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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,
– Implant Q&A: An Interview with Dr. David Little – 43