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Inclusive
Restorative Driven Implant Solutions Vol. 3, Issue 2
A Multimedia Publication of Glidewell Laboratories • www.inclusivemagazine.com
I/O Scanning and Model-less
Implant Restorations
Dr. Tarun Agarwal
Page 13
Guided Surgery for
Single Tooth Replacement
Dr. Bradley Bockhorst and Zach Dalmau
Page 19
Soft Tissue Contouring and
Successful Implant Treatment
Dr. Robert Horowitz
Page 50
Immediate Loading or
Provisionalization: Do’s & Don’ts
Dr. Darrin Wiederhold
Page 35
2 NEW COLUMNS!
‘My First Implant’
with Dr. Gordon Christensen
Page 11
Small Diameter Implants
with Dr. Paresh Patel
Page 26
Implant Q&A:
Dr. Perry Jones
Virginia Commonwealth University
Page 42

On the Web
Here’s a sneak peek at additional
Inclusive magazine content available online
ONLINE Video Presentations
■ Dr. Perry Jones talks about the transforming effects of digital
technology on the quality of dentistry, including how it takes
accuracy and predictability to a new level.
■ Dzevad Ceranic, CDT, and Glidewell staff showcase cutting-edge
CAD/CAM processes used to produce a screw-retained crown with
Ivoclar Vivadent’s strong, highly esthetic IPS e.max ® .
■ Glidewell VP of R&D Robin Carden sheds light on the intrinsic
material properties of monolithic BruxZir ® Solid Zirconia that make
it ideal for implant restorations.
■ Dr. Darrin Wiederhold outlines the Do’s and Don’ts of immediate
loading, providing guidelines for maximizing short- and long-term
restorative success.
■ Inclusive ® Tooth Replacement Solution Tips and Techniques:
• Proper use of the prosthetic guide.
• How the cemented custom temporary abutment and
BioTemps ® provisional crown can easily be converted to a
one-piece, screw-retained prosthesis.
• The simple process of adjusting and relining the patientspecific
temporary components chairside.
Check out the latest issue of Inclusive
magazine online or via your smartphone at
www.inclusivemagazine.com
gIDE LECTURE-ON-DEMAND PREVIEW
■ Dr. Sascha Jovanovic takes viewers through the planning, surgical
procedure, and immediate provisionalization of a maxillary premolar
in this gIDE video lecture, “Single Implant Placement for Missing
Upper Premolar.”
Look for these icons on the pages that follow
for additional content available online
ONLINE CE credit
■ Get free CE credit for the material in this issue with each test you
complete and pass. To get started, visit our website and look for
the articles marked with “CE.”
– www.inclusivemagazine.com –

Contents
13
Intraoral Scanning and Model-less
Implant Restorations
Discover why digital implant restorations make sense in this photo
essay by Dr. Tarun Agarwal. In his first model-less restoration,
Dr. Agarwal shows how going digital not only simplifies the implant
restoration process, making it available at a reduced lab fee within
a quicker turnaround time, but also offers the convenience of an
open platform that works with almost any digital impression system
on the market today.
19
Guided Implant Surgery for Single-Tooth
Restorations: Streamlining the Process
Digital treatment planning and guided surgery can be of significant
aid in the diagnosis and treatment of dental implant cases,
adding a degree of precision and predictability unmatched by
conventional procedures. Addressing common concerns regarding
time and expense, Dr. Bradley Bockhorst and Zach Dalmau,
DTP and guided surgery production manager at Glidewell Laboratories,
provide options for reducing cost and maximizing efficiency
when utilizing this technology, making it feasible even for singletooth
restorations.
35
The Do’s and Don’ts of Immediate Loading or
Provisionalization of Dental Implants
As the cosmetic expectations of implant patients increase, clinicians
are strongly motivated to meet the demand for immediate
loading or provisionalization of freshly placed implants. Bearing in
mind the fundamental importance of unimpeded osseointegration,
Dr. Darrin Wiederhold outlines the Do’s and Don’ts of immediate
loading, providing guidelines for maximizing both short- and longterm
restorative success.
– Contents – 1

Contents
42
50
Implant Q&A: An Interview with Dr. Perry Jones
For some dentists, life after the discovery of technology can
be many things — from fascinating to humbling to confidencebuilding
— all in the same moment. Technology advocate Dr. Perry
Jones explores the transforming effects of digital technology on the
quality of dentistry, including how it takes accuracy and predictability
to a new level.
The Critical Nature of Tissue Contouring from a
Periodontist’s Perspective
Peri-implant health and soft tissue contouring are integral to the
successful implant restoration. Dr. Robert Horowitz’s answer to the
limitations of stock components is patient-specific tissue contouring.
As his article demonstrates, working with Glidewell’s Inclusive
Tooth Replacement Solution custom temporary components saves
chairtime, minimizes typical errors in soft tissue recording sent to
the lab, and helps patients obtain an ideal restorative outcome.
ALSO IN THIS ISSUE
8 Trends in Implant Dentistry:
Custom Abutments
11 My First Implant:
Dr. Gordon Christensen
17 Product Spotlight:
Prismatik PEEK Prosthetics
26 Small Diameter Implants:
Drilling Protocol for Achieving
Primary Stability
28 Clinical Tip: Using the Inclusive
Tooth Replacement Solution
Prosthetic Guide
31 R&D Corner: Strength and Flexibility
of BruxZir Solid Zirconia Implant
Restorations
39 Clinical Tip: Creating a
Screw-Retained Temporary
47 Lab Sense: Back to the Future
The IPS e.max Screw-Retained Crown
56 Clinical Tip: Modifying Inclusive
Custom Temporary Components
2
– www.inclusivemagazine.com –

Publisher
Jim Glidewell, CDT
Editor-in-Chief and clinical editor
Bradley C. Bockhorst, DMD
Managing Editors
David Casper, Barbara Young
Creative Director
Rachel Pacillas
Contributing editors
Greg Minzenmayer; Dzevad Ceranic, CDT
copy editors
Eldon Thompson, Jennifer Holstein,
David Frickman, Megan Strong
digital marketing manager
Kevin Keithley
Graphic Designers/Web Designers
Jamie Austin, Deb Evans, Joel Guerra,
Audrey Kame, Phil Nguyen, Kelley Pelton,
Melanie Solis, Ty Tran, Makara You
Photographers/Videographers
Sharon Dowd, Mariela Lopez,
James Kwasniewski, Andrew Lee,
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.
© 2012 Glidewell Laboratories
Neither Inclusive magazine nor any employees involved in its publication
(“publisher”) makes any warranty, express or implied, or assumes
any liability or responsibility for the accuracy, completeness, or usefulness
of any information, apparatus, product, or process disclosed, or
represents that its use would not infringe proprietary rights. Reference
herein to any specific commercial products, process, or services by
trade name, trademark, manufacturer or otherwise does not necessarily
constitute or imply its endorsement, recommendation, or favoring
by the publisher. The views and opinions of authors expressed
herein do not necessarily state or reflect those of the publisher and
shall not be used for advertising or product endorsement purposes.
CAUTION: When viewing the techniques, procedures, theories and
materials that are presented, you must make your own decisions
about specific treatment for patients and exercise personal professional
judgment regarding the need for further clinical testing or education
and your own clinical expertise before trying to implement new
procedures.
Inclusive is a registered trademark of Inclusive Dental Solutions.
4
– www.inclusivemagazine.com –

Letter from the Editor
Welcome to the Summer 2012 issue of Inclusive magazine. As technology
continues to grow at a seemingly exponential rate, there is a point when
all things start to come together. And that’s a great place to be. While
the dental field is not completely there yet — new advancements on the
digital front are ever-present — great strides have been made.
Take this issue’s contributors. On the theme of “technology on the verge,”
Drs. Perry Jones and Tarun Agarwal share how intraoral scanning can
significantly improve the quality of dentistry. Another article simplifies
the process for digital treatment planning and guided surgery.
Our last issue coincided with the launch of the Inclusive ® Tooth Replacement
Solution, an exciting, comprehensive approach to tooth replacement
that could just revolutionize implant dentistry. Along those lines,
Dr. Robert Horowitz discusses the importance of soft tissue contouring
and custom abutments in the optimal shaping of the gingiva for successful
implant restorations. Another piece reviews parameters for immediate
temporization. The three Clinical Tips provide suggestions for properly
using the prosthetic guide, prepping and relining provisional restorations,
and converting a cemented temporary to a screw-retained restoration.
We are also pleased to introduce two new columns. In each issue we will
feature a short piece on Small Diameter Implants to keep you aware of
the possibilities with mini implants, starting with Dr. Paresh Patel. We
will also highlight doctors from around the country taking a moment
to recall their first implant case. Sometimes funny, but always meant to
communicate the singular point that everyone has to start somewhere,
My First Implant features leading clinician Dr. Gordon Christensen in
this inaugural installment. Be sure to let us know what you think of our
evolving format.
Ultimately, our goal is to bring you timely, useful topics — both practical
and on the cutting edge — that are insightful about the world of implants,
so you can provide the highest quality of care to your patients. Education
is key in addressing inhibitions about the learning curve involved with
some of these technologies, and that’s one of the things we do best here
at Glidewell Laboratories. To take advantage of the courses offered at our
state-of-the-art technology center, visit www.glidewellce.com.
All the best in your practice,
Dr. Bradley C. Bockhorst
Editor-in-Chief, Clinical Editor
inclusivemagazine@glidewelldental.com
– Letter from the Editor – 5

Contributors
■ Bradley C. Bockhorst, DMD
After receiving his dental degree from Washington
University School of Dental Medicine,
Dr. Bradley Bockhorst served as a Navy Dental
Officer. Dr. Bockhorst is director of clinical
technologies at Glidewell Laboratories, where
he oversees Inclusive ® Digital Implant Treatment
Planning services and is editor-in-chief
and clinical editor of Inclusive magazine. A member of the
CDA, ADA, AO, ICOI, and the AAID, Dr. Bockhorst lectures internationally
on an array of dental implant topics. Contact him
at 800-521-0576 or inclusivemagazine@glidewelldental.com.
■ ROBIN A. CARDEN
Robin Carden founded Talon Composites, the
manufacturer of Talbor ® — a composite material
that uses advanced ceramics and metals.
He holds more than 30 patents, mostly related
to metal and ceramic composites. In 1998,
Robin won the Design Engineering Award
from Design News. He is also inventor of the
translucent orthodontic braces for 3M ESPE and Ceradyne
Inc., the latter at which he worked for eight years as a senior
engineer. Ceradyne awarded Robin the prestigious President’s
Award for his work with advanced ceramics. Currently, Robin
is vice president of Glidewell Laboratories’ R&D department.
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 real-world 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.
■ DZEVAD CERANIC, CDT
Dzevad Ceranic began his career at Glidewell
Laboratories while attending Pasadena
City College’s dental laboratory technology
program. In 1999, Dzevad began working at
Glidewell as a waxer and metal finisher, then
as a ceramist. After being promoted to general
manager of the Full-Cast department, he
assisted in facilitating the lab’s transition to CAD/CAM. In
2008, Dzevad took on the company’s rapidly growing Implant
department, and in 2009 completed an eight-month implants
course at UCLA School of Dentistry. Today, Dzevad leads a team
of 170 people at the lab and continues to implement cuttingedge
technology throughout his department. Contact him at
inclusivemagazine@glidewelldental.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.
■ GORDON J. CHRISTENSEN, DDS, MSD, Ph.D
Dr. Gordon Christensen is a practicing prosthodontist
in Provo, Utah. His degrees include
DDS, University of Southern California; MSD,
University of Washington; and Ph.D, University
of Denver. He is a Diplomate of the American
Board of Prosthodontics; Fellow and Diplomate
of the ICOI; Fellow of the AO, ACD, ICD, ACP,
and Royal College of Surgeons of England; Honorary Fellow of
the AGD; and an Associate Fellow of the AAID. Dr. Christensen
is CEO of the nonprofit Gordon J. Christensen CLINICIANS
REPORT ® , which he co-founded with his wife Dr. Rella Christensen.
He also serves as director of Practical Clinical Courses.
Contact him at 801-226-6569 or info@pccdental.com.
6
– www.inclusivemagazine.com –

■ ZACH DALMAU
Zach Dalmau began his dental career in 2006
at the nSequence Center for Advanced Dentistry
in Reno, Nev. As the director of guided
implant surgery and 3-D diagnostic imaging,
he played a key role in building the company’s
CT guided implant surgery and 3-D diagnostic
imaging departments from the ground up. In
September 2009, he moved to Baltimore, Md., to work at Materialise
Dental Inc. There, he managed the design and production
of all SimPlant ® SurgiGuides ® for the North American market.
Zach joined the Digital Treatment Planning team at Glidewell
in October 2011 and currently serves as DTP and guided surgery
production manager. Contact him at inclusivemagazine@
glidewelldental.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.
■ ROBERT A. HOROWITZ, DDS
Dr. Robert Horowitz graduated from Columbia
University School of Dental and Oral Surgery
in 1982. After a one-year general practice
residency, he finished a two-year specialty
training program in periodontics at New York
University and the Manhattan VA Hospital. He
began placing implants in 1985. In 1996, he
completed a two-year fellowship program in implant surgery at
NYU, focusing on bone grafting procedures. Dr. Horowitz is a
clinical assistant professor in the department of periodontology
and implant dentistry at NYU College of Dentistry, where he is
also on faculty and conducts research in the departments of oral
surgery, biomaterials and biomimetics, and oral diagnosis.
Dr. Horowitz has lectured nationally and internationally and
published more than 40 scientific articles and case studies.
Contact him at rahdds@gmail.com.
■ DARRIN M. WIEDERHOLD, DMD, MS
Dr. Darrin Wiederhold received his DMD
in 1997 from Temple University School of
Dentistry and a master’s degree in oral biology
in 2006 from Medical University of Ohio at
Toledo. Before joining Glidewell in August
2011, he worked in several private practices
and as a staff dentist for the U.S. Navy. As staff
dentist in Glidewell’s Implant division, he performs implant
and conventional restorative procedures at the lab’s on-site
training facility and helps support the lab’s digital treatment
planning and guided surgery services. An integral part of the
lab’s Implant Research & Development group, he is also involved
in training and education on implant surgery and prosthetics.
Contact him at inclusivemagazine@glidewelldental.com.
■ Perry E. Jones, DDS, FAGD
Dr. Perry Jones received his DDS from Virginia
Commonwealth University School of Dentistry,
where he has held adjunct faculty positions
since 1976. He maintains a private practice in
Richmond, Va. One of the first GP Invisalign ®
providers, Dr. Jones has been a member of
Align’s Speaker Team since 2002, presenting
more than 250 Invisalign presentations. He has been involved
with Cadent optical scanning technology since its release to the
GP market and is currently beta testing its newest software.
Dr. Jones belongs to numerous dental associations and is a
fellow of the AGD. Contact him at perry@drperryjones.com.
– Contributors – 7

Trends in
Implant Dentistry
Custom Abutments
With the large number of implant-borne cases fabricated
at Glidewell Laboratories, it’s interesting to look at what
types of restorations are being utilized and where.
Which teeth are most
commonly replaced?
Maxilla
l Custom Abutments
Tooth # 1-16
29 %
Mandible
Total Custom Abutments
Tooth # 17-32
are first molars
The many benefits of
custom implant abutments
• Proper support of the soft tissues
• Creation of the emergence profile
• Ideal placement of the margin
• Angle correction as well as retention
• Support of the restoration
8 9 10 11 12 13 14 15
18 19 20 21 22 23 24 25 26 27 28 29 30 31
Total Custom Abutments
(by tooth number in descending order)
Total
Tooth # 1-32
8 7 14 5 12 3 29 20 18 11 31 6 28 21 15 2 23 26 25 24 27 22
Abutment type
by percentage
Titanium is the clear leader with
82% of the total. Zirconia is gaining
popularity with 11%. Currently
representing 7%, gold UCLA-type
abutments are trend ing down.
Abutment Breakdown
Titanium
82%
Maxilla
nium vs. Zirconia
Tooth # 1-16 8
Mandible
Titanium vs. Zirconia
Tooth # 17-32– www.inclusivemagazine.com –

Tooth # 1-16 Tooth # 17-32
Maxilla
Mandible
Custom abutments fabricated by tooth number over a one-year period
Total Custom Abutments
Total Custom Tooth Abutments # 1-16
– Maxilla
Total Custom Abutments
Total Custom Tooth Abutments # 17-32
– Mandible
Tooth #2–#15
Tooth #18–#31
2 3 4 5 6 7 8 9 10 11 12 13 14 15 18 19 20 21 22 23 24 25 26 27 28 29 30 31
2 3 4 5 6 7 8 9 10 11 12 13 14 15
2 3 4 5 6 7 8 9 10 11 12 13 14 15
Total Custom Abutments
(by tooth number in descending order)
Total
Tooth # 1-32
(by tooth number in descending order)
Total Custom Abutments
Total
Tooth # 1-32
Total custom abutments by tooth number in descending order
Total Custom Abutments
(by tooth number in descending order)
Total
Tooth # 1-32
18 19 20 21 22 23 24 25 26 27 28 29 30 31
18 19 20 21 22 23 24 25 26 27 28 29 30 31
19 30 4 10 9 13 8 7 14 5 12 3 29 20 18 11 31 6 28 21 15 2 23 26 25 24 27 22
19 30 4 10 9 13 8 7 14 5 12 3 29 20 18 11 31 6 28 21 15 2 23 26 25 24 27 22
Titanium Maxilla vs. zirconia abutments by tooth Mandible number
Comparing Titanium titanium vs. Zirconia and zirconia abutments by location, the results Titanium are just as you’d vs. Zirconia expect:
zirconia Tooth is used # primarily 1-16 in the anterior maxilla, due to superior esthetic Tooth characteristics. # 17-32
Maxilla
19 30 4 10 9 13 8 7 14 5 12 3 29 20 18 11 31 6 28 21 15 2 23 26 25 24 27 22
Maxilla
Tooth #2–#15
Titanium vs. Zirconia
Tooth # 1-16
Mandible
Mandible
Tooth #18–#31
Titanium vs. Zirconia
Tooth # 17-32
Maxilla
Titanium vs. Zirconia
Tooth # 1-16
Mandible
Titanium vs. Zirconia
Tooth # 17-32
2 3 4 5 6 7 8 9 10 11 12 13 14 15
2 3 4 5 6 7 8 9 10 11 12 13 14 15
Watch here for emerging trends
Titanium Zirconia Titanium Zirconia
The clinical benefits of CAD/CAM technologies are numerous. Based on the number of cases we restore, some clear trends
come to light about your choices in materials. Check back here for more observations in the next issue!
2 3 4 5 6 7 8 9 10 11 12 13 14 15
18 19 20 21 22 23 24 25 26 27 28 29 30 31
Titanium Zirconia Titanium Zirconia
Data Source: Glidewell Laboratories March 2011–March 2012
18 19 20 21 22 23 24 25 26 27 28 29 30 31
18 19 20 21 22 23 24 25 26 27 28 29 30 31
Titanium Zirconia Titanium Zirconia
– Trends in Implant Dentistry: Custom Abutments – 9

my first
implant
with Gordon J. Christensen, DDS, MSD, Ph.D
Inclusive magazine would like to thank Dr. Gordon
Christensen for generously agreeing to appear in our
inaugural My First Implant column, where clinicians
take a moment to recall what it was like to place an
implant for the first time — because everyone has to start
somewhere.
Inclusive magazine: What made you decide to start placing
implants?
Gordon Christensen: I have been placing implants for
about 25 years now. My first course was at Mayo with
[Per-Ingvar] Brånemark himself as the instructor. Then
I went to Sweden for subsequent courses. After working
with oral surgeons and periodontists, some of whom did an
excellent job, I decided that the prosthodontic portion was
often more difficult than the surgical portion, so I started
placing implants myself.
IM: Tell me about your first experience. How did you choose
that first patient, and what was the treatment plan?
GC: The first patient was an elderly edentulous female. I
placed two implants in the mandibular canine areas — an
excellent way to start.
IM: Were you nervous before the procedure?
GC: Of course. Any new procedure causes anxiety.
IM: So, how did that first case go? Did it turn out as you’d
expected?
GC: It went perfectly, just as I had planned.
IM: Any surprises? Looking back, would you have done anything
differently?
GC: I placed implants in animal heads that I obtained from
a local slaughterhouse before placing them in an actual
person. This made the first human placement very easy. I
would do that again. In the hands-on courses I personally
provide in Utah through our organization today, Practical
Clinical Courses, we have participants place implants in
two different simulated mandibles. Then, taking that next
step, placing implants in a human, is relatively easy for
course participants.
IM: What implant system did you use? How did you decide
on this?
GC: My first implants were Brånemarks — which are no
longer made. That particular system was the one on which
I originally was instructed.
IM: How long before the final restoration was delivered? What
was it like?
GC: Twenty-five years ago, we were instructed to cover the
implants with soft tissue and wait at least four months —
preferably six — before loading. The prosthesis was an
overdenture. I have subsequently placed hundreds of these
with success.
IM: Did this first case have any impact on your second case?
How long before the next patient was treated?
GC: My second implant case took place within a few weeks.
The success of that initial case made the next one easy and
eagerly anticipated.
IM: What advice would you give to someone looking to get
started placing implants?
GC: My advice would be:
Take a broad-based, overall implant course.
Decide which brand of implants you want to pursue.
Take a course from that company.
Do your first case on a patient with an edentulous
mandible.
Make an overdenture.
Do your next patient as soon as possible after that first
patient.
Continue to enroll in more complex courses.
Join an implant organization such as the American
Academy of Implant Dentistry, the International
Congress of Oral Implantologists or the Academy of
Osseointegration.
Enjoy this relatively simple and highly successful
procedure. IM
– My First Implant: Dr. Gordon Christensen – 11

Photo Essay
Intraoral Scanning and
Model-less Implant Restorations
by
Tarun Agarwal, DDS, PA
Go online for
in-depth content
Digital Implant Restorations
Are you looking to simplify your
implant restoration process? Imagine
being able to offer custom implant
restorations for a reduced lab fee
within a quicker turnaround time. The
answer is simple: Go digital. In this
article, I’d like to show why digital
implant restorations make sense,
using an example of such a case.
The beauty of this technology is that
it’s not limited to a particular brand of
implants and can be used with nearly
every digital impression system on the
market today.
Nearly all custom abutments, with the
exception of UCLA abutments, are digitally
fabricated using a sophisticated
CAD/CAM process. With the conventional
approach, the laboratory
converts an analog impression to a
digital version. But by taking a digital
implant-level impression in the mouth,
you can go directly to digital software,
bypassing the conversion process and
the errors that come with it.
Case Presentation
Figure 2: After treatment possibilities were discussed,
the patient opted for implant therapy. The
tooth was carefully removed using an atraumatic
technique.
Figure 1: A patient presented with a severely fractured tooth #14 that had a questionable prognosis.
Figure 3: An implant was placed at the time of
extraction.
– Intraoral Scanning and Model-less Implant Restorations – 13

Figure 4: Following a six-month osseointegration
period, the implant was ready for loading.
Figure 5: Second-stage surgery was completed with
the placement of a healing abutment.
Figure 6: Taking a digital implant impression in this
case was the same as taking a digital impression
for a traditional crown, the only difference being the
placement of the Inclusive ® Scanning Abutment.
Figure 7: The CEREC ® AC Bluecam (Sirona; Long
Island City, N.Y.) was used to digitally capture the
implant impression.
Figure 8: Another advantage of the digital process
is that any shade photographs are included with the
digital information.
Figure 9: Following the creation and verification of
a virtually articulated digital model, the case was
securely transmitted to Glidewell Laboratories via
the Sirona Connect portal.
10a
10b
10c
Figures 10a–10c: The case was virtually designed in the laboratory. The flexibility of the digital system allows fabrication of titanium custom abutments, zirconia custom
abutments, lithium disilicate final restorations, BruxZir ® final restorations, and even my preferred favorite, the all-in-one screw-retained abutment and crown — made from
either IPS e.max ® lithium disilicate (Ivoclar Vivadent; Amherst, N.Y.) or BruxZir Solid Zirconia.
14
– www.inclusivemagazine.com –

11a
11b
Figures 11a, 11b: In this case, an all-in-one screw-retained IPS e.max abutment and crown were fabricated.
A screw-retained crown has all the benefits of a custom abutment emergence profile, the convenience of
retrievability, and cost-saving advantages. However, the most important aspect of a screw-retained implant crown
is the lack of intraoral cementation. In fact, cement sepsis — caused by the incomplete removal of cement from
around implants — is the main cause of implant failure. If you haven’t looked at screw-retained implant crowns
recently, be sure to give them another look.
Figure 12: The healing abutment prior to removal.
Figure 14: A radiograph was taken to verify complete
seating.
Figure 13: The restoration was tried in the mouth.
Figure 15: The restoration was torqued according to
manufacturer recommendation.
By taking
a digital
implant-level
impression ...
you can
go directly
to digital
software,
bypassing the
conversion
process — and
the errors
that come
with it.
Figure 16: Teflon tape was used to plug the access
hole over the screw.
Figure 17: A matching composite restoration was
placed over the plugged access hole.
– Intraoral Scanning and Model-less Implant Restorations – 15

18a
18b
18c
Figures 18a–18c: The completed implant restoration
Let Technology Transform Your Practice
In our practice, we’ve gone completely
digital for single-unit implants — both
for posterior and anterior cases. We
enjoy the speed of acquisition thanks
to the power of CEREC with Bluecam
and the predictable results from the
implant department at Glidewell Laboratories.
You owe it to your patients
and your practice to consider moving
toward digital implant impressions. IM
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PRODUCT
SPOT
light
Prismatik PEEK Prosthetics
Intraoral Components with
Radiographic Visibility
by
Grant Bullis
Director of Implant R&D and Digital Manufacturing
Polyether ether ketone (PEEK) is an engineering
thermoplastic that has many applications
in health care. Its stiffness, toughness, durability,
and biocompatibility make it the material of choice
for everything from temporary dental restorations
to femoral implants. PEEK can be repeatedly sterilized
by various methods (e.g., steam, gamma, and ethylene
oxide) without degrading its mechanical properties
or biocompatibility. It is also radiolucent, appearing
only vaguely on X-ray and CT imaging applications.
This presents an obvious difficulty to the clinician or
radiologist looking to verify the complete seating of
PEEK prosthetic components on dental implants.
Advanced formulations enhance the radiopacity of
PEEK prosthetic components by incorporating a radiopaque
filler. Barium sulfate is a widely used,
dense, insoluble material that can be added in varying
concentrations to increase the radiopacity of PEEK.
Prismatik Dentalcraft’s intraoral scanning abutments,
made from barium sulfate-filled PEEK, provide optimal
function and can be easily viewed radiographically.
The custom healing abutment and custom
temporary abutment featured in Glidewell’s Inclusive ®
Tooth Replacement Solution are milled
from the same material, providing
the same high degree of radiographic
visibility. IM
PA demonstrating the visibility of a standard PEEK
component (left) compared to a radiopaque PEEK
component (right)
– Product Spotlight: Prismatik PEEK Prosthetics – 17

Guided Implant Surgery for
Single-Tooth Restorations
Streamlining the Process
Go online for
in-depth content
by
Bradley C. Bockhorst, DMD and
Zach Dalmau, DTP and Guided Surgery Production Manager
T
he use of digital treatment
planning and guided surgery
for the placement of dental
implants entails many benefits, including
the ability to plan cases in
a virtual environment from the surgical
and prosthetic perspectives,
and then to accurately transfer
the plan to the clinical setting. This
technology can be used for essentially
all indications, from single-tooth
to full-arch restorations. There are
certainly specific situations where
the technology is most advantageous,
such as congenitally missing
lateral incisors with narrow interproximal
spaces between adjacent
roots, or mandibular posteriors in
proximity to the inferior alveolar
nerve. However, the additional presurgical
procedures, time, and
expense can often foster a bias
against going guided. Fortunately,
there are now options available that
help streamline the process, provide
enhanced precision, and are
more economical.
– Guided Implant Surgery for Single-Tooth Restorations: Streamlining the Process – 19

Are Scan Appliances Necessary?
While a scan appliance is required for
larger cases such as fully edentulous
arches, they may not be necessary
for single-tooth and short-span cases.
An optical scan of the models can be
performed and the missing tooth virtually
waxed-up in the CAD software.
This provides the prosthetic information
to plan the case without incurring
the cost and time delay of a scan
appliance. It also avoids potential inaccuracy
if the scan appliance is not
fully seated during the CT scan. As
a caveat, if the patient has a large
number of metallic restorations, a
scan appliance may be necessary due
to scatter that may interfere with the
accuracy of merging the patient scan
and model optical scan in the planning
software.
Access and Cost for CT Scans
With the expansion of the CBCT
market, patients can be scanned at a
significantly lower radiation dose and
cost than they can with traditional
spiral beam scanners. If the clinician
does not have a CBCT scanner in their
office, typically a radiology lab can
be found locally. If working with a
radiology lab, make sure the technician
understands the protocol. You may
want to accompany your patients until
you have confidence that the scans are
being performed correctly.
While a
scan appliance
is required for
larger cases such
as fully edentulous
arches, they may
not be necessary
for single-tooth and
short-span cases.
Procedure
Diagnostic Appointment
• Perform a standard diagnostic workup:
review of the patient’s health
and dental history (including the
cause of tooth loss), clinical exam,
periodontal status, and appropriate
radiographs.
• Take very accurate full-arch impressions
(use a custom or metal tray
and VPS final impression material)
and bite registration, and take the
shade (intraoral photos are extremely
helpful).
CT Scan
• The patient should be scanned (at
1 mm or smaller slice intervals/
thickness) with the occlusal surfaces
separated by at least 8 mm. This
may be accomplished with a stack
of tongue depressors (Figs. 1, 2)
or, ideally, with a thick bite registration
fabricated on an articulated
study model (Figs. 3, 4). Whatever
is used must be radiolucent. The
potential problem with using cotton
rolls is that the teeth may overlap if
the patient bites firmly or changes
bite pressure during the scan.
Figure 1: Patient seated in PreXion 3D scanner (PreXion Inc.; San Mateo, Calif.)
20
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Figure 2: Tongue depressors used to separate patient’s teeth
• The patient must remain perfectly
still during the scan. One of the
major causes of artifacts and other
quantitative inaccuracies in a CT
scan is patient movement.
Submitting the Case
• Access and fill out your online
digital Rx securely at https://
myaccount.glidewelldental.com (Fig.
5). Note: Quick links are also available
on the Treatment Planning
page of www.inclusivedental.com
under the heading “Submit Digital
Case” (Fig. 6).
• Print out the summary page at the
end of the Rx. Upload the folder
containing the DICOM files of the
patient’s scan.
• Send your impressions and bite registration
with the digital Rx printout
to Glidewell Laboratories.
Figure 3: Pin opened on articulator to separate teeth
Figure 4: Bite registration fabricated on articulated
study model with Capture ® Clear Bite (Glidewell
Direct) for use in CBCT scanning process
Figure 5: Screen capture of the My Account login
page at www.glidewelldental.com
Figure 6: Screen capture of the Treatment Planning
page at www.inclusivedental.com
– Guided Implant Surgery for Single-Tooth Restorations: Streamlining the Process – 21

By eliminating
the need for a
scan appliance,
the cost is
decreased and
treatment time
shortened.
Figure 7: Optical scans of opposing models merged with CT scan in planning software (In2Guide , Cybermed
Inc.; Irvine, Calif.). The mandibular canal has been identified, the missing tooth virtually waxed-up, and the
implant planned.
Digital Treatment Planning and
Surgical Guide Fabrication
• Once your case is received, the
models are poured and optically
scanned. The missing tooth is added
virtually in the CAD program.
• The optical scans of the models and
the patient’s CT scan files (DICOM)
are imported into the implant planning
software (Figs. 7–9).
Digital Plan Review and Acceptance
• A draft of the digital implant plan
is created in the proposed site.
A Web-based teleconference is
conducted with the treating clinician
(or clinicians, if there is a surgicalrestorative
team) to review and
finalize the plan.
Figure 8: The implant is spaced evenly between the adjacent teeth, the trajectory is through the center of the
occlusal table, and there is a good safety margin from the mandibular canal.
• The plan is posted to your online
account. Once you accept the plan,
your surgical guide is fabricated
(Figs. 10a, 10b).
Figure 9: Virtual view of the tooth-borne surgical guide. Inspection windows are added to visualize complete
seating intraorally.
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10a
Summary
Digital treatment planning and guided
surgery provide tremendous tools
to diagnose and treat implant cases
predictably and precisely. This technology
is not just indicated for fully
edentulous arches; it can also be indicated
for short edentulous spans,
including single tooth replacement.
By eliminating the need for a scan
appliance, the cost is decreased and
treatment time shortened. The keys
are to make accurate impressions,
as the surgical guide is based on the
model, and to CT scan the patient
with their teeth separated. Utilizing a
full-arch intraoral scan instead of
impressions is another option, but that
is the subject for a future article. IM
10b
Figures 10a, 10b: Completed tooth-borne surgical guide
– Guided Implant Surgery for Single-Tooth Restorations: Streamlining the Process – 23

SMALL DIAMETER
implants
Drilling Protocol for
Achieving Primary Stability
with Paresh B. Patel, DDS
Choosing the appropriatesized
drill in combination
with the correct drilling
depth is key to ensuring good
primary stability when placing smalldiameter
implants. Dense mandibular
bone may require site preparation to
full length, particularly when using
wider diameters, which comprise a
larger overall surface area. Conversely,
site preparation in the maxillary
arch might necessitate the use of an
undersized osteotomy drill as well as
decreased drilling depth, depending
on the den sity of cortical bone.
Inclusive ®
Mini Implant
Diameters
Ø 2.2 mm
Ø 2.5 mm
Ø 3.0 mm
Corresponding
cortical bone
drill diameters*
Ø 1.5 mm
Ø 1.7 mm
Ø 2.4 mm
*Dependent on bone density
Mandibular Arch
Before beginning the procedure,
determine the quality of bone. It is
important not to over-prepare or
over-drill the initial osteotomy. It is
best to drill halfway first, and then
assess the underlying bone. Try
using the blunt end of an endodontic
explorer to push on the bone and
determine the level of resistance. If
no trabecular bone is found and you
feel ample resistance, then D1 bone
is present. At that point, it may be
prudent to increase the osteotomy to
the full length of the small-diameter
implant. If you encounter D2 or D3
bone, allow the self-tapping design of
the small-diameter implant to thread
its way to full seating depth.
Maxillary Arch
To achieve good primary stability,
assess the bone before starting. Try
26
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Type D1
Type D2
Endodontic probe being used to feel density of the
mandibular cortical bone
Pilot drill taken to one-half the length of the smalldiameter
implant
sounding the bone with the sharp end
of an endodontic explorer, even before
using the drill bit, to determine how
much of a cortical plate there is to
work with. If it is nice and thick, you
will get lots of resistance. If it is thin,
you may find your endodontic explorer
has pierced the outer cortical plate
and you are now in the soft trabecular
bone. If the latter is the case, use the
pilot drill to perforate the cortical
plate only. Then, thread the implant
through, allowing it to condense and
compress the bone. Another way to
achieve additional primary stability in
the maxillary arch is to use the smaller
diameter drill.
For example, if you were going to place
a 3.0 mm implant in the maxillary arch
and the bone happened to be very
soft (D3- or D4-type bone), instead of
using a 2.4 mm pilot bit as suggested
in the placement protocol, a 1.5 mm
or 1.7 mm pilot drill may be used to
remove less bone. In essence, this gives
the implant more bone to act upon as
an osteotome. IM
Bone Types
D1
D2
D3
D4
Almost the entire
jaw is composed of
homogenous compact/
cortical bone.
A thick layer of cortical
bone surrounds a core
of dense trabecular
bone.
A thin layer of cortical
bone surrounds a core
of dense trabecular
bone of favorable
strength.
A thin layer of cortical
bone surrounds a
core of low-density
trabecular bone.
Adapted from the Lekholm-Zarb
bone quality classification
Type D3
Type D4
– Small Diameter Implants: Drilling Protocol for Achieving Primary Stability – 27

CLINICAL
TIP
Go online for
in-depth content
Using the Inclusive Tooth Replacement Solution
Prosthetic Guide
by
Darrin M. Wiederhold, DMD, MS
One of the most innovative and useful aspects of the Inclusive ® Tooth Replacement
Solution is that it provides the implant surgeon and restorative dentist with an array
of custom components, each designed to facilitate the placement and temporization
of implants. Among these innovative components is the prosthetic guide, a custom
stent designed to aid the clinician in selecting the location for the planned implant.
Much like the other components of the Inclusive Tooth Replacement Solution, the
prosthetic guide is based on the ideal placement of the final prosthesis. Its design
is driven not by the characteristics of the edentulous space, but rather where the
final crown will be placed.
28
– www.inclusivemagazine.com –

1Prosthetic guide in situ
Because the prosthetic guide is
based on a study model generated
by a diagnostic wax-up of the
planned restoration, it functions
simply as a reference tool — without
consideration of the soft or
hard tissue of the area, anatomical
landmarks or structures, adjacent
roots, or contraindications. Therefore,
it is imperative that the clinician
utilizes the prosthetic guide in
conjunction with appropriate radiography,
CBCT scans, and other
diagnostic information available.
Doing this will enable the surgeon
to optimize the placement of the
implant, as well as the functionality
and esthetics of the other components of the package, including the custom
temporary abutment and BioTemps ® provisional crown. However, because of this
limitation, it is often the case that the prosthetic guide’s proposed location and
angulation of the implant will need to be modified at the discretion of the clinician
who is placing the implant. Consequently, the experience and acumen of the
surgeon must be brought to bear on every case to determine what adjustments,
if any, are required. If changes are made to the prosthetic guide, the additional
Inclusive Tooth Replacement Solution components likely will need to be adjusted
and modified to accommodate the altered implant location or angulation.
2Lance drill through prosthetic
guide
Once the ideal dimensions have been established for implant placement, the
prosthetic guide is seated in the mouth (Fig. 1), and the lance drill is used to drill
through the pilot hole (Fig. 2). The prosthetic guide is then removed, and the
angulation and location of the lance drill verified with a PA. Once any necessary
adjustments are made to the osteotomy pilot hole, the osteotomy is completed
freehand in the usual and customary surgical manner.
The Inclusive Tooth Replacement Solution prosthetic guide can be a useful tool
for selecting the location of a planned implant, but it should not be regarded
as a standalone resource. The suggested osteotomy site of the prosthetic guide
must be viewed within the larger context of the case, taking into consideration
adjacent teeth and root dilacerations, proximity to vital anatomic structures, and
hard and soft tissue contours. When necessary, the prosthetic guide should be
adjusted to secure the ideal surgical and prosthetic outcome. IM
It is imperative that the clinician utilizes the prosthetic
guide in conjunction with appropriate radiography ...
and other diagnostic information available.
– Clinical Tip: Using the Inclusive Tooth Replacement Solution Prosthetic Guide – 29

R&D
CORNER
Go online for
in-depth content
Strength and Flexibility of BruxZir
Solid Zirconia Implant Restorations
by
Robin A. Carden, VP of Research & Development
A
critical consideration with implant-borne restorations
is the distribution of functional stresses. In
the absence of a periodontal ligament to serve as a
natural shock absorber, it is incumbent on the restoration
to withstand the full force of those stresses. BruxZir ® Solid
Zirconia, a monolithic ceramic restoration with no porcelain
overlay, has the ability to meet this demand with a blend
of strength and flexibility, due to a set of intrinsic material
properties that include high flexural strength, high fracture
toughness, low coefficient of friction, and low coefficient of
thermal expansion.
FLEXURAL STRENGTH
Typical zirconia materials demonstrate a flexural strength of
more than 900 MPa. As a result of the proprietary methods
used to process BruxZir milling blanks, BruxZir zirconia
exhibits an even greater strength, measured as high as
1,510 MPa in accordance with the JIS R 1601 standard on
an Instron-5564 electromechanical testing system (Fig. 1).
This standard, established by the Japan Fine Ceramics
Association, specifies the testing method for three-point and
four-point flexural strength of high-performance ceramics
at room temperature. Compared to the flexural strength of
Figure 1: Instron-5564, used to measure BruxZir zirconia’s flexural strength
conventional PFM restorations, measured at roughly 800
MPa or less, monolithic BruxZir zirconia boasts a strength
advantage of nearly twice that of the traditional alternative,
essentially allowing it to bend without breaking (Fig. 2).
R&D Corner: Strength and Flexibility of BruxZir Solid Zirconia Implant Restorations 31

1400
Average Flexural Strength Distribution
1300
Flexural strength (MPa )
1200
1100
1000
900
800
sagemax ht
zirconia
DoCERaM
zirconia
amann Girrbach
zirconia
Zirkonzahn
zirconia
Cercon
zirconia
BruxZir ®
zirconia
Figure 2: Graph showing the average flexural strength distribution of monolithic zirconia products, as tested by Glidewell Laboratories
FRACTURE TOUGHNESS
Fracture toughness (K 1c value) is a quantitative way of
expressing a material’s resistance to brittle fracture when
a crack is present. Materials such as lead or steel, for
example, demonstrate high fracture toughness, whereas
most ceramic and glass-ceramic materials exhibit low and
inconsistent fracture toughness. This means that a crack
can travel through a typical ceramic with little resistance,
resulting in immediate, brittle fracture and catastrophic
failure. Partially stabilized zirconia, however, contains an
internal mechanism that actually inhibits crack propagation.
This “self-healing” event is known as phase transformation
toughening. When faced with a propagating crack tip,
a zirconia grain particle is able to absorb the associated
energy by transforming from its tetragonal phase to the
more stable monoclinic phase. This results in an associated
volumetric expansion, effectively closing the advancing
crack. Transformation toughening gives partially stabilized
zirconia a K 1c value that is three to six times higher than
normal cubic zirconia and most other ceramics, resulting in
tremendous impact resistance.
Figure 3: Spring fabricated from BruxZir zirconia
Figure 4: Compressed BruxZir zirconia spring
32
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CONCLUSION
Partially stabilized zirconia …
contains an internal
mechanism that actually
inhibits crack propagation.
The fastest-growing product in the 42-year history of
Glidewell Laboratories, BruxZir Solid Zirconia has quickly
proven itself as a reliable, esthetic alternative to traditional
PFM and full-cast restorations. Manufactured from yttriastabilized
zirconia powder specially processed to achieve a
nanocrystalline particle size as small as 3 nm, BruxZir zirconia
exhibits class-leading strength and flexibility in addition
to its high biocompatibility. These mechanical properties
enable it to absorb high levels of functional stress, making
it an ideal material choice for implant-borne restorations,
whether cement-retained or screw-retained (Figs. 5, 6). IM
As a demonstration of this principle, note the fabrication
of BruxZir zirconia into a spring-shaped coil (Fig. 3). Due
in part to its high K 1c value and ability to transform its
structure, this coil can endure repeated compression cycles
(Fig. 4), returning each time to its original shape without
suffering the fracture damage one might expect of a typically
brittle ceramic.
COEFFICIENT OF FRICTION
Although dependent on system variables such as temperature,
velocity and atmosphere, the coefficient of friction
(COF) is often stated as a material property that describes
the ratio of the force of friction between two bodies and
the force pressing them together. Ice on steel, for example,
would tend to have a low COF, while rubber on pavement
tends to have a high COF. A material with a low COF value,
such as that exhibited by BruxZir zirconia, can be perceived
then as having a greater resistance to frictional wear present
in any nanomechanical system, enabling it to better withstand
the rigors of micromovement.
Figure 5: Cement-retained BruxZir crown with Inclusive ® All-Zirconia Custom
Implant Abutment
COEFFICIENT OF THERMAL EXPANSION
The coefficient of thermal expansion (CTE) describes how
the size of an object changes with a change in temperature.
In general, substances expand or contract when their
temperature changes, with expansion or contraction occurring
in all directions. This causes strain within the material,
which again can introduce the potential for fracture. A
lower CTE number indicates greater resistance to thermal
shock. Because the oral environment is highly susceptible
to rapid temperature changes, a material like BruxZir zirconia,
characterized by a relatively low CTE, is better suited
to withstand the rigors of that environment than a material
with a higher CTE.
Figure 6: Screw-retained BruxZir crown
R&D Corner: Strength and Flexibility of BruxZir Solid Zirconia Implant Restorations 33

The Do’s and Don’ts
of Immediate Loading
or Provisionalization
of Dental Implants
DO’S
Initial stability of 35 Ncm
Go online for
in-depth content
Figure 1: Torque wrench demonstrating 35 Ncm upon
final implant seating
by Darrin M. Wiederhold, DMD, MS
Much like Hamlet’s ageless lament, “To be, or not
to be,” implant surgeons around the world are
plagued daily by the conundrum: “To immediately
load, or not to load?” Is it far better to suffer a patient’s wrath
over a missing maxillary anterior tooth than endanger the
neophyte implant as it osseointegrates? That is the question,
and this, hopefully, is the answer.
An important distinction that must first be made concerns
the terms “immediate loading” versus “immediate nonfunctional
provisionalization” (or “temporization”). From an
academic point of view, “immediate loading” would be any
component that is attached to the implant within zero to
20 days of implant insertion and is placed under occlusal
stress or load. This term is further applied to any situation
where the implant undergoes micromotion and is designed
to be functional rather than just cosmetic. “Immediate nonfunctional
provisionalization” is a generic term denoting the
temporizing — generally for esthetics — of the implant, but
where the provisional component is purposely taken out
of occlusion in an effort to minimize any micromovement
of the implant that might hinder or compromise its
osseointegration. It is important to differentiate the two
terms and recognize that patients are demanding more
and more that we immediately provisionalize their implant,
but are not generally concerned with whether there is true
occlusal loading of the implant.
As with any surgical procedure, there are certain selection
criteria that, if heeded, can help to maximize the chance
of success. Conversely, there are those guidelines that
clinicians ignore at their own peril. The following are the
classic Do’s and Don’ts of immediate provisionalization or
immediate loading.
ISQ score of 50–80, with a higher
score correlating to a greater
degree of initial stability
Figure 2: Osstell ® ISQ implant stability meter (Osstell
USA; Linthicum, Md.)
1 mm–1.5 mm of facial bone
surrounding the implant
Figure 3: CT scan (cross-sectional view) demonstrating
adequate facial bone width
– The Do’s and Don’ts of Immediate Loading or Provisionalization of Dental Implants – 35

DO’S
Healthy, non-infected,
non-compromised bone
DON’TS
Bone that has been compromised,
either through abscess,
periodontal disease, or other
local pathology
Figure 4: Preoperative PA demonstrating healthy bone in
the edentulous space
No history of bruxism or other
parafunctional habits
Figure 7: Large periapical lesion
History of heavy bruxism,
clenching, or other destructive
parafunctional habits
Figure 5: Implant patient with healthy, unworn dentition
DON’TS
Initial stability of less than 35 Ncm
ISQ scores below 50
Deficiency of bone, particularly on
the facial aspect, or where bone
grafting is indicated or performed
Figure 8: Worn dentition suggesting history of heavy
bruxism
An important distinction ...
concerns the terms
“immediate loading” versus
“immediate non-functional
provisionalization” or
“temporization.”
Figure 6: CT (axial slice) showing buccal defect
When deciding whether to immediately provisionalize
or load, it is important to consider the
number of implants being placed and the ability to
splint those implants together. For single implant
36
– www.inclusivemagazine.com –

cases, the caveats noted previously are critical. For multiunit
cases, the ability to splint the implants together via the
provisional prosthesis — be it a complete denture, short- or
long-span bridge, or a hybrid — affords greater flexibility
in the decision to immediately load or provisionalize. There
is greater initial stability, minimization of occlusal stresses
and, therefore, reduced micromovement as a whole when
implants are splinted. As such, the ability of the implant to
integrate successfully into the surrounding osseous matrix
is greatly improved.
Bear in mind that these simple Do’s and Don’ts can help
maximize the odds of success when placing implants.
Patient demand for immediate provisionalization is greater
than ever, and as providers of a service, we are strongly
motivated to meet that demand. But as dental professionals,
we are the final arbiters of what is in the patient’s best
interest. If there is inadequate initial stability, compromised
bone quality or quantity, or if any of the other clinical
parameters are less than ideal, it is imperative that we as
clinicians make the unpopular decision not to immediately
provisionalize or load. It can be difficult to inform a patient
with high esthetic expectations that they will have to
endure a less-than-ideal cosmetic situation for the four to
six months of osseointegration. But, in the long run, what’s
best for the implant is best for the patient.
Custom-fitted components
designed to ... develop soft tissue
architecture, satisfy the patient’s
esthetic demands, and improve
impression quality ... simplify the
implant process.
Once the decision is made to temporize an implant case,
the method must be chosen. There are a variety of materials
and techniques available, but only the Inclusive ® Tooth
Replacement Solution comes packaged with patient-specific
temporary components at the time of surgery, with the
goal of increasing restorative predictability and reducing
chairtime when compared to the use of stock components
or handmade custom components. Additionally, the
Inclusive Tooth Replacement Solution gives the clinician
the flexibility to temporize the case at any point in the
process, be it the day of placement, or at a future date —
whenever it is determined that the implant has achieved
sufficient stability. In those instances where placement of
a custom temporary abutment and BioTemps ® provisional
crown are not immediately indicated, the option exists to
place the custom healing abutment instead. By doing so,
the benefit of immediately beginning to develop the soft
General References
tissue architecture around the implant is achieved
without the worry of any occlusal stress on the
newly placed fixture.
By treatment planning with the end in mind from
the outset, many of the challenges clinicians often
encounter, both surgically and restoratively, can
be minimized. Having custom-fitted components
designed to guide implant placement, develop
soft tissue architecture, satisfy the patient’s
esthetic demands, and improve impression
quality all help to simplify the implant process.
Furthermore, because the process is more
efficient and streamlined, fewer appointments
are required, and there is greater predictability
during those appointments. Greater predictability
means fewer scheduling challenges for the front
office staff, translating to greater profitability for
the practice. IM
• Attard NJ, Zarb GA. Immediate and early implant loading protocols:
a literature review of clinical studies. J Prosthet Dent. 2005
Sep;94(3):242-58.
• Balshi TJ, et al. A prospective analysis of immediate provisionalization
of single implants. J Prosthodont. 2011 Jan;20(1):10-5.
• Block M, et al. Single tooth immediate provisional restoration of
dental implants: technique and early results. J Oral Maxillofac
Surg. 2004 Sep;62(9):1131-8.
• Block MS, et al. Prospective evaluation of immediate and delayed
provisional single tooth restorations. J Oral Maxillofac
Surg. 2009 Nov;67(11 Suppl):89-107.
• Buser D, Martin W, Belser UC. Optimizing esthetics for implant
restorations in the anterior maxilla: anatomic and surgical considerations.
Int J Oral Maxillofac Implants. 2004;19 Suppl:43-61.
• Davidoff SR. Late stage soft tissue modification for anatomically
correct implant-supported restorations. J Prosthet Dent. 1996
Sep;76(3), pp:334-8.
• Degidi M, et al. Five-year outcome of 111 immediate nonfunctional
single restorations. J Oral Implantol. 2006;32(6):277-85.
•Kinsel RP, Lamb RE. Tissue-directed placement of dental implants
in the esthetic zone for long-term biologic synergy: a
clinical report. Int J Oral Maxillofac Implants. 2005 Nov-Dec;
20(6):913-22.
• Kourtis S, et al. Provisional restorations for optimizing esthetics
in anterior maxillary implants: a case report. J Esthetic Restor
Dent. 2007;19(1):6-16.
• Wismeijer D, et al. ITI Treatment Guide, Vol. 4: Loading Protocols
in Implant Dentistry: Edentulous Patients. 2010. Berlin: Quintessence
Publishing Co, Ltd.
– The Do’s and Don’ts of Immediate Loading or Provisionalization of Dental Implants – 37

CLINICAL
TIP
Go online for
in-depth content
Creating a Screw-Retained Temporary
by
Bradley C. Bockhorst, DMD
A temporary restoration provides a prosthetic prototype that helps not only
to sculpt the soft tissue contours, but also to simplify the seating of future
components. Think of it as a practice builder: it satisfies the patient because
they get their tooth back more quickly, and clinicians are better able to manage
patient expectations for the final restoration.
The custom temporary abutment and BioTemps ® provisional crown featured
with the Inclusive ® Tooth Replacement Solution from Glidewell Laboratories
are intended to provide a cement-on provisional restoration. However, they can
easily be converted into a one-piece, screw-retained restoration.
As the term implies, a temporary restoration will need to be replaced at a future
date. This is easily accomplished with a screw-retained restoration by uncovering
the access opening and loosening the abutment screw.
Advantages of
screw-retained
provisional restorations:
• Retrievability
• Elimination of potential
excess cement
• Ability to push soft tissues
One of the major challenges with cemented implant restorations is removal of
excess cement. In the procedure outlined here, the components are luted together
extraorally, ensuring complete seating of the crown to the abutment and
facilitating removal of excess cement. Using permanent cement will decrease the
chances of the temporary crown inadvertently coming loose.
To create an ideal emergence profile, you may need to displace or “push” the soft
tissues. This is much easier to do with a screw-retained restoration. If you attempt
to manipulate the tissues with a cemented provisional, you run the risk of having
difficulty seating the crown or the provisional coming loose.
Note: Roughening up the surface or creating grooves in
the abutment with a diamond bur or disc will create a
mechanical retention.
– Clinical Tip: Creating a Screw-Retained Temporary – 39

Step-by-Step
1Seat the temporary abutment and
hand-tighten the abutment screw.
2Seat the BioTemps crown on
the abutment. Check interproximal
and occlusal contacts. Make
adjustments as needed. Note: For
immediate non-functional provisionalization,
the crown should
be well out of occlusion.
Remove the BioTemps crown and
3 temporary abutment. Drill a hole
through the BioTemps crown,
following the trajectory of the
abutment screw.
Roughening up the surface or creating grooves in the abutment
with a diamond bur or disc will create a mechanical retention.
Mount the temporary abutment
4 on an implant analog for ease
of handling. Seat the BioTemps
crown on the abutment and verify
the size and position of the access
opening over the abutment screw.
Cover the head of the screw and
5 block out the screw access opening
with Teflon tape, a cotton
pellet and soft wax, or use a guide
pin. Lute the BioTemps crown
onto the temporary abutment with
permanent cement.
Meticulously remove all excess cement.
Finish and polish the screw-
6
retained temporary as needed.
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Seat the one-piece assembly on the implant and tighten the abutment screw
7 to 15 Ncm. Recheck the contacts.
Cover the head of the screw with Teflon tape or a cotton pellet, and seal the
8 access opening with acrylic or composite.
A key feature of the Inclusive Tooth Replacement Solution’s temporary abutment
and BioTemps crown is versatility. They can be used for cement-on temporary
restorations or easily converted to a screw-retained provisional prosthesis, each
with their own indications and corresponding benefits. IM
– Clinical Tip: Creating a Screw-Retained Temporary – 41

Implant&
Q A:
Go online for
in-depth content
An Interview with Dr. Perry Jones
Interview of Perry E. Jones, DDS, FAGD
by Bradley C. Bockhorst, DMD
Dr. Perry Jones maintains a private general practice in Richmond, Va.,
and also serves as the director of continuing education and faculty
development at Virginia Commonwealth University School of Dentistry.
One of the first certified Invisalign providers, Dr. Jones has been
involved with Cadent optical scanning technology since its release to
the GP market. He took time to talk about his experience with digital
intraoral scanning technology after attending a recent course at the
Glidewell International Technology Center.
Dr. Bradley Bockhorst: I wanted to
spend some time talking about one of
your passions, digital intraoral scanning.
Can you tell us a little bit about
how long you’ve been involved with
that technology?
Dr. Perry Jones: I have been involved
in optical/digital scanning in my practice
for the purpose of restorations
probably for the last five or so years.
I started when we did our first beta
testing of digital scanning equipment
and was lucky enough to have one of
the first units to be placed in service
in the United States. Coincidentally, it
happened to occur right when my son
joined my practice. It was pretty phenomenal
to have a young kid come in
and learn and see what digital scanning
was all about. He’s lucky enough not
to have lived through the days of VPS
impression taking, when impressions
didn’t come out the way we thought
they would.
BB: Intraoral scanning is obviously
the buzz right now. Every time you go
to any meeting, whether it’s for specialists
or general dentists, that’s one of the
hot topics. What would you consider the
primary benefits of intraoral scanning?
PJ: A digital scanning system has
many benefits. One is that you can do
any type of restoration — it could be
a gold restoration, a PFM, a porcelain
restoration, an intraoral inlay-onlay. It
could even be a provisional restoration,
anything you can think of that
can be made in the restorative world.
And it can be done either model-less
or on models.
Let’s also talk about some of the other
things we can do. We talked about
modeling. We can make polyurethane
models, and use these models for
a plethora of different things. For
example, we might use them for
thermoplastic materials to be made
on the model. The beauty is, when
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we separate the plastic material
from the model, there’s no tooth
breakage, so we can reuse it over and
over again. We might make full-arch
thermoplastic retainers, movement
appliances, canine-to-canine retainers,
occlusal guards, bleaching trays,
athletic guards. All of the different
things you can think of that we make
on conventional models, we can make
on the polyurethane models.
We also have the ability to export files.
So the STL files that we create can be
merged with the DICOM files from
cone-beam CT information, and the
merge allows us to do digital planning
to create surgical guides in a 100 percent
digital environment.
BB: Obviously, digital scanning has
a lot of indications. Do you have any
tips for dentists getting involved with
intraoral scanning, and how to easily
integrate it into their practices?
PJ: Let me make two comments. First,
as with anything, there’s a slight learning
curve. The learning curve is very
small, but like backing up a car with
a trailer behind it, your brain has to
think through exactly the placement
of the camera. I took a two-day inoffice
training and was expected to
bring some cases ready to scan. Honestly,
I went home the first night and
thought, “You know, I’m not sure this
is really for me,” because I didn’t grasp
the concept of simply looking at the
monitor and then relating my camera
position. But once I caught on to
that, the next day, I was a scanning
machine! In fact, my son and I would
fight over who got to scan the case —
and we still do to this day. Who gets to
scan — staff or one of the doctors? It’s
so much fun. The learning curve was
short, but there is a learning curve. I
think that’s probably the first thing I
would say about introducing it into
your practice.
The second thing I think that’s really
important is that doctors have to
understand that there will be a big
reduction in the time they spend
in delivery of the restoration. It’s
significant! Everybody I’ve talked to
who uses intraoral scanning finds
that the time they need for delivery
is radically cut by about half. In my
practice, we used to allow 30 minutes
for each restoration. We’ve gotten so
comfortable with it now, we don’t
even make a delivery appointment. We
simply insert them between the other
patient appointments.
“Hello, Mrs. Smith, we’d like to have
you come in today. We’ll see you at
2:30 p.m. to deliver your crown.” We
have such confidence that in a few
minutes we’ll be able to deliver the
crown with no mesial-distal or very
little, if any, occlusal adjustment, that
we prepare to be able to deliver the
case that way.
BB: So part of that is obviously the accuracy
of the system. Also, because you’re
doing intraoral scanning, you’re seeing
on screen whether you’re capturing the
margin, so you’re actually forced to do
a better job. Can you talk about your
experience along those lines?
PJ: Well, Brad, that is a humbling
experience, to be very honest. Let me
tell you a little anecdotal story. A digital
trainer from the Miami area came to
Doctors have to
understand that
there will be a
big reduction in
the time they
spend in delivery
of the restoration.
– Implant Q&A: An Interview with Dr. Perry Jones – 43

We have
been working
with dedicated
implant scanning
abutments to give
us the information
to create a final
restoration ... in a
100 percent
digital environment.
my office to practice and learn, and
to see a doctor who was recently
introduced to digital scanning. She
said she had a funny story. At first she
couldn’t find the doctor. When she
finally found him sitting in his office,
he had his head in his hands, leaning
on his elbows. He was literally almost
in tears because when he looked at
what was displayed on the screen, he
thought, “I am the worst dentist in the
world. I can’t believe the preps that
I’ve cut.” When you see what’s on the
screen, it makes you become a better
doctor, a better clinician.
I wear four-power loupes when I do
preparations, but to see that on the
screen — if you saw where I started
and where I am today, you would be
able to physically see the difference in
the quality of the preps.
BB: You also get a chance to check that
prep, go back and clean things up, and
scan again.
PJ: That’s right. Absolutely. It greatly
shortens the time it takes to evaluate
your prep and then react to what you
see on screen. For example, you can
outline an area where there is insufficient
occlusal reduction, and then
reduce that area and re-scan only that
area — not the whole prep.
BB: You say you’re going modelless.
Can you tell us a little bit about
articulation?
PJ: I’d love to talk about that because
we’ve done it with Glidewell and have
had fantastic success. In the last year
plus, we have been delivering fullcoverage,
all-zirconia restorations —
your product BruxZir ® Solid Zirconia.
And of the many benefits we’ve
seen, one is a less aggressive prep
than our PFM prep. That is a huge
benefit. Again we have the accuracy
of delivery, so the delivery time is
cut down. And, Brad, at the very
beginning, it was a challenge to look
in the box and go, “Wow, there’s no
model to go with it.” You think, “Is this
really going to work?” And the answer
is, “Yeah, it works. It works with such
accuracy that we’re fully confident
that in both mesial-distal and occlusal
relationships, we’re good to go.”
In recent months, I have started
using semi-adjustable articulators.
However, I will say that even the hinge
articulation is incredibly accurate.
So often it’s the case — especially if
we have mesial and distal full-tooth
contacts, where the prepped tooth
is between an occlusal mesial stop
and an occlusal distal stop — that incredibly
accurate restorations come
back just on that small partial quadrant.
It’s amazing that, universally,
little to no adjustments are necessary
on our restorations.
BB: A lot of our readers may have seen
your article in a recent issue of Inclusive
magazine, the Fall 2011 issue, “From
Intraoral Scan to Final Custom Implant
Restoration,” where you were working
on a BruxZir anterior bridge. Would
you comment on that case?
PJ: That was a huge leap of faith, to
be very honest. That case had two
screw-retained custom zirconia abutments
with a 4-unit bridge attached
to those two abutments. We were restoring
implants in the site of tooth #7
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and tooth #10. And the leap of faith
was that this box shows up, and there
are two screw-retained zirconia abutments
and a 4-unit bridge. I put in the
zirconia abutments and, literally, my
hands were almost shaking to think
what was going to happen when I put
the 4-unit bridge in place. I put it in
place, asked the patient to bite together
— a caveat was that this patient had
such a tight anterior coupling that he
would always break his provisional.
He had a little 4-unit flipper over
the two central incisors that would
break time and time again. This 4-unit
bridge went in place, and he said it
fit perfectly. I said, “OK, let’s check it.”
We checked it with articulating paper,
and I still couldn’t believe it. I called
my son in and asked him to check it,
and he said, “It’s amazing. I can’t believe
it. There are contacts. I can see
coupling marks, and the patient’s
posterior teeth fit together perfectly.”
There was no adjustment on that case,
done 100 percent digital.
BB: In the implant world, not only can
you use the intraoral scanner for scanning
preps, but you can also use it for
scanning the implant. You’ve been involved
with us from the beginning utilizing
the scanning abutment, so can you
comment on your experience so far?
PJ: Well, part of the frustration in getting
started was, there were really just
two big companies: Straumann and 3i,
that were sort of the leaders, the innovators,
having a system to place some
sort of scanning abutment on top of
the implant and get an impression via a
model or via scanning. I’m a big Nobel
guy. I’ve worked with those folks for
years and years and really wanted to
use the Nobel system. I was fortunate,
through a crazy combination of events,
to run into a former Nobel employee
who works here at Glidewell — Grant
Bullis. Grant and I have become collaborators
on working with a system
to be able to use Nobel implants and
be able to scan the information using
digital scanning. We use what we call
dedicated scanning abutments. They’ve
gone through several iterations. Our
first ones were 13 mm in length.
So the concept was: 13 mm implant,
13 mm scanning abutment — it’ll give
us more information. But we found
out that it’s kind of tough to close into
occlusion. So we’ve gone now to a
6.5 mm height scanning abutment,
which seems to work fine. Certainly
for a period over the last six months,
maybe a little longer than that, we have
been working with dedicated implant
scanning abutments for the Nobel
system to give us the information to
create at Glidewell a final restoration
from the information that I send to
you. And that is now done in a 100 percent
digital environment. That’s phenomenal.
Our most current iteration of
that is a custom-milled titanium insert
with an all-zirconia body around it, so
it’s screw-retained. The beauty is that
the interface is titanium-to-titanium
between the implant and the restoration,
so it can be screw-retained. We’re
having phenomenal results with that.
BB: Another benefit of using scanning
abutments is not having to worry about
margins. Do you agree?
PJ: Oh, absolutely. It cannot get more
precise than that. We can take the
analog and reproduce what the scanning
abutment tells us is there. The
phenomenal thing is that it’s done in
a digital environment, as opposed to
modeling. We’ve been very happy with
our results.
BB: Just so our readers understand how
the scanning abutment works, can you
explain the distal impression process?
PJ: Yes. Let’s go through the workflow:
The patient comes in, and let’s say
there’s a healing abutment in place.
We remove the healing abutment and
select the appropriate scanning abutment
for the size of the implant. In
the case of Nobel, it could be a narrow
platform (NP), a regular platform
(RP) or wide body (WP). Then we
place that scanning abutment in place
and digitally scan it. That information
is sent directly to Glidewell Laboratories.
Software at Glidewell allows
us to design what would then be the
final restoration for that case. It could
be many different things — it could
be a cement-retained, or in the cases
that we’re working with mostly now,
a titanium insert with an all-zirconia
body. Where that is derived from is
the scanning abutment that’s screwed
in place, directly to the implant fixture
itself.
BB: Earlier on, we were talking about
the many different indications for
intraoral scanning, and one you
mentioned was guided surgery. Maybe
you can talk a little bit about your
experience with that.
PJ: This is so new to us that we are
just learning all of the nuances. And
some of the workflow has been a little
awkward as we were beginning to try
to make all the parts work. Let’s just
see if we can walk through what we
were actually able to do.
We can create a 3-D rendering of
the information that represents the
patient’s bone and, to some degree,
soft tissue structure, and we can do
that in a 3-D rendering on a computer
screen. That’s derived by way of taking
a cone-beam CT scan and capturing
the information in DICOM files — the
common medical term for passing
that information. The thing that we’re
missing at that point is the accuracy
of the morphology of the occlusion of
the teeth. So if we were to make, let’s
say, a surgical guide, we’d need to have
that accuracy. You don’t get that level
of accuracy from our cone-beam CT.
So the beauty would be, suppose we
– Implant Q&A: An Interview with Dr. Perry Jones – 45

had another way to put the occlusal
accuracy in the very same rendering.
We can do that with the STL files
created by our scan. When the patient
comes in, they’ll have their cone-beam
CT, and they’ll have their scanning
done in the office. Those files, in my
case, are then sent to a third-party
provider. That third-party provider
merges those files together so you
physically can see in the rendering
the accuracy of the STL files and the
morphology of the occlusion of the
teeth and all the bony structures.
Now, in the virtual world, we can
use what I’ll call a “virtual ceramist.”
We can take a software program that
allows us to create a representation
of the crown of the tooth, or multiple
crowns of the teeth, and we can put
that into virtual occlusion and make
sure they are placed where we want
them to be, and then — we’ll call it
a “crown-down” plan — we can go
to the hard tissue. And as you see in
many different implant planning systems,
we can place those implants in
the bone, be sure that the exit hole, or
its relationship to the physical crown,
is proper to that implant, and create a
plan that tells us: this is where we want
the implant to be in terms of the final
restoration. That virtual planning then
can be carried to the next level, which
allows us to send that information to
a computer that can use a milling process
to create a precise surgical guide.
Usually, in the cases we’re doing now,
a little guided cylinder allows you to
place drills sequentially to place the
implant precisely where you planned
it in all dimensions, including depth.
That’s amazing.
BB: We offer a similar service, and we’ve
found that it’s just phenomenal when
you start merging these technologies.
When you merge the cone-beam scan
and the intraoral scan, you’ve got the
soft tissue information, too, which you
really didn’t have before with just the
cone-beam scan. And what we’ve found
through our research is that the fit of a
surgical guide based on an intraoral
scan is superior to other methods.
PJ: That has been my observation,
too. Absolutely. In fact, a case that was
done at Virginia Commonwealth University
in our oral surgery department
comes to mind. One of our residents
actually did the drilling on the case
and he commented, “I think we could
bring the cleaning lady in and she
could do just as well as I can, you’ve
made it so simple with guided surgery.”
They are now strong believers
in the system.
Before I came out to see you guys,
our chairman asked me if the two of
us would collaborate to do a case —
because they believe so much in the
benefit of guided surgery. We’ve done
it with soft tissue; the trick is now
being able to do it with teeth. I think
it’s going to raise the bar in terms of
what doctors can expect, and raise the
bar in terms of what will be expected
of us across the country.
BB: Along those lines of doing toothborne
surgical guides, do you see that
becoming a standard of care for specific
indications, such as single teeth?
PJ: That’s a healthy discussion. A lot
of folks who do surgical placement
feel very comfortable once they’ve
looked at the CT scan that they’re
where they should be. I’ve got to tell
you though, it’s often the case that I’m
disappointed in the placement, and
I think we could do better. I’m not
just talking about not ending up in
the interior alveolar canal; I’m talking
about the relationship to the crown of
the tooth. I think it’s always a help, and
I think where it’s going is getting the
costs to be reasonable. I know there
are many third parties out there who
are doing planning, and I think we
can see that price being driven down.
I know here at Glidewell you have an
awesome deal going. We’re getting
ready to do our first mini implant case
with guided surgery, so I’m looking
forward to seeing how that works. In
fact, I’m here to actually take one of
your courses.
BB: That’s one of our goals, to be
able to provide that service and that
technology at an affordable price, so it
doesn’t become prohibitive. And to let
clinicians know they can use it for other
indications, including single teeth.
PJ: Exactly.
BB: Well, it’s exciting technology, and
it’s obviously the future. I’d like to thank
you for spending time with us today. I’d
also like our readers to know that we’ll
be working with you a lot, and that
there’s going to be a flow of articles like
this in Inclusive magazine.
PJ: I hope to have some articles with
more information about some of the
things that we’re doing. It’s all about
trying to get our family of GPs up to
speed and to understand the things we
can do. I think it’s very exciting. IM
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LAB
SENSE
Go online for
in-depth content
by
Back to the Future
The IPS e.max
Screw-Retained Crown
Dzevad Ceranic, CDT
Implant Department General Manager
In processing restorations for more than 160,000 implant
cases, the implant department at Glidewell Laboratories
has accumulated a unique understanding of the industry
as a whole. Among the recent trends observed at Glidewell
Laboratories is the demand for monolithic screw-retained
restorations such as the IPS e.max ® screw-retained crown
(Ivoclar Vivadent; Amherst, N.Y.). While screw-retained
restorations represent a long-accepted prosthetic solution,
the combination of this restorative paradigm with strong,
highly esthetic monolithic materials and cutting-edge
CAD/CAM digital technology has allowed us to produce
an exciting alternative to conventionally processed PFM
implant restorations.
IPS e.max lithium disilicate has already established itself
as a leading ceramic in conventional crown & bridge cases,
highly regarded for its unique blend of flexural strength
(360–400 MPa) and natural esthetics. Available in multiple
translucencies, IPS e.max provides lab technicians with
great flexibility and ease of use when it comes to matching
the warmth and shade of natural dentition. And because
there is no porcelain veneer, there is no risk of porcelain
chipping or fracture.
By affixing IPS e.max to a screw-retained titanium base in
the lab, doctors and their patients receive the full benefits
of both the material and a screw-retained design. There
are additional benefits inherent in the CAD/CAM processes
used to fabricate these restorations. One such benefit is
reduced cost, as an IPS e.max screw-retained crown is less
expensive to produce than a traditional screw-retained PFM
from a UCLA wax-up. A second benefit is reduced lab time,
as the typical turnaround for an IPS e.max screw-retained
crown is typically half of that required for a crown over a
custom abutment.
The combination of … strong, highly esthetic
monolithic materials and cutting-edge CAD/CAM
digital technology has allowed us to produce an
exciting alternative to conventionally processed
PFM implant restorations.
– Lab Sense: The IPS e.max Screw-Retained Crown – 47

PRODUCTION WORKFLOW
The following overview provides a brief, insider’s look at
the state-of-the-art process employed at Glidewell Laboratories
to digitally design and fabricate an IPS e.max
screw-retained crown.
Step 1: Model Scan
For the first optical scan, a soft tissue study model is
created from conventional impressions, and a scanning
abutment is attached to the implant analog, serving to
capture the implant angulation, position, and abutment
connection orientation (Fig. 1). The scanning abutment is
then removed and the arch is scanned a second time, with
the soft tissue mask in place. A scan of the opposing model,
followed by a scan of the fully articulated casts enables the
design software to construct and properly align a complete
3-D model.
Step 2: Digital Design
Once the fully articulated case exists in a virtual environment,
the restoration can be digitally designed using software that
contains a proprietary library of morphology (Figs. 2, 3).
The software enables the technician to exercise
precise control, measured in mere microns.
The technician refines the emergence profile, interproximal
contacts and occlusion — every aspect that would be
estimated and executed by hand if using a conventional
wax-up technique. The software enables the technician to
exercise precise control, measured in mere microns. Such
detailed, comprehensive control is especially critical with
implant restorations, which must be built up subgingivally
from the implant platform, rather than simply dropped onto
a natural tooth prep.
Step 3: Perfactory Crown Printing
Once the digital restoration is complete, the electronic file is
forwarded to a Perfactory ® printer (envisionTEC; Torrance,
Calif.) for three-dimensional printing. The Perfactory system
builds solid 3-D objects by using a DLP ® projector (Texas
Instruments; Dallas, Texas) to project sequential planes of
data into a photoactive liquid resin, causing the affected
resin to cure from liquid to solid. Each data plane is made
Figure 1: Onscreen display showing full-arch model
scan with digital scanning abutment
Figure 2: Computer-aided design of restoration in a
virtual environment
Figure 3: Completed virtual design of screw-retained
implant crown
Figure 4: Plate of printed Perfactory crowns
Figure 5: Individual Perfactory crown and titanium base
48
– www.inclusivemagazine.com –

up of tiny voxels (volume pixels), allowing the printer to
produce, layer by layer, a physical duplicate that precisely
matches the form set by the design pattern (Figs. 4, 5). The
entire printing and curing process takes a little less than
two hours, after which the physical crown can be tested on
the model to ensure proper fit.
Step 4: Ceramic Pressing
Once proper fit is verified, the Perfactory crown is sprued
and invested for ceramic pressing using a traditional lostwax
technique and the appropriate weight and shade of
IPS e.max Press ingots (Figs. 6, 7). After divesting, the IPS
e.max crown has the exact form and shape of the original
printed pattern.
Step 5: Finishing
During finishing, the pressed IPS e.max crown undergoes
a comprehensive quality control inspection to ensure
accurate fit, contacts, and occlusion. After being trimmed
and polished (Fig. 8), the all-ceramic crown is stained and
glazed to match the doctor’s specific instructions concerning
final esthetics (Fig. 9).
Step 6: Cementation and Delivery
Finally, the IPS e.max crown is luted to a premachined
titanium base (Fig. 10). Performing this step in the lab
makes it easy to remove excess cement (Fig. 11). The crown
is then shipped to the prescribing doctor, along with
a positioning index (jig) that can be used at the time of
delivery to ensure and maintain complete, accurate seating
of the restoration while the abutment screw is inserted
and tightened.
SUMMARY
Glidewell Laboratories has long been a proponent of
CAD/CAM technology as a way to produce restorations that
are more precise and less expensive to manufacture, making
them more accessible to a greater number of patients. The
IPS e.max screw-retained crown is another example of this
technology being used to merge proven restorative concepts
with the latest biomimetic materials. For doctors looking
to place a screw-retained restoration that exhibits both
strength and esthetics, IPS e.max represents an advanced
solution at an affordable price. IM
Figure 6: Invested pattern ready for burnout oven
Figure 7: Invested pattern ready for press furnace
Figure 8: Trimming and polishing the all-ceramic
IPS e.max crown
Figure 9: Staining the all-ceramic IPS e.max crown
Figure 10: In-lab cementation of the IPS e.max crown
to its titanium base
Figure 11: Final IPS e.max screw-retained crown
free of excess cement
– Lab Sense: The IPS e.max Screw-Retained Crown – 49

The Critical Nature of Tissue Contouring
from a Periodontist’s Perspective
by Robert A. Horowitz, DDS
■ The Importance of Peri-Implant Health
Most people who need dental implants have lost their
teeth due to restorative or endodontic complications,
or to the ravages of periodontal disease. These conditions
result either from failure of the patient to properly
cleanse, or from iatrogenic dentistry that has left uncleansable
margins.
Once patients lose their teeth, there is often bone loss
as well as a loss of keratinized tissue. This can lead to
black triangle disease, the loss of gingival papillae between
teeth that may result in esthetically compromised
restorations or significant interdental food impaction.
As there is a different attachment apparatus from the
gingiva to implants compared to that of natural teeth,
there is more susceptibility to peri-implant disease from
proximal inflammation. Published periodontal literature
has shown that when periodontal measurements are
taken around implants with inflamed soft tissues, the
endodontic probe tip reaches the alveolar bone. Due to
inflammation, bone loss around implants can be quicker
and more catastrophic than around natural teeth.
An ideal implant-supported restoration, then, should have
the same gingival contours and proximal contacts it would
have were it a natural tooth. It is the goal of the surgeon
to maximize bone and soft tissue preservation at the time
of extraction. If a tooth is not extracted properly, or if the
alveolar bone and keratinized tissue are not preserved at
the time of extraction, multiple surgical procedures may
be required to regenerate or rebuild the alveolar housing,
further lengthening and complicating treatment.
Using properly designed temporary and final restorative
components enables an ideal emergence profile to be
engineered from the shoulder of the implant through the
keratinized tissues to the contact point. When all these
pieces of the restorative puzzle come together properly,
the patient will have an ideal environment for keeping
the area free of inflammation. Minimizing inflammation
increases the longevity of the alveolar bone, keratinized
tissue, and the dental implant.
An ideal implant-supported
restoration should have the
same gingival contours and
proximal contacts it would
have were it a natural tooth.
■ Soft Tissue Contouring and
Successful Implant Restorations
Natural teeth and crowns have certain self-cleansing
contours. Contact points are located at different heights
from the alveolar ridge, depending on the location of the
tooth in the arch. Buccal and lingual contour heights also
vary depending on the tooth. Proper sculpting of the soft
tissues around an implant-supported crown will help keep
the gingiva at a similar height to that of a natural toothsupported
crown. In this manner, the natural actions of
the lips and tongue help move food and plaque away
from the gingival margin, rather than packing it into large
spaces between the contact point and the gingival margin,
or allowing it to build up on the facial or lingual surfaces
in a more receded environment.
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After most extractions, a loss of facial bone occurs in the
vertical and horizontal dimensions. This bone loss can
be regained surgically or prosthetically; however, adding
facial bone around an implant requires the use of grafts,
barriers, and techniques that are often more advanced
than the average practitioner is prepared for. Therefore,
preserving the facial and lingual surfaces with bone at the
time of extraction is a more predictable procedure. If the
surgeon is not familiar with these techniques, however,
and their value is not communicated to the patient, the
patient will likely experience a site collapse (Figs. 1a–1c).
The most ideal time to augment the soft tissue profile is at
the time of conventional implant placement.
Figure 1c: This can give the final crown the appearance of being “stuck” on
the gingiva.
■ Understanding the Limitations of
Stock Components
Stock or standard abutments are designed in the shape
of a perfect circle at the shoulder, or prosthetic base, of
the abutment. The problem with this standard design is
that no naturally occurring tooth is perfectly round at
the alveolar crest or the cementoenamel junction (CEJ).
While flared healing abutments are available, these
stock components still provide only a generic solution,
forming gingival contours that may be less than ideal for a
specific patient.
Figure 1a: After extraction, there is often site collapse necessitating implant
placement further palatally to ensure 2 mm of bone on the facial aspect of
the implant.
To sculpt the soft tissues around an implant, the surgeon
or restorative dentist should mimic the shape of the soft
tissue around the natural tooth in that same area. There are
numerous ways to do this. Many dentists take an implantlevel
impression, insert a round healing abutment, and
let the laboratory do the rest (Fig. 2). But if the laboratory
makes an overly bulky crown or abutment that squeezes,
pushes or compresses the gingival tissues, there is no way
to account for the potential recession that can result. If the
dentist places a stock final abutment on the implant and
Figure 1b: In such cases, to ensure proper occlusion and esthetics, the restoration
requires a facial cantilever of porcelain.
Figure 2: Implant placed properly in center of ridge. Note there is no tissue
sculpting with this conventional, non-contoured healing abutment.
– The Critical Nature of Tissue Contouring from a Periodontist’s Perspective – 51

attempts to shape the tissues with a cementable temporary
crown, there are two potential problems: depending on
the depths of the margin subgingivally, the crown may
not seat fully, leading to a dislodging of the crown and
the gingiva growing over the margins of the abutment. To
avoid this, the dentist may fill the crown with cement and
seat it using excessive pressure; however, this can cause the
cement to be expressed subgingivally around the abutment
or even the implant itself, leading to inflammation and
bone loss.
The optimal treatment for obtaining an esthetic result
around an implant is to place an ideally shaped transitional
restoration (Figs. 3a, 3b). This includes the crown
and — more importantly — the abutment. The abutment
must be shaped in such a way to develop smooth
transitions from the round prosthetic connection of the
implant to the various unique tooth shapes at the CEJ.
The abutment should be at a proper gingival height,
so that any expressed cement can easily be located and
removed. With this accomplished, the transitional crown
will affect the rest of the tissue sculpting.
After soft tissue sculpting has proceeded for one to three
months, the patient is ready for final impressions (Fig. 4).
At this time, the soft tissue dimensions and positions
must be accurately transferred to the laboratory. Using
Figure 3b: Upon insertion of the crown, the gingival tissue is slightly compressed
facially and on the interproximal surfaces. This cannot be accomplished with a
cement-retained restoration without risking residual subgingival cement.
The problem with this
standard design is that no
naturally occurring tooth
is perfectly round.
Figure 3a: Transitional screw-retained crown.
Figure 4: After the tissue has been sculpted with an ideal provisional restoration,
the emergence profile is established 360 degrees around the shoulder of
the implant, up to the contact points.
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computer technology, the ideal emergence profile of the
restoration can then be designed (Fig. 5), and a patientspecific
final restoration created (Figs. 6a–6d).
Figure 6c: Final radiograph shows proximal sculpting of the soft tissues by the
restoration, starting at the abutment-fixture junction.
Figure 5: CAD file showing fabrication of a screw-retained BruxZir ® crown.
This one-piece restoration is designed to the ideal contours and contacts in a
virtual environment.
Figure 6d: Ideal gingival contours one month after insertion of the restoration.
Figure 6a: The lab returns the finished abutment and crown.
Figure 6b: Close inspection of the final restoration shows no cement line, with
smooth contours to maintain the shape of the gingival tissues.
■ Patient-Specific Tissue Contouring:
Working with the Inclusive Tooth
Replacement Solution
Making optimal treatment possible, the Inclusive ® Tooth
Replacement Solution from Glidewell Laboratories gives
the surgeon the ability to place an implant ideally and
begin sculpting the soft tissue on the day of implant
placement. A prosthetic guide fabricated from highly
accurate diagnostic casts is delivered to the surgeon,
enabling ideal implant placement from a prosthetic
perspective that is unique to the patient. Radiography is
then utilized to determine the appropriate implant size.
This would be for conventional placement. There is also a
CT-based option that includes a digital implant plan and
surgical guide.
– The Critical Nature of Tissue Contouring from a Periodontist’s Perspective – 53

As implant dentistry is a restoratively driven surgical
discipline, an ideal crown surrounded and supported
by keratinized tissue should be the ideal end-point of
most implant therapy. The Inclusive Tooth Replacement
Solution helps the surgeon and the restorative dentist
achieve this goal.
With the team approach, the surgeon places the implant
and — in most cases — the custom healing abutment
(Fig. 7a). This will begin to sculpt the soft tissue and
aid in the creation of an ideal emergence profile, all
before the patient returns to the restorative dentist
(Fig. 7b). When ready to proceed, the restorative dentist
temporizes the patient (utilizing the custom temporary
abutment and crown) and then transfers the soft tissue
contour information to the laboratory using the custom
impression coping. The final custom abutment and crown
are delivered to the dentist and ultimately the patient is
definitively restored.
Figure 7b: After removal of the healing abutment, the gingival tissues have
been shaped to the custom-designed configuration.
As implant dentistry is a
restoratively driven surgical
discipline, an ideal crown
surrounded and supported
by keratinized tissue should
be the ideal end-point of
most implant therapy.
From a specialist’s perspective, this is an excellent practice
builder because the restorative dentist does not incur
any laboratory fees or component charges for either the
temporary crown or final restoration. The patient may also
be temporized sooner than they otherwise would, and the
overall restoration provides for better peri-implant health.
Restoring form, function, and esthetics is a given for all
clinicians involved in implant dentistry. It is of course
critical that clinicians understand the importance of periimplant
health from a preventive standpoint and educate
patients along the way. But as we continue to encounter
those who would benefit most from implant therapy, it
is vital that we appreciate the direct correlation between
patient-specific soft tissue contouring and successful implant
restorations, and start to consider the individualized
solutions that are finally at our disposal. Modern dentistry
continues to evolve toward more precision and predictability
when we are able to address the unique needs of
each patient. IM
Figure 7a: The custom healing abutment included with the Inclusive Tooth
Replacement Solution is packaged with a matching impression coping, custom
temporary abutment and provisional crown. From the occlusal view, the shape
of a molar tooth is evident.
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CLINICAL
TIP
Go online for
in-depth content
Modifying Inclusive Custom
Temporary Components
by
Bradley C. Bockhorst, DMD
Temporizing implants can provide multiple benefits, including managing the soft
tissues, preventing the adjacent teeth from shifting, and providing the prosthetic
prototype for the final restorations. The custom temporary abutment and
BioTemps ® provisional crown packaged with the Inclusive ® Tooth Replacement
Solution are fabricated presurgically and will most likely need to be adjusted at
the time of delivery.
Each Inclusive custom temporary abutment is precision-milled from
specifically compounded, medical-grade polyether ether ketone (PEEK), a
thermoplastic material with excellent mechanical and chemical resistance
properties. This advanced biomaterial is used in medical implants and
has a proven long-term track record in dental implantology. These
temporary abutments can easily be adjusted and polished chairside.
BioTemps crowns are milled from poly(methyl methacrylate) (PMMA)
and should be relined with a compatible material (i.e., cold-cured
MMA, Jet Acrylic [Lang Dental; Wheeling, Ill.], ColdPac [Yates Motloid;
Chicago, Ill.] or Palavit ® 55 [Heraeus Kulzer; South Bend, Ind.]). Other
reline materials such as composites and ethyl methacrylate will only
semi-chemically bond to the BioTemps material.
Note: Roughening up the surface or creating grooves
in the abutment with a diamond bur or disc will create
a mechanical retention. This would be done after the
crown is relined, prior to cementation.
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Adjusting the Inclusive Custom Temporary Abutment
1Place the temporary abutment on
the implant and tighten the abutment
screw.
2Seat the BioTemps crown on the
abutment and adjust contacts as
needed.
3Remove the BioTemps crown, and
mark the areas on the abutment to
be adjusted.
4Remove the temporary abutment,
and mount it on an implant analog
for ease of handling. Use a
diamond or acrylic bur to do the
bulk reduction.
5 Smooth and polish the abutment with a polishing wheel and bristle brush.
Reseat the temporary abutment intraorally and tighten the abutment screw. Seat
the BioTemps crown to verify the adjustments. Repeat the process as needed.
Once the adjustments are completed, the BioTemps crown should be relined.
– Clinical Tip: Modifying Inclusive Custom Temporary Components – 57

Relining the BioTemps Crown
If there is marginal fit of the BioTemps crown to the temporary abutment, the
reline can be done extraorally. Otherwise, the BioTemps crown should be relined
on the abutment in the mouth following standard procedure. In this case, the
goal was to lower the buccal margin for esthetic purposes, while leaving the
interproximal and palatal margins supragingival to facilitate hygiene and removal
of excess cement. IM
6Roughen the surface of the Bio-
Temps crown where temporary
acrylic will be added.
7Place the crown on the adjusted
temporary abutment.
Add temporary acrylic to the
8 crown.
The custom temporary abutment and BioTemps provisional crown …
are fabricated presurgically and will most likely need to be adjusted
at the time of delivery.
9 Adjust the crown with an acrylic bur and finish with a polishing wheel. Reglaze the crown. Palaseal®
10 (Heraeus Kulzer) would be a
chairside option.
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Delivering the Provisional Restoration
Seat the abutment on the implant, and ensure the screw is tightened to
11 15 Ncm. Note: If the vertical height is short, you may want to “roughen
up” the coronal section of the abutment to provide additional mechanical
retention for the crown.
Seal the screw access opening
12 with Teflon tape.
Cement the BioTemps crown
13 with a non-eugenol temporary
cement. Important: Ensure all
excess cement is removed.
Recheck the occlusion and
14 schedule the patient for a
follow-up appointment.
– Clinical Tip: Modifying Inclusive Custom Temporary Components – 59

Congratulations, Inclusive Contest Winners!
Thank you to all of the dentists who participated in last issue’s challenge, “How Many Implants?”
Did your estimates come close to the correct answers below?
Length: 13 mm
Diameter: 3.7 mm
Mass: 0.29 g
Surface Area: 319.14 mm 2
Surface Roughness (Ra): 1.5μ
Center of Mass: Y = -6.52 mm
Nitrogen Content (Max.): 0.05%
Oxygen Content (Max.): 0.130%
300
Internal Hex Depth: 2.0 mm
Bonus Question Answer: With these implants inside, this 100 ml beaker would hold 62 ml of water.
To reward your efforts, everyone who participated will receive one free Inclusive ® Custom Abutment
of their choice. The one dentist among you who correctly answered the Bonus Question will also receive
one free BruxZir ® Solid Zirconia crown.
Inclusive Contest entries were individually scored after being sent to the lab via e-mail and standard mail. Prizewinners were notified by standard mail and/or phone.
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