-646-8651, drkosin@aol.com or
smilecreator.net.
■ Ann M. Drewenski, RDH
Ann Drewenski has been in clinical practice
since 1997. She is a member of the
American Dental Hygiene Association
and has served on the board of trustees
for the Chicago component of the ADHA.
Ann has lectured alongside Dr. Russell A.
Baer, conducting presentations in the Chicago
area on implant maintenance and
implant longevity. Her professional affiliations include the
American Academy of Cosmetic Dentistry and the American
Academy of Laser Dentistry. To contact Ann, e-mail
inclusivemagazine@glidewelldental.com.
■ Greg Minzenmayer
Glidewell Laboratories Director of Business
Development Greg Minzenmayer
joined the lab in 2006. With a career in
the dental industry that spans nearly 15
years, Greg has a proven track record in
sales, product management, marketing
and business development. Greg attended
Chapman University in Orange, Calif. In
1994, he began at Den-Mat and in 1996 moved to Steri-
Oss. In 1998, Steri-Oss was acquired by Nobel Biocare, and
Greg was later promoted to product manager in charge of
the Steri-Oss family of products. In 2002, he was promoted
to Director of Marketing for the Americas. Contact him at
inclusivemagazine@glidewelldental.com.
■ John C. Kois, DMD, MSD
Dr. John Kois is a graduate of the
UPenn School of Dental Medicine. He
holds an MSD/Certificate in Periodontal
Pros-thodontics. Dr. Kois maintains a private
practice focused on prosthodontics in
Seattle-Tacoma, Wash., and is an affiliate
professor at UW. He is reviewer for the
International Journal of Prosthodontics
and is a member of the editorial board for the Compendium
of Continuing Education in Dentistry. A member of
AARD and AAED, Dr. Kois works with dentists at the Kois
Center, a didactic and clinical teaching program. Contact
him at 206-515-9500 or drkois.com.
■ Robert rosen, CDT
Robert began his career in dental technology
in 1973 and received his Dental Technology
degree from Albrecht Dürer College
in Düsseldorf, Germany, in 1977. After
serving in the German Air Force from
1977 to 1979, Robert promptly returned to
work as a CDT in various German dental
laboratories. He joined Glidewell Laboratories in 1986
and helped establish the BioTemps Department, which focuses
on creating highly esthetic provisional restorations.
In 2002, Robert became president of BDL Prosthetics, a
comprehensive fixed ceramics lab, where he currently leads
350 employees. To contact Robert, visit bdlprosthetics.com
or call 800-411-9723.
– Contributors – 5

Optimizing Implant
Placement and Aesthetics:
Technology to the Rescue!
by Timothy F. Kosinski, DDS, MAGD
The continually evolving science of implant dentistry has
led to a growing recognition that many treatment options
offer predictable long-term results. Dental implants have certainly developed
into a viable alternative to conventional prosthodontic reconstruction
of edentulous spaces, and have afforded us a restorative tool for use
in difficult aesthetic cases. Optimizing aesthetics in the anterior maxillary
incisor area is critical to a successful outcome.
The therapeutic goal of implant dentistry is not merely tooth replacement,
but total oral rehabilitation. Implants provide excellent support
for fixed appliances, increasing function as compared to conventional
dental therapies. Implant dentistry has gone through many phases over
the years. Modern design allows us to predictably place dental implants
in immediate extraction sites. 1-3 Single tooth-by-tooth reconstruction provides
the patient with easy access to floss and clean the affected area
compared with the relative difficulty of maintaining splinted crowns.
There is now a low risk of abutments loosening under function, as was
the case in the past.
This case study will serve to demonstrate a maxillary anterior reconstruction
using immediate placement of dental implants, following diagnosis
using Computed Tomography (CT) scanning software, immediate
loading using transitional abutments, splinted composite crowns, and
dynamic and aesthetic smile design using zirconia abutments and freestanding
all-ceramic crowns. 4-6
Advantages of Computed
Tomography Scanning Technology
Figure 1: NobelGuide software is used to idealize implant
size and position.
Figure 2: Virtually planning the case proves a tremendous
advantage.
CT scanning is becoming more and more prevalent for use in ensuring
proper dental implant placement. Bitewings, periapicals, panoramic
radiographs, and even medical CT scans only give a two-dimensional
image for implant planning. One of the latest CT planning software programs
(NobelGuide CT [Nobel Biocare; Yorba Linda, CA]) provides as
much information as possible to assist during surgical planning.
We can now visualize vital anatomy in 2-D and 3-D prior to surgery, and
can virtually assess the location of implants prior to surgical intervention.
7 Diagnosing anatomic issues specific to the patient, planning the
implant type, and determining position and orientation in the bone are
Figure 3: Retracted view of preoperative dentition.
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all easily accomplished with the help of this technology. The process is
both user-friendly and intuitive.
NobelGuide CT scanning software, as demonstrated in this article, allows
us to simulate the placement of implants accurately prior to surgery. A
Surgical Template created from the 3-D images helps place the implants in
the proper positions, without the need for a flap incision. 8,9 This technique
proves to be a cost-effective solution for assisting the implant dentist in the
planning of an aesthetic final result and minimizing any surgical challenges
that are faced. The CAD/CAM planning and placement system supplied
by NobelGuide provides a high level of comfort and safety for the patient
by reducing surgical and restorative time. This is done by utilizing an accurate
3-D plan prior to implant placement. There are obvious advantages,
including: easy visual understanding for clear case presentation, reduced
surgical chairtime, reduced restorative chairtime in certain cases, reduced
stress for the clinician and the patient, the avoidance of surprises during
surgery, implants that are placed optimally for long-term implant and prosthetic
success and, most importantly, an improved aesthetic result. 10-12
Figure 4: This radiograph illustrates severe root resorption.
Computed Tomography
Scanning Technique
Prior to the CT scan, a Radiographic Guide is fabricated. This will serve
to aid in the visualization of the optimal prosthetic outcome. The teeth
are positioned properly in wax, and then a master cast is fabricated to
illustrate what the case will look like finished before ever starting. All appropriate
dental anatomy is included. The Radiographic Guide is placed in
the mouth during the CT scan. This allows us to see the ideal position of
the teeth on a 3-D model. The entire 3-D image is analyzed and the implant
planning and simulation of implant placement completed using the computer
(Fig. 1, 2). The surgical placement of dental implants can be done in
a conventional manner using the newly created Surgical Template to help
direct the implant in the ideal position. However, optimally the surgery can
be completed without making any incisional flap. The implants are placed
to the desired depth using the computer software and Surgical Template.
Figure 5: Laboratory casts and components used for immediate
transitional splinted crowns for teeth #7-10.
Materials and Methods:
Advantages of Tapered Design
Nobel Biocare’s Replace Implant System has evolved considerably since
its introduction in 1997. The implants and all related surgical and prosthetic
components incorporate a color-coded system that allows users to
identify at a glance which restorative parts go with which size implant
placed. In 1999, the Replace Tapered Implants became available with an
internal connection that simplifies the impression technique, seating of
abutments and crown & bridge placement. Three locking channels guide
the positioning of the abutment. Once torqued into place, the zirconia
abutment does not loosen, making single-tooth restoration reliable. The
system can be used in one- or two-stage surgical procedures. Primary
stability is the key factor for successful early and immediate loading.
The tapered design of Replace Select gives placement alternatives in sites
with anatomical limitations, such as labial concavities in the premaxilla
and converging adjacent tooth roots. Since they approximate the shape
of a natural tooth root, they provide better stability in extraction sites.
Figure 6: Laboratory casts and components used for immediate
transitional splinted crowns for teeth #7-10.
Figure 7: Flapless extraction site.
– Optimizing Implant Placement and Aesthetics: Technology to the Rescue! – 7

There are several collar heights and designs available in these titanium
surface-treated (TiUnite; Nobel Biocare) implants, including no collar,
1.5 mm and 2 mm. The shorter collar designs are indicated for aesthetic
areas. Nobel Biocare’s NobelProcera process produces custom-shaped
zirconium oxide abutments to create the most natural form and emergence
profile. The ultimate aesthetic solution, especially for patients with
a high smile line and thin tissue, is achieved using NobelProcera abutments.
Every aspect of the implant system makes the restoration of teeth
on implants as easy as crown & bridge. 13-15
The Replace Select implant has a tapered body and an internal prosthetic
connection. The internal connection is tri-channeled. The internal
lengths of the channels are approximately 1.5 mm. The implant has a
wide crestal interface with a tapered thread design. The diameters, at the
crest of the implant, are 3.5 mm, 4.3 mm, 5 mm and 6 mm. This allows
for a better emergence profile from the top of the implant. Anatomical
considerations for the use of the implant include converging roots and
concavities with the bone, which makes placing a parallel-walled implant
more difficult. Interface of the implant increases dramatically as implant
diameter increases. This may be more relevant than implant length.
The tapered design of the implant promotes elevated levels of fatigue
endurance because the coronal portion is wider in diameter than the
apical portion. This taper also ensures a tight fit and promotes function
coronally to help offset stress shielding along the narrow, smooth crestal
band on the implant. This reduces bone resorption that may result from
hypo function, which is especially important during placement of the
implant in a fresh extraction site.
Figure 8: NobelGuide Surgical Template with precision
openings for drills.
Figure 9: The NobelGuide Surgical Template with precision
openings for drills is placed in the mouth.
Taper also reduces the incidence of cortical plate bone perforation during
osteotomy preparation near anatomic undercut areas and protects
adjacent natural tooth roots. Also, the tapered design of the implant
often allows for better angulation of the implant. It is important to have
an implant design that allows for placement of the fixture in a way that
places the forces down the long axis. The implant has versatility and allows
for aesthetic and variable bone morphology.
Case Report
A 38-year-old female presented with mobile maxillary anterior lateral
and central incisors. These teeth had been orthodontically treated in the
years before, resulting in resorption, mobility and aesthetic problems
(Fig. 3). Her main concerns were that she would have to go without teeth
for any length of time, or the possibility of having to wear a removable
appliance. The patient requested something she referred to as “teeth in
a day.” Oral and radiographic evaluation indicated severe root resorption
around teeth #7-10 (Fig. 4). Her teeth were deemed to be untreatable
using traditional dental techniques.
Figure 10: Surgical Template in place with narrow platform
guide, used for pilot drill angulation and depth.
Diagnosis and Treatment Planning
The decision was made to have a Cone Beam CT scan done and evaluated
using the NobelGuide software. Virtually placing the dental implants
using the computer, prior to ever touching the patient, would prove to
be a tremendous advantage in diagnosing and preparing for this case
(Fig. 5, 6).
Figure 11:. A 3.5 mm surgical drill is used.
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There were no medical conditions, allergies or sensitivities that would preclude
the use of necessary implant procedures or medications. Because
there was no need to work around any habits involving the use of nicotine
or alcohol, healing was expected to be good and uncomplicated.
Proper diagnosis for dental reconstruction is the most critical aspect of
any surgical intervention. Determining the design of the final prosthetic
reconstruction may be the most difficult procedure. It is this author’s belief
that the restoring dentist should be dictating dental implant position
and angulation prior to surgical placement. To help achieve this goal,
Diagnostic Wax-Ups, modern computer-generated scanning or simple
common-sense design should be considered.
The Diagnostic Wax-Up is an invaluable aid in determining the proper
placement of implants in the center, between the proposed abutment
teeth. The wax-up is particularly valuable when cement-retained or screwretained
crown & bridge is planned. NobelGuide software is used to create
a Surgical Template that is used pre-surgically in determining the ideal
location and angulation of the implant site, and to optimize placement of
dental implants for maximum aesthetic and functional results.
Figure 12: A 3.5 mm Replace Select (Nobel Biocare)
dental implant treated to depth and angulation using the
Surgical Template.
Surgical Template, Extractions
and Implant Placement
Prior to extraction of the mobile teeth (Fig. 7), a surgical template was
fabricated using a master cast of the patient’s existing bridgework (Fig.
8, 9). Tapered drills of increasing widths were used to prepare the bone
to accept the proper-size implant. Replace Select 3.5 x 13 mm dental implants
were guided into place using the NobelGuide surgical template in
the #7 and #10 areas, and 4.3 x 13 mm Replace Select implants surgically
guided into the #8 and #9 areas (Fig. 10, 11).
A color-coded threadformer, corresponding to the implant diameter selected,
was then used. The maximum recommended setting is 30 rpm.
Firm pressure was applied to the threadformer and it was rotated slowly.
Once the threads were engaged, the threadformer was allowed to feed
without pressure. The osteotomy was threaded to the single depth reference
line on each drill. The dental implants were then removed from
their sterile packaging and threaded into the prepared site. When more
torque is needed to complete the placement, a ratchet and insertion assembly
is used to place the implant to its final depth. A marking indicates
that one of the three tri-channeled internal connections is placed to the
facial (Fig. 12-14).
Figure 13: A 4.3 mm Replace Select dental implant is positioned.
Figure 14: Implants placed ideally with flapless procedure.
Immediate loading of dental implants has proven to be a predictable
method of improving emergence profile and smile design. The Nobel
Biocare immediate temporary abutments were used to secure transitional
splinted crowns and allow the gingiva to respond positively (Fig. 15).
Immediate aesthetics and function were achieved (Fig. 16). Simple colorcoded
transfer assembly can duplicate the position of the dental implant
on a working cast. NobelProcera abutments were reshaped in the dental
laboratory with slightly subgingival margins. These abutments were tightened
to 35 Ncm to ensure that they would not loosen (Fig. 17).
Figure 15: Immediate conical abutments positioned.
– Optimizing Implant Placement and Aesthetics: Technology to the Rescue! – 9

Summary
The goal for this patient
was to create an aesthetic
smile design using individual
dental implants to
reconstruct the edentulous
spaces. NobelProcera
crowns aesthetically restored
the separate and distinct
teeth (Fig. 18, 19). The
patient was thrilled with the
final aesthetic result, and
she was able to smile confidently
again (Fig. 20). n
Figure 16: Retracted view of transitional splinted crowns,
cemented temporarily during healing.
Figure 17: NobelProcera abutments torqued into position.
References
1. Locante WM. Single-tooth replacements in the esthetic zone with an immediate function implant: a
preliminary report. J Oral Implantol. 2004;30:369-375.
2. 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 followup
of up to 24 months. Int J Oral Maxillofac Implants. 2005;20:99-107.
3. Villa R, Rangert B. Early loading of interforaminal implants immediately installed after extraction of
teeth presenting endodontic and periodontal lesions. Clin Implant Dent Relat Res. 2005;7(suppl
1):28-35.
4. Glauser R, Rée A, Lundgren A, et al. Immediate occlusal loading of Brånemark implants applied
in various jawbone regions: a prospective, 1-year clinical study. Clin Implant Dent Relat Res.
2001;3:204-213.
5. Lozada JL, Ardah AJ, Rungcharassaeng K, et al. Immediate functional load of mandibular implant
overdentures: a surgical and prosthodontic rationale of 2 implant modalities. J Oral Implantol.
2004;30:297-306.
6. Ganeles J, Wismeijer D. Early and immediately restored and loaded dental implants for singletooth
and partial-arch applications. Int J Oral Maxillofac Implants. 2004;19(suppl):92-102.
7. van Steenberghe D, Glauser R, Blombäck U, et al. A computed tomographic scan-derived
customized surgical template and fixed prosthesis for flapless surgery and immediate loading of
implants in fully edentulous maxillae: a prospective multicenter study. Clin Implant Dent Relat Res.
2005;7(suppl 1):111-120.
8. 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;7:24-31.
9. Maló P, Rangert B, Nobre M. All-on-4 immediate function concept with Brånemark System implants
for completely edentulous maxillae: a 1-year retrospective clinical study. Clin Implant Dent
Relat Res. 2005;7(suppl 1):88-94.
10. Lee CY. Immediate load protocol for anterior maxilla with cortical bone from mandibular ramus.
Implant Dent. 2006;15:153-159.
11. Olsson M, Urde G, Andersen JB, et al. Early loading of maxillary fixed cross-arch dental prostheses
supported by six or eight oxidized titanium implants: results after 1 year of loading, case series.
Clin Implant Dent Relat Res. 2003;5(suppl 1):81-87.
12. Ostman PO, Hellman M, Sennerby L. Direct implant loading in the edentulous maxilla using a
bone density-adapted surgical protocol and primary implant stability criteria for inclusion. Clin
Implant Dent Relat Res. 2005;7(suppl 1):60-69.
13. Scortecci G. Immediate function of cortically anchored disk-design implants without bone
augmentation in moderately to severely resorbed completely edentulous maxillae. J Oral Implantol.
1999;25:70-79.
14. Babbush CA. Provisional implants: surgical and prosthetic aspects. Implant Dent. 2001;10:113-
120.
15. Becker W, Wong J. Early functional loading in the fully edentulous mandible after mandibular
resection and reconstruction due to anameloblastoma: case report. Clin Implant Dent Relat Res.
2003;5:47-51.
Figure 18: Individual NobelProcera crowns in place.
Figure 19: Panoramic view of implant, zirconia abutments
and crowns in place.
Reprinted with permission of Dentistry Today. Copyright ©2009 Dentistry Today, Inc.
All rights reserved.
Figure 20: Final smile line, with individual all-ceramic
crowns (NobelProcera Zirconia) in place.
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Predictable Single-Tooth
Peri-Implant Esthetics
Five Diagnostic Keys
by John C. Kois, DMD, MSD
ABSTRACT: The creation of an esthetic implant restoration with gingival architecture that harmonizes
with the adjacent dentition is a formidable challenge. The predictability of the peri-implant esthetic outcome
may ultimately be determined by the patient’s own presenting anatomy rather than the clinician’s ability to manage
state-of-the-art procedures. To more accurately predict the peri-implant esthetic outcome before removing a failing
tooth, five diagnostic keys are discussed. These keys include relative tooth position, form of the periodontium, biotype of
the periodontium, tooth shape and position of the osseous crest.
After the loss of an anterior tooth, the normal sequela of wound healing will create an unfavorable esthetic soft-tissue
complex. The remaining facial mucosa often recedes apically and palatally. 1-4 Typically, this cervical recession results
in a restoration that appears too long and may be compounded with the loss of the interdental papilla. 5 In addition,
using a single-tooth replacement minimizes the restoration and surgical options necessary to the optimal management
of the problem. Therefore, the creation of an esthetic implant restoration with gingival architecture that harmonizes
with the adjacent dentition is a formidable challenge.
Five Diagnostic Keys
To more accurately predict the peri-implant esthetic outcome
before removing a failing tooth, an understanding of five
diagnostic keys is essential:
1. Relative tooth position.
2. Form of the periodontium.
3. Biotype of the periodontium.
4. Tooth shape.
5. Position of the osseous crest.
Any of these five keys can be combined or altered independently. Ultimately, the predictability of peri-implant esthetics
may be determined by the patient’s presenting anatomy rather than the clinician’s ability to manage state-of-the-art
procedures. In addition, these five diagnostic keys will enable the clinician to develop treatment options and clinical
procedures that are more specific to the desired therapeutic outcome.
– Predictable Single-Tooth Peri-Implant Esthetics: Five Diagnostic Keys – 11

1. Relative Tooth Position
The hopeless tooth must be evaluated based on its relative position to the remaining
dentition in three planes of space because the existing tooth position
will influence the presenting configuration of the gingival architecture. The
alteration of this tooth position will be reflected by the change in the configuration
of the gingival architecture.
Gingival recession
is the most common
complication of anterior
single-tooth implants.
Figure 1a: Preoperative clinical presentation with a hopeless
right central incisor.
Figure 1b: Initial radiograph. Note the square tooth shape,
which creates thinner interproximal bone.
In the vertical (apicocoronal) plane, the cervical portion of the tooth may be
more apical, more coronal, or ideal and mimic the facial level of the free gingival
margin (FGM). After tooth removal, a minimum of 2 mm of apical migration
of the facial FGM may occur during pontic site development, and up to 1 mm
of apical migration of the facial FGM will occur during immediate implant site
development. 8,9 Therefore, hopeless teeth with the FGM 1 mm to 2 mm more
coronal to their harmonious facial gingival position are in a more favorable position
(Fig. 1a, 1b). A hopeless tooth with the FGM positioned ideally or more apically would benefit from orthodontic
extrusion before extraction (Fig. 2a, 2b). 10,11 In this way, the ensuing apical resorption after wound healing can provide
a more harmonious gingival level. In the facial-lingual plane, the tooth position may create different concerns. Teeth
positioned too far facially often result in very thin or nonexistent labial bone. These teeth compound the predictability
of determining the cervical position of the facial FGM, because there may be more vertical loss and facial collapse of
the gingival architecture. These situations are also poor candidates for orthodontic correction because of the inadequate
underlying labial bone. It would be preferable to consider grafting procedures both before and after tooth extraction
as part of a proactive treatment protocol. In contrast, a tooth positioned lingually may allow for a thicker labial portion
of bone or facial tissue. This position is more favorable before extraction because the resultant cervical discrepancy in
the facial FGM may be minimal.
The mesiodistal tooth position has two concerns. The first concern is the proximity of adjacent teeth necessary for providing
proximal support and volume of the interdental papilla. The second concern is the inclination, which contributes
to proximal support but also influences the position of the contact point. The mesially inclined tooth usually creates a
contact point more incisally located and a gingival embrasure much larger spatially, which would require more volume
to attain the same vertical height. This problem is a more significant concern when the tooth is present. When this tooth
is removed, however, the same mesial inclination may be an advantage because the interproximal bone is thicker and
at less risk of resorption after wound healing. Hopeless teeth with diastemas have similar advantages because of their
thicker interproximal bone. Teeth with root proximity possess very thin interproximal bone. This thin bone creates a
greater risk of lateral resorption, which will decrease the vertical bone height after extraction or implant management.
Ideally, interproximal bone width should be about 1.5 mm at the crest before extraction to minimize lateral resorp-
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Figure 2a: Preoperative clinical presentation with a hopeless
right central incisor.
Figure 2b: Initial radiograph. Note the triangular tooth shape,
which creates thicker interproximal bone.
tion of the osseous crest and further resorption caused by lateral violation of biologic width after implant restoration. 12
When teeth are present, the creation of close parallel roots with orthodontics is beneficial for support of the proximal
gingival architecture. However, this may be a concern when extraction of one of these teeth is necessary because of the
thinner interproximal bone at the height of the crest.
2. Form of the Periodontium
The basic human periodontal forms have been previously described. 13-15 For discussion, three categories of gingival
scallop will be included: high, normal and flat. Based on a clinical survey of 100 patients, the average or normal gingival
scallop is positioned 4 mm to 5 mm more incisally than the FGM. 16 The same clinical survey found that visually,
because a central incisor is approximately 10 mm from the facial FGM to the incisal edge, the interdental tissue will
occupy about 50 percent of the exposed tooth length. 16
Of importance is the relationship to the underlying osseous crest. In the healthy periodontium, the underlying bony
crest is about 2 mm apical to the cementoenamel junction (CEJ) and follows the scallop of the CEJ. This scallop of
the central incisors is 3.5 mm. Therefore, in the normal and high-scalloped gingival architecture, there is more tissue
coronal to the bone interproximally than facially for this scallop (Fig. 2a). The greater this discrepancy, the higher the
scallop and the higher the risk for gingival loss after extraction.
Figure 3: Diagnostic total dentogingival complex measurement
of 3 mm facially.
Figure 4: Diagnostic total dentogingival complex measurement
of 3 mm to the interproximal crest of mesial tooth #9.
– Predictable Single-Tooth Peri-Implant Esthetics: Five Diagnostic Keys – 13

Figure 5: Diagnostic total dentogingival complex measurement
of 3 mm to the interproximal crest of adjacent mesial tooth #7.
Figure 6: A Periotomea was used to atraumatically remove
compromised tooth #8.
In contrast, the flatter gingival scallop tends to mimic the osseous scallop, creating less discrepancy and more predictable
maintenance of the interproximal papilla (Fig. 1a). A highly scalloped gingival architecture that is the result of facial
recession can be misleading. In this scenario, the interproximal papilla may be in the normal or flat position, relative to
interproximal bone, but appear to have a highly scalloped form. This interdental papilla is also in a favorable position
and not at risk of being lost after extraction.
3. Biotype of the Periodontium
The biotype of the gingiva is typically considered thick or thin. The thick or dense biotype may be fibrotic. 13 Thicker
tissue is usually more resistant to recession and results often include pocket formation after any apical migration of the
junctional epithelium (Fig. 1a). The thin gingival biotype is often friable and results in increased risk of facial recession
and interproximal loss of gingival tissue after any surgical procedure (Fig. 2a).
Gingival recession is the most common complication of anterior single-tooth implants. 17 Thicker tissue is inherently
more favorable and thin tissue provides more concerns. For thin tissue, minimally invasive or flapless surgery is more
appealing because it minimizes compromises to the blood supply of underlying bone and decreases the risk of recession
after implant management protocols.
4. Tooth Shape
Three basic tooth shapes — square, ovoid and triangular — influence peri-implant
esthetics. The impact is both coronal and apical to the FGM. Coronal to the FGM, the
tooth shape will influence the volume and height of the gingival embrasure. Apical
to the FGM, the tooth shape will influence the proximity of the roots and support of
the gingival tissue both facially and interproximally.
Coronal to the FGM, the square tooth shape is the most favorable because the proximal
contact is longer and more tooth structure fills the interdental area (Fig. 1a). This
creates less risk of “black holes.” The triangular tooth shape creates the highest risk
for black holes because the proximal contact point is more incisally positioned and
would require more tissue height to fill the interproximal area (Fig. 2a). Therefore,
even minimal amounts of tissue loss may create large black holes. These situations
may require modification of the adjacent tooth shape with either direct composite
or porcelain veneers after an implant-retained restoration.
Tooth shape will
influence the volume
and height of the
gingival embrasure.
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Figure 7: The socket is inspected for the presence of an intact
labial plate.
Figure 8: The surgical protocol is followed without a flap to position
the fixture with a surgical guide. The position is slightly lingual
to allow for ensuing facial shrinkage and 3 mm apical to the
predicted free gingival margin to develop the emergence profile.
Surgery performed by Dr. Lloyd Dixon.
Figure 9: Implant diameter chosen to allow for thickness of the
interproximal osseous crest to minimize vertical loss as a result
of lateral resorption after restoration.
Figure 10: Graphic depicts fixture diameter selected not to fill
socket, but to provide interproximal crest thickness of 1.5 mm.
Apical to the FGM, the tooth shape creates very different diagnostic concerns. Triangular tooth shapes allow for roots
that are positioned farther apart, which provides potentially thicker interproximal bone (Fig. 2b). This may actually
minimize loss of vertical bone height after extraction procedures and implant placement as a result of lateral resorption
with lateral violation of biologic width. 12 The ovoid and square tooth shape with proximal contact may, therefore, be
at a greater risk of more vertical bone loss because the osseous crest is thinner (Fig. 1b). This shape, however, provides
more proximal support for the interdental gingival tissue.
The presenting tooth shape will influence the implant-retained restoration shape. The implant restoration will need to
mimic its contralateral natural tooth coronal to the FGM; however, apical to the FGM, the implant restoration will not
be an anatomic replica. An often-delicate balance must be developed that provides support of the gingival architecture
yet does not provide excessive pressure. Although the implant position will dictate the emergence profile of the implant
restoration, ideally, the facial contour should be slightly flatter than the contralateral natural tooth to minimize apical
displacement of the FGM after insertion. 18
The interproximal position of the fixture is below the osseous crest of the adjacent teeth. The interproximal emergence
profile of the abutment should be straight and scalloped until it is coronal to the osseous crest. This distance occupies
approximately 3 mm.
– Predictable Single-Tooth Peri-Implant Esthetics: Five Diagnostic Keys – 15

The greater the
distance of the
osseous crest to the
FGM, the greater the
risk of tissue loss after
an invasive procedure.
5. Position of the Osseous Crest
The osseous crest is a critical foundation for gingival levels. The position of this
relationship is an important predictor for gingival levels after any intervention.
Previous clinical data on 100 healthy patients developed quantitative data for
three different biologic variations. 16 These variations — normal, high, and low
— are based on the vertical distance of the osseous crest to the FGM. The greater
the distance of the osseous crest to the FGM, the greater the risk of tissue loss
after an invasive procedure. If the vertical distance of the total dentogingival
complex on the midfacial aspect is 3 mm, a slight apical loss of tissue (up to 1
mm) is anticipated after extraction and immediate fixture placement (Fig. 3).
Greater or less than 3 mm of vertical distance indicates the change will be relative
and range from negligible change to potentially >1 mm apical. Measuring
the distance from the FGM to the osseous crest before extraction is an important
and valuable diagnostic procedure. If the facial gingival levels are harmonious
Figure 11: Graphic depicts ideal vertical fixture position measure
of 3 mm to 4 mm apical to the harmonious free gingival
margin position.
Figure 12: A 3 mm healing abutment with vertical emergence
profile is placed.
Figure 13: An interim removable partial denture is positioned
for lateral tissue support coronal to the healing abutment.
Figure 14: Final impressions without stage 2 surgery. The adjacent
teeth are prepared for veneers for esthetic reasons.
and the distance to the osseous crest is 3 mm or more, orthodontic extrusion is recommended to move the osseous crest
more coronally to account for subsequent osseous resorption and potentially greater soft tissue loss.
The interproximal relationship has consistent logic, but the measurement is different. In the interproximal area, a vertical
distance up to 4 mm measured from the FGM to the osseous crest would present less risk. It is possible to generate
greater interproximal distances, 19 but these are not predictably maintained after any surgical intervention. The inter-
16
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Figure 15: Laboratory result using a milled titanium custom
abutment metal-ceramic crown on tooth #8 and porcelain
veneers on teeth #6, 7, 9, 10 and 11. Ceramics by Steve
McGown, CDT, Arcus Dental Laboratory.
Figure 16: Graphic depicts fixture relationship to the restorative
result. For this patient, a variety of implant systems and restorative
options are possible.
Figure 17: Final radiograph implant in the #8 position. The implant
diameter (4.3 mm) allows for adequate interproximal crest
width.
Figure 18: Final restorative result with predictable peri-implant
esthetics.
proximal numbers are based on the most coronal portion of the interproximal osseous crest of adjacent teeth and are
not related to the interproximal position of the osseous crest of the tooth being removed (Fig. 4, 5). Therefore, if the
interdental papilla measures >4 mm (low crest) on the adjacent teeth, there will predictably be some interproximal tissue
loss after extraction to the 3 mm to 4 mm vertical distance.
Conclusion
This article has focused on the five diagnostic keys for predictable peri-implant esthetics.
Each key is intimately related to the others, making treatment decisions difficult.
For example, it is possible to have a thin biotype and triangular tooth in a
highly scalloped periodontium that appears at high risk of facial recession and “black
holes” after extraction and implant placement. However, because the tooth is positioned
slightly more coronally with a vertical distance of

a variety of implant systems, surgical protocols and restorative options can provide similar therapeutic outcomes for
this anatomical clinical situation. 20 In contrast, if the patient presented with unfavorable anatomical keys, the clinician
would face much higher risk and a less predictable outcome for peri-implant esthetics, despite state-of-the-art procedures
(Table 1).
Using a proactive protocol that alters the periodontium toward less risk and more favorable assessment of the five diagnostic
keys before implant placement will provide the most predictable peri-implant esthetic outcome. Reliance on
“state-of-the-art procedures” provides different options; however, these results are not as predictable. n
Table 1
References
1. Abrams H, Kopczyk RA, Kaplan AL. Incidence of anterior ridge deformities in partially edentulous patients. J Prosthet Dent. 1987;57:191-194.
2. Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Dent. 1980;1:205-213.
3. Tarnow DP, Eskow RN. Considerations for single-unit esthetic implant restorations. Compend Contin Educ Dent. 1995;16:778-788.
4. Jansen CE, Weisgold A. Presurgical treatment planning for the anterior single-tooth implant restoration. Compend Contin Educ Dent. 1995;16:745-761.
5. Weisgold AS, Arnoux JP, Lu J. Single-tooth anterior implant: a word of caution. Part I. J Esthet Dent. 1997;9:225-233.
6. Garber D. The esthetic dental implant: letting restoration be the guide. J Am Dent Assoc. 1995;126:319-325.
7. Becker W, Ochsenbein C, Tibbets L, et al. Alveolar bone anatomic profiles as measured from dry skulls. Clinical ramifications. J Clin Periodontol. 1997;24:727-731.
8. Kois JC. Esthetic extraction site development: the biologic variables. Contemporary Esthetics and Restorative Practice. 1998;2:10-18.
9. Saadoun A, LeGall M, Touati B. Selection and ideal tridimensional implant position for soft tissue aesthetics. Pract Periodontics Aesthet Dent. 1999;11:1063-1072.
10. Salama H, Salama M, Garber D, et al. Developing optimal peri-implant papillae within the esthetic zone: guided soft tissue augmentation. J Esthet Dent. 1995;7:125-
129.
11. Salama H, Salama M. The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach
to the management of extraction site defects. Int J Periodontics Restorative Dent. 1993;13:312-333.
12. Tarnow DP, Cho SC, Wallace SS. The effect of interimplant distance on the height of inter-implant bone crest. J Periodontol. 2000;71:546-549.
13. Weisgold AS. Contours of the full crown restoration. Alpha Omegan. 1977;70:77-89.
14. Olsson M, Lindhe J. Periodontal characteristics in individuals with varying forms of the upper central incisors. J ClinPeriodontol. 1991;18:78-82.
15. Sanavi F, Weisgold AS, Rose LF. Biologic width and its relation to periodontal biotypes. J Esthet Dent. 1998;10:157-163.
16. Kois JC. Altering gingival levels: the restorative connection part I: biologic variables. J Esthet Dent. 1994;6:3-9.
17. Goodacre CJ, Kan JY, Rungcharassaeng K. Clinical complications of osseointegrated implants. J Prosthet Dent. 1999;81:537-552.
18. Phillips K, Kois JC. Aesthetic peri-implant site development. The restorative connection. Dent Clin North Am. 1998;42:57-70.
19. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental
papilla. J Periodontol. 1992;63:995-996.
20. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans. J Periodontol.
2003;74:557-562.
Reprinted with permission of Compendium. John C. Kois, DMD, MSD: Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compendium. 2004:25
(11):585. AEGIS Communications ©2004.
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Digital Implant Treatment Planning
The Importance of the Scan Appliance
by Bradley C. Bockhorst, DMD
One of the fastest growing segments of implant dentistry is the utilization of CT scan data and treatment
planning software in conjunction with guided surgery for implant reconstruction cases. The scan appliance
is critical to the process and success of these cases. The primary purpose of the scan appliance is to show the
ideal prosthetic positions of the teeth to be replaced in the digital plan. 1 By utilizing a scan appliance, the case can be
planned from both a prosthetic and surgical perspective, making implantology a truly restoratively-driven process.
There are several excellent implant treatment planning and guided surgery systems available. We will focus on two of
the most popular programs on the market: NobelGuide from Nobel Biocare and SimPlant ® from Materialise (Fig. 1).
While the names of their scan appliances are different, their purpose is the same. Which system you choose is typically
driven by the implant system you are utilizing. NobelGuide is designed for use with Nobel Biocare implants. SimPlant
has an open architecture, so most available implants can be planned with its software.
Digital Treatment Planning and Guided Surgery
NobelGuide #
Nobel Biocare implants only
Planning Software
SimPlant #
Open architecture — most implant systems
Radiographic Guide
(Clear acrylic with gutta percha markers)
Radiographic Index (bite registration)
Dual-scan protocol
Surgical Template
Drill direction and depth control
NobelGuide Surgical Kit required
Radiographic Guide/
CT Scan Appliance
Surgical Template/Guide
Scan Appliance
(Clear acrylic with gutta percha markers)
Scan Index (bite registration)
Dual-scan protocol
Scan Appliance
(Barium sulphate -acrylic mix)
Tissue-supported (20% teeth /10% base)
Tooth or Bone-supported (20% teeth /clear base)
Scan Index (bite registration)
Single-scan protocol
Safe SurgiGuide
Classic SurgiGuide
Pilot SurgiGuide
Universal SurgiGuide
Drill direction and depth control
One Surgical Guide
Requires Guided Surgical Kit
Astra Facilitate
Biomet 3i Navigator
Straumann Guided Surgery
NobelGuide Compatible
Drill direction control
Multiple SurgiGuides # (One per drill Ø)
Standard Surgical Kit may be utilized
Drill direction control
One SurgiGuide #
Standard Surgical Kit may be utilized
Drill direction control
One SurgiGuide #
Requires Universal SurgiGuide Drill Keys
Standard Surgical Kit may be utilized
Figure 1: NobelGuide and SimPlant flow chart of terms and options.
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Role of the Scan Appliance
The primary purpose of the scan appliance is to show
the ideal prosthetic positions of the tooth or teeth to be
replaced. It provides an invaluable diagnostic tool to relate
the tooth-to-bone relationship. 2 This is critical for the
planning process. While the SimPlant “virtual teeth” function
is useful for short spans such as single tooth replacement
(Fig. 2), an appliance in which the teeth have been
set in the ideal position(s) provides the most accuracy.
Both NobelGuide and SimPlant advocate a dual-scan protocol.
In these cases, the surgical guide is literally fabricated
from the CT scan of the scan appliance (Fig. 3a-3d).
Figure 2: “Virtual teeth” are inserted to represent teeth #8-10.
Figure 3a: Radiographic Guide
Figure 3b: Virtual rendering of
Radiographic Guide
Figure 3c: Virtual rendering of Surgical
Template
Figure 3d: Surgical Template
Types of Scan Appliances
The types of scan appliances can be split into single- and dual-scan protocols (Fig. 4a,
4b). SimPlant traditionally utilizes a single-scan protocol. With the introduction of its
dual-scan module, Materialise now recommends the dual scan. NobelGuide utilizes a
dual-scan protocol.
Single-Scan Appliance: Barium sulphate is mixed with acrylic to identify various
structures radiographically. The teeth to be replaced contain a 20 percent barium sulphate
mix. If the goal is to perform a flapless procedure on a fully edentulous case,
the teeth are made with a 20 percent BaSO4 mix and the base a 10 percent mix. This
allows the teeth to be identified as well as the soft tissue in the CT study. 3 For partially
edentulous cases, the scan appliance can be a flipper-type design or it can overlay the
remaining teeth, depending on the clinician’s preference.
The types of scan
appliances can basically
be split into single- and
dual-scan protocols.
Figure 4a: Single-scan appliances
Figure 4b: Dual-scan appliance
Dual-Scan Appliance:
Scatter from neighboring
restorations can obscure
the view of the teeth in the
scan appliance during single
scans. Barium sulphate
can also cause a minor
amount of scatter and potentially
obscure the view
of vital structures. The
dual scan avoids this potential
complication. The
patient is scanned with the
– Digital Implant Treatment Planning: The Importance of the Scan Appliance – 21

scan appliance, and then the scan appliance is scanned alone. The dual-scan appliance is typically fabricated from clear
acrylic with approximately eight 1 mm to 1.5 mm spherical gutta percha markers. The planning software converts the
CT scan files and merges the two scans by matching the gutta percha markers, aligning the radiopaque markers so that
the prosthesis will be visible over the available osseous anatomy. 4
Utilizing the Patient’s Existing Denture as a Scan Appliance
While utilizing the patient’s existing denture as a scan appliance is possible, it can be problematic. Gutta percha markers
can be added to the patient’s existing denture, or the denture can be duplicated and utilized only if it is well-fitting
Figure 5a: View of well-fitting scan appliance
Figure 5b: Radiolucent area shows crestal and facial ridge atrophy. The Radiographic
Guide should be hard relined and the case rescanned.
and the teeth are in the correct positions (Fig. 5a, 5b). If
the denture is worn down and has a poor fit, a new appliance
should be fabricated. For fully edentulous cases,
this involves the same steps as fabricating a new denture
including wax rims to establish the occlusal records and
a wax try-in to evaluate the VDO, CR, tooth set-up and
esthetics. (NOTE: This set-up will not only be used to create a
proper scan appliance, it can also be used as a guide for the
provisional and final prostheses.) By receiving the patient’s
acceptance of the prosthesis before CT scans are done,
the potential for success is also increased. 5
Figure 6: The patient’s existing denture was used as the scan appliance. The thin
flanges will result in fenestrations and potential weak areas in the surgical guide.
Another issue that can arise when utilizing the patient’s existing denture is the thickness, particularly in the flange areas.
Dentures, by design, are thin for patient comfort. The scan appliance should ideally be about 3 mm thick. The use of a
thin denture could result in fenestrations and potential weak areas in the surgical guide (Fig. 6).
Verify Fit of the Scan Appliance
Once the scan appliance has been fabricated it should
be tried-in to verify fit (Fig. 7). If the lab did not provide
one, a scan index should be fabricated. The scan index,
or Radiographic Index as it is called in the NobelGuide
system, is a bite registration of the scan appliance to the
opposing dentition (Fig 8). The purpose of the scan index
is to ensure that the appliance remains completely seated
during the scan. It must be made out of a radiolucent
material so that it does not block out the teeth. We have
Figure 7: Try-in of the scan appliance
to verify fit. Note: Inspection windows
can be used as an aid in partially
edentulous cases.
Figure 8: Scan appliance and scan
index on articulated models.
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Figure 9a: SimPlant Scan protocol
Figure 9b: NobelGuide Scan protocol
found Capture ® Clear Bite (Glidewell Laboratories) to be an acceptable material.
Once the fit of the scan appliance and scan index are verified, the patient can
be sent for the CT scan.
The CT scan protocol for the system you intend to utilize should be followed
(Fig. 9a, 9b). The scan protocols for NobelGuide and SimPlant can be found at
inclusivedental.com. The scan appliance and scan index must be fully seated
for the patient scan. If a dual scan is being utilized (Fig. 10a), the second scan
is taken of the scan appliance alone (without the scan index). The appliance
should be up off the metal table or bar in the same orientation as it was in the
patient’s mouth (Fig. 10b). The standard files generated by a CT scan are called
DICOM files (Digital Imaging Communication of Medical Images). The radiologist
should reconstruct the scan per the protocol. Typically, the radiology lab
burns the CT scan data onto a CD. In order to avoid confusion, request that the
radiologist create two folders: one containing the DICOM files of the patient
scan and, if a dual scan was done, a second folder of the scan appliance. If you
are using the NobelGuide or SimPlant software yourself or are utilizing Glidewell
Laboratories’ Digital Implant Treatment Planning Services, the DICOM files
are converted and utilized to virtually plan the case.
The scan appliance
and scan index
must be fully seated
for the patient scan.
Scan 1 Scan 2
Patient
Radiographic
Guide
Radiographic
Index
Figure 10a, 10b: Dual scan: The patient is scanned with the scan appliance and scan index. A second scan of the scan appliance alone is performed.
– Digital Implant Treatment Planning: The Importance of the Scan Appliance – 23

Single Tooth
Figure 11a: Plan for replacement of tooth #19. The cross-sectional slice
through tooth #19 can be seen on the right side of the screen.
Figure 11b: Virtual plan to replace congenitally missing lateral incisors.
Multiple Teeth
Full Arch
Figure 11c: Multiple implants can be planned with appropriate implant-implant
and implant-root spacing, as can areas to be grafted.
Figure 11d: Case planned for eight implants for a fixed restoration.
Figure 11e: Case plan for a mandibular All-on-4 restoration.
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Restoratively Driven Treatment Planning
The whole point of the diagnostic work-up and utilization of the scan appliance is to show the ideal positions of the
tooth or teeth to be replaced. While digital treatment planning guided surgery protocol was initially developed for the
fully edentulous patient, it has advantages for partially edentulous patients as well. 6 Whether you are replacing one
tooth, multiple teeth or a full arch, digital treatment planning allows you to virtually plan the case from both a surgical
and prosthetic perspective in a 3-D environment (Fig. 11a-e). This allows you to make almost all of the clinical decisions
up front. The result is implants that are more ideally placed and, therefore, simpler prosthetics and superior restorations.
In appropriate cases, the prosthesis can be prefabricated for an immediately loaded restoration. 7 If you plan to
immediately load the case, we recommend you deliver a provisional restoration at the time of surgery and then proceed
to the definitive prosthesis at a later date.
Fabrication of the Surgical Guide
Once completed, the virtual plan can be transferred to the
clinical setting through the use of a surgical guide. The
guide produced for NobelGuide is referred to as a Surgical
Template (Fig. 12a). The guide from Materialise (Sim-
Plant) is called a SurgiGuide (Fig. 12b). Using the surgical
guides allows the surgeon to place the implants according
to a restoratively driven treatment plan. 8 We will review
the various types of guides in a future article.
Conclusion
Figure 12a: NobelGuide Surgical
Template
Figure 12b: Materialise Simplant
SurgiGuide
Digital treatment planning and guided surgery is rapidly gaining popularity and is becoming a standard of care. A key
benefit to this approach is that the case can be planned from the beginning with the final restoration in mind. The scan
appliance can be utilized to its fullest by:
• Working with an experienced lab to ensure it is properly fabricated
• Verifying clinically that it and the scan index fit well and are completely seated for the CT scan
• Ensuring the radiologist is familiar with the scan protocol.
By understanding the role and proper use of the scan appliance in the digital implant treatment planning and guided
surgery process, the clinician can take full advantage of this technology. n
References
1. Kosinski T. Optimizing implant placement and aesthetics: technology to the rescue! Dentistry Today Aug 1009.
2. Ganz S. CT scan technology; an evolving tool for avoiding complications and achieving predictable implant placement and restoration. International Magazine of Oral
Implantology-1/2001.
3. Rosenfeld A, Mandelaris G. Prosthetically directed implant placement using computer software to ensure precise placement and predictable prosthetic outcomes.
Int J Periodontics Restorative Dent. 2006 Jun; 26(3):215-21.
4. Moy P, Palacci P, Ericson I. Immediate function & esthetics in implant dentistry. Odont PhD, Quintessence Publishing Co. Ltd.
5. Amet E, Ganz S. Implant treatment planning using a patient acceptance prosthesis, radiographic record base, and surgical template. Part 1: Presurgical Phase.
Implant Dent 1997;6: p.193-197.
6. Balshi T, Balshi S. CT-generated surgical guides and flapless surgery. Int J Oral Maxillofac Implants 2008; Vol 23, Num 2.
7. Marchack C. An immediately loaded CAD/CAM-guided definitive prosthesis: A clinical report. J Prosthetic Dent 2005;93:8-12.
8. Orentlicher G, Goldsmith D, Horowitz A. Compendium Apr 2009, Vol. 30, Num 3.
– Digital Implant Treatment Planning: The Importance of the Scan Appliance – 25

R&D Corner
A Tightening Technique to Minimize
Loosening of Prosthetic Screws
by Grant Bullis
While the use of torque wrenches has greatly decreased its occurrence, screw loosening
remains a prosthetic complication. When a screw is tightened by the application of torque,
the screw elongates and a clamping force, called preload, is produced under the screw head. Preload
prevents the implant prosthetic screw joint from separating under occlusal loading. As long as the screw
preload is greater than the external forces, the screw joint will not loosen.
Insufficient preload of the
screw joint can result in
screw loosening and fatigue
failure of the prosthetic
assembly. Excessive
preload can exceed the
elastic limit of the screw,
causing screw breakage
or damage to the screw
threads and prosthetic
hardware. Preload is proportional
to the torque
applied, and the use of a
torque wrench provides a
simple means of control
(Fig. 1).
Figure 1
Because loss of preload or insufficient preload to resist the external forces acting on the screw joint
is a major cause of screw loosening, careful attention to the implant manufacturer’s screw tightening
parameters is a must. An additional factor to consider when tightening prosthetic screws is embedment
relaxation of the prosthetic screw joint once tightened.
The surfaces underneath the prosthetic screw head and of the screw seat are not perfectly smooth.
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When the screw is tightened to the recommended torque setting, the opposing surface imperfections
experience localized stress concentrations above the yield strength of the material. At these points the
material will deform until the stress is sufficiently relieved, diminishing the screw preload. Although
embedment relaxation occurs to some degree during prosthetic screw tightening, loss of preload due to
embedment relaxation can be mitigated by technique. 1,3
One technique is to tighten the prosthetic screw to the manufacturer’s recommended torque, then wait
approximately 10 minutes and re-torque the screw. 3 This allows time for embedment relaxation to take
place. The second time the screw is tightened, there should be less decay in the screw preload. 2
If loosening still occurs, the clinician should go through a troubleshooting list to determine possible
causes, including 3 :
• Passive fit of the prosthe sis (this should
have been evaluated at the try-in/delivery
appointment)
• Occlusion
• Parafunctional habits
• Excessive transverse loading.
Once the probable cause is identified and addressed,
the screws can be retightened.
By understanding basic engineering principles
and then incorporating techniques around them,
you can minimize potential complications on
your implant cases. The recommendation is to
use a torque wrench and to tighten the screws at
least twice, preferably waiting at least 10 minutes
between each tightening. n
References
1. Siamos G, Winkler S, Boberick KG. The relationship between
implant preload and screw loosening on implant-supported restorations.
J Oral Implantol. 2002;28:67–73.
2. Byrne D, Jacobs S, O’Connell B, Houston F, Claffey N. Preloads
generated with repeated tightening in three types of screws used in
dental implant assemblies. J Prosthodont 2006;15(3):164-171.
3. Winker S, Ring K, Ring JD, Boberick KG. Implant screw mechanics
and the settling effect: an overview. J Oral Implantol. 2003;29:242–245.
Go to inclusivemagazine.com to
see an animation of this technique.
– A Tightening Technique to Minimize Loosening of Prosthetic Screws – 27

Inclusive® Custom Abutments
Using 3-D Virtual Design
CAD/CAM technology is at the heart of the design process.
by Greg Minzenmayer
It seems that everywhere you turn
today, people are promoting one or
another form of CAD/CAM application. This technology
often brings synergy and efficiency to the
lab, but the ultimate benefit to the dentist is not
always immediately apparent.
In the video available at inclusivemagazine.com,
I will demonstrate how this technology allows
Glidewell to provide precision-milled CAD/CAM
custom abutments at the price of a standard stock
abutment using Computer-Aided Design.
This line of custom CAD/CAM abutments is sold
under the brand name of Inclusive ® and is available
in titanium, all-zirconia and zirconia with a
titanium insert. For many implant systems, you
will actually pay less for this custom solution.
Without this advanced technology, the only way to
make a custom abutment is to use a gold cylinder
or UCLA abutment, and hand-wax the appropriate
design. We then cast that design using a noble alloy.
This approach requires skilled hands and expensive
implant components.
The virtual design process utilized begins by scanning
your implant model using the Inclusive Scanning
Abutment Kit. Inclusive abutments are then designed
utilizing CAD/CAM technology and milled from precision-machined
blanks. Extensive mechanical testing
is performed and high-strength materials utilized, to
provide you with a consistent, quality product.
In an online presentation, we will take you through
the process of creating and milling Inclusive Custom
Abutments, from the scanning process to the final design,
so you can see for yourself how CAD/CAM provides
you and your patients with superior results. n
To watch Greg’s video presentation on the fabrication of
Inclusive Custom Abutments using 3-D virtual design,
log on to inclusivemagazine.com.
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Product Spotlight
BioTemps® Over Implants
by Robert Rosen, CDT
Provisional restorations can
play a huge role in managing
clinical situations to ensure the success
of the final prosthesis. From sculpting
the tissues for an ideal emergence profile
to papilla and ovate pontic development,
BioTemps ® (Glidewell Laboratories; Newport
Beach, CA) are the ideal soft tissue
template for shaping gingival tissues to
match your esthetic needs.
BioTemps also provide an excellent prototype
to evaluate shade and contours,
leading to greater patient acceptance and
a superior definitive restoration.
Whether you are restoring vertical dimension
or undertaking months of periodontal
therapy, you won’t find a better longterm
provisional.
BioTemps improve your productivity, allowing
you to accomplish more dentistry
in a single visit due to decreased time
spent fabricating provisionals chairside.
They offer true versatility and can be utilized
for all your implant-borne crown &
bridge cases, from single tooth to full-arch
temporization.
To see clinical videos of the BioTemps
provisional, go to inclusivemagazine.com.
Three-unit BioTemps bridge with pontic
over healing abutment
Immediate BioTemps crown on zirconia abutment (#29)
Screw-retained BioTemps crown
– Product Spotlight: BioTemps Over Implants – 31

Hygiene and the Implant Patient
A Preventive Perspective
by Ann M. Drewenski, RDH
Dental implants are a major investment
that with proper care can last a lifetime.
Advantages of implants include comfort, heightened selfesteem,
ease of eating, and improved appearance, speech
and oral health. With comprehensive education from the
entire dental team, patients can better understand the importance
of home care and regular maintenance visits.
Infection control lies at the heart of peri-implant treatment.
With regular evaluation, plaque and calculus removal,
and patient commitment to an infection-free environment,
implant longevity can be lifelong. As dental
hygienists, we are obligated to educate and motivate every
patient. In doing so, it’s imperative that we take into
consideration each patient’s home care, systemic health
and periodontal history.
Clinical inspection for signs of inflammation, exudate,
mobility, increased sulcus depth and occlusal trauma are
very important in evaluating the status and durability of
the dental implant or prosthesis. Clinical assessments
used routinely, with the exception of periodontal probing
around the peri-implant, should be documented. Routine
periodontal probe readings are not recommended. Probe
readings should be used only when needed due to signs
of inflammation, bleeding or loose implant. Routine probing
could cause damage to the weak epithelial attachment
around the implant, possibly creating a pathway for periodontal
pathogens. Should probing be indicated, use of a
plastic rather than a metal probe is recommended.
Proper monitoring and maintenance is essential to ensure
the durability and health of a dental implant. The key
to long-term maintenance is to begin with a customized
treatment plan for each patient. Preoperative oral hygiene
instructions will greatly benefit the patient and enhance
the long-term predictability of the implant. The goal is to
maintain a stable, infection-free, healthy environment. n
Figure 1: An implant with plaque and
debris causes irritation and infection.
Figure 3: Plastic instrumentation removes
infection-causing debris.
Figure 2: Probing with a plastic
probe.
Figure 4: A torque wrench is used to
uncover implants.
To read Ann's full article on proper hygiene for the implant patient,
please visit inclusivemagazine.com.
Figure 5: Removal of an “All-on-4”
prosthesis.
Figure 6: Implant is checked for
mobility.
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“
What People Are Saying”
“
I loved the first issue of Inclusive magazine!
I am looking forward to receiving the next
issue, as well as the Removable and Digital
Treatment Planning technical guides. ”
Michael B. Cook, DDS
Toledo, Ohio
“
Hope this note finds you warm and smiling in Southern
California! I wanted to high-five you on the great new publication
you produced. I just looked through the first issue of Inclusive
and felt compelled to write and congratulate you. The
layout and graphics are clean and the information presented
is very well done and timely. Keep up the great work. ”
Thomas J. Balshi, DDS, FACP
Fort Washington, Pa.
“
Glidewell Laboratories has done a fantastic job
with Inclusive magazine. I am impressed with the
informative articles and will be sending in a few
implant cases as a result. ”
Tom Northway, DDS
Grandville, Mich.
– What People Are Saying – 33