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Inclusive 

Restorative Driven Implant Solutions Vol. 3, Issue 3 

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

Implant Position in the Esthetic Zone 

Dr. Siamak Abai 

Page 27 

Immediate and Post-Placement 

Utilization of the Inclusive ® 

Tooth Replacement Solution 

Drs. Bradley Bockhorst and Darrin Wiederhold 

Page 53 

Creating Surgical Guides Using 

CBCT and Intraoral Scanning 

Dr. Perry Jones 

Page 83 

COLUMNS 

NEW! Hygienist’s Corner 

with Susan Wingrove, RDH 

Page 15 

‘My First Implant’ 

Industry Pioneer Dr. Jack Hahn 

Recalls First Implant Case — 

And the Rest Is History 

Page 11 

Implant Q&A: 

Dr. David Little 

San Antonio, Texas 

Page 39

On the Web 

Here’s a sneak peek at additional 

Inclusive magazine content available online 

ONLINE Video Presentations 

■ Dr. Bradley Bockhorst details the process by which the Inclusive ® 

Tooth Replacement Solution can be used to efficiently and predictably 

restore a missing mandibular molar. 

■ Dr. Siamak Abai outlines spatial and angular considerations for the 

optimal placement of dental implants in the esthetic zone. 

■ Dr. David Little discusses some of the exciting services made possible 

by cutting-edge dental technologies, emphasizing the beneficial 

nature of personalized diagnoses and treatments. 

■ Dr. Michael DiTolla illustrates the use of a lab-fabricated verifi cation 

jig to obtain an accurate occlusal relationship in distal free-end cases. 

■ Glidewell Laboratories unveils the Open Platform Inclusive Tooth 

Replacement Solution, expanding this revolutionary treatment package 

to accommodate other popular implant brands. 

■ Drs. Darrin Wiederhold and Bradley Bockhorst demonstrate the 

clinician’s option with the Inclusive Tooth Replacement Solution to 

immediately temporize an implant with custom healing components 

or to provide patient-specific temporization post-implant placement. 

■ Dzevad Ceranic, CDT, and Glidewell staff showcase the advantages, 

increasing popularity, and industry-leading quality of Inclusive ® 

Custom Abutments. 

Check out the latest issue of Inclusive 

magazine online or via your smartphone 

at www.inclusivemagazine.com 

■ Dr. Christopher Travis reviews the symptoms, causes, and treatment 

of dry mouth, promoting implant-borne restorations as a solution 

for the partially or fully edentulous xerostomia patient. 

■ Dr. Perry Jones highlights the merging of CBCT and intraoral 

scanning technology to create precise surgical guides for safer, 

more predictable implant surgeries. 

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 

19 

Restoring Mandibular Single Teeth with the 

Inclusive Tooth Replacement Solution 

The replacement of missing mandibular molars with single-tooth, 

implant-borne restorations provides many benefits over fixed partial 

dentures, and is by far the most common indication for implant treatment, 

according to laboratory statistics. Dr. Bradley Bockhorst offers 

a detailed walkthrough of the process by which the Inclusive Tooth 

Replacement Solution can be used to simplify the restorative process 

and provide a predictable outcome for this common restoration. 

27 

Implant Position in the Esthetic Zone 

Proper implant positioning is patient- and quite often implant-specific, 

making prosthetic treatment planning and pre-placement protocol 

paramount for achieving predictable restorative results. Dr. Siamak 

Abai, staff dentist of clinical research at Glidewell Laboratories, details 

some of the established parameters with regard to implant spacing and 

angulation, and highlights the use of advanced tools such as Inclusive 

Digital Treatment Planning services and the Inclusive Tooth Replacement 

Solution to execute precise control over each individual case. 

39 

Implant Q&A: An Interview with Dr. David Little 

In this interview, a Texas-sized passion for excellence and commitment 

to improving quality of life for edentulous patients comes through as 

Dr. David Little weighs in on several aspects of what makes today’s 

progressive dental practice a success. Find out what this general dentist 

has to say on topics ranging from building a truly interdisciplinary 

practice, to incorporating advanced technologies, to educating the 

entire team, to treatment planning for patients as if they were family. 

53 

Photo Essay: Immediate and Post-Placement 

Utilization of the Inclusive Tooth Replacement Solution 

The Inclusive Tooth Replacement Solution enables clinicians to 

place and immediately temporize single-unit implants in edentulous 

spaces. It can also be used in cases where the implant has already 

been placed. With a pair of case reports, Drs. Darrin Wiederhold 

and Bradley Bockhorst illustrate the simplified, predictable process 

by which this versatile, one-of-a-kind solution addresses implant 

placement and soft tissue healing in a manner that will help pave 

the path to a superior final restoration. 

– Contents – 1

Contents 

75 

83 

91 

Treating Xerostomia Patients: 

A Clinical Conversation with Dr. Christopher Travis 

Dentists are often the first to identify patients who are experiencing 

the effects of xerostomia, or dry mouth. Here, Dr. Christopher 

Travis offers a brief refresher on oral anatomy and the major sets 

of salivary glands as he explores the symptoms, causes, treatment 

options, and advantages of dental implants for xerostomia patients. 

Implant prostheses can provide a good solution for these patients. 

Creating Surgical Guides Using CBCT and 

Intraoral Scanning 

Among recent advances in the use of Align Technology’s iTero 

optical scanner is the ability to merge its generic STL files 

directly with CBCT DICOM files to allow for the creation of very 

precise, tooth-borne surgical guides. In this clinical case report, 

Dr. Perry Jones showcases the use of oral scanning technology to 

plan implant placement, create a precise surgical guide in a virtual 

environment, place implant fixtures, and restore those implants — 

all without the use of a conventional analog model. 

“Rules of 10” — Guidelines for Successful 

Planning and Treatment of Mandibular Edentulism 

Using Dental Implants 

The three “Rules of 10” for treatment planning dental implant therapy 

in the edentulous mandible are designed to improve the success 

of both endosseous implants and the prosthesis. These so-called 

rules acknowledge and provide a method to control the mechanical 

environment, addressing factors affecting implant and prosthesis 

longevity. Dr. Lyndon Cooper, et al., outline and provide support 

for these rules, then illustrate their application in the treatment of 

mandibular edentulism. 

ALSO IN THIS ISSUE 

8 Trends in Implant Dentistry 

Average Number of Implants per Case 

11 My First Implant 

Dr. Jack Hahn 

15 Hygienist’s Corner 

A Probing Question 

31 Small Diameter Implants 

Planning from the 

Prosthetic Perspective 

35 Clinical Tip 

Bone Quality Based Drilling 

Protocol: Achieving High 

Primary Stability 

47 Product Spotlight 

Inclusive Tooth Replacement 

Solution: Open Platform 


Obtaining Accurate Occlusal Records 

in Kennedy Class I and Class II 

Implant Cases 


When a Flapless Approach 

Makes Sense 

67 Lab Sense 

Best in Class: Inclusive 

Custom Abutments 

2 


Publisher 

Jim Glidewell, CDT 

Editor-in-Chief and clinical editor 

Bradley C. Bockhorst, DMD 

Managing Editors 

David Casper, Jennifer Holstein, Barbara Young 

Creative Director 

Rachel Pacillas 

Contributing editors 

Greg Minzenmayer; Dzevad Ceranic, CDT; 

Eldon Thompson 

copy editors 

David Frickman, Megan Strong 

digital marketing manager 

Kevin Keithley 

Graphic Designers/Web Designers 

Emily Arata, Jamie Austin, Deb Evans, 

Kevin Greene, 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 


Letter from the Editor 

There are many axioms used in implantology, such as, “begin with the end 

in mind” and “implant dentistry is a restorative procedure with a surgical 

component,” all pointing to the importance of proper diagnosis and case 

work-up. Addressing this topic we have: an article on implant planning 

in the esthetic zone, penned by our own Dr. Siamak Abai; an interview 

with Dr. David Little, where we look at treating the edentulous patient; 

and, because treatment planning should be considered not just from the 

surgical perspective but from the prosthetic aspect as well, we’ve included 

an informative article by Dr. Lyndon Cooper, et al., with guidelines for 

restoring edentulous mandibles. Our Small Diameter Implants column 

reviews the importance of planning from the prosthetic perspective for 

overdenture cases. 

As you’ve seen in the last few issues, the Inclusive ® Tooth Replacement 

Solution has the potential to change the way implant dentistry is practiced. 

We are pleased to announce the expansion of this comprehensive solution 

for other major implant platforms, as well as post-placement utilization 

of its patient-specific components. For more on this topic, check out our 

product spotlight (page 47) and photo essay (page 53). 

In our My First Implant column, we feature one of implant dentistry’s 

pioneers, Dr. Jack Hahn, who takes us back to 1969 — when another 

revolution entirely was taking place. We are confident you’ll enjoy this 

retrospective from a clinician who has made major contributions to 

implantology. We are also introducing a new column that will focus on a 

very critical aspect of implant dentistry: the role of the dental hygienist. 

Susan Wingrove, RDH, skillfully kicks off the Hygienist’s Corner with her 

discussion of evaluating implants at the recall appointment. 

These are exciting times. The field of implant dentistry is rapidly advancing, 

and we are committed to keeping you up to date with new technologies 

and procedures as we continue to provide easy, convenient, and 

affordable solutions for you and your patients. 

Wishing you continued success, 

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. 

■ DZEVAD CERANIC, CDT 

Dzevad Ceranic began his career at Glidewell 

Laboratories while attending Pasadena 

City College’s dental laboratory technology 

program. In 1999, Dzevad began working at 

Glidewell as a waxer and metal finisher, then 

as a ceramist. He was then promoted to general 

manager of the Full-Cast department. In 2008, 

Dzevad took on the company’s rapidly growing Implant department, 

and in 2009 completed an eight-month implants course 

at UCLA School of Dentistry. Today, Dzevad leads an implant 

team of more than 250 employees at the lab. Contact him at 


■ SIAMAK ABAI, DDS, MMedSc 

Dr. Siamak Abai earned his DDS degree from 

Columbia University in 2004, followed by 

two years of residency in general dentistry. 

After two years of general private practice in 

Huntington Beach, Calif., Dr. Abai returned 

to academia and received an MMedSc degree 

and a certificate in prosthodontics from 

Harvard University. Before joining Glidewell in January 

2012, he practiced at the Wöhrle Dental Implant Clinic in 

Newport Beach. Dr. Abai brings nearly 10 years of clinical, 

research, and lecturing experience to his role as staff dentist 

of clinical research at Glidewell Laboratories. Contact him at 


■ LYNDON F. COOPER, DDS, Ph.D 

Dr. Lyndon Cooper serves as a professor 

and current chair of the University of North 

Carolina at Chapel Hill School of Dentistry 

Department of Prosthodontics and has an 

adjunct appointment at the UNC School of 

Medicine. Dr. Cooper is also director of the 

graduate prosthodontics program and the 

Bone Biology and Implant Therapy Laboratory. He is a 

Diplomate of the American Board of Prosthodontics and 

current president of the American College of Prosthodontics 

Board of Directors. His lab’s research findings have been 

presented in more than 70 publications. Contact him at 

lyndon_cooper@dentistry.unc.edu. 

■ 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. 

■ JACK A. HAHN, DDS 

Dr. Jack Hahn earned his DDS from Ohio State 

University College of Dentistry, and completed 

postgraduate coursework at Boston University, 

New York University, the University of Michigan 

and the University of Kentucky. A pioneer in the 

field who developed the NobelReplace ® dental 

implant system for Nobel Biocare, Dr. Hahn 

has been actively involved in placing and restoring implants for 

40 years. In addition to lecturing to dentists around the world, 

he maintains a private practice in Cincinnati, Ohio, focused 

on placing and restoring implants. In 2004, he received the 

Aaron Gershkoff Lifetime Achievement Award in implant 

dentistry. Contact him at replace7@mac.com. 

6 


■ 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. 

■ CHRISTOPHER P. TRAVIS, DDS 

Dr. Christopher Travis received his dental 

degree and certificate in prosthodontics from 

USC School of Dentistry, where he served as an 

assistant clinical professor in predoctoral and 

graduate prosthodontics. For the past 30 years, 

he has maintained a full-time private practice 

specializing in prosthodontics in Laguna 

Hills, Calif. Dr. Travis is director of the Charles Stuart Study 

Group in Laguna Hills, prosthodontic coordinator for the 

Newport Harbor Academy of Dentistry and active member of 

the Pacific Coast Society for Prosthodontics, American College 

of Prosthodontists and AO, as well as a Fellow of the ACD. 

Contact him at 949-683-7456 or surfnswim@fea.net. 

■ DAVID A. LITTLE, DDS 

Dr. David Little received his DDS at the University 

of Texas Health Science Center at San 

Antonio Dental School and now maintains a 

multidisciplinary, state-of-the-art dental practice 

in San Antonio, Texas. An accomplished 

national and international speaker, professor, 

and author, he also serves the dental profession 

as a clinical researcher focusing on implants, laser surgery, 

and dental materials. As a professional consultant, he shares 

his expertise on emerging restorative techniques and materials 

with industry peers. Highly respected for his proficiency in 

team motivation, Dr. Little’s vision, leadership, and experience 

are recognized worldwide. Contact him at dlittledds@aol.com. 

■ 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. He has worked in several 

private practices, and as a staff dentist for 

the U.S. Navy and the Glidewell Laboratories 

Implant department. While at Glidewell, he performed implant 

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

training facility and helped support the lab’s digital treatment 

planning and guided surgery services. He is currently in private 

practice in San Diego, Calif. Contact him at 619-469-4144 

or DMWDMD97@hotmail.com. 

■ MICHAEL McCRACKEN, DDS, Ph.D 

After completing dental school at University of 

North Carolina at Chapel Hill and a prosthodontic 

residency at University of Alabama at 

Birmingham, Dr. Michael McCracken received 

a Ph.D in biomedical engineering for research 

related to growth factors and healing of implants 

in compromised hosts. Dr. McCracken is 

a professor in the department of general dental sciences at UAB 

School of Dentistry, where he has also served as associate dean 

for education, director of graduate prosthodontics, and director 

of the implant training program. He maintains an active 

research program within the university and a private practice 

focused on implant dentistry. He also lectures internationally. 

Contact him at inclusivemagazine@glidewelldental.com. 

■ SUSAN S. WINGROVE, RDH 

Susan Wingrove is a national and international 

speaker and practicing dental 

hygienist, who does regeneration research as 

a consultant for Regena Therapeutics and 

instrument design for Paradise Dental Technologies 

Inc. She designed the Wingrove 

Implant Series, ACE probes, and Queen of 

Hearts instruments. A member of the AO and The Implant 

Consortium (TIC), she is also a published author on implant 

dentistry who has written articles for Hygienetown and the 

British Society of Dental Hygiene and Therapy, as well as the 

textbook “Peri-Implant Therapy for the Dental Hygienist: A 

Clinical Guide to Implant Maintenance” (Wiley-Blackwell). 

Contact her at sswinrdh@gmail.com. 

– Contributors – 7

Trends in 

Implant Dentistry 

Average Number of Implants per Case 

With the large number of implant-borne cases fabricated at Glidewell Laboratories, certain 

evolving trends have come to light. Here are some stats about the number of implants that 

are being placed per case. 

1 Implant 2 Implants 3 Implants 4 Implants 5+ Implants 

Number of Implants per Case 

2010 


2011 

71% 

75% 

3% 

3% 

7% 

16% 

1% 

1% 

4% 

19% 

Data Source: Glidewell Laboratories January 2010–August 2012 

8 


In an evaluation of more than 70,000 cases, 

the average number of implants per case is 

Of all the cases we have processed 

over the last three years… 

1.43 

66%…were single teeth 


2012 YTD 


January 2010–August 2012 

60% 

69% 

1% 

1% 

24% 

14% 

1% 

2 % 11% 

17% 

Watch here for emerging trends 

Check back here for more observations in the next issue. 

– Trends in Implant Dentistry: Average Number of Implants per Case – 9

my first 

implant 

with Jack A. Hahn, DDS 

ack in the summer of 1969, against the 

backdrop of the cultural craziness that 

was the late sixties, there was another, 

quieter revolution taking place. Not man 

walking on the moon. Not the Beatles’ “Sgt. Pepper” 

album taking hold of a generation. But a sign of the 

times that technologies were changing the way we 

do things across professions, including the field of 

dentistry. Here, Dr. Jack Hahn recalls placing his 

first implant, an experience that would set the 

course for the rest of his professional life — and 

the lives of his future patients. 

– My First Implant: Dr. Jack Hahn – 11

We’ve Come a Long Way 

From subperiosteal implants… 

...to combined root-form and blade implants… 

...to the modern endosseous designs and CAD/CAM restorations of today. 

I got interested in implants when a patient 

came into my office one summer, decades ago, holding a 

shoebox that contained no less than 17 sets of dentures. She 

had a severely atrophic mandible that made it impossible 

to retain a mandibular conventional denture — and she 

was an emotional wreck. Her husband, who was a wellrespected 

orthopedic surgeon, explained that she was a 

dental cripple and that this condition had all but destroyed 

their social lives. They declined invitations to parties and 

avoided going out in public because she couldn’t wear her 

lower teeth. So sad. At the time I didn’t think there was any 

hope, and I told her so. (But the seed was planted.) 

Then, I ran into her husband at a hospital function. He’d 

since read about dental implants in an orthopedic journal, 

but I told him those things didn’t work. “There is infection 

and rejection.” That’s what we were told in school. In short, 

I gave them no solution or possibility for a better quality 

of life. I saw the husband yet again about five months later 

at a hospital meeting. He had since taken his wife to New 

York, and a Dr. Linkow had placed a subperiosteal implant 

that changed their lives. She could eat anything. They were 

able to go out in public again. And her self-confidence improved 

significantly. He said to me, “Implant dentistry is 

the future,” and that I should learn all about it — or get left 

behind. This advice, coming from an orthopedic surgeon, 

was a wake-up call. 

In January of 1970, I went to New York to take Dr. Leonard 

Linkow’s course. It was two days with a hands-on portion 

where the participants placed an endosseous blade in a 

clear plastic model. In order to take the course, you had to 

12 


The House that Jack Built 

Inspired by that first experience, Dr. Jack Hahn went 

on to develop implant techniques and devices known 

for their simple yet ingenious designs that are used 

around the world today. 

1977 Miter blade-form implants 

1979 Titanodont root-form implants 

1986 Steri-Oss root-form and blade implants 

1997 

NobelReplace ® Tapered implant 

(Nobel Biocare) 

I didn’t sleep the 

night before. 

Evolution in Immediate Function 

purchase the implant kit, which consisted of 12 one-piece 

blades, 700 XXL burs, depth gauge, mallet, pliers, and seating 

instrument. A channel was prepared, and the implants 

were malleted into place using the seating instruments. As 

the implants were one piece with an abutment portion, 

one or two of the anterior abutment teeth were prepared, 

and an immediate provisional restoration was placed for 

immediate function. Three to six weeks post-insertion, 

impressions were taken for the final restoration: basically, 

a fixed bridge. 

Two months after completing the course, my first potential 

implant patient was sitting in my office for a consultation. 

She was bilaterally edentulous from the second premolars 

in the posterior mandible back. Her partial denture was 

wrapped in Kleenex in her purse. She said: “I can’t wear 

this thing, and I hate it. I want something permanent.” 

I told her that I had just taken an implant course, that 

she would be my first patient, and that I didn’t know if 

the things I demonstrated to her on my model would last 

10 minutes or 10 years. But she had good height and width 

of bone, so it seemed to me to be an ideal case. I told her 

we could do one side first, see how it went, and do the 

other side a month later. I also told her that because it was 

my first implant, I wouldn’t charge her for the implant, only 

the fixed bridge. She said, “Let’s do it.” 

In March of that same year, we scheduled Irma from 1:30 

p.m. to 5 p.m. I didn’t sleep the night before. I kept going 

over in my mind the incision, reflection of the soft tissue, 

implant groove preparation, implant placement, suturing, 

and fabrication of the provisional restoration. 

– My First Implant: Dr. Jack Hahn – 13

Sage advice for doctors 

new to implants 

1 

Enroll in an introductory 

course. Get a feel for whether implant 

dentistry is right for you. 

2 

3 

Educate yourself by enrolling 

in multiple courses. If implant 

dentistry is something you want to 

pursue, take an adequate number 

of courses — and wait until you feel 

confident in doing implant procedures. 

Learn basic surgical 

techniques. Aside from identifying 

important anatomical structures, 

diagnosis, treatment planning, 

radiographic interpretation and basic 

implant prosthetic principles — it’s 

critical that you understand basic 

surgical techniques. 

Start with an ideal case. Look 

for cases that have a good level of 

height and width of bone. Also, you 

want anatomical safe regions, such 

as the anterior mandible and single 

tooth replacements in both arches, 

eliminating three-unit bridges. 

Implant dentistry 

changed my life, 

as well as the 

lives of thousands 

of my patients. 

I started the procedure at 1:30 p.m. and had the provisional 

cemented by 3:30 p.m. Everything went absolutely perfectly. 

I was so excited that I said to my partner, “I don’t 

want to do anything else.” Replacing what nature had taken 

away was, from that instant on, exactly what I wanted to 

do for the rest of my professional life. Four weeks later, I 

placed her final bridge and placed the other implant on the 

opposite side. I told her that I’d have to charge her for that 

one because now I was an expert. We both laughed. She 

hugged me and said that I changed her life. Irma passed 

away in October 2000, 30 years later, with her implants and 

bridge still functioning until the day she died. 

After that first time, I went on to place many implant 

restorations, all types and various systems, over the next 

42 years. I estimate that I have placed and restored more 

than 30,000 implants. IM 

14 


Hygienist’s 

Corner 

A Probing Question 

with Susan S. Wingrove, RDH 

When assessing for peri-implant disease, “bleeding on 

probing” (BOP) is invaluable in the diagnostic process for 

peri-implant mucositis, and probing depths are valuable 

in assessing loss of bone support around osseointegrated 

implants. 1,2 An important yet controversial component of 

the assessment is probing the dental implant. 

Some implant surgeons recommend not probing the 

implant, or waiting three to six months following abutment 

attachment to avoid disrupting the perimucosal seal. 3 The 

perimucosal seal is fragile, and penetration during probing 

can introduce pathogens and jeopardize the success of the 

implant. Recent studies show that 0.15 Ncm may represent 

the threshold pressure to be applied in order to avoid false 

positive BOP readings around oral implants. 4 Currently, 

clinicians are using 0.15 Ncm–0.20 Ncm of pressure, but most 

agree that probing around dental implants is more sensitive 

than probing natural teeth; thus, caution should be used. 4 

Emerging research holds that probing is not harmful, 

however, and is actually essential to the overall health of the 

implant. Complete regeneration of junctional epithelium and 

establishment of new epithelial attachment has been studied, 

revealing that probing around osseointegrated implants 

does not appear to have detrimental effects on the perimucosal 

seal. 5 Peri-implantitis infections occur in 28 to 56 percent 

of implants after five years. 6 An increase in reported cases 

of peri-implant diseases (collective term for inflammatory 

lesions, mucositis, and peri-implantitis) is a significant reason 

for monitoring and probing dental implants. 

The hygienist needs to know baseline measurements to be 

able to distinguish health from disease, or loss of osseointegration. 

This can give the hygienist a way of determining 

at recall visits whether detrimental changes have occurred. 

Also, if more than one hygienist is employed in the office, 

measurement with compatible probes in millimeters for all 

inflammation, exposed threads, or bone loss on films allow 

for more accurate monitoring and consistency. 

Courtesy of PDT Inc. 

Figure 1: Note difference in flexibility between metal probe (left) and plastic 

probe (right) 

There is a recommended protocol for probing dental 

implants. First, the complexity of implants makes the 

flexibility of the probe essential. Now with more platformswitching 

implants, narrow implants, and fixed prostheses, 

the tip needs to be flexible to follow the anatomy of the 

implant and get an accurate reading. Using a flexible 

plastic probe reduces the potential for trauma to the 

perimucosal seal and the risk of scratching the implant’s 

surface (Fig. 1). 

– Hygienist’s Corner: A Probing Question – 15

Protocol for Probing of Dental Implants 

Record the baseline measurements at the first implant maintenance appointment or after 

the allotted three months. 

● Use a flexible probe with 1 mm markings to de-plaque, which may be adequate 

supportive therapy. 

● Place the probe parallel to the long axis of the implant, six measurements per implant, 

and identify a location on the restoration as a monitor marker. 

● Gently probe using light pressure (only 0.15 Ncm) to check the clinical parameters. 

For new patients, record a baseline and note placement date, doctor who placed the implant, 

and any other details. 

Record if inflammation, bleeding on probing, cement, or exudate are present. 

Report findings to the dentist for evaluation. 

The hygienist needs to know 

baseline measurements 

to be able to distinguish 

health from disease, 

or loss of osseointegration. 

Second, record a probe baseline measurement, at a specific 

location, to establish a clinical parameter for the patient’s 

record (Fig. 2). Place the probe parallel to the long axis of 

the implant, six measurements per implant, and identify 

a location on the restoration as a monitor marker. Record 

this baseline measurement in the patient notes at the first 

maintenance appointment after the allotted three months. 7 

Ideally the measurement should read 2.5 mm–5 mm or 

less, depending on soft tissue depth, with no other signs of 

inflammation. 8 Compare this measurement to the baseline, 

and if the probe depth changes, note this in the chart. If 

the implant has a probing depth of 5 mm–6 mm or greater, 

bleeding, or a presence of exudate, a radiograph should 

be taken to assess the implant, and the doctor needs to 

evaluate for bone loss. 9 

16 


Probe using only 0.15 Ncm of pressure so as not to jeopardize the success 

of the implant by possibly introducing pathogens into the peri-implant sulcus, 

or by damaging the delicate fibers that surround the implant. 

Courtesy of Dr. J Remien 

Courtesy of Nancy Adair, RDH 

Hygiene Excellence Inc. 

Figure 2: Recording and probing the baseline 

Figure 3: Probing the dental implant 

Third, probe using only 0.15 Ncm of pressure so as not 

to jeopardize the success of the implant by possibly 

introducing pathogens into the peri-implant sulcus, or by 

damaging the delicate fibers that surround the implant 

(Fig. 3). The perimucosal seal of the implant is fragile and 

more susceptible to trauma from probing than a natural 

periodontal ligament. If the tissue is healthy, the probe will 

stop at the coronal level, and if inflammation is present, 

the probe tip will penetrate close to the bone. 

Finally, use the probe as a measuring device for documenting 

inflammation and measuring exposed implant threads 

for monitoring. Continue to record and monitor by comparing 

the measurement to the baseline at every implant 

maintenance appointment. If probe depths have changed 

or inflammation, bleeding on probing, cement, or exudate 

are present, bring this information to the dentist’s attention 

per proper protocol for probing of implants. 

Using proper protocol, probing is one of the key monitoring 

tools in evaluating the health of the tissue surrounding 

the dental implant. Inflammation or bleeding on probing 

should not occur with healthy peri-implant tissue. Keep in 

mind that peri-implant infections can progress more rapidly 

than an infection in a natural tooth. Therefore, monitoring 

the tissue surrounding the dental implant is critical in the 

overall long-term success of the implant. IM 

– Hygienist’s Corner: A Probing Question – 17

Using proper protocol, probing is one of the key monitoring tools 

in evaluating the health of the tissue surrounding the dental implant. 

References 

1. Salvi GE, Lang NP. Diagnostic parameters for monitoring peri-implant conditions. 

Int J Oral Maxillofac Implants. 2004;19 Suppl:116-127. 

2. Lang NP, Mombelli A, Tonetti MS, Brägger U, Hämmerle CH. Clinical trials on 

therapies for peri-implant infections. Ann Periodontol. 1997 Mar:2(1):343-356. 

3. Bauman GR, Mills M, Rapley JW, Hallmon WH. Clinical parameters of evaluation 

during implant maintenance. Int J Oral Maxillofac Implants. 1992 Summer; 

7(2):220-227. 

4. Gerber JA, Tan WC, Balmer TE, Salvi GE, Lang NP. Bleeding on probing and 

pocket probing depth in relation to probing pressure and mucosal health around 

oral implants. Clin Oral Implants Res. 2009 Jan:20(1):75-78. 

5. Etter TH, Hakanson I, Lang NP, Trejo PM, Caffesse RG. Healing after standardized 

clinical probing of the peri-implant soft tissue seal: a histomorphometric study in 

dogs. Clin Oral Implants Res. 2002 Dec;13(6):571-580. 

6. Nogueira-Filho G, Iacopino AM, Tenenbaum HC. Prognosis in implant dentistry: 

a system for classifying the degree of peri-implant mucosal inflammation. J Can 

Dent Assoc. 2011;77:b8. 

7. Mombellli A, Mühle T, Brägger U, Lang NP, Bürgin WB. Comparison of periodontal 

and peri-implant probing by depth-force pattern analysis. Clin Oral Implant 

Res. 1997 Dec;8(6):448-454. 

8. Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis: Mosby;2008:1061. 

9. Stuart J. Froum, DDS. My patient’s implant is bleeding; what do I do? DentistryIQ, 

July 13, 2011. 

18 


Restoring Mandibular Single Teeth 

with the Inclusive Tooth Replacement Solution 

Go online for 

in-depth content 

by 


While the prosthetic rehabilitation of 

full-arch cases provides a tremendous 

service for the patient and can be very 

professionally rewarding for the clinician, single 

tooth replacement is by far the most common 

implant restoration. Restoring single posterior 

teeth with implants provides a viable treatment 

option and has been well documented. 1-5 Of the 

single posterior teeth, the first molar, or “money 

tooth” as termed by Dr. Curtis Jansen, very 

often requires replacement. 6 At the Glidewell 

Laboratories operatory, 59 percent of the single 

Inclusive ® Tapered Implants placed have been 

in the posterior mandible. 

One of the most obvious concerns when placing 

implants in the posterior mandible is identifying 

and avoiding the inferior alveolar nerve (IAN). 7 

This can be accomplished through the use of 

appropriate radiography and proper planning. 

– Restoring Mandibular Single Teeth with the Inclusive Tooth Replacement Solution – 19

Conventional implant planning typically involves the use 

of a periapical radiograph (PA) and/or a panoramic film. 

The drawback to these types of two-dimensional images is 

distortion. The PA should be taken with a paralleling technique 

to avoid vertical distortion as much as possible. A 

radiographic marker of known diameter (e.g., 5 mm ball 

bearing) can be used to determine the distortion in the 

planned implant site. The marker is measured on the film 

to determine the distortion factor in that area. A transparent 

overlay can be used as an aid to determine the correct 

implant selection (Fig. 1). 

Another option is a CT scan. Cone beam scanners provide a 

three-dimensional image and a precise method for identification 

of the IAN. 8 The patient’s scan can be imported into 

planning software, the mandibular canal identified, and the 

implant placed in a virtual environment (Fig. 2). 

In the case presented here, the canal was well differentiated 

and identified. The mandibular canal is typically identifiable. 

However, there are situations where the cortical bone 

surrounding the canal is not dense and therefore does not 

show up radiographically. These cases present a significant 

challenge. One rule of thumb for first molars is to not drill 

deeper than the roots of the adjacent teeth. 

An optical scan of the model provides a clear view of 

the anatomy of the teeth and the soft tissue (Fig. 3). The 

appropriate-sized implant is placed within the confines of 

the available bone (Fig. 4). It is important to be aware that the 

drills are approximately 1 mm longer than the stated length 

of the implant. The trajectory of the implant is aimed toward 

the opposing stamp cusp through the center of the 

occlusal table. 

Figure 1: Implant radiographic template for Inclusive Tapered Implants 

Figure 2: Digital Treatment Plan 

Surgery 

The osteotomy should be prepared with the aid of a 

surgical or prosthetic guide. The prosthetic component of 

the Inclusive ® Tooth Replacement Solution is a traditional 

surgical stent designed to convey the ideal position of the 

implant platform from the restorative perspective (Figs. 5, 6). 

By starting the osteotomy using this guide, the implant will 

be inserted in the appropriate location to take advantage of 

the custom temporary abutment and BioTemps ® provisional 

crown. The prosthetic guide is intended for prosthetic 

reference only, and does not take into consideration any 

anatomical landmarks or contraindications. This guide 

should be used in combination with the radiographic and 

clinical information to determine the best position for 

the implant. 

Figure 3: View of mandibular arch with proposed implant trajectory 

A surgical guide based on the virtual plan utilizing a CBCT 

scan of the patient provides the option of drill depth and 

angulation control. Based on the amount of guidance 

desired, a surgical guide can be produced that guides the 

pilot drill. Subsequent drilling with progressively wider 

20 


Figure 4: Cross-sectional view of proposed implant site 

Figure 7: Universal SurgiGuide 

Figure 5: The Inclusive Tooth Replacement Solution prosthetic guide 

Figure 8: Universal SurgiGuide in situ 

surgical drills (as needed) and implant placement are 

performed freehand. 

If additional guidance is needed, Universal SurgiGuides (Materialise 

Dental; Glen Burnie, Md.) are available (Figs. 7, 8). 

In these cases, all the drills can be guided. The implant is 

placed freehand once the osteotomy has been created. 

At the time of placement, a custom healing abutment can be 

delivered (Figs. 9, 10). The custom healing abutment allows 

you to start anatomically sculpting the soft tissues at the 

time of surgery. 

Figure 6: Prosthetic guide in situ 

A custom temporary abutment and BioTemps crown also 

are provided with the Inclusive Tooth Replacement Solution. 

If high primary stability is achieved and the crown is 

taken well out of occlusion, the implant can be temporized 

at the time of surgery. Due to the occlusal forces that can be 

exerted in the molar region, another approach would be to 

utilize the custom healing abutment at the time of surgery 

and provisionalize the case at a later date. 


Temporization 

Temporization utilizing the Inclusive Tooth Replacement 

Solution consists of seating the custom temporary abut ment, 

then relining and cementing the BioTemps provisional crown 

(Fig. 11). If a screw-retained temporary is preferred, after 

adjustments are made, an occlusal hole is drilled through 

the crown (Fig. 12). The abutment and internal surfaces are 

roughened up to help create mechanical retention. A guide 

pin is used to maintain the screw opening, and the crown is 

luted to the abutment with permanent cement. The crownabutment 

assembly is then delivered to the implant (Fig. 13), 

and the abutment screw is tightened to 15 Ncm (Fig. 14). 

The occlusal screw is covered with a piece of Teflon tape 

and the access opening sealed with composite (Fig. 15). The 

crown should be out of occlusion (Fig. 16). 

Figure 9: Inclusive Tooth Replacement Solution custom healing abutment 

Final Impressions 

The final impression is made with the Inclusive Tooth 

Replacement Solution custom impression coping (Fig. 17). 

The custom impression coping allows you to transfer the 

position of the implant as well as the soft tissue contours to 

the master cast. The custom impression coping is seated on 

the implant and the screw is tightened (Fig. 18). 

The access opening is sealed with soft wax to prevent 

impression material from flowing into the coping (Fig. 19). 

The closed-tray impression is made following standard 

technique. When the material has set, the impression is 

pulled. The impression coping is removed and replaced 

with the healing abutment or provisional restoration. The 

shade is selected (Fig. 20) and clinical photos are taken. 

A bite registration and impression of the opposing arch 

are made. The pre-populated Inclusive Tooth Replacement 

Solution lab prescription is filled out and the case sent to 

the lab. 

Figure 10: Custom healing abutment in place with access opening sealed 

Laboratory Fabrication 

Upon receipt, the lab will mount the custom impression 

coping on an implant analog (Fig. 21) and reseat it back 

into the impression (Fig. 22). A soft tissue model will be 

poured (Fig. 23), the case articulated, and the final restoration 

fabricated. 

Figure 11: Custom temporary abutment and BioTemps crown 

Based on the clinician’s preference, a cemented or screwretained 

prosthesis can be ordered. In this case, the 

cemented restoration consisted of an Inclusive ® All-Zirconia 

Custom Abutment (Figs. 24a, 24b) and an IPS e.max ® crown 

(Ivoclar Vivadent; Amherst, N.Y.) (Fig. 25). An acrylic jig is 

fabricated to aid in seating the abutment (Figs. 26a, 26b). 

Final Delivery: Cement-Retained Crown 

When the healing abutment or provisional restoration 

is removed, the soft tissues will have healed to more 

Figure 12: After adjustments, a hole is drilled through the crown and the 

crown cemented to the abutment. 

22 


Figure 13: Seated provisional restoration 

Figure 17: Custom impression coping 

Figure 14: The abutment screw is tightened 

Figure 18: The impression coping is seated 

Figure 15: The occlusal access opening is sealed 

Figure 19: The screw access opening is sealed with soft wax 

Figure 16: The temporary crown is out of occlusion 

Figure 20: Shade selection 


anatomically correct contours (Fig. 27). The abutment is 

seated utilizing the jig (Fig. 28) and the screw tightened 

to 35 Ncm (Fig. 29). The jig is then removed (Fig. 30). The 

crown is seated and the margins and interproximal and 

occlusal contacts are checked (Figs. 31a, 31b). Any necessary 

adjustments are made. There should be light centric contact 

with a firm bite and no lateral contacts. The interproximal 

contacts should be light. The abutment screw is tightened 

once more to 35 Ncm, and the access opening sealed with 

a piece of Teflon tape. The crown is cemented in place 

with RelyX Unicem Self-Adhesive Resin Cement (3M ESPE; 

St. Paul, Minn.). All excess cement must be meticulously 

removed. A PA was taken to verify complete seating and 

cement removal (Fig. 32). 

Final Delivery: 

IPS e.max Screw-Retained Crown 

If a screw-retained crown was selected (Figs. 33a–33c), the 

one-piece restoration is seated on the implant (Fig. 34). The 

abutment screw is tightened to 35 Ncm utilizing the jig 

(Fig. 35). The interproximal and occlusal contacts are 

checked and adjusted as needed (Fig. 36). The screw access 

opening is sealed with a piece of Teflon tape and an occlusal 

composite (Fig. 37). 

Figure 22: Assembly reseated into impression 

Summary 

Replacement of missing mandibular molars with singletooth 

implant-borne restorations provides many benefits 

over fixed partial dentures. It avoids having to prep adjacent 

teeth, it makes hygiene easier for the patient, and it allows 

for flexure of the mandible. 2 The osteotomy can be created 

conventionally or through a guided surgical procedure. 

The Inclusive Tooth Replacement Solution provides the 

components to simplify the restorative process and provide 

a superior final restoration for this common restoration. IM 

Figure 23: Soft tissue model 

Figures 24a, 24b: Inclusive All-Zirconia Custom Abutment 

Figure 21: Custom impression coping mounted on implant analog 

Figure 25: Inclusive All-Zirconia Custom Abutment and IPS e.max crown 

24 


Figures 26a, 26b: Acrylic abutment seating jig 

Figure 30: The jig is removed 

Figure 27: The provisional restoration is removed 

Figures 31a, 31b: After adjustments, the IPS e.max crown is cemented in place 

Figure 28: The abutment is seated with the jig 

Figure 32: PA verifying seating and cement removal 

Figure 29: The abutment screw is tightened to 35 Ncm 

Figures 33a–33c: IPS e.max screw-retained crown 


References 

1. Becker W, Becker BE. Replacement of maxillary and mandibular molars with single 

endosseous implant restorations: a retrospective study. J Prosthet Dent. 1995 Jul; 

74(1):51–55. 

2. Misch CE, Misch-Dietsh F, Silc J, Barboza E, Cianciola LJ, Kazor C. Posterior 

implant single-tooth replacement and status of adjacent teeth during a 10-year 

period: a retrospective report. J Periodontol. 2008 Dec;79(12):2378-82. 

3.Misch CE. Endosteal implants for posterior single tooth replacement: alternatives, 

indications, contraindications, and limitations. J Oral Implantol. 1999;25(2):80-94. 

4. Ekfeldt A, Carlsson GE, Börjesson G. Clinical evaluation of single tooth restorations 

supported by osseointegrated implants: a retrospective study. Int J Oral 

Maxillofac Implants. 1994 Mar-Apr;9(2):179–83. 

5. Muftu A, Chapman RJ. Replacing posterior teeth with freestanding implants: fouryear 

prosthodontic results of a prospective study. J Am Dent Assoc. 1998 Aug; 

129(8):1097–102. 

6. Jansen C. Presentation given at the Academy of Osseointegration 2012 Annual 

Meeting, Phoenix, Ariz. 

7. Anderson LC, Kosinski TF, Mentag PJ. A review of the intraosseous course of the 

nerves of the mandible. J Oral Implantol. 1991;17(4):394-403. 

8. Alhassani AA, AlGhamdi AS. Inferior alveolar nerve injury in implant dentistry: diagnosis, 

causes, prevention, and management. J Oral Implantol. 2010;36(5):401-7. 

Epub 2010 Jun 14. 

Figure 34: Abutment screw tightened utilizing jig 

Figure 35: IPS e.max screw-retained crown seated 

Figure 36: Occlusion verified 

Figure 37: Access opening sealed with composite 

26 


IMPLANT POSITION 

IN THE ESTHETIC ZONE 

Go online for 


by 

Siamak Abai, DDS, MMedSc 

Since the advent of modern root 

form osseointegrated implant 

dentistry in 1952 by Per-Ingvar 

Brånemark 1 and colleagues, clinicians 

have strived for improvements in 

implant positioning in the esthetic 

zone to achieve predictable restorative 

and esthetic results. Years of clinical 

experience in congruence with controlled 

clinical studies have led to 

established parameters as a guide 

for these results. Prosthetic treatment 

planning and establishing a set clinical 

protocol prior to implant placement 

are paramount. It is important to note 

that proper implant positioning is 

patient- and often implant-specific, and 

that inter-patient generalizations can 

result in myopic treatment planning 

and decrease the predictability of an 

esthetic outcome. 

Treatment planning prior to implant placement traditionally 

begins with comprehensive medical and dental evaluation, 

articulated diagnostic casts, periapical and panoramic radiographs, 

cone beam computed tomography (CBCT) scans, and 

a diagnostic wax-up. Patient demands must always be taken 

into consideration prior to surgery, and presurgical mockups 

may be necessary to convey the information to the patient. 

Prosthetic treatment planning helps the clinician with a 

restorative-driven implant placement rather than a bonedriven 

approach, with the latter leading to poor abutment 

angulations and drastically reduced restorative options. Bone 

augmentation is often necessary in order to achieve optimal 

residual ridge dimensions prior to implant placement. 

The inventive work of Sir Godfrey Hounsfield 2 and the 

advancement of CBCT technology have led the dental 

profession into a new realm of dimensional accuracy that 

is often unattainable with conventional dental radiography. 

In combination with the use of a surgical or guided stent, 

proper 3-D positioning of a dental implant has become 

an attainable goal, leading to increased confidence for 

the clinician and accurate clinical results. The importance 

– Implant Position in the Esthetic Zone – 27

IMPLANT POSITION IN THE ESTHETIC ZONE 

of the implant position can be manifested in the four 

dimensionally sensitive positioning criteria: mesiodistal, 

labiolingual, and apico-coronal location, as well as implant 

angulation. 3 The ultimate goal is not only to avoid adjacent 

sensitive structures, but to respect the biological principles 

that have been established to achieve esthetic results. 

MESIODISTAL CRITERIA 

Correct implant position in a mesiodistal orientation allows 

the clinician to avoid iatrogenic damage to adjacent critical 

structures. Maintaining adequate distance from adjacent 

teeth also helps preserve crestal bone and interproximal 

papillary height. When placing an implant adjacent to a 

tooth, it has been shown that crestal bone peak is based on 

and maintained by the bone level of the teeth adjacent to 

the missing space. A minimum distance of 1.5 mm between 

implant and existing dentition has been determined to 

prevent damage to the adjacent teeth and to provide proper 

osseointegration and gingival contours 4–6 (Fig. 1a). Implants 

placed too closely together can reduce the height of the 

inter-implant bone crest, and a distance of less than 3 mm 

between two adjacent implants leads to increased bone 

loss. It has been shown that a distance of more than 3 mm 

between two adjacent implants preserves the interproximal 

bone peak and results in 0.45 mm of resorption on average, 

giving a better chance of proper interproximal papillary 

height (Fig. 1b). If the space between implants is 3 mm 

or less, the average resorption of the interproximal bone 

peak increases to 1.04 mm, compromising support for the 

interdental papilla. 4,7 As a result, wide-bodied implants less 

than 3 mm apart in the esthetic zone would compromise 

the desired outcome. 

LABIOLINGUAL CRITERIA 

Labiolingual implant position is often determined by the 

gingival biotype, occlusal considerations of opposing teeth, 

and desired emergence profile. An implant placed too far 

labially can cause bone dehiscence and gingival recession 

leading to exposure or show-through of the implant collar. 

An implant placed too far lingually can cause prosthetic 

difficulties with ridge-lap restorations that can be unhygienic 

and unesthetic. A thickness of 1.8 mm of labial bone has 

been determined to be critical in maintaining an implant soft 

tissue profile and increasing the likelihood of an esthetic 

outcome 8 (Fig. 2). Labially oriented implants compromise 

the subgingival emergence profile development, creating 

long crowns and misalignment of the collar with respect to 

the adjacent teeth. 9 

APICO-CORONAL CRITERIA 

Peri-implant crestal bone stability plays a critical role in the 

presence of interdental papilla. 10 Many factors contribute 

to crestal bone resorption, including existing anatomy, surgical 

trauma, overloading, peri-implantitis, implant surface 

characteristics, microgap at the implant-abutment junction, 

Figure 1a: Minimum distance of 1.5 mm between implant and existing dentition 

Figure 1b: Minimum distance of 3 mm between two adjacent implants 

Figure 2: Proper labiolingual placement with 1.8 mm thickness of labial bone 

28 


type of connection between implant, and prosthetic components. 

11 Several factors are cause for concern in the 

apico-coronal placement of implants. Implants placed too 

shallow may reveal the metal collar of the implant through 

the gingiva. Countersinking implants below the level of 

the crestal bone may give prosthetic advantages with more 

running room for prosthetic components and tissue contouring, 

but can lead to crestal bone loss due to the location 

of a microgap at the implant-abutment interface. The 

ideal solution to exposure of the implant collar would be 

the placement of an implant equicrestal or subcrestal to 

the ridge. However, the existing microgap at the implantabutment 

junction leads to bone resorption due to periimplant 

inflammation. 12 It is suggested that an implant collar 

be located 2 mm apical to the CEJ of an adjacent tooth 

if no gingival recession is present 13 (Fig. 3). Implant diameter 

also plays a role in apico-coronal position, with smaller 

diameter implants needing more space for soft-tissue development 

and tissue contouring. 

Figure 4: Proper implant angulation with screw access in the cingulum area 

Figure 3: Lateral view of implant placed with the collar at the level of crestal bone 

with adjacent teeth CEJ 2 mm coronal to the collar of the implant 

IMPLANT ANGULATION 

Implant angulation is particularly important in treatment 

planning for screw-retained restorations. Implants angled 

too far labially compromise the placement of the restorative 

screw, leaving the clinician with fewer restorative options. 

Implants angled too far lingually can result in unhygienic 

and unesthetic prosthetic design. For every millimeter 

of lingual inclination, the implant should be placed an 

additional millimeter apically in order to create an optimal 

emergence profile. 14 In general, implant angulation should 

mimic angulation of adjacent teeth so long as they are 

in reasonable alignment (Fig. 4). Furthermore, maxillary 

anterior regions require a subtle palatal angulation to 

INCLUSIVE TOOTH 

REPLACEMENT SOLUTION 

The Inclusive ® Tooth Replacement Solution was developed 

by Glidewell Laboratories as a complete, prosthetically 

driven method of restoring missing dentition. The solution 

comprises treatment planning, implant placement, patientspecific 

temporization, and the definitive restoration 

(Figs. 5a–5f). When utilizing the comprehensive range of 

Inclusive Digital Treatment Planning services for guided 

implant surgeries and restorations, the clinician has absolute 

and precise control of each step. This results in an efficient 

and accurate workflow that is beneficial for the clinician and, 

ultimately, the patient. With the Inclusive Tooth Replacement 

Solution, the clinician has control of the four dimensions of 

implant placement in the esthetic zone, creating a consistently 

predictable result. Having a single source of services and 

materials is also advantageous in providing a more affordable 

yet high-value product for patients. 

increase labial soft tissue bulk. 15 – Implant Position in the Esthetic Zone – 29

IMPLANT POSITION IN THE ESTHETIC ZONE 

Figure 5a: Inclusive Tapered Implant at placement 

Figure 5b: Inclusive custom healing abutment in place 

Figure 5c: Contoured soft tissue sulcus after healing 

Figure 5d: Screw-retained IPS e.max ® crown (Ivoclar 

Vivadent; Amherst, N.Y.) in place 

Figure 5e: PA to verify seating of crown 

Figure 5f: Buccal view of final restoration at delivery 

IM 

REFERENCES 

1. Albrektsson T, Brånemark PI, Hansson HA, Lindstrom J. Osseointegrated titanium 

implants. Requirements for ensuring a long-lasting, direct bone-to-bone 

implant anchorage in man. Acta Orthop Scand. 1981;52(2):155-70. 

2. Hounsfield GN. Computerized transverse axial scanning (tomography): Part I. 

Description of system. Br J Radiol .1973;46:1016-22. 

3. Al-Sabbagh M. Implants in the esthetic zone. Dent Clin N Am. 2006 Jul;50(3): 

391-407. 

4. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the 

height of inter-implant bone crest. J Periodontol. 2000 Apr;71(4):546-49. 

5. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone thickness on 

facial marginal bone response: stage 1 placement through stage 2 uncovering. 

Ann Periodontol. 2000 Dec;5(1):119–28. 

6. Saadoun AP, LeGall M, Touati B. Selection and ideal tridimensional implant position 

for soft tissue aesthetics. Pract Periodontics Aesthet Dent. 1999 Nov-Dec; 

11(9):1063-72. 

7. Degidi M, Perrotti V, Shibli JA, Novaes AB, Piatelli A, Lezzi G. Equicrestal and 

subcrestal dental implants: a histologic and histomorphometric evaluation of 

nine retrieved human implants. J Periodontol. 2011 May;82(5):708-15. Epub 

2010 Dec 7. 

8. Hermann JS, Buser D, Schenk RK, Schoolfield JD, Cochran DL. Biological width 

around one- and two-piece titanium implants. Clin Oral Implants Res. 2001 Dec; 

12(6):559-71. 

9. Kazor CE, Al-Shammari K, Sarment DP, Misch CE, Wang HL. Implant plastic 

surgery: a review and rationale. J Oral Implantol. 2004;30(4):240-54. 

10. Berglundh T, Lindhe J. Dimension of the periimplant mucosa. Biological width 

revisited. J Clin Periodontol. 1996 Oct;23(10):971-73. 

11. Hermann F, Lerner H, Palti A. Factors influencing the preservation of the 

periimplant marginal bone. Implant Dent. 2007 Jun;16(2):165-75. 

12. Broggini N, McManus LM, Hermann JS, Medina RK, Buser D, Cochran DL. 

Peri-implant inflammation defined by the implant-abutment interface. J Dent 

Res. 2006 May;85(5):473-78. 

13. Saadoun AP, LeGall M, Touati B. Selection and ideal tridimensional implant 

position for soft tissue aesthetics. Pract Periodontics Aesthet Dent. 1999 

Nov-Dec;11(9):1063-72. 

14. Potashnick SR. Soft tissue modeling for the esthetic single-tooth implant restoration. 

J Esthet Dent. 1998;10(3):121-31. 

15. Tishler M. Dental implants in the esthetic zone. Considerations for form and 

function. N Y State Dent J. 2004 Mar;70(3):22-6. 

30 


SMALL DIAMETER 

implants 

Planning from the 

Prosthetic Perspective 

with Bradley C. Bockhorst, DMD 

Whether you’re placing small-diameter or conventionaldiameter 

implants for an overdenture, the case must be 

planned from surgical and prosthetic perspectives. The 

restorative aspect of the Inclusive ® Mini Implant involves 

encasing the O-ring housings within the denture base and 

creating a parallel line of draw. 

O-ring Housing Dimensions 

4.75 mm 

The height of the O-ring housing is 3.5 mm (Fig. 1). There 

is a space of approximately 1.0 mm between the top of 

the collar and the base of the O-ring housing to allow 

the housing to be rotated in cases where the implants 

are divergent. The housings can accommodate up to 

30 degrees of angular divergence between implants. 

However, the implants should be placed parallel to one 

another as much as possible to provide an ideal prosthetic 

fit and to avoid excessive wearing of the O-rings. 

There should be a minimum of 3 mm thickness of acrylic 

in the denture base above the housing to provide adequate 

strength to the prosthesis. Therefore, there should be at 

least 8 mm of vertical space from the top of the collar. The 

denture teeth would be in addition to this space. 

1.0 mm 

Figure 1: O-ring housing with 3.5 mm height 

3.5 mm 

– Small Diameter Implants: Planning from the Prosthetic Perspective – 31

Figure 2a: Cast framework 

Figure 2b: Framework incorporated into overdenture 

Providing implant-retained 

overdentures can be one of the 

most professionally rewarding 

aspects of your practice. 

Figure 3: Virtual framework design with strut over attachment housing 

If vertical space is lacking, a cast framework can be incorporated 

into the new denture to provide strength (Figs. 2a, 2b). 

Frameworks are designed to have a strut over the top of the 

attachment housing (Fig. 3). 

In mandibular overdenture cases, it is customary to place 

four mini implants within the symphysis area with as wide 

an anterior-posterior spread as possible while still ensuring 

an adequate margin of safety from the nerve (Fig. 4a). 

In maxillary overdenture cases, it is customary to place six 

mini implants anterior to the sinuses (Fig. 4b). The O-ring 

housings are 4.75 mm in diameter, and there should be at 

least 2 mm of acrylic between these metal housings in the 

denture base (Fig. 5). Therefore, the centers of the implants 

should be at least 7 mm apart. 

Providing implant-retained overdentures can be one of 

the most professionally rewarding aspects of your practice 

— and it can be life-changing for your patients. Planning 

from both the prosthetic perspective and the surgical 

perspective will help the cases go smoothly and minimize 

future complications. IM 

32 


Mandibular Spacing 

Maxillary Spacing 

Figure 4a: Typical placement of mini implants in the mandible 

Figure 4b: Typical placement of mini implants in the maxilla 

Figure 5: Digital treatment plan for four Inclusive Mini Implants in an edentulous mandible. Cross-sectional view (upper right quadrant) shows O-ring housing well positioned 

within the denture base. 

– Small Diameter Implants: Planning from the Prosthetic Perspective – 33

CLINICAL 

TIP 

Bone Quality Based Drilling Protocol: 

Achieving High Primary Stability 

by 

Darrin M. Wiederhold, DMD, MS 

Figure 1: 

Planning software 

used to evaluate 

relative bone 

density showing 

Type IV bone 

ONE OF THE MOST FUNDAMENTAL PROCEDURES performed 

by implant surgeons is the creation of the osteotomy for 

implant placement. Without a well-developed osteotomy 

site, both the immediate surgical and future restorative 

success of the case can be compromised. There are various 

factors that must be considered when performing the 

osteotomy, such as location, angulation, and spacing for 

multiple implants. Critical decisions to be made concern the 

choice of whether to follow the soft or dense bone protocol 

for a given case, and whether to utilize a bone tap drill. The 

goal is to achieve high primary stability, at least 35 Ncm, 

at the time of implant placement. This will also impact the 

decision whether to immediately provisionalize the case. 

As with most things implant-related, assessment of the 

preoperative bone quality and quantity is critical to planning 

the osteotomy. If using conventional radiography, such as 

periapicals and panoramics, evaluation of the trabecular 

pattern of the bone, the amount of cortical versus cancellous 

bone, and the vertical height of the bone can often indicate 

the likely density of the underlying bone. The use of cone 

beam computed tomography (CBCT) and digital treatment 

planning software can provide an even clearer preoperative 

assessment of the bone to be drilled, by allowing the surgeon 

to examine the bone three dimensionally, and providing a 

Hounsfield or relative density scale of a planned osteotomy 

site (Fig. 1). By carefully considering all of these factors, the 

surgeon often has a sense of which drilling protocol will be 

– Clinical Tip: Bone Quality Based Drilling Protocol – 35

used before the patient even presents for the surgery. As is 

often the case, however, many surgical decisions are made 

intraoperatively. In essence, sometimes even the best-laid 

plans need modification. 

A good rule of thumb in osteotomy preparation is to start 

small and advance as needed. In other words, drill to the 

manufacturer’s recommendations for your specific implant 

system for soft bone. Once you have done so, if you feel 

that the bone was particularly difficult to penetrate with the 

drills, or, when you attempt to place the implant, it does not 

easily advance to full depth, then it is typically advisable 

to enlarge the osteotomy diameter with the dense bone 

drill. The potential dangers in not having an adequately 

sized osteotomy include: damaging the implant connection 

during placement, not fully seating and properly positioning 

the implant in the bone, and creating excess pressure on the 

surrounding bone. All of these are detrimental to the longterm 

success of the implant and restoration. Some surgeons 

advocate drilling to the dense bone diameter in all cases. 

This is certainly an option, but the risk is that you could 

compromise the amount of initial stability that you achieve 

and that the drill or the implant could be displaced into an 

unfavorable location due to loss of resistance and torque. 

So, again, it is at the discretion of the surgeon. 

Screw taps are used in cases of extremely dense bone, 

Type I and perhaps Type II. Essentially, the screw taps 

precisely mimic the thread patterns of the proposed implant. 

Therefore, by tapping the bone with these specialized drills, 

the internal configuration of the osteotomy is identical to 

that of the threads of the planned implant. This allows for 

a more passive, complete placement of the implant with 

less insertional torque, and is therefore gentler to the 

surrounding bone. Many implants today purport to be 

self-threading or tapping, often eliminating the need for 

the screw tap. But in those instances where the bone is 

particularly dense, screw taps are useful. The screw tap 

may be used as an alternative to, or in conjunction with, the 

dense bone drill. 

There is a great deal of latitude in the choice of whether to 

utilize the soft or dense bone protocol, as well as whether 

to use a screw tap (Fig. 2). From pre- and intraoperative 

evaluation of the bone quality and density, to the decision to 

precisely shape the internal anatomy of the osteotomy site 

with a screw tap, a variety of factors must be considered to 

create the ideal osteotomy and achieve good implant primary 

stability. But the extra time and attention to detail needed to 

make that informed decision will be rewarded with simpler 

surgeries and long-term restorative success. IM 

Figure 2: Drill sequence for 4.7 mm x 11.5 mm 

Inclusive Tapered Implant. The dense bone drill 

and screw tap are optional. Note: Drill charts for 

3.7 mm and 5.2 mm Inclusive Tapered Implants 

are also available. 

Short 

Drills 

Long 

Drills 

16 mm 

13 mm 

11.5 mm 

10 mm 

8 mm 

Ø1.5 mm 

Lance Drill 

Ø2.3/2.0 mm 

Pilot Drill 

Ø2.8/2.3 mm 

Surgical Drill 

Ø3.4/2.8 mm 


Final Drill 

Soft Bone 

Ø3.8/3.4 mm 


Final Drill 

Dense Bone 

Ø4.4/3.8 mm 


Optional 

Dense Bone 

Ø4.7 mm 

Screw Tap 

Ø4.7 mm 

Inclusive 

Tapered Implant 

36 


Implant& 

Q A: 

Go online for 


An Interview with Dr. David Little 

Interview of David A. Little, DDS 

by Bradley C. Bockhorst, DMD 

Dr. David Little maintains a multidisciplinary, state-of-the-art 

dental practice in San Antonio, Texas, where he dedicates himself 

to developing and refining his knowledge skills — as well as those 

of his colleagues and peers — through extensive continuing 

education and product research. As a clinical researcher 

focusing on implants, restorative materials, and technology, 

Dr. Little develops predictable procedures for successful 

functional and esthetic outcomes. His passion for helping others 

drives him to share this expertise in emerging restorative 

techniques and materials, as evident in the following interview. 

Dr. Bradley Bockhorst: Your practice 

is a little different from the typical practice 

out there. Tell us how you’re set up. 

Dr. David Little: My practice is in a little 

town called China Grove, which the 

Doobie Brothers made famous. It’s a 

sleepy little town around San Antone, 

but you can see downtown from my 

office. I built the office around a lake, 

so all the treatment rooms look out on 

the water. One half of the office is a 

specialty wing. I have a fully equipped 

surgical suite and orthodontic bay, 

and every specialist in dentistry rotates 

through my practice. We have 

CBCT technology, intraoral scanners, 

lab support — just about everything 

under one roof. And they’re not part 

of my practice, they just rent from me. 

Together we provide many services. 

BB: So you can refer a case and still 

keep it in-house? 

DL: Exactly. 

BB: You’re a general dentist. You place 

and restore implants. How do you decide 

which ones you’re going to place 

and those you’re going to refer out? 

– Implant Q&A: An Interview with Dr. David Little – 39

BB: Sounds like it’s a truly interdisciplinary 

practice. 

DL: Absolutely. We’re really blessed to 

be able to jump in and take care of 

things, especially trauma cases. 

BB: You mentioned medical considerations 

as a determining factor when deciding 

what you might refer out. What 

are red flags for you when you’re looking 

at a patient’s medical history? 

Figure 1: Digital treatment plan 

Figure 2: Surgical guide 

Figure 3: Denture-modified surgical stent 

The key to 

success is 

treatment 

planning from 

the restoration 

backward. 

DL: First of all, you look at medical 

history. Also, in our office, we can do 

everything from just local anesthesia 

all the way to IV sedation, depending 

on what patients want along those 

lines. Then, the key is to determine 

the factors necessary for success: Is 

it great bone? Is it good occlusion? Is 

everything set up to make it successful? 

If so, then it’s one that I’m going to do. 

If the patient needs a sinus lift or bone 

augmentation, I’m going to refer it. We 

do really well referring together. The 

oral surgeon will do the bone grafts, 

we’ll do the implants, or if we need 

periodontal plastic surgery, we’ll bring 

in the periodontist. It actually works 

very well. 

DL: Uncontrolled diabetes, blood disorders, 

the use of bisphosphonates — 

those are things that we shy away 

from. Essentially anything that makes 

us uncomfortable. If I wouldn’t do an 

extraction, then I’m probably not going 

to do an implant on them. So, I use 

that as my guideline. 

BB: Do you have any advice for aspiring 

implantologists — how they should 

get started, and what they should look 

for in first cases? 

DL: First of all, I think you need to 

have an eye for implants. I think you 

have to start looking for cases where 

implants will be the best solution for 

the patient. Second, get educated. 

Go out and really learn your craft. 

And then use mentors. Mentors are a 

really good thing. Today, by using a 

team approach, you can work with a 

laboratory like Glidewell, and sit down 

and plan out the case, looking at it 

from the restorative aspect backward, 

so that everything is planned out. By 

using CBCT and surgical guides, you 

can do it very predictably and get 

great results. The bottom line is: It’s 

better for our patients. 

BB: You mentioned earlier that you have 

a cone beam scanner in your office. 

DL: I do. Even before I had one, I 

would send it out to get that done 

because I think it’s really valuable information. 

Sometimes all you need is 

a scan to say, “Yes, OK, I’ve got this 

much bone — great.” Sometimes I 

look at it and go: “Wow, I’m glad I did 

that. I didn’t want to do that case.” 

40 


But the real key is not just the CBCT. 

It’s putting it in the software and being 

able to manipulate it. I call it virtual 

planning. I want to be able to show 

my patient that I’m going to put in 

this size implant, and this is why, and 

this is how it’s going to be contoured 

and shaped, all the way to the final 

restoration. Because I think the key to 

success is treatment planning from the 

restoration backward. 

BB: What is your favorite planning software? 

There are several on the market. 

DL: I use SimPlant ® (Materialise Dental 

Inc.; Glen Burnie, Md.), mostly 

because you can use every implant 

system. But with whatever implant 

you’re using, there is going to be a 

system that will work with you. So, 

again, I think you’ve got to look at the 

total picture. 

BB: We’ve had the same experience. We 

do a lot of SimPlant cases here because it 

has an open architecture. Let’s talk about 

guided surgery and level of guidance. 

DL: Obviously, you can have the lab 

make a guide for you from a wax-up. 

That will kind of give you the position, 

but it doesn’t really give you the angle, 

doesn’t give you the depth. It just gives 

you a guide to stay within that area. 

Or you can go all the way to where 

you can actually control depth, angle, 

and position; you can even place the 

implant through the guide (Figs. 1, 2). 

Everything is planned out. I like that 

the best because it gives me the perfect 

emergence profile. The software helps 

me establish what my abutment is 

going to be like, so the laboratory can 

work with me to create a provisional 

that stays in that same position — 

everything is worked through. 

I’ll also say that using even the 

patient’s denture as a guide is huge 

because that makes sure that you keep 

those implants in the neutral zone, 

and you’re going to get a great result 

as well (Fig. 3). There are a lot of guide 

techniques, but I like using the one 

that controls all of it, if I can. 

BB: At the California Dental Association 

(CDA) meeting in Anaheim last 

May, you spoke on the topic of overdentures. 

Can you talk a little bit about how 

you approach your edentulous patients? 

DL: A lot of denture patients are dental 

cripples. They really can’t function 

and they can’t eat. So, one of the 

things I do is I ask them, “Do you want 

to eat what you want, or eat only what 

you can?” Then I talk about what the 

different solutions are. I ask questions 

like, “At the end of this, would you just 

like it that your denture stays in a little 

better, or are you looking for something 

that you never have to take out?” 

Their answers will tell you the direction 

they want to go. Then I look at 

implant-retained, soft tissue-supported 

as a solution. You can do that with 

mini implants, or you can do that with 

two or four conventional implants, 

with different attachments such as O- 

rings and Locator ® attachments (Zest 

Anchors; Escondido, Calif.) (Figs. 4, 5). 

Or, you could go to implant-retained, 

implant-supported. The ANKYLOS ® 

SynCone ® (DENTSPLY Friadent) is what 

I use for that particular one. It is implant-retained 

and implant-supported, 

but still removable. And, finally, we 

have the option to go screw it in and 

either use processed denture teeth, 

which are very esthetic today, or make 

it out of porcelain. 

So, you have that whole range of solutions. 

And I really like what Glidewell 

has done in establishing one fee. If you 

ask a dentist how much an implant 

costs, they know the surgical fee off the 

top of their head. But if you ask them 

how much a crown is, they go: “Uh, it 

depends.” On what? Well, it depends 

on abutments, etc. So it’s having a 

solution — a two-implant solution, a 

four-implant solution. If you include 

everything in that, it’s just a whole lot 

better when you present it to patients. 

BB: And you understand all your costs 

as a dentist. Talking about the edentulous 

patient, how do you make that 

decision between a screw-retained denture 

and a crown & bridge procedure? 

Figure 4: Locator attachments and overdenture 

Figure 5: Restored overdenture case 

DL: I look at the situation and treat 

it four ways: First, I look at it and 

treat it in my mind. Second, I wax it 

up so I can see if what I’m thinking 

can work. Then I sit down with the 

lab and we discuss how this is going 

to work out. Then we ask the patient 

because they’re most important. That’s 

who we’re doing it for. Do they want it 

fixed? Hopefully, if they want it fixed, 

they have enough bone to do it. That’s 

usually what we have to deal with. If 

they do have enough bone, then I tell 

them, “Look, if you have a lower denture, 

you’re eating at about 10 percent 

efficiency.” If I put in two or four implants 

— implant-retained, soft-tissue 

supported — you’ll be at about 40 to 

60 percent. But if you really want to 


Figure 6: Double-cord tissue retraction and laser 

troughing tissue management 

get back to the way you were chewing, 

we can do this screw-retained, or 

porcelain, and then I can get you back 

to functioning even better than you 

were before. So, those are the things 

I look at. And I really ask that question 

of my patients: “Do you want to 

eat what you want, or eat only what 

you can?” 

BB: Regarding screw-retained dentures 

versus porcelain, how do you make a 

decision on which way to go? 

DL: That’s a good question. What do 

patients think? They all think porcelain 

is better. Well, porcelain is better 

if you have the space for it. And 

lip support is the number one thing. 

You’ve got to do a wax rim and make 

sure your lip support is proper because 

I think you can do a better job 

with acrylic a lot of times. So, it’s all 

in the diagnosis — looking at it and 

seeing what is best for that individual 

patient. Because the cost on those is 

not as much as you’d think, when you 

get to that point. A lot of factors are involved, 

but really, listen to the patient. 

I think that’s the main thing. 

BB: A suggestion I’ve heard you give in 

When I talk to 

young dentists 

who are coming 

out of dental 

school, I tell 

them, “Don’t 

biopsy wallets.” 

... Always do 

what’s best. 

a past presentation is, “Treat the patient 

as you’d treat yourself.” Can you expand 

on that treatment approach? 

DL: When I talk to young dentists 

who are coming out of dental school, 

I tell them, “Don’t biopsy wallets.” 

Treatment plan what you would do 

for yourself, for your mom. Don’t 

make value judgments. Tell them what 

you’d recommend. You can always 

back off and sequence it, but always 

do what’s best. They want what’s right. 

I think that’s my best advice: Don’t 

biopsy wallets. 

BB: I also know you’re a big proponent 

of education and the importance of 

educating the team. What are your 

thoughts along those lines? 

DL: Here’s the truth: As dentists, we 

spend more time with our team than 

we do with our family during waking 

hours, so we’ve got to be on the 

same page. So many times you go to 

a seminar and you’re all fired up, but 

when you come back to the office, after 

a couple weeks, things are back 

to normal. Unless you take it back 

and implement it, nothing happens. 

And the key to that is, when you do 

bring implants into your practice, you 

have to have systems, strategies, and 

everybody talking the same language 

because the very first part of case acceptance 

is the phone call. Sometimes 

I’ll actually do random care calls. I’ll 

call offices and say, “I need implants,” 

and see what they say because everybody 

needs to be on the same page. 

BB: We were talking about different 

technologies — guided surgery, cone 

beam scanning. Another is intraoral 

scanning. Are you involved in that? 

DL: Absolutely, and I’ve been involved 

with that from the beginning. Looking 

at the different technologies out there, 

I definitely get better fits when I use 

an intraoral scanning device. I definitely 

get less chairtime when I seat 

them, so that’s the real value for the 

dentist. There’s also that wow factor. 

Patients love it, there’s no gagging. But 

I really think it also makes you a better 

dentist. If we take an impression 

and look at it and go, “It looks pretty 

good, the lab will make that work” 

versus blowing it up and looking at it 

and saying, “Wow, I can’t see that,” it 

really makes us prepare teeth better, 

and see things more accurately. Key, 

though, is still tissue management. 

Figure 7: Temporary abutment and provisional crown 

42 


The holy grail would be when we can 

scan it and that’s no longer a factor. 

But I think that’s going to be the future 

of dentistry, where we’re headed. 

I’m a big believer of doing the scanning 

yourself and letting the lab do 

the work. That’s just not my type of 

practice, where I’d plan it and mill it 

right there in the office. I think it’s a 

great service and a great technology, 

but I prefer to use the lab because my 

chairtime is more valuable to me. 

BB: Regarding tissue management with 

intraoral scanning, do you have a particular 

technique that you like to use? 

DL: Tried and true, the gold standard 

is still the double-cord technique — 

I can teach that all day long — and 

I’ve gotten into diode (AMD) and CO 2 

(DEKA) soft tissue lasers . I think lasers 

have really made a big difference 

in being able to manage tissue. And 

there are lots of products out there 

that help that. I think doing whatever 

you need to do to be able to see that 

margin is the key. 

BB: As far as the different materials 

that are out there right now, is there 

anything you’re experimenting with or 

starting to work with? 

DL: We’ve seen a growth in monolithic 

restorations, which is probably the 

biggest thing happening right now. 

When we first thought about that, we 

said: “Oh my goodness, that material 

is so hard. How is it going to wear 

the opposing?” Concerns like that. But 

there are companies out there, like 

Glidewell, that have done all the tests, 

and I now know it’s not going to wear 

the opposing enamel. And you’re not 

going to have to worry about it breaking. 

Also, the esthetics continue to get 

better and better. That goes back to 

CAD/CAM, and using that technology 

to its finest. But I don’t think there’s a 

single perfect solution for every case. 

You’ve got to evaluate each case individually. 

Lithium disilicate is good in 

some areas, zirconia is good in other 

areas. I think you need to look at the 

case and the technologies available 

and make the best decision. 

BB: Going back to implant placement, 

are you immediately provisionalizing 

your cases? 

DL: I’m very conservative in that respect. 

There are a lot of things I look 

at to make sure I can do that. Let’s 

look at single-tooth for a minute, upper 

anterior (Fig. 7). If I can get the 

tooth out atraumatically, that’s number 

one. I have to have the buccal plate 

solid and in good shape. Two is if I 

can place the implant and get a little 

bit of bone apical. So if I have apical 

stability, place it a little bit more 

toward the palate to get a little palatal 

stability. And the most important 

thing is that I can have it in disclusion 

so there’s no pressure on it. 

Doing that, our success rate in our 

office — and we track everything — 

is just as good as if we don’t provisionalize. 

And our papillae are better. 

So, I’m seeing great results doing that. 

But if those things don’t match, I don’t 

do it. There are some great provisional 

techniques we can apply to wait out 

that healing period. 

Now, let’s talk full arch. There’s a 

big trend, especially among baby 

boomers, where they want it now. 

They don’t want to wait. So, if we can 

extract, place the implants, and seat an 

immediate screw-retained provisional, 

I think that’s a beautiful service for 

patients. Patients are really enjoying 

that (Fig. 8). 

BB: And are you doing everything in 

one surgery? 

DL: We are. But again, not for every 

case. We don’t promise it, either. I always 

start out with a full denture. And 

if it’s not the bone that I want to see, 

if I don’t have the torque I want, then 

we just reline it. But I usually know 

because I’ve used the planning CBCT, 

and I know exactly what I have. I’ve 

measured my vertical. I know every 

detail about it. So we are doing cases 

where we’re doing upper and lower 

immediate extractions and immediate 

placement and immediate screwretained 

provisionalization, and then 

coming back later with CAD/CAM 

Figure 8: Immediate screw-retained provisional restoration 

and building the final prosthesis. And 

that’s a great service to patients. 

BB: Have you worked much with Allon-4 

(Nobel Biocare; Yorba Linda, Calif.) 

when you’re doing screw-retained restorations? 

DL: I have. That’s been around now 

for 10 years, so we’ve got some track 

record to look at. And for patients 

who don’t have adequate bone, that’s 

a great solution. Honestly, if I have a 

choice, I’d rather have six straight. But 

a lot of times I can’t. So, in situations 

where you don’t want to do bone 

grafts and other things, it is a solution. 

We mentioned SynCone earlier. One 

of the things I like about SynCone in 

the lower is that I can put four implants 

in between the mental foramen, 


It’s a great 

time to be in 

dentistry. And 

the best thing is, 

the people who 

benefit the most 

are our patients. 

I can load that immediately, and the 

costs are a lot less, so it opens that 

treatment solution up to more patients. 

Sometimes I even use that as 

a provisional technique, and then 

graft and come back later in the other 

areas. Again, you’ve got to look at 

what is best for the patient and make 

the diagnosis. 

BB: Going back to single teeth and 

immediately provisionalizing, in what 

percentage of your cases do you think 

you’re actually doing that? 

DL: If I do that in that upper anterior 

area, I plan on doing it every time I 

can. Now, the truth is, that’s probably 

only about 80 percent of the time because 

there are some times when we 

just don’t. We always have the lab fabricate 

some type of provisional for me. 

BB: Have that flipper ready. 

DL: Always have that ready. Like an 

Essix ® appliance (Raintree Essix Inc.; 

Wilmington, Del.) or something that 

I can put in there so that we have 

something for the patient to wear 

without any worry and without compromising 

their care. And, obviously, 

patients want it now. If you can do it 

now, patient acceptance goes up. With 

the technology we have today, we can 

do that. 

BB: Once you provisionalize at the time 

of placement, how long are you waiting 

until you do the final restoration? 

DL: There are a lot of different opinions 

on that, a lot of different research 

out there. I’m still waiting three 

months. Truthfully, if they’re in a good 

provisional that looks great and you 

have to wait longer, it’s not a problem. 

They’re happy. So, it’s not as big an 

issue from that standpoint. 

BB: How about full-arch cases? If you 

immediately provisionalize, how long 

are you waiting? 

DL: With those cases we’re actually 

waiting a little bit longer — about four 

months on most of those cases. It depends. 

When wI put that in, I can tell 

right then how long it’s going to be. If 

I have any concerns, I’ll wait longer. 

There’s no rush because you have a 

good provisional for them to work with. 

It goes back to working with the lab 

and having everything in proper order. 

It’s to the point now where we’ve become 

so good at the provisionals that 

we can use that as part of our diagnostics 

for our final, and even eliminate 

some appointments. The more planning 

you do, the better your results 

are going to be. 

BB: Right. It gives you that ideal prototype 

to work from. Are there any future 

technologies you see coming to the fore 

in dentistry? 

DL: I think implants are going to 

continue to grow. More dentists 

are going to be able to get into that 

technology, and more patients are 

going to be able to afford it. In our 

practice, it’s one of the most successful 

things that we do, so there’s a bright 

future for that. As I said before, a lot 

of people who are edentulous are 

dental cripples, and we can really help 

with the use of implant overdentures. 

Those treatment options are going to 

become more and more popular. 

Scanning technologies are also going 

to change things, even if it’s just with 

diagnostic impressions. We’re going to 

be able to do more and more things 

digitally, and anything we can do 

digitally, I think, is going to help us 

all the way through a given procedure 

to final restoration. We’re looking at 

doing dentures digitally now, which 

is something else becoming more 

prevalent in our field and that will 

continue to evolve. It’s a great time to 

be in dentistry. And the best thing is, 

the people who benefit the most are 

our patients. IM 

44 


Go online for 


Coming Soon… 

PRODUCT 


Open Platform 

SPOT 

light 

The Inclusive ® Tooth Replacement Solution, released 

in March of this year, is the first all-in-one 

treatment package for a missing tooth, featuring 

implant, surgical drills, custom temporary components 

for patient-specific soft tissue management, and the final 

CAD/CAM restoration. The complete solution is available 

for one low price, with no hidden fees. With this solution, 

the ease of re-creating a natural emergence profile and 

natural esthetics for a predictable outcome is an attainable 

reality, both for specialists and general dentists alike. 

Inclusive Implant Solutions 

Compatibility Chart 

In response to the dental implant market embracing the 

importance of soft tissue contouring and its benefits to the 

surgeon, the restorative doctor, and the patient, Glidewell’s 

Implant department has now expanded the solution to 

accommodate all implant systems compatible with the 

Inclusive ® Custom Implant Abutment product line. This 

creates the opportunity for more clinicians to offer their 

patients the advantages of the tissue contouring system 

contained within the Inclusive Tooth Replacement Solution. 

Whatever implant system you use, you and your patients 

can now benefit from the tremendous effects of training 

tissue from the time of implant placement, establishing the 

clinical advantages of a stable tissue bed. IM 

AstraTech Dental # OsseoSpeed # 

Certain # 

Biomet 3i # 

External Hex 

(4.1mm) 

Brånemark System # 

Nobel Biocare # NobelActive # 

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Zimmer Dental # Screw-Vent # 

AstraTech OsseoSpeed is now Dentsply Astra Tech Implant System. 

# Not a trademark of Glidewell Laboratories 

– Product Spotlight: Inclusive Tooth Replacement Solution — Open Platform – 47

CLINICAL 

TIP 

Go online for 


Obtaining Accurate Occlusal Records in 

Kennedy Class I and Class II Implant Cases 

by 


One of the challenges when restoring distal free-end 

cases, also referred to as Kennedy Class I and Class 

II cases, is obtaining accurate occlusal records. 

Clinicians will typically use bite registration material 

between the remaining teeth or attempt to inject enough 

bite registration material to fill the edentulous space. This 

may not be adequate to obtain an accurate articulation, 

however. In these situations, utilizing a simple bite block 

while obtaining occlusal records can be a tremendous help. 

The result of inaccurate records is that the case is then 

articulated incorrectly. This further compounds the occlusal 

discrepancies in the final prosthesis. To minimize this 

potential occlusal anomaly, an occlusal verification jig can be 

fabricated by the laboratory. To fabricate the jig, an implantlevel 

impression, bite registration, and opposing model or 

impression are made and forwarded to the laboratory. 

LABORATORY PROCEDURE 

A soft tissue model is poured and the case articulated. 

Inclusive ® Custom Implant Abutments are fabricated and 

mounted on the implant analogs. An acrylic custom jig is 

fabricated to seat securely over the abutments and extended 

to function as an occlusal index. This appliance is then sent 

to the clinician’s office. 

Clinical Procedure 

When the patient returns for their CR/VDO (centric relation/ 

vertical dimension of occlusion) record verification, the 

abutments are mounted on the implants and the abutment 

screws tightened (Figs. 1a, 1b). The occlusal verification 

jigs are then seated on the abutments (Fig. 2), and the bite 

is checked. 

1a 

1b 2 

Figures 1a, 1b: Abutments mounted on implants 

Figure 2: Jigs seated on the abutments 

– Clinical Tip: Obtaining Accurate Occlusal Records in Kennedy Class I and Class II Implant Cases – 49

If it is not repeatable and verifiable, 

a new bite should be made (Fig. 3). 

This is done by trimming the jigs until 

there are no occlusal contacts from the 

opposing dentition (Figs. 4a–4c). 

3 

Figure 3: Note open posterior bite 

4b 

4a 

4c 

Figures 4a–4c: Adjusted jigs completely out of occlusion 

50 


5a 

Figures 5a, 5b: A new bite registration is made 

Then an accurate bite registration 

is made (Figs. 5a, 5b). The new bite 

registration should be verified and 

repeatable. 

5b 

– Clinical Tip: Obtaining Accurate Occlusal Records in Kennedy Class I and Class II Implant Cases – 51

The bite registration, incorporating the 

jigs, is carefully removed and returned 

to the laboratory (Figs. 6a, 6b). 

6a 

Figures 6a, 6b: The bite registration, incorporating 

the jigs, is returned with the case for completion. 

Case completion 

The case is remounted and should 

proceed in the usual manner to 

completion, with greater certainty of 

an accurate occlusal relationship. Use 

of the occlusal verification jig will help 

minimize adjustments and remakes for 

distal free-end cases. IM 

6b 

52 


Photo Essay: 

Immediate and Post-Placement 

Utilization of the Inclusive 

Tooth Replacement Solution 

Go online for 


by 

Darrin M. Wiederhold, DMD, MS 

and Bradley C. Bockhorst, DMD 

The Inclusive ® Tooth Replacement Solution provides clinicians the armamentarium to place 

and immediately temporize single-unit implants in edentulous spaces. The components 

further assist the restorative dentist by immediately beginning to guide the soft tissue 

development around the implant. However, there are also cases in which the implant has 

already been placed. The Inclusive Tooth Replacement Solution line offers the versatility to 

address these post-placement cases as well, with the difference being that the custom temporary 

components are designed and milled based on an implant-level impression. The following pair 

of case reports demonstrates both situations. The first illustrates the use of the Inclusive Tooth 

Replacement Solution to replace a missing maxillary right second premolar at the time of surgery. 

The second illustrates the introduction of the Inclusive Tooth Replacement Solution during the 

healing phase, post-implant placement. 

– Photo Essay: Immediate and Post-Placement Utilization of the Inclusive Tooth Replacement Solution – 53

Case #1: Implant Placement and Immediate Non-Functional Temporization 

The patient is a 46-year-old female who initially presented 

to our office with a chief complaint of: “I have a brokendown 

tooth that I would like to have extracted and replaced 

with an implant.” After evaluation of the patient, the crown 

of tooth #4 was found to be fractured, and decay was noted 

subgingivally. The tooth was determined to be nonrestorable, 

and was atraumatically extracted under local anesthesia, 

with care taken to preserve the buccal plate. The socket 

was gently currettaged and Puros ® Cortico-Cancellous Particulate 

Allograft material (Zimmer Dental; Carlsbad, Calif.) 

was placed in the extraction site for socket preservation and 

covered with a BioMend ® Absorbable Collagen Membrane 

(Zimmer Dental). The membrane was then secured using 

4-0 Vicryl ® suture (Ethicon Inc; Somerville, N.J.). 

After four months, the patient returned to our office for 

evaluation, during which the extraction site and graft were 

determined to have adequately matured to proceed with 

implant placement. After reviewing the CBCT scan in the 

In2Guide implant planning software (Cybermed Inc.; 

Irvine, Calif.), the decision was made to place a 3.7 mm x 

10 mm Inclusive ® Tapered Implant. 

1a 

The requisite polyvinyl siloxane impressions were taken, as well as an accurate bite registration and preoperative intraoral 

photographs, including selection of the shade for the BioTemps ® provisional crown. 

1b 

2 

The diagnostic records were submitted, 

along with a completed Inclusive Tooth 

Replacement Solution digital Rx, to 

Glidewell Laboratories for fabrication 

of the Inclusive Tooth Replacement 

Solution components. Upon receipt of the 

patient’s diagnostic records and digital 

Rx, the Inclusive Tooth Replacement 

Solution components were fabricated 

and forwarded to our office for implant 

placement and temporization. 

✔ 

James Smith 

10-5217558 

drjsmith6585@yahoo.com 

123 Main Street Suite #1 Anywhere, USA 

Jane 

Doe 

✔ 

4 A3 

Please fabricate components for replacement of #4. 

J Smith 

555-555-5555 

✔ 

✔ 

✔ 

✔ 

1265287 

✔ 

✔ Shade photos 

54 


4a 

On the day of surgery, the risks and benefits of the 

planned implant surgery were reviewed thoroughly with 

the patient, and her verbal and written informed consent 

was obtained. The patient was then draped in the 

usual sterile fashion for implant surgery, and instructed 

to swish preoperatively with 0.12% chlorhexidine gluconate 

oral rinse for one minute. The surgical area was 

anesthetized using 4% Septocaine ® with epinephrine 

1:100,000 (Septodont; Lancaster, Pa.), buccally and 

palatally. A full thickness mucoperiosteal flap was then 

reflected between the mesial of tooth #3 and the distal 

of tooth #5 to allow visualization of the alveolus. 

3 

The fit of the Inclusive Tooth Replacement Solution 

prosthetic guide was confirmed, and the proposed 

location of the osteotomy site verified using a periodontal 

probe. With the prosthetic guide in place, 

the planned site was marked using the Inclusive ® 

Lance Drill. 

4b 

The prosthetic guide was then removed and the pilot 

hole made utilizing the 2.3 mm/2.0 mm diameter surgical 

drill to a depth of 10 mm. 

5 


6a 

The location and angulation of the osteotomy were confirmed with a digital periapical digital, with the 2.3 mm/ 

2.0 mm surgical drill in place. 

6b 

7 8 

Once the proper angulation and location were confirmed, 

the osteotomy was completed, ending with 

the 2.8 mm/2.3 mm diameter surgical drill due to 

the relatively soft bone in the area. 

A 3.7 mm x 10 mm Inclusive ® Tapered Implant was 

delivered to the site and advanced initially by hand with 

the plastic carrier. 

56 


With the implant securely hand-threaded into the 

osteotomy, the Handpiece Hex Driver was attached 

to the handpiece and used to rotate the implant 

to depth. 

9 

Final seating of the implant was accomplished with 

the Torque/Ratchet Wrench, achieving a torque 

value of 40 Ncm. 

10 

Because the custom temporary components are 

fabricated with one of the implant hexes aligned to 

the direct buccal, it is imperative that the implant 

be rotated to the proper orientation at the time 

of surgery. This was accomplished and confirmed 

with the Implant Driver attached to the Torque/ 

Ratchet Wrench. 

11 

It is imperative 

that the implant 

be rotated to 

the proper 

orientation at 

the time 

of surgery. 


12a 

As sufficient initial implant stability was achieved in this case (35–40 Ncm), the decision was made to immediately 

temporize the implant with the custom temporary abutment and BioTemps crown. 

12b 

13 

Both the custom abutment and BioTemps crown 

exhibited excellent fit and orientation in all dimensions. 

It was further confirmed that the BioTemps 

crown was out of occlusion by 1.5 mm, which is 

desirable for immediate temporization so as to 

avoid any lateral micromotion on the neophyte 

implant that might compromise its osseointegration. 

The patient tolerated the procedure 

very well, and there were no operative complications. 

Postoperative home care instructions were 

reviewed thoroughly with her, and she was 

appointed in one month for follow-up. 

14 

A three-month postoperative checkup revealed 

excellent healing of the soft tissues. Final 

impressions were scheduled to follow one 

month later. 

58 


Case #2: Post-Placement Utilization of the 


A 41-year-old male presented with a chief complaint of: 

“I had my molar taken out over 10 years ago, and I would 

like an implant to replace it.” Following appropriate workup, 

a 5.2 mm x 8 mm Inclusive Tapered Implant was placed 

without complication in the edentulous area #19. The 

5.2 mm diameter implant features a platform-switching 

design that utilizes 4.5 mm diameter prosthetic components. 

A flaring Inclusive ® Healing Abutment 4.5 mm x 5.7 mm x 

3 mm was tightened to 15 Ncm into the implant in a singlestage 

procedure. 

To ensure proper tissue management specific to his anatomy, 

in the interest of gingival health and natural esthetics, the 

patient elected to take advantage of the custom healing 

features of the post-placement Tooth Replacement Solution. 

An advantage of the post-placement solution is that the 

custom temporary components are designed and milled 

based on an implant-level impression, mitigating or even 

eliminating any need for chairside adjustment of the custom 

components upon delivery. Continued on page 62 

Upon return to the office post-implant placement, 

the patient exhibited excellent soft tissue healing 

around the standard titanium healing abutment. 

The resulting tissue formation, however, is of a 

generic, round geometry commonly encountered 

with stock components, rather than being optimized 

for the anatomy of the edentulous space. 

1 

The stock healing abutment was removed so that 

a closed-tray impression coping could be seated 

on the implant and the closed-tray screw handtightened. 

2 


3 4 

A periapical radiograph was taken to verify complete 

seating of the custom impression coping. 

A standard closed-tray impression was taken. The 

impression coping was then removed and the healing 

abutment replaced. The impression, an opposing model, 

bite registration, and prescribed shade of BioTemps 

provisional crown were sent to Glidewell Laboratories 

with the Tooth Replacement Solution Rx. 

5a 

Upon receipt of the Tooth Replacement Solution components, the stock healing abutment was removed 

and replaced with a custom healing abutment. This patient-specific abutment is anatomically 

contoured, unlike standard, round components. The abutment screw was tightened to 15 Ncm and 

the access opening sealed with a piece of Teflon tape, covered with flowable composite. Had the 

patient desired a temporary restoration in this posterior space, the custom temporary abutment 

and BioTemps provisional crown could have been delivered in lieu of the custom healing abutment, 

with the same emphasis on sculpting the desired soft tissue contours. 

5b 

62 


7a 

Once an appropriate osseointegration period had 

passed, the case was ready for final impressions. 

The matching custom impression coping allows the 

transfer of the final soft tissue contours and implant 

position to the master cast. 

6 

The resulting impression, complete with the custom impression 

coping, opposing model, bite registration, and prescribed 

shade of final restoration were submitted to the lab 

on the pre-populated Tooth Replacement Solution Rx. In this 

case, a BruxZir ® Solid Zirconia screw-retained crown was 

requested. 

8 

The custom healing abutment was removed, 

so that the custom impression coping could be 

seated on the implant and the abutment screw 

hand-tightened. A periapical radiograph was 

taken to confirm complete seating of the custom 

impression coping. The top of the screw access 

opening was then blocked out with soft wax to 

prevent impression material from flowing inside the 

coping. A closed-tray impression was taken. 

7b 


10a 

9 

Delivery of the final prosthesis involved 

removing the custom healing abutment 

and then seating the one-piece BruxZir 

screw-retained crown. The abutment screw 

was tightened to 35 Ncm and a periapical 

radiograph taken to verify final seating. 

10b 

Once the interproximal and occlusal contacts 

had been checked, the occlusal screw access 

opening was sealed with a piece of Teflon 

tape and composite, bringing the case to a 

successful conclusion. 

A Road Map for Surgical and Restorative Success 

The Inclusive Tooth Replacement Solution is designed to 

address communication and component issues known to 

complicate implant treatment and too often compromise 

the final result. By planning the case from the restorative 

perspective prior to implant placement, and taking advantage 

of custom temporary components for patient-specific soft 

tissue management, clinicians are finding it much easier 

to achieve the desired, esthetic outcome. These case 

presentations highlight the simplified, predictable process 

by which this versatile, one-of-a-kind solution addresses 

implant placement and soft tissue healing in a manner that 

will help pave the path to a superior final restoration. IM 

64 


CLINICAL 

TIP 

When a Flapless Approach Makes Sense 

by 

Michael McCracken, DDS, Ph.D 

For many dentists who place 

implants, the lure of the “perfect 

surgery” is almost irresistible. 

Picture it in your mind. It starts 

with a flapless approach, continues 

with a flawless six-minute implant 

placement, and ends with the stunned 

appreciation of the patient and a 

satisfied smile on the face of the 

dentist. The fact is, however, that 

flapless surgery can present serious 

challenges to the beginning surgeon. 

In the university residency setting, 

a flapless surgery is automatically 

categorized as a minimum of 3 on a 

4-point scale, just because it is flapless. 

These surgeries can be difficult! 

I have seen more than one experienced 

and proficient surgeon become 

embarrassed when demonstrating a 

flapless surgical approach. 

Clinicians disagree on whether keratinized 

tissue is critical for implant 

longevity. There is no doubt, however, 

that keratinized tissue is generally desirable 

because it improves esthetics 

Figure 2: Favorable bone architecture 

When is a flapless approach reasonable? 

Look for three things: 

n Abundant keratinized tissue (Fig. 1) 

n Favorable bone architecture (Fig. 2) 

n Easy access to treatment planning technology (Fig. 3) 

Figure 1: Abundant keratinized tissue 

– Clinical Tip: When a Flapless Approach Makes Sense – 65

The Benefits of Digital Treatment Planning 

and Guided Surgery in Conjunction with 

Small-Diameter Implants 

n 3-D view to determine the quality and quantity of bone 

as well as identify critical structures 

presurgically 

n Minimally invasive procedure through a flapless 

approach 

n Accurate transfer of the digital plan to the clinical 

setting utilizing a pilot surgical guide 

Criteria for Flapless Approach 

u ≥7 mm keratinized gingiva 

u Adequate bone to encase 

implant 

u Appropriate diagnostic 

work-up (e.g., CBCT) 

Benefits of Flapless 

u Minimally invasive 

u Less potential for bone loss 

as there is no disruption of 

blood supply 

and frequently aids in patient comfort. 

If keratinized tissue is minimal, I 

prefer to raise a flap to preserve what 

tissue is there. If less than 3 mm of 

keratinized tissue is present, incise 

lingually to the band and leave it on 

the facial of the implant. If more than 

3 mm of keratinized tissue exists, split 

the band, putting some on each side 

of the implant. If you leave a small 

gap in the surgical margins around 

the implant at closure, this gap will 

fill in with keratinized tissue, actually 

increasing its width. 

If the bone architecture is not ideal, 

laying a flap is often necessary to 

correct the situation. This may require 

alveoplasty to broaden and flatten 

the ridge, or grafting to increase the 

ridge width. These procedures may be 

impossible without a flap. 

Finally, use technology to make your 

flapless approach successful and accurate. 

CBCT scans are present in most 

dental communities, and laboratory 

support is readily available to facilitate 

guide fabrication. This takes the 

guesswork out of implant placement. 

Although I am reluctant to admit it, 

some of my most esthetic implants 

have been placed with a surgical guide 

based on CBCT analysis. 

So when you have all three — 

abundant keratinized tissue, favorable 

bone architecture, and prior 3-D 

planning — go for it! There is nothing 

like that satisfied smile, especially 

when it’s yours. IM 

If the bone architecture 

is not ideal, laying a flap 

is often necessary to 

correct the situation. 

Benefits of Flapped 

u Direct visualization 

u Ancillary procedures 

(e.g., grafting) 

Figure 3: 3-D treatment planning technology 

66 


LAB 

SENSE 

Go online for 


by 

BEST IN CLASS: 

Inclusive Custom 

Abutments 

Dzevad Ceranic, CDT, Implant Department General Manager 

and Grant Bullis, Director of Implant R&D and Digital Manufacturing 

OVER THE PAST FIVE YEARS, the Implant department at 

Glidewell Laboratories has witnessed a tremendous rate 

of growth in the demand for its line of Inclusive ® Custom 

Abutments (Fig. 1). By pioneering advance ments in the 

computer-aided design and manufacturing techniques used 

to produce these patient-specific restorations, the laboratory 

has developed and refined processes that are far more 

predictable, more precise, 1 and more efficient than traditional 

waxing and casting techniques. The end result is a custom 

solution at or near the cost of a generic, prefabricated 

abutment, making it the first choice of a growing number 

of clinicians. 

Digital Abutment Units 

Nov 09 

Jan 10 

Mar 10 

May 10 

July 10 

Sept 10 

Nov 10 

Jan 11 

Mar 11 

May 11 

July 11 

Sept 11 

Nov 11 

Jan 12 

Mar 12 

May 12 

Figure 1: Graph charting growth in demand for digitally designed Inclusive Custom Abutments at Glidewell Laboratories. The last three years have seen average monthly 

prescriptions increase by nearly 3,000 percent. 

– Lab Sense: Inclusive Custom Abutments – 67

Figure 2a: Clinical image of an Inclusive Custom Abutment with delivery jig 

Figure 2b: Clinical image of a custom abutment, freshly seated, demonstrating 

proper soft tissue support 

Custom Abutments or 

Stock Abutments 

The clinical benefits of patient-specific 

implant abutments have been well 

documented in the dental literature. A 

prefabricated “stock” abutment lacks 

the flexibility in form to address the 

unique challenges, individual complexities, 

and esthetic demands of a given 

case. In the majority of implant cases, 

the patient is best served by an abutment 

specifically tailored to the natural 

emergence profile of the tooth being 

replaced, the morphology of adjacent 

and opposing dentition, the presence 

of defects, and proper support of the 

eventual restoration, among other factors. 

2 To provide optimal function and 

esthetics, stock abutments must often 

be modified by the lab to establish 

suitable height, margins, and path of 

insertion, which can vary, depending 

on the location and angulation of implant 

placement. Not only does this 

modification process provide a less 

than ideal emergence profile, but the 

cost is often as much or more than the 

cost of a custom abutment. 

through proper support and management 

of the soft tissue with a properly 

placed margin, which facilitates 

cement removal during delivery of the 

final restoration (Fig. 3). 

Digital Custom Abutments or 

UCLA Abutments 

Since its introduction in 1987, the 

universal clearance-limited abutment 

(UCLA) has enabled technicians to 

create the wax-up of a custom abutment 

by hand, allowing them to design 

abutments that adapt to conditions 

of restricted occlusal and interproximal 

clearance. While suitable in most 

clinical situations, the UCLA process 

can be tedious, time-consuming, and 

less precise 3 for both the clinician and 

laboratory. Given the high cost of noble 

metals, and the intensive laboratory 

procedures required to fabricate 

the final solution, an overwhelming 

number of clinicians are switching 

from UCLA abutments to digital custom 

abutments (Fig. 4). 

Digital Inclusive Custom 

Abutments or Other Digital 


With a greater number of clinicians 

choosing the esthetics, function, and 

Glidewell provides an acrylic jig with 

each Inclusive Custom Abutment to 

help ensure swift, accurate seating, 

thereby minimizing chairtime and patient 

discomfort (Figs. 2a, 2b). Once 

delivered, these patient-specific abutments 

promote peri-implant health 

Figure 3: Illustration depicting the subgingival location of the cement junction found on a typical stock abutment, 

in comparison to the tissue-level cement junction found on an Inclusive Custom Abutment 

68 


Digitally (CAD) Designed vs. Waxed Units 

2009 

2012 

90% 

80% 

90% 

80% 

91% 

70% 

82% 

70% 

60% 

60% 

50% 

50% 

40% 

40% 

30% 

30% 

20% 

10% 

18% 

CAD 


Waxed 


20% 

10% 

CAD 


9% 

Waxed 


Figure 4: Comparative percentages of digitally designed Inclusive Custom Abutments versus conventionally waxed Inclusive Custom Abutments ordered from Glidewell 

Laboratories in 2009 and 2012 

efficiency of CAD/CAM custom abutments, 

it bears looking at some of 

the industry-leading options available 

today. Dedicated to providing 

the highest-quality implant prosthetics 

possible, Glidewell Laboratories 

continuously improves the technologies, 

materials, and processes used to 

design and manufacture its Inclusive 

line of products. Recently, the lab’s research 

and development department 

conducted a same-case, microscopic 

comparison of an Inclusive Titanium 

Custom Abutment alongside patientspecific 

titanium abutments from two 

other leading manufacturers. Scanning 

electron microscopy (SEM) images 

provide an up-close look at the critical 

implant-abutment interface of these 

competing solutions (Fig. 5). 

Seen from this highly magnified view, 

the Inclusive Custom Abutment presents 

favorably in relation to its peers. 

The Inclusive abutment exhibits 

smooth transitions between features, 

an absence of burs or tooling marks, 

and an excellent finish of the mating 

surface. The second sample lacks a 

smooth transition between features, 

displays more pronounced roughness 

of the mating surface, and exhibits an 

inconsistent blend line in the gingival 

portion of the abutment. The third 

sample exhibits burs on and around 

the mating surface and connection 

geometry, and a tri-lobe interface with 

geometry that differs from the implant’s 

prosthetic connection. The clinical 

relevance of these defects could 

include an increased potential for 

micro-leakage 4 between implant and 

abutment, and a higher risk of screw 

loosening 5 caused by a less intimate fit 

around the connection. 

The fit and finish displayed in these images 

are indicative of the commitment 

at Glidewell Laboratories to achieve 

and maintain an unsurpassed level of 

quality. As the world’s largest dental 

implant laboratory, Glidewell leverages 

the expertise of dozens of certified 

dental technicians in the design of its 

prosthetic components. The abutment 

manufacturing division is ISO 13485 

Figure 5: SEM images comparing an Inclusive Titanium Custom Abutment (left) to same-case samples from a pair of leading custom abutment manufacturers 


Figure 6: Inclusive Titanium Custom Abutment Figure 7: Inclusive All-Zirconia Custom Abutment Figure 8: Inclusive Zirconia with Titanium Base Custom 

Abutment 

certified, and operates under FDA 

Current Good Manufacturing Practices 

(CGMPs). The lab’s abutments are produced 

on high-precision Swiss lathes 

and multi-axis milling machines. As 

the leader in digital dentistry, Glidewell 

employs an experienced staff of 

engineers and machinists to ensure 

that each abutment they produce is 

one that clinicians and their patients 

can rely on. 

Inclusive Custom 

Abutment Options 

Inclusive Custom Abutments are available 

in titanium, all-zirconia, or hybrid 

(zirconia with titanium base) options. A 

titanium abutment (Fig. 6) is the most 

frequently prescribed, particularly in 

the posterior. An all-zirconia abutment 

(Fig. 7), favored for its more natural esthetics, 

is indicated for all areas of the 

mouth, and is a popular choice for anterior 

restorations. A hybrid abutment 

(Fig. 8) combines the esthetics of a zirconia 

coping with a titanium abutment 

connection, resulting in a all-titanium 

implant-abutment interface. All three 

varieties are compatible with a number 

of popular implant systems (Fig. 9), 

in addition to their compatibility with 

the Inclusive ® Tapered Implant System. 

While other custom abutment manufacturers 

can accept digital files from a 

few dental scanners, Glidewell Laboratories 

accepts and works with files from 

almost any digital scanner or design 

software, providing industry-leading 

flexibility for both clinicians and laboratories 

(Fig. 10). 

Inclusive Tooth 

Replacement Solution 

The Inclusive ® Tooth Replacement Solution, 

is a comprehensive, restorativedriven 

treatment package with patientspecific 

temporary components that 

begin sculpting the soft tissue from 

the moment of implant placement. It 

features a matching custom impression 

coping for transferring the final 

soft tissue architecture to the laboratory. 

Taking advantage of these tissue 

contouring components ensures that 

the patient’s soft tissue is ideally prepared 

to provide a natural emergence 

profile (Figs. 11a, 11b). This helps to 

Inclusive Custom Abutments Compatibility Chart 

Astra Tech # Biomet 3i Keystone 

Zimmer 

# 

Dental 

Nobel Biocare # Straumann # # Neoss# Dental # 

OsseoSpeed # Certain # External Hex 

(4.1mm) 

PrimaConnex # Neoss # Brånemark 

System # NobelActive # NobelReplace # Bone Level # Screw-Vent # 

Titanium 3 3 3 3 3 3 3 3 3 3 

Zirconia w/ Ti-Base 3 3 3 3 3 3 3 3 3 3 

All-Zirconia 3 3 3 

#Not a trademark of Glidewell Laboratories 

Figure 9: Inclusive Custom Abutments are compatible with most major implant systems, in addition to the Inclusive Tapered Implant System. 

70 


mitigate the painful and disruptive 

blanching often associated with seating 

a final abutment through tissue 

that has been left to form around a 

stock healing abutment. 

Summary 

A prefabricated implant abutment is 

often viewed as the most immediate, 

least expensive option for restoring 

implant cases. But a patient-specific 

abutment that takes into consideration 

the unique anatomical qualities of 

the patient’s edentulous space will, in 

most situations, provide more reliable 

function and more natural esthetics, 

maximizing long-term health and performance. 

As technological advancements 

decrease the costs associated 

with the design and manufacture of 

digital custom solutions, clinician demand 

for traditional cast and stock 

abutments is rapidly waning in favor 

of CAD/CAM precision and efficiency. 

Available for most major implant systems, 

Inclusive Custom Abutments 

consistently deliver the high quality 

that clinicians expect. IM 

References 

1. Castillo de Oyagüe R, Sánchez-Jorge MI, Sánchez 

Turrión A, Monticelli F, Toledano M, Osorio R. 

Influence of CAM vs. CAD/CAM scanning methods 

and finish line of tooth preparation in the vertical 

misfit of zirconia bridge structures. Am J Dent. 2009 

Apr;22(2):79-83. 

2. Kerstein RB, Castellucci F, Osorio J. Ideal gingival 

form with computer-generated permanent healing 

abutments. Compend Contin Educ Dent. 2000 Oct; 

21(10):793-7, 800-1; quiz 802. 

3. Lewis SG, Llamas D, Avera S. The UCLA abutment: 

a four-year review. J Prosthet Dent. 1992 Apr; 

67(4):509-15. Review. 

4. Silva-Neto JP, Nobilo MA, Penatti MP, Simamoto PC 

Jr, Neves FD. Influence of methodologic aspects on 

the results of implant-abutment interface microleakage 

tests: a critical review of in vitro studies. Int J 

Oral Maxillofac Implants. 2012 Jul;27(4):793-800. 

5. Kano SC, Binon P, Bonfante G, Curtis DA. Effect 

of casting procedures on screw loosening in UCLAtype 

abutments. J Prosthodont. 2006 Mar-Apr;15(2): 

77-81. 

Dental Scanning Systems 

Laboratory 

3Shape Dental System 

(3Shape) 3 

DentalCAD 

(exocad America) 3 

DWOS 

(Dental Wings) 3 

DentSCAN 

(Delcam) 3 

Lava C.O.S. 

(3M ESPE) 3 

Optimet Dental CAD/CAM Scanner 

(Optical Metrology) 3 

Chairside 

iTero 

(Align Technology) 3 

CEREC 

(Sirona Dental Systems) 3 

Lava C.O.S. 

(3M ESPE) 3 

E4D Dentist 

(D4D Technologies) 3 

IOS FastScan 

(IOS Technologies) 3 

Dental Software 

3Shape Dental Designer (3Shape) 3 

DentalCAD (exocad America) 3 

DWOS (Dental Wings) 3 

DentCAD (Delcam) 3 

Figure 10: Digital scanning systems and design software formats supported by Glidewell Laboratories 

Figure 11a: Representation of the soft tissue architecture 

resulting from the use of a custom healing 

component featured with the Inclusive Tooth Replacement 

Solution 

Figure 11b: Representation of the final Inclusive 

Custom Abutment, easily seated in the anatomically 

contoured sulcus 


Production Workflow 

The following overview presents an insider’s look at how Inclusive 

Custom Abutments are fabricated at Glidewell Laboratories. 

1 

Model 

Scan 

A soft tissue study model is created from an implant-level 

impression. A scanning abutment attached to the implant 

analog serves to capture the implant angulation, position, 

and abutment connection orientation. 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. 

2 

Digital 

Design 

Once the fully articulated case exists in a virtual environment, 

the abutment can be digitally designed using software 

that contains a proprietary library of morphology. 

The technician adjusts the soft tissue margins to create 

an optimal emergence profile, then adjusts the angle (up 

to 20 degrees) to account for implant angulation and to 

avoid undercuts. The dimensions of the abutment are precisely 

modified to ensure proper support for the eventual 

restoration, including appropriate interproximal and occlusal 

space. 

3 

Milling 

Once the digital restoration is complete, the electronic file 

is forwarded to a top-of-the-line Haas 5-axis CNC milling 

station (Haas Automation; Oxnard, Calif.) for precision milling 

from either a titanium blank or BruxZir ® zirconia block. 

An M-series FANUC robot arm (FANUC Robotics; Rochester 

Hills, Mich.) assists with 24/7 loading of titanium 

blanks to help the laboratory meet increasing demand. 

4 

Once milled, each abutment is forwarded to a quality 

control technician, where a comprehensive inspection is 

conducted to ensure accurate fit and design. 

Final QC 

5 

As a final addition, each Inclusive Custom Abutment — 

whether titanium, zirconia, or zirconia with titanium base — 

includes an acrylic jig used at the time of delivery to 

ensure and maintain complete, accurate seating while the 

abutment screw is inserted and tightened. 

Delivery 

Jig 

72 


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Treating 

Xerostomia 

Patients 

A Clinical Conversation 

with Dr. Christopher Travis 

Interview of Christopher P. Travis, DDS 

by Bradley C. Bockhorst, DMD 

Dr. Christopher Travis is a practicing prosthodontist in South Orange County, Calif. We spoke 

the other day about one of the problems we face in practice: treating patients who suffer 

from xerostomia, or dry mouth. I was intrigued to discover that up to one-third of his patients 

deal with this condition to some degree. Implant prostheses are a good option for xerostomia 

patients who are wearing full or partial dentures. 

Dr. Bradley Bockhorst: What are the causes of xerostomia, 

and how do you treat it? What are the complications? How has 

it impacted your practice? 

Dr. Christopher Travis: Xerostomia is abnormal dryness 

in the mouth caused by dysfunction in the salivary gland. 

There are many causes. Probably the major cause is the 

many medications we are using nowadays. They can be 

as innocuous as antihistamines, decongestants, and antidiuretics 

to more prescription-oriented medications for 

anxiety or depression, possibly for cancer therapy — they 

can cause a lot of problems with salivary gland function. 

BB: When we are talking about cancer patients, it’s not just 

medications for chemotherapy we’re referring to, it’s also from 

the radiation. 

CT: If the cancer is in the head and neck area, you’re 

definitely going to be affected by the radiation. Also, aging 

seems to be correlated with saliva flow, but that’s not quite 

accurate. Aging itself is not really the problem. The problem 

is when health is compromised as people get a bit older 

and they’re taking more medications. Those two go hand in 

hand with the possibility of the lack of salivary flow from 

the salivary glands. 

Another problem can be with HIV patients who are taking 

antiviral drugs. Others are Sjögren’s syndrome, which is 

an autoimmune disease. A lot of the autoimmune diseases, 

like lupus erythematosus, erythema multiforme, von Recklinghausen’s 

disease and Sjögren’s, can cause salivary flow 

dysfunction, and the drugs used to treat these diseases can 

cause it as well. 

– Treating Xerostomia Patients: A Clinical Conversation with Dr. Christopher Travis – 75

Treating Xerostomia Patients 

Xerostomia 

at a glance 

Dryness of the mouth resulting from diminished 

or arrested salivary secretion. Several factors, 

both natural and induced, can lead to the 

occurrence of xerostomia. 

SYMPTOMS 

• Lipstick on teeth caused by lack of salivary 

function 

• Thick, ropey, mucous-like saliva 

• Dry mouth 

• Sore, thick throats and difficulty talking 

• Malodor or bad breath 

• Candida albicans – fungus normally present on the 

skin and in mucous membranes such as the vagina, 

mouth, or rectum. Becomes an infectious agent 

when there is some change in the body environment 

that allows it to grow out of control 

• Oral candidiasis (thrush) or vaginal candidiasis 

(vaginitis) – fungal infection commonly referred to as 

a yeast infection 

BB: I also read on the Sjögren’s Syndrome Foundation website 

that they estimate there are 4 million Sjögren’s patients out 

there, and that 9 out of 10 are women — 

CT: — who are post-menopausal. That’s right. I’ve been in 

practice almost 31 years, and I would say about half of the 

women in my practice, which would be about a third or 

more of my practice, have a Sjögren’s type of symptom, 

including sialoliths, which are salivary gland stones. Of 

course, that can be checked out by sialography, and can be 

dealt with in that respect. 

BB: I read on the foundation’s website that, on average, it takes 

seven years to be diagnosed with Sjögren’s. So as dentists serving 

our patients, we can be on the forefront of diagnosis. If we have 

patients who come in with dry mouth or dry eyes, those types 

of things should be red flags that we should automatically pick 

up on. Have you ever been the primary clinician spotting that? 

CT: I have. I’ve told a patient that she may have Sjögren’s 

syndrome, and she was tested and — boom! — she had 

it. And one of the reasons is because a lot of the time, the 

physician will not test for Sjögren’s specifically. But once 

the patient tests positive for Sjögren’s, they can be treated 

properly and not necessarily shotgunned with a whole lot 

of drugs. 

Smoking and chewing tobacco, especially, can hamper 

salivary flow terribly. And, of course, smoking and chewing 

isn’t good for the mouth anyway — you can develop cancer. 

Another thing is snoring and wearing a sleep apnea 

appliance. Of course that can be a yin and a yang: you want 

to stop snoring so you wear an appliance, yet it can also 

lead to salivary flow dysfunction. 

BB: They’re breathing through their mouths all night, so 

obviously there are going to be potential complications. 

CT: That’s right. People with strokes can get it because they 

lose their nervous input into the salivary glands. Also, Bell’s 

palsy from the facial nerve can be a problem, as well as 

other little palsies. So, neuromas and so on can cause issues 

as well. 

BB: You named off general categories of pharmaceuticals. Are 

there particular drugs that, when you’re looking at a patient’s 

chart, almost pop out at you as being related to xerostomia? 

CT: Yes, especially antidepressants, anti-anxiety drugs: 

ZOCOR ® (Merck & Co. Inc; Whitehouse Station, N.J.), 

Xanax ® (Pfizer; New York, N.Y.) — you’ve got some of those 

medications that you have to be careful with, especially if 

the patient does have a lack of salivary flow. And if some 

of the diagnostics include periodontal disease and caries, 

along with the lack of the salivary flow, then we have to be 

careful. A lot of times the patient can’t get off the meds, so 

we have to do a sort of palliative treatment. Really, in the 

last decade there has not been a lot of research in this area. 

One of the reasons is that the scientists who want to do 

research want to make money and get grants. Well, there’s 

not a lot of money in salivary dysfunction. But there should 

be because it affects a lot of things. 

BB: I wanted to talk a little bit more about aging. It’s not 

aging, per se, that can cause the potential for xerostomia. Can 

you expand on that? 

CT: Usually, aging has a tendency to go hand in hand with 

patients’ limited health issues, and the medications they 

may have to take regarding some of their health issues — 

high blood pressure, for instance. Also, antihistamines and 

decongestants, because people tend to get more allergic to 

things as they get older. Another is anti-diuretics. People 

become incontinent and sometimes have to be treated as 

well. That seems to go hand in hand, but aging in itself is 

not the criteria for salivary gland dysfunction. 

76 


BB: For the sake of our audience, can you do a quick anatomy 

review? 

CT: Absolutely. 

We’re just going to go through three major sets of salivary 

glands surrounding the mouth. The first set we’ll talk about 

is the parotid glands. There is one large parotid gland on 

either side, usually located just below the zygomatic arch, 

and just outside of the coronoid process of the mandible. 

The parotid duct goes into the molar area, where sometimes 

patients bite. It’s that duct that goes into the mouth with 

their molars, and it’s on either side. 

The second set of salivary glands are the sublingual glands. 

They go just posterior to the synthesis of the mandible. You 

can see the sublingual fossa, sometimes called clefts. And 

this is where the salivary glands are housed. A Wharton’s 

duct comes right into the floor of the mouth, and that’s where 

sometimes when you’re doing dentistry you occasionally 

get spit on. 

Anatomical view of the parotid gland 

Courtesy of Primal Pictures Ltd. 

www.primalpictures.com 

Anatomical view of the sublingual gland 



Anatomical view of the parotid duct 



Anatomical view of the submandibular gland 





DISEASES that can CONTRIBUTE 

to salivary flow dysfunction 

• Sjögren-Larsson syndrome – systemic 

autoimmune disease; immune cells attack and 

destroy the exocrine glands that produce tears 

and saliva. Pronounced SHOW-grins, this disease 

is common in those with fibromyalgia and chronic 

fatigue syndrome. 

• Lupus – collection of autoimmune diseases; 

a hyperactive immune system attacks normal, 

healthy tissues and can affect the joints, skin, 

kidneys, blood cells, heart, and lungs 

• Erythema multiforme – condition of the skin and 

oral mucous membrane ranging from a mild rash 

to life-threatening rash. Usually follows an infection 

or drug exposure. Peak incidence occurs in the 

second and third decades of life. 

• Von Recklinghausen’s disease 

(neurofibromatosis) – genetic disease in 

which patients develop multiple soft tumors 

(neurofibromas). Tumors occur under the skin 

sand throughout the nervous system. 

• Sialolithiasis – formation of calculus, or stones, 

in the salivary glands 

• Bell’s palsy – disorder of the nerve that controls 

movement of facial muscles. Damage to this nerve 

causes weakness or paralysis of these muscles. 

Cannot use muscles due to paralysis. 

• Stroke – rapid loss of brain function due to 

disturbance in the blood supply to the brain 

The submandibular salivary glands are located in the 

submandibular fossa of the mandible, or cleft, on both sides. 

Their ducts go into the ventral side of the oral cavity on 

either side of the mouth. It is very important for the surgeon 

who places implants not to drill their osteotomy into this 

area. Of course we’re using guided surgery with CT scans 

now, so those things are definitely less of an occurrence. 

All three sets of salivary glands are the main salivary glands 

that allow us to chew our food in our mouth. There are 

minor ones, too, some of which are called molar glands, but 

these are the three sets of two that are the most important. 

BB: We’ve talked about the causes of xerostomia, and we just 

reviewed the anatomy of the three sets of salivary glands. Can 

you tell us a little bit about the ways of diagnosing xerostomia? 

CT: That’s very important because you have to treat the 

patient who has xerostomia a little differently — a lot of 

the diagnoses come from the patients’ symptoms. One of 

the most important things, especially with women, is that 

they come in with lipstick on their teeth. Women who have 

lipstick on their teeth usually are experiencing a lack of 

salivary flow — there is no saliva there to rinse the lipstick 

off their teeth. That’s one of the first things I notice. 

The next thing I notice obviously is a dry mouth. Maybe 

thick and ropey saliva, almost a mucous-like saliva. Sore 

throats. Difficulty talking. Sometimes they’ll complain about 

a tongue that’s really sore all the time, and feeling thick — 

those kind of symptoms. And I ask specific questions in the 

initial consultation when the patient is sitting in my chair. 

Lots of them — especially, again, postmenopausal women — 

say they have a lot of these symptoms. It’s a tough nut 

to crack. 

BB: Are there other things you can detect from your patients, 

such as taste, or a malodor? 

CT: That’s correct. A lot of times there are specific causes 

of bad breath. Now, obviously, bad breath can be the result 

of periodontal disease or caries caused by salivary gland 

dysfunction. Because the saliva has certain bactericidal 

properties, bad breath, malodor, and a bad taste in their 

mouth can be symptoms of gland dysfunction. 

BB: And then you mentioned caries, lack of salivary flow can 

obviously affect that, right? 

CT: Tremendously, especially near the gingival tissues and 

the areas of the CEJ (cementoenamel junction) of the teeth. 

They become rampant caries, and it can be very difficult to 

treat. You have to go with certain preventive measures, such 

as using PreviDent ® (Colgate; New York, N.Y.) or some kind 

of fluoride rinse, drink water a lot, and so forth. 

BB: So if they have cervical lesions, does that become part of 

the differential diagnosis as to what’s causing that? 

CT: Correct. That is definitely one of the major pop-up 

symptoms. 

BB: As far as developing fungal and other infections, you 

mentioned the bactericidal properties of saliva. What are some 

other things that can show up? 

CT: It isn’t necessarily specifically from salivary gland 

dysfunction, but those people who have autoimmune 

problems or who are taking medications can have candida 

problems all throughout their body, especially the ladies. So 

what happens is they get candidiasis in their mouths, and 

a lot of the people I treat have to wear prostheses — either 

fixed or removable prostheses — and that can be a problem 

when you do get candida because it’s tough to keep treating 

it with Nystatin or Monistat ® (Insight Pharmaceuticals; 

78 


A lot of times, having the prosthesis off the mucosa 

is something the patient can tolerate really well. 

And, of course, implants don’t have caries. 

Ways Sjögren’s Syndrome may affect the body 

Neurological problems, 

concentration/memory-loss 

(brain fog) 

Dry eyes, 

corneal ulcerations, 

and infections 

Dry nose, recurrent 

sinusitis, nose bleeds 

Difficulty swallowing, 

heartburn, reflux 

esophagitis 

Dry mouth, mouth sores, 

dental decay: difficulty with 

chewing, speech, taste, and 

dentures 

Recurrent bronchitis, 

pneumonia, interstitial 

lung disease 

Dry skin, vasculitis, 

Raynaud’s phenomenon 

Arthritis, muscle pain 

Stomach upset, 

gastroparesis, 

autoimmune pancreatitis 

Abnormal liver function 

tests, chronic active 

autoimmune hepatitis, 

primary biliary cirrhosis 

Peripheral neuropathy 

(numbness and tingling in 

the extremities) 

Vaginal dryness, 

painful intercourse 

Diagram of the many effects of Sjögren’s syndrome on the body, including symptoms that can contribute to xerostomia 

Courtesy of Sjögren’s Syndrome Foundation, www.sjogrens.org 



HABITS/CONDITIONS that can 

INHIBIT salivary flow 

• Smoking 

• Chewing tobacco 

• Wearing sleep apnea appliances 

• Postmenopausal stage of life (women) 

• Aging 

DRUGS THAT CAN INHIBIT 

SALIVARY FLOW 

• Over-the-counter medications – antihistamines, 

decongestants, anti-diuretics 

• Prescription medications for anxiety or depression, 

cancer therapy, radiation therapy 

• Antiviral drugs for HIV 

Trevose, Pa.) or something similar, to get rid of it, because 

it’s a continuous infective condition, and it’s a tough call. 

BB: What are some of the complications patients suffer through 

when they have dry mouth or xerostomia? 

CT: Oh, it makes it very difficult. They can’t eat very well. 

The complications are systemic in nature, sometimes — they 

don’t want to eat because they can’t, and they can’t chew 

their food well. It’s the first stage of digestion, so these 

people have systemic problems from eating improperly. 

They have problems wearing dentures — sometimes they 

can’t wear them at all. Of course other complications are 

periodontal disease or cervical caries that have to be treated 

in a little different fashion. 

Many times, as I said previously, the patient with complications 

can get candida albicans, or candidiasis, which 

makes it very difficult to wear dentures. And then the 

tongue can get very painful and enlarged. Sometimes the 

taste buds on the tongue don’t perform properly and don’t 

give off a good taste. Those types of complications can 

come about, and you need to be familiar with those so you 

can symptomatically treat them, if possible. 

BB: Earlier we were talking about dry mouth caused by sleep 

apnea appliances, but can dry mouth also exacerbate this? 

CT: It can. The tongue has the tendency to get sticky, so it 

will stick to the soft palate of the throat and keep people 

from breathing properly through their nose. They start 

snoring, and might actually stop breathing for a certain 

period of time. That’s when the sleep apnea symptoms start. 

BB: We’ve talked about the causes and the complications. How 

are you treating the xerostomia patients in your practice? 

CT: Initially we start with palliative treatment. We want 

them to brush their teeth and floss properly — make sure 

everything is really clean. Fluoride pastes like PreviDent 

are very important to keep caries down to a minimum. 

Another thing is to be able to buy products like Biotène ® 

(GlaxoSmithKline; Philadelphia, Pa.) or Spry ® (Xlear; Orem, 

Utah), or Thayers ® Dry Mouth Spray (Thayers; Westport, 

Conn.), or any of those products that contain carboxymethyl 

cellulose. It allows a sort of lubrication in the mouth. I 

really like using Biotène in my practice. Also, Omni used to 

have TheraSpray. It’s the same kind of product, containing 

carboxymethyl cellulose that allows for more lubrication in 

the mouth, and actually helps in caries prevention as well. 

Other products can be a little bit more gutsy — you can 

take medications like pilocarpine, or cevimeline, which is a 

cholinergic agonist, and those medications can help create 

more saliva flow. However, they do have side effects. Other 

salivary-stimulating drugs would be anetholtrithione. It’s a 

good drug, but it has the tendency to cause flatulence. So 

you’ve got to watch that; the side effects are not necessarily 

pleasant. But I like some of those, and I will go ahead and 

prescribe a pilocarpine every once in a while if indicated. We 

have to know what kind of medical history a given patient 

has, because if the patient has glaucoma, for example, you 

certainly don’t want to give them pilocarpine because that 

could exacerbate their problem. 

BB: You’ve named off some over-the-counter-products, sprays, 

and lozenges, and you’ve gone into pharmaceuticals. So maybe 

you can go into more specifics regarding the over-the-counter 

products. When you’re prescribing these to your patients, what 

instructions are you giving them? 

CT: I usually go PRN, because if you buy the Thayers 

products or the Spry or the Salese (Nuvora; Santa Clara, 

Calif.) or the Biotène — and I like Biotène — I just tell 

them, “Take it with you in your purse” — they’re mainly 

women. They can of course brush their teeth at home with 

all of the salivary stimulating products, but I like them to 

use them as needed. If they start feeling a dry mouth, then 

they can go ahead and spray their mouth. Maybe before 

lunch, maybe before breakfast and before dinner they can 

use the products — and at bedtime. 

BB: OK, those are the artificial salivas. How often are you 

actually prescribing pharmaceuticals? 

CT: Not as often as I do the palliative agents for nonprescription 

drugs. Again, pilocarpine and cevimeline do 

have side effects so you have to be careful with respect to 

the health history of the patient. And I might do that for a 

patient who just has no saliva, cannot eat, and is in pain all 

80 


the time, and then I will prescribe those agents. 

BB: And do you typically do that in coordination with the 

patient’s physician? 

CT: Always. In fact, I call the patient’s physician and tell them 

that I would like to prescribe this kind of medication, and 

then we’ll go over the list together. Of course, I usually have 

a list a mile long of the medications the patient is already 

taking, and if I see some conflict, then I will definitely call 

the physician. 

BB: What this leads into, depending on how the patient 

presents, is that this could dictate or affect the type of denture 

or prosthesis you’re going to use when restoring that patient. 

Can you talk about what you do with these patients? Obviously, 

dentures are very problematic for them. How do you treat them 

and when might implants be appropriate? 

TREATMENT Options 

Products that help relieve dry mouth: 

• Oral rinses and sprays that contain carboxymethyl 

cellulose 

• Prescription-strength fluoride toothpaste 

• Antifungal agents 

Salivary-stimulating drugs/products: 

• Pilocarpione or cevimeline – cholinergic agonists that 

help to create saliva flow 

• Anetholetrithione – drug that stimulates saliva flow 

CT: I’ll start with natural teeth that have carious prevalence 

due to a lack of salivary gland function. With extensive 

cervical caries, I would probably do full-coverage restorations 

to make sure the margins are in the sulcus of the 

teeth, because the bug that creates the cervical caries 

really doesn’t get into the sulcus. The sulcus has its own 

bactericidal effects so you don’t have that problem in the 

sulcular areas. 

BB: When you’re prepping those teeth, how far subgingival are 

you placing that margin? 

CT: One millimeter. You don’t want to get involved with the 

biological width. You don’t want to get too involved with 

the emergence profile and angle. You really want it perfect 

so you don’t have any periodontal problems. If the caries 

is not extensive, then I will probably do some composite 

bondings and make sure that the patient uses PreviDent 

every evening, brushes it on their teeth and just spits out 

the excess and goes to bed — no rinsing. When using 

PreviDent or any of these fluoride rinses or pastes, it’s very 

important not to rinse it out, just spit out the excess. 

Now, if the patient has partial or full anodontia, removable 

prostheses can be a problem because the dentures 

themselves can actually hamper the salivary gland flow. 

They stop salivary gland flow. 

A lot of times, having the prosthesis off the mucosa is 

something the patient can tolerate really well. And, of 

course, implants don’t have caries, and they don’t have the 

periodontal applications in the same way that salivary gland 

dysfunction goes hand in hand with periodontal disease. So, 

that’s when we would do a hybrid prosthesis either through 

a guided type of restoration, or create a bar overdenture 

that may be off the ridge a little bit more. 



BB: To recap, if a patient is partially edentulous, could you 

possibly place a couple of implants and put them in a bridge, 

and that way get them out of the partial? 

CT: You could do a fixed partial prosthesis in the 

posterior area, and that patient would have neither caries 

involvement, nor would there be any problem with the 

mucosal involvement. 

BB: And then with the fully edentulous patients, as you 

mentioned, it could be an overdenture or a bar-supported 

prosthesis off the tissue, right? Or, even better, it might be 

heading into a screw-retained denture or a fixed type of 

prosthesis where you’re actually up off the tissue. 

A screw-retained denture to replace a removable denture (palatal view) 

CT: That would be ideal, a fixed prosthesis — the old standard 

Brånemark hybrid is the most successful restoration 

in the history of dentistry, and that’s something that works 

really well with the lack of saliva flow. IM 

Bilateral posterior implant-borne bridges to replace a partial denture 

(occlusal view) 

The old standard Brånemark hybrid is the most successful 

restoration in the history of dentistry, and that’s something 

that works really well with the lack of saliva flow. 

82 


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Creating Surgical Guides Using 

CBCT and Intraoral Scanning 

by 

Perry E. Jones, DDS, FAGD 

INTRODUCTION 

One 

 

of the recent advances in the use of the iTero 

optical scanner (Align Technology; San Jose, Calif.) 

has been the use of generic STL files to allow the 

creation of very precise surgical guides. CBCT DICOM files 

can be merged with iTero STL files to create 3-D renderings 

that support virtual planning of prosthetic restorations and 

“crown down” planning of hard tissue considerations. Soft 

tissue-borne surgical guides have been used for several years; 

however, limitations of CBCT DICOM data has restricted 

the development of tooth-borne surgical guides. This article 

will demonstrate the merging of CBCT DICOM and iTero 

STL files, virtual wax-up with case planning in the 3-D 

environment, CAD/CAM processing of the surgical guide, 

and clinical application consisting of implant placement 

and the fabrication of final, model-less implant restorations 

through the use of dedicated scanning abutments. 

Dental History 

A 50-year-old Caucasian male in good health presented with 

multiple missing teeth amid otherwise healthy dentition 

(Fig. 1). The patient reported he had several congenitally 

Figure 1: Mandibular occlusal view demonstrating healthy dentition, with 

edentulous sites #29 and #30 planned for implant restoration 

– Creating Surgical Guides Using CBCT and Intraoral Scanning – 83

Creating Surgical Guides Using CBCT and Intraoral Scanning 

“missing” teeth, and had also lost a number of teeth after 

failed endodontic procedures. The patient was first seen 

by the Department of Oral and Maxillofacial Surgery of 

Virginia Commonwealth University’s School of Dentistry, 

with a stated desire for using dental implants to restore 

the missing teeth. The patient was referred to my private 

practice for an evaluation of his restorative needs. 

Treatment Plan 

After a discussion of the alternatives, benefits, and complications 

of treatment options, the patient stated that 

he wished to receive implant restorations. Following a 

discussion of financial considerations, it was agreed that 

the treatment plan would be divided into several phases. 

Phase one would be to place two implant fixtures in the 

area of tooth #29 and tooth #30. It was agreed that a custom 

surgical guide would be created using CBCT and digital 

scanning technology, for the ultimate purpose of facilitating 

guided placement of the dental implants. 

Scan Procedure 

A full-arch optical scan of both maxillary and mandibular 

arches with a centric record of the teeth in maximum 

intercuspation was taken using the iTero intraoral scanning 

unit. The resultant generic STL data files, the standard 

CAD/CAM file format, were exported directly from this 

user’s “MyAligntech” account. A CBCT scan was taken with 

a NewTom CBCT scanner (ImageWorks; Elmsford, N.Y.) and 

the resultant DICOM data files exported to the In2Guide 

(Cybermed; Irvine, Calif.) software. The DICOM and STL 

files types were then merged via the In2Guide software to 

produce a 3-D rendering. 

Virtual Planning 

Using the principles of “crown down” planning, a virtual waxup 

added the crown morphology to represent a mandibular 

right second bicuspid (tooth #29) and a mandibular right 

first molar (tooth #30) (Fig. 2). Using the implant placement 

planning features of the In2Guide software, an optimized 

position for each of the implant fixtures was developed. 

This case demonstrates the value of virtual planning, as 

there were several anatomical and dental issues requiring 

close attention to fixture placement detail. The mandibular 

second molar is mesial-tipped, presenting a clearance 

and path of insertion issue for the prosthetic restoration 

of the implant fixture. Further, the hard tissue anatomy 

exhibits limited freedom of placement, given the position 

of the inferior alveolar canal, mental foramen, and lingual 

Figure 2: In2Guide planning software with virtual wax-up of tooth #29 and 

#30 

mylohyoid concavity. With the virtual planning complete, 

the completed implant fixture placement was submitted for 

CAD processing. 

Surgical guide 

In a 100 percent digital environment, a model-less printed 

surgical guide was produced by the Cybermed In2Guide 

manufacturing process. The surgical guide was delivered in 

a sealed package for patient try-in. Planned visual cutouts 

allowed verification of proper seating of the surgical guide 

(Fig. 3). Prior to the surgical appointment, the surgical guide 

was trial fitted to the mandibular dentition (Fig. 4), and 

optimal fit confirmed (Fig. 5). 

Surgical Procedure 

After a review of the patient’s health history, including 

basic vital signs such as blood pressure and pulse, informed 

consent was received. The patient was given two 1.7 ml 

carpules of Lidocaine Hydrochloride 2% with 1:100,000 

Epinephrine. Upon profound local anesthesia, with the 

surgical guide in place, a single disposable tissue punch 

(Fig. 6) was used to remove a precise cylinder of tissue to 

access the mandibular ridge of bone at the planned implant 

surgical site. NobelGuide drill guides and guided drills 

(Nobel Biocare; Yorba Linda, Calif.) were used to perform 

the surgical procedure. The drill series consisted of an 

initial “flare” drill (Guided Start Drill) (Fig. 7), a 2 mm depth 

drill (Guided 2.0 Twist Drill) used with a precise drill guide 

(Fig. 8), and sequential full-depth drills (Guided Tapered 

84 


Figure 3: In2Guide surgical guide created with cutouts to verify full seating 

Figure 6: Disposable tissue punch used with surgical guide in place 

Figure 4: Intraoral occlusal view of In2Guide surgical guide during try-in. Note 

the seating verification cut-outs. 

Figure 7: First sequence flare drill used to perform the surgical drill procedure 

Figure 5: Occlusal view of In2Guide surgical guide. Note full seating and 

excellent retention. 

Figure 8: In2Guide with collimator for the 2 mm surgical drill 



Figure 9: Full-depth surgical drill placed in metal guide holes of the surgical 

guide 

Figure 10: Implant delivery tool on the handpiece 

Drills) to match the implant fixture shape (Fig. 9). These 

drills were used to precisely create the osteotomy in all 

dimensions of space, including depth. Both implant sites 

were drilled to the precise depth and shape for planned 

implant placement. 

An 8 mm long NobelReplace ® Tapered RP implant (Nobel 

Biocare) was placed at the site of tooth #29, and a 10 mm 

long NobelReplace Tapered RP implant was placed at the 

site of tooth #30. Using the guided implant mount, the two 

respective implant fixtures were carried with the implant 

driver (Fig. 10) and rotated to a position just short of full 

depth (Fig. 11). Using a manual torque wrench, the implants 

were rotated into place such that the shoulder of the implant 

holder mated with the surgical guide at a torque value of 

35 Ncm (Figs. 12, 13). The guided mount and surgical guide 

were removed and 5 mm RP Healing Abutments (Nobel 

Biocare) were rotated into the NobelReplace Tapered RP 

implant (Figs. 14, 15). There were no complications, and 

in fact, the patient reported this was the easiest dental 

procedure performed on him to date. 

Figure 11: Placement of implant with the delivery tool with full depth held 

back approximately 1 mm 

Implant Restoration 

After four months of healing, the patient returned for 

restoration of the two implants. The healing abutments were 

removed (Fig. 16) and an Osstell ® ISQ implant stability meter 

with SmartPeg attachments (Osstell Inc. USA; Linthicum, 

Md.) was used to check the level of relative implant osseous 

integration (Fig. 17). A SmartPeg attachment was placed in 

each implant fixture and a reading of 85 was recorded for 

each implant. Further, a “reverse” torque test was performed 

using a manual torque wrench, with no movement 

at 35 Ncm. The implants were deemed satisfactory for 

restoration and functional occlusal loading. 

Figure 12: Manual torque wrench used for final seating of the implants to 

35 Ncm 

86 


Figure 13: Implants torqued to full-depth position with surgical guide in place 

Figure 16: Healing abutments removed with excellent tissue health four 

months post-op 

Figure 14: Soft tissue view immediately after implant placement 

Figure 17: Osstell ISQ with SmartPeg used to help gauge level of osseous 

integration 

Figure 15: Healing abutment in place. Note minimal tissue trauma. 

The merging of CBCT 

DICOM files with iTero STL 

files to create surgical guides 

provides clinicians a higher 

level of confidence when 

placing implants. 



Figure 18: Inclusive Scanning Abutments used for the iTero scan process 

Figure 20: BruxZir screw-retained crowns, consisting of titanium base and 

monolithic body 

Figure 19: iTero scan software demonstrating Inclusive Scanning Abutments 

at site #29 and #30 

Figure 21: BruxZir screw-retained crowns with access openings revealing 

titanium retention screws tightened into place 

Posterior Inclusive ® Scanning Abutments for NobelReplace 

RP were secured at fixture level on each NobelReplace 

implant, by way of internal titanium retention screws (Fig. 

18). A radiograph was taken to verify that the scanning 

abutments were properly seated on the implant fixtures, 

and to further aid in confirmation of osseous integration. 

A mandibular full-arch scan, maxillary full-arch scan, and a 

centric position of maximum intercuspation were recorded 

with the iTero digital scan technology (Fig. 19). The STL 

files were sent directly to Glidewell Laboratories. Using 

the Abutment Designer software program (3Shape; New 

Providence, N.J.) and a proprietary design library, the 

virtual design of the implant crowns was completed. Two 

model-less, custom-milled, screw-retained crowns were 

fabricated (Fig. 20). The screw-retained crowns were made 

with a titanium base to allow a titanium-to-titanium interface 

between the crown and implant connection. The body of 

these crowns were milled from BruxZir ® Solid Zirconia, 

a high-strength monolithic ceramic material. Milling took 

place in a 100 percent digital environment, without models. 

The screw-retained crowns were delivered for evaluation, 

and the patient was seen for try-in and delivery. The healing 

abutments were removed so that the restorations could be 

seated and then tightened into place (Fig. 21) using the 

supplied titanium retention screws and a standard Nobel 

Biocare abutment driver. A manual torque wrench was used 

to tighten the titanium retention screw of implant crown #29 

and crown #30 to a value of 35 Ncm. The occlusal access 

holes were filled with Teflon plumber’s tape (Fig. 22) and 

the access holes sealed with TPH ® 3 universal composite 

resin (Dentsply Caulk; Milford, Del.) (Fig. 23). A routine 

periapical radiograph confirmed an excellent interface 

88 


Figure 22: Teflon plumber’s tape used to protect titanium screws 

Figure 24: Radiograph to verify proper seating of restoration to implant 

Figure 23: Composite resin placed to seal the screw access holes 

Figure 25: Buccal view demonstrating excellent tissue adaptation 

between the crown’s titanium base and the implant (Fig. 24). 

The occlusion was checked in various functional positions 

as well as maximum intercuspation, with an objective to 

minimize lateral occlusal forces transmitted to the implant. 

The occlusal composite was checked in occlusal function 

and deemed to be satisfactory. The final BruxZir implant 

restorations on tooth #29 and tooth #30 can be seen from 

buccal (Fig. 25) and occlusal views (Fig. 26). The patient was 

seen for a post crown insertion visit after two weeks to 

reevaluate the crowns, and they were deemed to have an 

excellent fit and occlusal relationship. 

Conclusion 

Software development now enables the merging of CBCT 

DICOM files with Align Technology’s iTero STL files. The 

Figure 26: Occlusal view of final restorations 



generic STL files may be exported directly from the iTero 

user’s account to planning software available to various 

services such as Cybermed’s In2Guide. Virtual wax-up 

and planning may be done to create surgical guides, with 

simultaneous consideration of hard tissue and optimal 

restoration location, providing clinicians a higher level of 

confidence when placing implants. Final implant restoration 

may be done with digital scanning systems such as iTero 

using dedicated Inclusive Scanning Abutments, which are 

available for a number of the most popular implant systems. 

Remarkable advances in implant crown manufacture allow 

Glidewell Laboratories to create screw-retained crowns in 

a 100 percent digital environment without conventional 

models. The clinical example presented in this article 

showcases the use of scanning technology to plan implant 

placement, create a precise surgical guide in an all-digital 

environment, place implant fixtures, and restore these 

implants with digital scanning technology and highly 

precise all-digital manufacturing technology — all without 

the use of a conventional analog model. The promises of 

the digital future of dentistry are now here. IM 

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author reply 249-50. No abstract available. 

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168-71. No abstract available. 

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141 Suppl 3:19S-24S. 

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Kahn JL, Sixou M. Accuracy of 3D reconstructions based on cone beam computed 

tomography. J Dent Res. 2010 Dec;89(12):1465-9. Epub 2010 Oct 7. 

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Implant Dent. 2010 Aug;19(4):288-98. 

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of scanning and reconstruction parameters on quality of three-dimensional 

surface models of the dental arches from cone beam computed tomography. 

Clin Oral Investig. 2010 Jun;14(3):303-10. Epub 2009 Jun 9. 

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North Am. 2008 Oct;52(4):707-30, v. 

• D’souza KM, Aras MA. Types of implant surgical guides in dentistry: A review. 

J Oral Implantol. 2011 Sep 9. Epub ahead of print. 

• Cassetta M, Giansanti M, Di Mambro A, Calasso S, Barbato E. Accuracy of two 

stereolithographic surgical templates: A retrospective study. Clin Implant Dent 

Relat Res. 2011 Jul 11. doi: 10.1111/j.1708-8208.2011.00369.x. Epub ahead of 

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Accuracy of implant placement using a CAD/CAM surgical guide: an in vitro study. 

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anatomical data obtained by CT imaging and 3D optical scanning for computer 

aided implant surgery. BMC Med Imaging. 2011 Feb 21;11:5. 

• Al-Harbi SA, Sun AY. Implant placement accuracy when using stereolithographic 

template as a surgical guide: preliminary results. Implant Dent. 2009 Feb;18(1): 

46-56. 

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beam CT technology. J Prosthodont. 2008 Aug;17(6):476-81. Epub 2008 May 9. 

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Impression-Case-Study-Full-Arch-Fixed-Provisional-Bridge/. 

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90 


“Rules of 10” 

Guidelines for Successful Planning and Treatment 

of Mandibular Edentulism Using Dental Implants 

by 

Lyndon F. Cooper, DDS, Ph.D; 

Bryan M. Limmer, DMD; and W. Day Gates III, DDS, MS 

The treatment of mandibular edentulism 

using dental implants is now well 

established as a biologically sound 

treatment option. More than 40 years 

after Swedish orthopedic surgeon 

Per-Ingvar Brånemark intro duced the 

process of transforming oral function 

in the edentulous patient using endosseous 

dental implants, a picture 

of success has emerged that is recognized 

worldwide. The use of one or 

two implants to retain a mandibular 

overdenture and the use of four or 

more implants to support and retain 

a fixed dental prosthesis is widely 

known to provide improved function 

and increased satisfaction in the 

edentulous patient when compared to 

conventional denture therapy. 1-6 

The three “Rules of 10” for treatment planning dental implant therapy 

in the edentulous mandible are designed to improve the success of both the 

endosseous implants and the prosthesis. These “rules” acknowledge and 

provide a method to control the mechanical environment, addressing factors 

affecting implant and prosthesis longevity, including magnitude of forces, 

resistance of the prosthesis against these forces, and the biology of bone and 

its ability to respond to loading environments. The rules specify that for any 

implant-retained overdenture (IRO) or implant-supported fixed prosthesis (ISFP), 

there must be a minimum of 10 mm of alveolar dimension (inferior/superior) 

and a minimum of 10 mm of interocclusal (restorative) dimension measured 

from the soft tissue ridge crest to the occlusal plane. Additionally, for an ISFP, the 

anterior/posterior distribution of implants must be greater than 10 mm. This 

article provides support in the literature for these rules and illustrates their 

application in the treatment of mandibular edentulism. 

The contemporary literature demonstrates 

a high degree of survival 

over the 10- to 20-year time horizon 

when implants are placed in the 

parasymphyseal mandible and restored 

with an IRO or with an ISFP. 7-10 

These studies invoke inclusion and 

exclusion criteria that favor success, 

benefit from the local factors of 

mandibular bone quality and quantity, 

and commonly employ the use of an 

opposing maxillary denture. However, 

all the studies indicate high 

and lasting rates of implant survival. 

Less well documented and perhaps 

equally significant is the quality 

of the prosthesis, its longevity and 

maintenance requirements, and the 

related issues of patient-perceived 

satisfaction. There is also a history 

– “Rules of 10” — Guidelines for Successful Planning and Treatment of Mandibular Edentulism Using Dental Implants – 91

“RULES OF 10” 

Figure 1: Failure of fixed and removable implant prosthesis 

(acrylic fracture) 

Figure 2: Failure of fixed and removable implant prosthesis 

(framework fracture) 

of common limitations associated 

with dental implant therapy for the 

edentulous mandible. 

The commonly prescribed IRO and 

ISFP prostheses are based upon denture 

fabrication techniques that utilize 

methyl methacrylate “acrylic” 

resin chemistry and cross-linked denture 

teeth. These materials serve as 

the functional substrate and esthetic 

foundation of the implant-based 

prostheses for the edentulous mandible. 

Support for the acrylic-veneered 

prosthesis has commonly been provided 

by gold-based dental alloy frameworks 

and, more recently, computer 

numeric controlled (CNC)-milled titanium 

or chromium-cobalt frameworks. 

The functional stresses — impact and 

imposed bending — endured by the 

esthetic veneer must be supported by 

and transmitted through the framework 

and the components to the supporting 

implants. The data for IRO 

and ISFP prostheses suggests that 

the incidence of complications with 

these prosthetic components is greater 

than the failure of the implants 11 

(Figs. 1, 2). The materials, designs, and 

techniques used in the production of 

implant-supported prostheses for the 

treatment of mandibular edentulism 

require further consideration. 

One hypothesis to explain the 

prosthetic failures and complications 

associated with the IRO and ISFP is 

that the mechanical environment 

established by implant placement 

is inadequate to permit proper construction 

of a robust and resilient IRO 

or ISFP prosthesis. Three different 

factors are essential to defining this 

mechanical environment (Fig. 3). One 

is the magnitude of forces — specifically, 

bending moments, which are 

dependent on the magnitude of the 

load and the length of any cantilever. 

The second is the resistance of the 

prosthesis (of a defined material) 

against these relatively high and 

repetitive loads. The third factor is the 

biology of bone and its innate ability 

to respond to loading environments. 

The aim of this report is to provide 

simple rules for treatment planning 

dental implant therapy in the edentulous 

mandible that both acknowledge 

and control the mechanical environment. 

This ultimately influences the 

success of both the endosseous dental 

implants and the prosthesis, and can 

offer lasting success for treatment of 

mandibular edentulism. 

In order to provide a conceptual 

framework to manage the treatment 

of mandibular edentulism using dental 

implants, the three aforementioned 

factors affecting implant and prosthesis 

longevity have been addressed 

and are embodied in three “rules” for 

treatment planning. For any IRO or 

ISFP, there must be a minimum of 

10 mm of alveolar dimension (inferior/ 

superior) and a minimum of 10 mm of 

interocclusal (restorative) dimension 

measured from the soft tissue ridge 

crest to the occlusal plane. Additionally, 

for an ISFP, the anterior/posterior 

distribution of implants (commonly 

referred to as “A-P spread”) must be 

greater than 10 mm. Together, these 

three rules are referred to as the “Rules 

of 10.” This report will provide the rationale 

to support these general rules 

and illustrate their application in the 

treatment of mandibular edentulism. 

Rule No. 1: Inferior/superior 

dimension of the mandible must 

be ≥10 mm 

This rule states that the minimum alveolar 

dimension sufficient to support 

an IRO or ISFP must be equal to that 

required to use implants of approximately 

10 mm in length. 

The use of implants of 10 mm or less 

in length for ISFP is well defined and 

successful. More than a decade ago, 

Brånemark and co-workers 12 compared 

the outcome of ISFP treatment using 

implants of greater than 10 mm and 

less than 10 mm after 10 years. The 

outcome with different lengths of 

3.75 mm machined surface implants 

revealed no difference in implant 

survival after 10 years. In a more 

recent 5-year prospective evaluation, 

Gallucci and others 13 confirmed a 

high (100 percent) implant survival 

rate associated with treatment of 

mandibular edentulism using ISFP 

supported with four, five, or six 

implants of between 8 mm and 16 mm. 

In all cases, implant failures occurred 

before loading. A recent evaluation of 

119 patients rehabilitated with four 

implants to support mandibular ISFP 

revealed a 99.1 percent success rate. 14 

There is little information that indicates 

the use of longer implants improves 

the survival of implants placed in the 

parasymphyseal edentulous mandible. 

It has also been suggested that 

longer implants may be required to 

resist the function of long cantilever 

prostheses. There is little clinical data 

to support or refute this notion. A 

three-dimensional (3-D) finite element 

model demonstrated that implant 

length had no appreciable effect on 

stress distribution at the bone/implant 

interfaces when loaded by a cantilever 

prosthesis, suggesting that implant 

length does not dictate survival. 15 

92 


Some added concern is focused on 

the IRO. One evaluation revealed a 

93.9 percent success rate for implants 

supporting an IRO, and the authors 

concluded that implant-retained overdentures 

are an established treatment 

modality, with implant success rates 

that are very similar to the results obtained 

with implant-supported fixed 

prostheses. 16 A long-term examination 

of a two-implant mandibular IRO 

specifically considered the impact of 

implant length as one variable affecting 

implant survival. A high survival 

rate (95.5 percent) was recorded after 

20 years of loading. Although 21 percent 

of implants were 8.5 mm or shorter, 

implant length and bone quality 

did not affect implant survival. 17 The 

conclusions that may be drawn are 

that implants of approximately 10 mm 

have equally high survival in the parasymphyseal 

mandible for both IRO 

and ISFP, and that increasing implant 

length beyond 10 mm does not improve 

biologic outcomes in the ISFP 

with an appropriately designed cantilever. 

Thus, a mandible of 10 mm 

height, or inferior-to-superior dimension, 

is sufficient for an IRO or ISFP. 

Conventional concepts for planning 

implant therapy have focused on bone 

quality and quantity. 18 However, when 

considering the parasymphyseal mandible, 

rarely is type III and type IV bone 

encountered. Further, ridge resorption 

frequently results in a tall mandible 

that displays narrow buccolingual 

dimension (5 mm) and ensures that the osseous 

crest is at least 10 mm to 12 mm 

inferior to the planned occlusal plane 

(Rule No. 2). Paradoxically, ISFP or 

IRO treatment is facilitated by marked 

alveolar resorption. Thus, more favorable 

prosthetic scenarios involve residual 

mandibles of 10 mm to 15 mm 

in height, while the more challenging 

prosthetic scenarios are associated with 

large residual alveolar ridges (e.g., after 

extraction). Infrequently, mandibles 

of less than 10 mm superior-to-inferior 

dimension are encountered. When four 

implants of 10 mm cannot be placed 

in a severely resorbed mandible, additional 

implants of shorter dimension 

may be considered. For example, in an 

8 mm mandible, the use of 8 mm or 

9 mm implants might be considered 

if additional implants are included. 

Mandibular fracture is not common, 

but is recognized as a serious potential 

complication among high-risk individuals. 

19 

Rule No. 2: Interocclusal 

(restorative) dimension measured 

from ridge crest to occlusal plane 

must be ≥10 mm 

The interocclusal dimension directly 

impacts the quality and integrity 

of both an IRO and an ISFP. Both 

overdentures and fixed prostheses 

require a minimal dimension to provide 

structural integrity and to permit 

the establishment of proper contours 

in support of comfort, mastication, 

and speech. 

When planning for implant placement, 

it is essential to first understand the 

planned position of the prosthetic 

teeth. In other words, plan down from 

the occlusal plane and not up from 

the osseous crest. This assures better 

control of the restorative dimension. 

The location of the occlusal plane 

is defined by proper denture construction 

at the appropriate vertical 

dimension of occlusion. While it is 

beyond the scope of this discussion, 

widely accepted anthropomorphic 

averages suggest that the distance 

from the mandibular incisal edge to 

the reflection of the buccal vestibule 

is approximately 18 mm. 20 Therefore, 

if an existing denture measures less 

than 15 mm to 16 mm from the incisal 

edge to the buccal flange, there may 

be cause to reconsider the vertical 

dimension of occlusion and/or the 

placement of the occlusal plane. 

This concept of restorative dimension 

was initially addressed by Phillips and 

Wong 21 and reiterated by Lee and Agar 22 ; 

however, there is little data in support 

Figure 3: Conceptualization of stresses and strains 

encountered for a mandibular prosthesis supported 

by dental implants. High magnitude masticatory forces 

(i.) are enacted through long lever arms (ii.), creating 

bending moments and force magnification in the 

components (iii.). The forces cause deformation in the 

prosthesis and challenge the integrity of the implantabutment 

interface. The transmitted forces are further 

encountered at the implant-bone interface (iv.). 

Figure 4: The mandible must be at least 10 mm in 

superior-inferior dimension. Rarely are mandibles of 

less than 10 mm observed clinically. 

of this inferior-superior dimension for 

planning of a mandibular IRO or ISFP. 

Practically, the restorative dimension 

for any implant prosthesis includes 

four key components, each with 

its own minimum dimension. They 

are: 1) the transmucosal dimension 

(biologic width) of approximately 

2 mm; 2) a supramucosal abutment 

height (0 mm to 2 mm) that permits 

hygiene; 3) a framework or attachment 

height between 3 mm and 5 mm; and 

4) acrylic veneer thickness greater 

than 2 mm (Fig. 5). It must also be 

acknowledged that the replacement 

mandibular teeth should accommodate 

their full contours. The average 

height of mandibular anterior teeth is 

approximately 10 mm. 23 A minimum 

10 mm of restorative space places 



Figure 5: Accounting for a minimal restorative 

dimension. A fixed or removable mandibular prosthesis 

must allow for placement of: (i.) the transmucosal 

abutment; (ii.) adequate room and access for periimplant 

mucosal hygiene; (iii.) restorative components, 

abutment, and bridge screws; and (iv.) an 

esthetic and phonetically accepted veneer. 

Figure 6: Defining the depth of implant placement. 

Implant placement may be at the osseous crest if 

there is sufficient buccolingual width at that location 

and sufficient restorative dimension (from the crest 

to the occlusal plane). However, if these requirements 

are not met, implant placement is planned in 

a subcrestal location with a need for accompanying 

alveolectomy. 

Figure 7: A-P spread in clinical situation. Providing 

a single premolar and a single molar (16.5 mm 

in length) in the distal cantilever requires approximately 

10 mm A-P spread (X) to maintain a 1.5:1 

relationship. 

average-size mandibular prosthetic 

teeth precisely at the soft tissue crest 

with only a minimal dimension for the 

prosthetic components. 

It becomes evident that the planning 

of an implant-supported or implantretained 

prosthesis for the edentulous 

mandible begins with defining a superior-inferior 

reference, namely, the 

occlusal plane. Space accommodation 

for the dimension and location of 

teeth, frameworks, attachments, retaining 

abutments (balls, bars, etc.), and 

biologic width will direct planning of 

implant position. 

Finally, the location of the osseous 

crest in relationship to the planned 

implant position dictates the extent 

of the alveolectomy required (Fig. 6). 

Jensen and colleagues provide an 

excellent review of the surgical and 

prosthetic considerations for the proposed 

alveolectomy and describe it 

as the creation of a mandibular 

“shelf.” In addition to establishing 

restorative space and alveolar width, 

the shelf design facilitates visualization 

of the inferior alveolar nerve, 

inspection of any lingual concavities, 

and collection of bone stock for any 

secondary grafting. 24 

This approach differs from the evaluation 

of bone as a primary step in the 

planning of mandibular implant prostheses. 

This second rule is essential for 

providing a robust and lasting fixed 

or removable prosthesis supported or 

retained by dental implants. 

Rule No. 3: Anterior/posterior 

distribution of implants must be 

at least 10 mm for the ISFP 

The ISFP was originally envisioned for 

treatment of mandibular edentulism by 

using the abundant bone of the mandibular 

parasymphysis. A cantilever 

design of the ISFP was inherent to the 

solution, using multiple anterior implants. 

The implants must be able to 

support functional loads at the posterior 

occlusal contacts via the cantilever. 

These loads, however, are magnified 

within the framework and components, 

and potentially at the implant-bone interface. 

In the early conceptualization 

of this therapy, the anterior-posterior 

distribution of dental implants was 

recognized as a key factor affecting 

the incidence of complications in the 

cantilevered mandibular ISFP. To counteract 

the imposed bending moments 

of the loaded cantilever, maximum 

distribution of implants was recommended. 

This anterior-posterior distribution 

of implants is referred to as the 

“A-P spread.” Clinicians were quick to 

point out that there were anatomic constraints 

for implant placement in the 

parasymphyseal mandible. Com pared 

to curved or V-shaped mandibles, 

square-shaped mandibles often provide 

little anterior-posterior dimension 

anterior to the inferior alveolar nerve 

(Figs. 7–9). Additionally, anatomic variations 

in the inferior alveolar nerve (e.g., 

anterior loop) are not uncommon 25 and 

can reduce the available A-P spread. 

A number of different models have 

been used to estimate the proper 

cantilever length in relationship to 

the A-P spread. These approaches 

include the use of photoelastic models, 

piezoelectric strain sensors, and finite 

element models. The results are diverse 

and the majority examined the stresses 

that accumulate at the implant-bone 

interface. Interestingly, the focus on 

the implant, per se, does not match 

the clinical situation where implant 

failures are infrequent and prosthesis 

complications are more prevalent. 

Any discussion of cantilever length 

requires that: 1) the position of the 

distal-most implant be anticipated; and 

2) the number of teeth to be provided 

distal to that implant be defined. 

For the purposes of establishing a 

concept that meets the needs of most 

patients, the goal is to have the distal 

implant in the distal-most location 

that does not impose on the inferior 

alveolar nerve, which is generally 

located in the canine or first premolar 

region. Further, distal inclination of 

the posterior implants may place the 

prosthetic interface even more distal 

in the first premolar region. 26 

94 


The all-on-four concept generally 

requires that posterior teeth beyond 

the first premolar are supported 

by a cantilever. Efforts to reduce or 

eliminate the cantilever by distal 

orientation of terminal implants are 

advocated. Bridge screws emerging 

at the first premolar or molar position 

can be achieved in this way. Malo 

has reported that this approach is 

associated with high implant and 

prosthesis survival over 10 years. 26 In 

2011, Malo reported on 245 patients in 

whom 980 implants were placed and 

immediately loaded. The cumulative 

patient-related and implant-related 

success rates were 94.8 percent and 

98.1 percent, respectively, at five years, 

and 93.8 percent and 94.9 percent, 

respectively, at 10 years. 26 

One other key factor contributing to 

the overloading of these components 

is prosthesis misfit. However, the accuracy 

of contemporary impression 

materials and the introduction of precision-milled 

frameworks for the ISFP 

reduce the prevalence of prosthetic 

misfit and its impact on the therapeutic 

outcome. The geometric distribution 

of the implant-abutment and the abutment-prosthesis 

interfaces remain the 

significant features of ISFP therapy 

that can be clinically managed to reduce 

complications. 

When considering the number of teeth 

to be provided distal to the canine or 

first premolar site, the minimal provision 

of one additional premolar and 

one molar is sufficient to meet the 

esthetic and functional requirements 

of most individuals. 27 These general 

guidelines can be converted to linear 

measurements. The average dimension 

of a mandibular premolar is 

approximately 6 mm, and that of the 

mandibular first molar is approximately 

10 mm. 23 Thus, a cantilever of 

16 mm can suffice to provide function 

and esthetics. The functional relationship 

between the cantilever length 

and the A-P spread has been debated 

(Figs. 7–9). More than 30 years of opinion, 

experimentation, and calculation 

have generated an array of suggested 

Figure 8: A-P spread in clinical situation. The parallel 

placement of the implants resulted in approximately 

4 mm to 5 mm of A-P spread. 

solutions. To provide the broadest 

range of success for the largest set of 

patients, a conservative estimate of 

this functional relationship should be 

selected. For a mandible with no more 

than four implants to be restored with 

a rigid framework, utilizing a cantilever 

length to A-P spread ratio of 1.5:1 

has been advised. 28 Thus, for the ideal 

situation of four implants placed in 

the parasymphyseal mandible with 

the distal-most implants located in the 

first premolar region, a cantilever of 

approximately 15 mm (one premolar 

and molar tooth) requires 10 mm of 

A-P spread. This represents the third 

Rule of 10. 

Applying the Rules of 10 

Several key steps are required for 

using the Rules of 10 in the treatment 

of mandibular edentulism. The previously 

mentioned reference points 

(i.e., occlusal plane and osseous crest) 

must be firmly established. To assure 

accurate measurement, all treatment 

should begin with the proper fabrication 

of complete dentures and 

verification of ideal tooth position 

(Figs. 10, 11). 

Rule No. 1 requires a volumetric 

assessment of the edentulous mandible 

with cone-beam computed tomography 

(CBCT). However, other 

important information can be found 

in the radiographic process, and no 

radiograph should be made for ISFP 

treatment-planning purposes without 

the presence of a radiographic stent. 

Figure 9: A-P spread in clinical situation. The divergent 

placement of the implants resulted in 

approximately 10 mm of A-P spread measured at the 

abutment/prosthesis interface. 

Figure 10: Conventional dentures 

Figure 11: Surgical guide 

The resultant images should display 

the location of the planned prosthesis 

in relation to the mandible. 

Rule No. 2 requires that the plane of 

occlusion is properly located and the 

appropriate vertical dimension of occlusion 

is defined. If the patient is also 

edentulous in the maxilla, this involves 

the fabrication of ideal maxillary and 

mandibular dentures. The dentures 

will define the location of the occlusal 



plane and mandibular tooth position, 

where the mandibular denture can 

be duplicated in radiopaque acrylic 

for a radiographic stent. The amount 

of alveolectomy needed can then be 

determined from the CBCT images. 

Rule No. 3 requires an understanding 

of the anatomy of the edentulous 

mandible in relationship to the location 

of the planned prosthetic teeth, as 

well as the ability to translate this 

information to the implant placement, 

generally via a surgical guide. This can 

be accomplished practically in one 

of two ways. One method involves 

evaluation of the CBCT images using 

3-D planning software (e.g., Simplant ® 

[Materialise Dental; Glen Burnie, Md.] or 

NobelClinician [Nobel Biocare; Yorba 

Linda, Calif.]) and then modifying a 

duplicate denture made from clear 

acrylic (Figs. 10, 11). The other involves 

use of a third-party company to 

fabricate a digital surgical guide. 

Conclusion 

Dental implant therapy for the edentulous 

mandible has been successful. Data 

concerning implant survival is high 

and reflects the quality and quantity 

of bone available for osseo-integrated 

implant function. The complications 

associated with both removable and 

fixed dental implant prostheses reflect 

the constraints of current materials and 

design limitations. The Rules of 10 assure 

that there is: 1) adequate bone 

for osseointegration and its long-term 

success; 2) sufficient dimension for 

fabrication of an esthetic, comfortable, 

and robust prosthesis; and 3) proper 

distribution of imposed forces from occlusal 

function within the prosthesis, at 

the implant-abutment screw interfaces, 

and at the implant-bone interfaces. Following 

these simple geometric and linear 

guidelines to treatment planning 

enables proper implant placement 

decisions that underscore robust and 

lasting prosthesis construction. IM 

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