Dr. Irfan Atcha's article in Inclusive magazine


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Dr. Irfan Atcha's case was published in the Inclusive magazine about the All-on-4 Dental Implant concept. It's a great read for someone to gain insight into the All-on-4 Technology.

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Dr. Irfan Atcha's article in Inclusive magazine

  1. 1. Inclusive®Restorative Driven Implant SolutionsA publication of Glidewell LaboratoriesVol. 1, Iss. 1
  2. 2. Utilizing Digital Treatment Planning and GuidedSurgery to Restore Fully Edenulous Arches with theAll-on-4 TechniqueIn this case report, Dr. Irfan Atcha details the process and ben-efits of utilizing digital treatment planning and guided surgery torestore fully edentulous arches using the All-on-4 Technique. Dr.Atcha explains that this technology can be used to rehabilitate afully edentulous patient in just one appointment.Screw-Retained Denturewith CAD/CAM FrameworkDr. Kenneth Hebel and Victor Rodriguez, CDT, present this photoessay on delivery of a screw-retained denture featuring a preci-sion-milled CAD/CAM framework. In this piece, the clinician offersstep-by-step instructions on delivering such a case, complete withdetails on how to proceed at each appointment.The Restorative-Driven Surgical PracticeWhat is the “restorative-driven surgical practice”? Dr. George V.Duello describes it as a dentist, specialist or laboratory that usesa menu of services to provide patients and referrals with theirimplant services. Find out more about Dr. Duello’s philosophy onimplant dentistry in this excerpt from a video lecture you’ll find atwww.inclusivemagazine.com.Cone Beam Computed Tomography:Applications in Diagnostic Oral and MaxillofacialRadiology and PathologyDr. Parish Sedghizadeh discusses the benefits and increased utili-zation of Cone Beam CT scanning. Three-dimensional imaging israpidly becoming the standard of care in dentistry, he explains,and its applications are increasing. Dr. Sedghizadeh also offers arefresher on pathology, as well as a discussion on medical-legalliability and CBCT.Determining Implant FeesDr. Samuel Strong provides a strategy to help clinicians decidewhat to charge for their implant cases. Taking into account labcosts, implant component costs and overhead costs, Dr. Strong de-termines: Are you charging too little for your implant cases? Readhis fee analysis to find out.Contents61330313322 R&D Corner: Mechanical Testingof Inclusive®Custom Abutments byGrant Bullis24 Product Spotlight: BruxZir®SolidZirconia and Inclusive®TitaniumAbutments by Dr. Richard Seberg26 My First Implant by Dr. MichaelDiTolla27 Guided Surgery with Graftingand Ridge Expansion by Dr. RichardSeberg32 Removable and Digital TreatmentPlanning Instructions for UseFeatures– Contents – 1
  3. 3. Implant dentistry is one of the fastest-growing fields in our profession. With to-day’s technologies and materials, implant placement is now truly a restoratively-driven procedure. To provide you with the latest information in this field, GlidewellLaboratories is pleased to present this inaugural issue of Inclusive, a new printand online magazine focused on implant dentistry. Inclusive will be a multimediapublication, offering printed articles in this magazine and complementary videosand expanded content online at www.inclusivemagazine.com.As your laboratory partner, our goal is to provide you with the most up-to-date,practical information available from some of the most knowledgeable, experi-enced educators, clinicians and technicians in the field. From tips on obtainingmore accurate implant impressions to the prosthetic benefits of digital treatmentplanning and guided surgery, we will cover an array of subjects related to implantreconstruction in our new quarterly publication. Included will be reviews of thelatest technologies and materials, along with information on how to utilize thesetools to provide a higher quality of care to your patients, improve your productiv-ity and increase your profitability.In our premiere issue, you’ll find an informative photo essay by Dr. Irfan Atcha on“Utilizing Digital Treatment Planning and Guided Surgery to Restore Fully Eden-tulous Arches with the All-on-4 Technique.” You’ll also learn about “Cone-BeamComputed Tomography: Applications is Diagnostic Oral and Maxillofacial Radiol-ogy and Pathology” in a piece by Dr. Parish Sedghizadeh, an expert in the fieldwho serves as an assistant professor at the USC School of Dentistry. Also, find outhow to determine fees for your overdenture cases in a practice management articleby Dr. Samuel Strong.At Glidewell, we are committed to continuing education. That’s why we offer youthe opportunity to earn CE credits by taking the online test that accompanies des-ignated articles. We’ll also provide you with information on how to access othercontinuing educational opportunities that may be of interest to you.We are eager to hear your feedback. Let us know what topics, products and proce-dures you would like to see discussed in future issues. We welcome your questionsand comments, as well. Contact us at inclusivemagazine@glidewelldental.comLetter From the EditorYours in quality dentistry,Dr. Bradley C. BockhorstEditor in Chief, Clinical Editorinclusivemagazine@glidewelldental.com– www.inclusivemagazine.com –2
  4. 4. Contributors■ GRANT BULLISGrant Bullis, Glidewell Laboratories’Research & Development Depart-ment Manager, began his career inthe dental industry at Steri-Oss in1997. After Nobel Biocare acquiredSteri-Oss, Grant worked in the R&Ddepartment, where he was responsi-ble for the development of implants,prosthetics, surgical tools and pack-aging. Today, Grant manages CAD/CAM, implant product development and manufacturingat Glidewell. Since joining the lab in March 2007, he hasobtained FDA 510K clearances for Inclusive Titaniumand Zirconia Custom Abutments on six major implantplatforms and now directs manufacturing for more than150 implant laboratory and prosthetic components.Grant has a degree in mechanical CAD/CAM from Ir-vine Valley College in Orange County, Calif., and anMBA from Keller Graduate School of Management. Tocontact Grant, call 800-521-0576 or e-mail inclusivemag-azine@glidewelldental.com.■ Irfan Atcha, DDS, DICOI, DADIADr. Irfan Atcha graduated from theUniversity of Illinois College of Den-tistry in 1996. Today, he operates aprivate practice in Dyer, Ind., thatfocuses on general, cosmetic, seda-tion and implant dentistry. Dr. Atchaowns the Center of Implants, Seda-tion and Cosmetic Dentistry andthe No Dentures Chicago DentalImplant Center. He is a Diplomateof the International Congress of Oral Implantologistsand American Dental Implant Association and board ofdirectors member of the American Dental Implant Asso-ciation. An expert on implantology, occlusion and TMJ,Dr. Atcha specializes in one-day implants and lecturesacross the U.S. Contact Dr. Atcha at www.NoDentures-Chicago.com, dratcha@sbcgobal.net or 888-416-4109.■ Bradley C. Bockhorst, DMDDr. Bradley Bockhorst is known forhis unique perspective, which incor-porates both clinical and industrialbackgrounds. After receiving hisdental degree from Washington Uni-versity School of Dental Medicine,Dr. Bockhorst served as a Navy Den-tal Officer. Dr. Bockhorst has heldpositions as Director of Marketingand Education for several leadingimplant companies. He is currently Director of Clini-cal Technologies at Glidewell Laboratories, where heoversees Inclusive®Digital Implant Treatment PlanningServices and acts as editor in chief and clinical editorof Inclusive magazine. A member of the CDA, ADA, theAcademy of Osseointegration, International Congressof Oral Implantologists and the American Academy ofImplant Dentistry, Dr. Bockhorst continues to lectureinternationally while maintaining a private practice inMission Viejo, Calif. Contact him at 800-521-0576 orinclusivemagazine@glidewelldental.com.■ Michael C. DiTolla, DDS, FAGDDr. Michael DiTolla is Director ofClinical Education & Research atGlidewell Laboratories in NewportBeach, Calif. Here, he performs clin-ical testing on new products in con-junction with the company’s R&DDepartment. Glidewell dental tech-nicians have the privilege of rotat-ing through Dr. DiTolla’s operatoryand experience his commitment toexcellence through his prepping and placement of theirrestorations. He is a CR evaluator and lectures nation-wide on both restorative and cosmetic dentistry. Dr. Di-Tolla has several clinical programs available on DVDthrough Glidewell Laboratories. For more informationon his articles or to receive a free copy of Dr. DiTol-la’s clinical presentations, call 888-303-4221 or e-mailmditolla@glidewelldental.com.– Contributors – 3
  5. 5. PublisherJim Glidewell, CDTEditor in ChiefBradley C. Bockhorst, DMDManaging EditorsJim Shuck, Mike Cash, CDTCreative DirectorRachel PacillasClinical EditorBradley C. Bockhorst, DMDContributing editorGreg MinzenmayerCopy EditorSMelissa Manna, Kim WatkinsMagazine CoordinatorsLindsey Lauria, Vivian TsangGraphic Designers/Web DesignersJamie Austin, Deb Evans, Joel Guerra, Lindsey Lauria,Phil Nguyen, Gary O’Connell, Rachel Pacillas,Staff Photographers/Clinical ImagesSharon Dowd, Kevin Keithley,Jennifer Brunst, RDAEF, James KwasniewskiIllustratorsPhil NguyenAd RepresentativeVivian Tsang (vivian.tsang@glidewelldental.com)If you have questions, comments or suggestions, e-mail us atinclusivemagazine@glidewelldental.com. Your comments may befeatured in an upcoming issue or on our Web site.© 2010 Glidewell LaboratoriesNeither Inclusive magazine nor any employees involved in its publica-tion (“publisher”), makes any warranty, express or implied, or assumesany liability or responsibility for the accuracy, completeness, or useful-ness of any information, apparatus, product, or process disclosed, orrepresents that its use would not infringe proprietary rights. Referenceherein to any specific commercial products, process, or services bytrade name, trademark, manufacturer or otherwise does not necessar-ily constitute or imply its endorsement, recommendation, or favoringby the publisher. The views and opinions of authors expressedherein do not necessarily state or reflect those of the publisher andshall not be used for advertising or product endorsement purposes.CAUTION: When viewing the techniques, procedures, theories and ma-terials that are presented, you must make your own decisions aboutspecific treatment for patients and exercise personal professional judg-ment regarding the need for further clinical testing or education andyour own clinical expertise before trying to implement new procedures.Inclusive is a registered trademark of Glidewell Laboratories.■ Kenneth s. Hebel, DDS, MSDr. Kenneth Hebel received his den-tal degree from the University ofWestern Ontario in 1979 and a mas-ter of science degree in anatomy atthe University of Rochester in 1985.Dr. Hebel has the appointment ofAdjunct Professor at the School ofDentistry, University of Western On-tario. He also maintains a privatepractice in London, Ontario. He isa certified prosthodontist, a Diplomate of the Interna-tional Congress of Oral Implantology and a fellow ofthe American Academy of Implant Dentistry. Dr. Hebelis a published author and lectures on implant dentistry.E-mail him at drhebel@handsontraining.com.■ George V. Duello, DDS, MSDr. George Duello graduated fromUMKC School of Dentistry in 1979and received a master’s degree inoral biology at UMKC School ofDentistry in 1981. He has been inprivate practice in St. Louis, Mo.,since 1983. Dr. Duello was nameda Diplomate of the American Boardof Periodontology in 1987 and is amember of the American Dental So-ciety, Academy of Osseointegration and the AmericanAcademy of Periodontology, among others. Dr. Duelloserves on the Professional Advisory Committee for No-bel Biocare. Contact him at 314-965-3271 or dr.duello@stlouisdentalimplants.com■ Greg MinzenmayerGlidewell Laboratories Director ofBusiness Development Greg Min-zenmayer joined the lab in 2006.With a career in the dental indus-try that spans nearly 15 years, Greghas a proven track record in sales,product management, marketingand business development. Gregattended Chapman University inOrange, Calif. In 1994, he began atDen-Mat and in 1996 moved to Steri-Oss. In 1998, Steri-Oss was acquired by Nobel Biocare, and Greg was laterpromoted to product manager in charge of the Steri-Oss family of products. In 2002, he was promoted toDirector of Marketing for the Americas. Contact him atinclusivemagazine@glidewelldental.com.– www.inclusivemagazine.com –4
  6. 6. ■ Parish P. Sedghizadeh, DDS, MSDr. Parish P. Sedghizadeh is Direc-tor of the University of SouthernCalifornia Center for Biofilms andassistant professor of Clinical Den-tistry. He received his undergradu-ate degree in biology from UCLA,and went on to receive his dentaldegree from USC. After his doctor-ate, he pursued specialty training inOral and Maxillofacial Pathology atOhio State University, where he also attained a Masterof Science degree in oral biology and Fellowship sta-tus in the American Academy of Oral and Maxillofa-cial Pathology. He was also awarded Fellowship in theAmerican Cancer Society for conducting research at theArthur G. James Cancer Hospital and Richard J. SoloveResearch Institute, investigating the early molecularevents involved in the progression of head and neckcancer. Dr. Sedghizadeh is a Diplomate of the AmericanBoard of Oral and Maxillofacial Pathology, and he con-ducts research, publishes, consults and teaches in thiscapacity. Contact Dr. Sedghizadeh at 213-740-2704 orsedghiza@usc.edu.■ Samuel M. Strong, DDS, DICOIDr. Sam Strong received his den-tal degree from Baylor College ofDentistry. He has been involvedin implant prosthetics and teach-ing since 1985. He is a member ofthe American Academy of FixedProsthodontics and InternationalCongress of Oral Implantologistswith Fellowship and Diplomate sta-tus. He is also a Diplomate of theAmerican Board of Dental Sleep Medicine. Dr. Strong’spatient education DVD, “Dental Implant and Alterna-tive Options Featuring Informed Consent,” has been ac-claimed as one of the most effective case presentationtools available. Presently, Dr. Strong maintains a privatepractice in Little Rock, Ark., and is an adjunct professorat the University of Oklahoma College of Dentistry. Heis co-designer and co-developer of the Massad Edentu-lous Impression Tray and the Strong-Massad DenPlantImpression Tray. Contact him at 501-224-2333 or info@strongdds.com.■ Victor Rodriguez, CDTVictorRodriguez,ManagerofRemov-able Implants at Glidewell Labora-tories, studied Dental Technology atOrange Coast College and SouthernCalifornia College of Medical andDental Careers. In 1994, he achievedcertification in the Swissedent Tech-nique and passed the national CDTexam in the area of Full Dentures.Victor spent most of his 25 years inthe industry as part of a restorative team focused on re-construction, as the in-house technician for a group ofprosthodontists in Newport Beach, Calif. In 1995, Victorreceived his Credential of Mastership in the Technologysection of the American Academy of Implant Prostho-dontics. Victor served as component president for theCalifornia Dental Laboratory Association (South Coun-ties) from 1996-1998. Today, Victor is a member of theOsseointegration Study Club of Southern California, aswell as the American Prosthodontic Society, lectures ex-tensively on removable and fixed-removable prostheticsfrom the laboratory perspective. Contact him at 800-521-0576 or inclusivemagazine@glidewelldental.com.■ Richard L. Seberg, DDSDr. Richard L. Seberg is a graduateof the Nebraska School of Dentistry.He entered the U.S. Navy RotatingInternship in 1964 and served onthe USS Sperry from 1965-1967. Dr.Seberg is a member of several pro-fessional organizations, includingthe American Dental Association,the Orange County Dental Society,the California Dental Associationand the American Academy of Osseointegration. He is aDiplomate of the American Board of Implant Dentistryand a Fellow in the American Academy of Implant Den-tistry and the Academy of General Dentistry.– Contributors – 5
  7. 7. Utilizing Digital Treatment Planning and Guided Surgery toRestore Fully Edentulous Arches with the All-on-4 TechniqueWe now have access to technologies thatgreatly enhance our abilities to restore ourpatients with high precision in a shortened treatment timeutilizing a minimally invasive surgical procedure. Thiscase report will demonstrate several of these technolo-gies. Utilizing Glidewell Laboratories’ Digital TreatmentPlanning Services allowed me to easily integrate thesetechnologies into my practice.There are several treatment planning software programson the market. These programs allow you to virtually planyour cases utilizing CT scans. Scanning the patient withan appliance that has the teeth to be replaced in the idealpositions allows you to digitally plan the case from boththe surgical and prosthetic perspectives, making it a trulyrestoratively-driven process. Because Nobel Biocare im-plants were to be placed, the NobelGuide™System (NobelBiocare; Yorba Linda, CA) was utilized for this case. Thecase was planned following the All-on-4 technique.1-5Thisdesign involves tilting the distal implant on each side ofthe arch distally in order to improve the anterior-posteriorspread and provide posterior support for the prosthesis.Using stereolithography, a Surgical Template was pro-duced to transfer the digital plan to the clinical setting.An immediate screw-retained provisional restoration wasdelivered at the time of surgery through a flapless proce-dure.This technology can be used to completely rehabilitatea fully edentulous patient by placing the implants anddelivering maxillary and mandibular provisional restora-tions in one appointment. These cases require meticulousattention to detail and must be staged correctly. I had re-stored more than 20 individual arches using the All-on-4protocol prior to restoring both arches in one appoint-ment. Working with Glidewell Laboratories and utilizingthe Digital Treatment Planning software allowed me tomake the major planning decisions pre-surgically.by Irfan Atcha, DDS, DICOL, DADIA– www.inclusivemagazine.com –6
  8. 8. Pre-surgical work-up anddigital treatment planningThe patient was a young male that had beenedentulous for some time. His chief desire wasto have a fixed restoration. Due to the amountof ridge resorption, screw-retained dentureswere the restoration of choice.Standard procedure was used to determinethe ideal positions of the teeth. Impressionsand bite blocks were used to fabricate and ar-ticulate the study models. A wax try-in wasdone to finalize the set-up.Radiographic Guides were fabricated and thepatient was sent for a CT scan.The DICOM filesof the three scans (patient with RadiographicGuides, then maxillary and mandiubular Ra-diographic Guides alone) were uploaded andsent along with my Digital Rx to Glidewell’sDigital Treatment Planning Department.Following a Web-based teleconference, theplan was finalized. Due to the size of the im-plants that could be placed and the patientprofile, six implants were planned in the max-illa: four in the anterior and two angled dis-tally paralleling the anterior walls of the max-illary sinuses (Fig. 1-3).The mandibular plan included four implants:two in the lateral incisor regions and two an-gled distally to improve the anterior-posteriorspread (Fig. 4,5).Figure 3: The implant parallels the anterior wall of the sinus.Figure 5: This is a view of the mandibular digital plan.Figure 4: The implant is angled distally to improve the A-Pspread.Figure 2: A digital plan of the implants and Anchor Pins is cre-ated.Figure 1: A panoramic view of the planned implants is shownin the scan.– Utilizing Digital Treatment Planning and Guided Surgery to Restore Fully Edentulous Arches with the All-on-4 Technique – 7
  9. 9. Pre-surgical laboratoryproceduresOnce the plans were approved, the SurgicalTemplates were ordered from Nobel Biocare.Master casts were fabricated from the Surgi-cal Templates (Fig. 6) and articulated utilizingduplicate dentures.Provisional restorations were fabricated basedon the approved set-up (Fig. 7).Jigs were fabricated to correctly repositioneach of the 30-degree Angled Multi-Unit Abut-ments in the mouth. A Surgical Index was fab-ricated to ensure accurate seating of the Surgi-cal Templates (Fig. 8).Surgical procedureAfter obtaining adeqaute anesthesia, the Sur-gical Templates were seated in the patient’smouth with the Surgical Index (Fig. 9). The1.5 mm Twist Drill was used through the sleevesfor the Anchor Pins in both arches.The Surgical Index and mandibular SurgicalTemplate were then carefully removed (Fig. 10).Figure 6: Master casts are fabricated from the Surgical Tem-plates.Figure 7: Reinforced provisional restorations are fabricated.Figure 8: A Surgical Index is fabricated.Figure 10: The anchor pins are placed and the index removed.Figure 9: The Surgical Templates and Index are seated intraoral-ly.– www.inclusivemagazine.com –8
  10. 10. Figure 13: Healing Abutments maintain the soft tissueopening.Figure 12: The remainder of the implant sites is pre-pared.Figure 11: The first site is prepared and the implant placed. ATemplate Abutment further secures the Surgical Template.Figure 15: The osteotomies are prepared and the implantsplaced.Figure 14: The mandibular Surgical Template is reseated andthe Anchor Pins pressed into place.The first maxillary implant was placed and aTemplate Abutment used to lock it to the Sur-gical Template (Fig. 11).The second implant was placed in the #10 areawith a Template Abutment. Between the threeAnchor Pins and the two Template Abutments,the Surgical Template is held securely in placeand the remaining oseotomies prepared (Fig.12) and the implants threaded into place usingthe Guided Implant Mounts.Healing Abutments were threaded into the im-plants to maintain the soft tissue opening dur-ing the mandibular surgery (Fig. 13).The mandibular Surgical Template was seatedand the Anchor Pins pressed into place (Fig.14).Standard NobelGuide procedure was followedto create the osteotomies and place the im-plants (Fig. 15).– Utilizing Digital Treatment Planning and Guided Surgery to Restore Fully Edentulous Arches with the All-on-4 Technique – 9
  11. 11. Prosthetic deliveryThe jigs were used to deliver the 30-degreeAngled Multi-Unit Abutments (Fig. 16,17).The anterior implants were restored at the im-plant level (no abutments).The remaining Healing Abutments were re-moved. The prostheses were delivered and theprosthetic screws tightened (Fig. 18).A post-operative radiograph was taken to ver-ify complete seating (Fig. 19).Adjustments were made and a bilateral bal-anced occlusion was verified. The screw ac-cess openings were then sealed (Fig. 20) andpost-operative instructions given.Impressions for the final prosthesis will bemade in approximately six months (Fig. 21).Figure 16: Jigs are used to correctly align the angled Multi-UnitAbutments.Figure 17: This is what the Multi-Unit Abutments look like inplace.Figure 18: Prostheses are seated and the prosthetic screwstightened.Figure 20a: The screw access openings are sealed.Figure 19: A post-op radiograph verifies complete seating.– www.inclusivemagazine.com –10
  12. 12. ConclusionThe All-on-4 technique in combination with digital treatment planning and guided surgeryhas allowed us to take a patient with a severely atrophic ridge from a poorly fitting dentureto a fixed prosthesis in a precise manner with a shortened treatment time.To earn Continuing Education credits on this topic, visit www.inclusivemagazine.com.References1. Malo P, MechEng MN, Rangert B. All-on-Four Immediate-Function Concept with Branemark System Implants for CompletelyEdentulous Mandibles: A Retrospective Clinical Study. Clinical Implant Dentistry and Related Research, Vol. 5, Supplement 1;2003.2. Malo P, MechEng MN, Rangert B. All-on-Four Immediate-Function Concept with Branemark System Implants for CompletelyEdentulous Maxillae: A 1-Year Retrospective Clinical Study. Clinical Implant Dentistry and Related Research, Vol. 7, Supplement1; 2005.3. Bellini CM, Romeo D, Galbusera F, Taschieri S, Raimondi MT, Zampelis A, Francetti L. Comparison of Tilted Versus NontiltedImplant-Supported Prosthetic Designs for the Restoration of the Edentulous Mandible: A Biomechanical Study. The Interna-tional Journal of Oral & Maxillofacial Implants, Vol. 24, Number 3; 2009.4. Cruz M, Wassall T, Toledo EM, Paulo de Silva Ba L. Finite Element Stress Analysis of Dental Prostheses Supported by Straightand Angled Implants. The International Journal of Oral & Maxillofacial Implants, Vol. 24, Number 3; 2009.5. Bedrossian E, Sullivan RM, Malo P. Fixed Prosthetic Implant Restoration of the Edentulous Maxilla: A systematic PretreatmentEvaluation Method. Journal of Oral and Maxillofacial Surgeons; 2008.Figure 20b: Mandibular Access openings are sealed. Figure 21: The provisional restorations in place.– Utilizing Digital Treatment Planning and Guided Surgery to Restore Fully Edentulous Arches with the All-on-4 Technique – 11
  13. 13. Screw-RetainedDenturewithCAD/CAMFrameworkThe screw-retained denture, also known as the hybrid denture, has been the standard fixed-removable res-toration for edentulous mandibles for more than 40 years. I used this prosthesis extensively 25 years ago.However, after experiencing problems obtaining a passive fit accompanied by routine screw loosening andfracture, I stopped providing it to my patients as a routine solution. It simply became too high-maintenanceand repair-intensive, creating frustration for both the patient and myself and hurting profitability. The intro-duction of new technologies such as CAD/CAM fabrication of frameworks and bars has allowed me to re-introduce the screw-retained denture back into my practice with confidence as a solution for the edentulouspatient.by Ken Hebel, DDS, MSLabwork by Victor Rodriguez, CDTThe patient, a 56-year-old female, presented with recurrent decayaround the crown margins of her mandibular teeth and a chronic in-ability to successfully wear a partial lower denture, which compro-mised her ability to function. She sought a long-term solution for hermandibular dentition. The recommended treatment plan was to removeher mandibular teeth and access the mandibular symphysis for place-ment of implants to support a fixed, detachable prosthesis. All otheroptions were discussed with the patient as part of the informed consentprocess.The severe atrophy of the posterior areas precluded the placement ofposterior implants. The teeth were extracted. Implants were placed be-tween the mental foramina and spaced according to the available bone.Two of the implants were placed closer together due to bone anatomy.An immediate denture was delivered. The intaglio surface of the den-ture was relieved and soft tissue relined in the area over the implants.ImplantPlacementPreoperativeAppointmentScrew-Retained Denture with CAD/CAM Framework 13
  14. 14. FirstProstheticAppointmentFigure 3: The decision was made to place and restore the case at the abutment level for ease of access andto avoid disturbing the soft tissues during the restoration process. Multi-Unit Abutments wereseated on the implants. The Abutment Screw was tightened to a torque of 35 Ncm with a manualwrench.Figure 4: The abutment collar heights were selected so the shoulder is supragingival. Once the abutments areplaced they will not be removed. All procedures are performed at the abutment level.Figure 5: Multi-Unit Abutment Transfer Copings are threaded on top of the abutments in preparation forpreliminary impression. The cast made from this impression will be used to fabricate a verificationjig. This will allow a final impression to be made with verification occurring within the impression.This step will be clarified as we move forward with the technique.Figure 6: Impression material is injected around the copings, taking care to capture the copings accurately.Figure 7: A stock tray is filled and seated.Figure 8: Once set, the impression is removed from the patient’s mouth. The impression is inspected for voidsand proper border extensions. An impression of the opposing dentition should be made. If thepatient is happy with the mould of the existing denture, an impression of the patient’s mandibulardenture is taken to help the lab select the proper denture tooth mould.Figure 3Figure 6Figure 4Figure 7Figure 5Figure 8– www.inclusivemagazine.com –14
  15. 15. Figure 9: The Transfer Copings are removed and replaced with Healing Caps. These caps will protect the topsof the abutments between appointments. The patient’s existing denture is relieved so that it doesnot ride on the Healing Caps. The denture is relined with tissue conditioner.LaboratoryFigure 10: A soft tissue model is poured from the preliminary impression utilizing Abutment Analogs.Figure 11: A bite block is fabricated. This consists of a base plate and a wax rim. Two Temporary Cylindersare incorporated to provide stability while obtaining occlusal records.Figure 12: Because all overdenture bars and screw-retained denture frameworks are fabricated utilizing CAD/CAM technology, it is critical to obtain accurate impressions. The procedure Glidewell Laborato-ries recommends involves “picking-up” an Implant Verification Jig (IVJ) in the final impression.The lab fabricates the IVJ by tying Titanium Cylinders together with Triad material. A thin slice ismade between each cylinder. Each section is numbered on the model.Figure 13: A custom tray is fabricated with openings to allow access to the tops of the Guide Pins.SecondProstheticAppointmentFigure 14: The Healing Caps are removed, exposing the tops of the Multi-Unit Abutments.Figure 9 Figure 10 Figure 11Figure 12 Figure 13 Figure 14Screw-Retained Denture with CAD/CAM Framework 15
  16. 16. Figure 15: The IVJ sections are seated in the mouth in the same positions as they were on the model. TheGuide Pins are hand-tightened. Ensure there is a thin space, about the thickness of a credit card,between each section of the IVJ. If necessary, the sections can be trimmed with a disk.Figure 16: The sections of the IVJ are luted together with a self-cured or light-cured resin material. The spaceshould be completely filled in order to ensure a solid connection.Figure 17: The custom tray should tried in, making sure there is clearance around the IVJ. Border moldingcan be done to ensure accurate border extensions.Impression material should be injected around and under the IVJ. The custom tray is filled andseated. Instruct the patient to lift their tongue and go through all border molding procedures asyou would for a denture impression. Uncover the heads of the Guide Pins.Once the material has set, loosen the Guide Pins and pull the impression. The IVJ will be pickedup in the impression. Inspect the impression for accuracy.Figure 18: The bite block is seated and the two prosthetic screws tightened, providing excellent stability.The wax rim should be adjusted to the correct vertical dimension of occlusion and the midlinemarked.Figure 19: Bite registration material is injected onto the top of the bite block and the patient closed intocentric relation.Figure 20: The bite block is removed and the Healing Caps replaced.Figure 15Figure 18Figure 16Figure 19Figure 17Figure 20– www.inclusivemagazine.com –16
  17. 17. LaboratoryFigure 21: The master cast is fabricated from the final impression.Figure 22: The models are articulated using the bite block and bite registration.Figure 23: Denture teeth are set on the bite block with a bilateral balanced occlusal scheme.ThirdProstheticAppointmentFigure 24: The trial set-up is seated and the two prosthetic screws hand-tightened.Figure 25: VDO, CR, midline and esthetics are evaluated, and any necessary changes are made or noted onthe Rx. Final tooth position is always established before the fabrication of the substructure. Thesubstructure needs to be designed under the teeth for esthetics and support.Figure 26: In this case a discrepancy was found in CR, so a new bite registration was made.Figure 21 Figure 22 Figure 23Figure 24 Figure 25 Figure 26Screw-Retained Denture with CAD/CAM Framework 17
  18. 18. LaboratoryFigure 27: A functional remount was done using the new bite registration.Figure 28: The teeth were adjusted to the new CR.Figure 29: The lingualized bilateral balanced occlusion was checked and adjusted as needed.Figure 30: A silicone putty index was made of the final set-up.Figure 31: The soft tissue model and the set-up were optically scanned and the framework was virtuallydesigned.Figure 32a: Once the CAD is completed, the framework is milled from a solid block of titanium.Figure 32b: The framework is seated back on the model. Here you can see the precision fit of the frameworkutilizing CAD/CAM technology.Figure 33: The putty index is used to transfer the tooth set-up to the framework.Figure 34a: The denture tooth set-up, on the framework in wax.Figure 34b: An occlusal view shows the locations of the prosthetic screws.Figure 27 Figure 28 Figure 29Figure 30 Figure 31 Figure 32a– www.inclusivemagazine.com –18
  19. 19. FourthProstheticAppointmentFigure 35: The Healing Caps are removed. The trial set-up is seated on the abutments.Figure 36: The fit of the framework is evaluated. This can be done by tightening one screw and making sureno lifting occurs on the opposite side. Remove the screw and repeat the process for each abut-ment. Periapical radiographs should be taken if the interface is subgingival or cannot be easilyseen clinically.Figure 37: In this case, the patient was very concerned about support for the lower lip. The anterior sectionof the prosthesis was built up to “plump out” the lip. Here you can see the patient profile duringthe try-in appointment.LaboratoryFigure 38: The model with the prosthesis is placed in a hydrocolloid flask.Figure 39: A hydrocolloid mold is fabricated.Figure 40: The teeth are removed and the wax boiled off the model. Pink opaque is applied to the frameworkto mask the gray color.Figure 32b Figure 33 Figure 34aFigure 34b Figure 35 Figure 36Screw-Retained Denture with CAD/CAM Framework 19
  20. 20. Figure 41: The denture teeth are seated back into the hydrocolloid mold. Note diatoric holes have beenadded to the base of the teeth for added retention.Figure 42: The prosthesis is processed.Figure 43a: The prosthesis is finished and polished.Figure 43b: The occlusion is verified.Figure 44: The screw access openings are checked to ensure there are no interferences for the prostheticscrews.Figure 45: In this case, the underside of the prosthesis is an ovate, high-water design to facilitate ease ofhygiene.FifthProstheticAppointment:FinalDeliveryFigure 46: Delivery of the definitive prosthesis. The Healing Caps are removed, the abutment screws of theMulti-Unit Abutments are retightened to 35 Ncm, the prosthesis is seated on the abutments andthe prosthetic screws tightened to 15 Ncm.Figure 47: The occlusion is checked and adjusted as needed.Figure 48: The heads of the prosthetic screws are covered with a cotton pellet and access opening sealedwith composite or acrylic.Figure 37Figure 40Figure 38Figure 41Figure 39Figure 42– www.inclusivemagazine.com –20
  21. 21. Figure 43aFigure 45Figure 48Figure 43bFigure 46Figure 49Figure 44Figure 47Figure 50Figure 49: Panoramic radiograph is taken to verify complete seating of the prosthesis.Figure 50: The patient is given oral hygiene instructions and put on a recall schedule.ConclusionThe use of CAD/CAM technology has allowed me to re-introduce the hybrid, or screw-retained, denture intomy practice. This case report illustrates how, working with an experienced lab, a severely resorbed edentu-lous mandible can be restored in a very systematic, predictable manner with a fixed prosthesis.Screw-Retained Denture with CAD/CAM Framework 21
  22. 22. Glidewell Laboratories offers three options for custom implant abutments under the Inclusive®brand:Titanium, Zirconia with Titanium Insert and All-Zirconia. We use your implant level impression and pro-vide a tailor-made CAD/CAM solution that is fabricated to fit your patients’ individual needs. The margin and gingivalcontours are designed to ensure ideal soft and hard tissue esthetics. The abutment height and the emergence profile areprecisely milled to facilitate gingival health and prosthetic support, resulting in a superior restoration.■ The Inclusive Titanium Abutment provides strength and biocompatibility. It is primarily indicated to support posterior restorations.■ The Inclusive All-Zirconia Abutment provides superior esthetics without sacrificing durability and is ideal for anterior restorations.■ The Inclusive Zirconia with Titanium Insert Abutment is another esthetic option that maximizes strength and is suited for anterior restorations. ♦ The All-Zirconia Abutment is available for the following implant systems: • NobelReplace • Biomet 3i Certain • Zimmer Screw-Vent ♦ The Titanium and the Zirconia with Titanium Insert Abutments are available for: • Noess • NobelReplace • NobelActive • Branemark System RP • Biomet 3i Certain • Zimmer Screw-Vent • Straumann Bone LevelRD CornerMechanicalTestingofInclusive®CustomAbutmentsby Grant Bullis, RD Manager, Glidewell Laboratories– www.inclusivemagazine.com –22
  23. 23. Zirconia with Titanium Insert Abutments include a metal insert and providea titanium-to-titanium abutment-implant interface. The insert is permanentlycemented to the zirconia section in the lab.Inclusive Abutments are designed utilizing CAD/CAM technology and milledfrom precision-machined blanks. Extensive testing is performed, and high-strength materials are utilized to provide a consistent, high-quality product.Superior materialsThe high strength of Inclusive Titanium Abutments begins with material se-lection. The titanium abutments are precisely machined from ASTM grade 23alloy titanium. Grade 23 titanium has a minimum yield strength of 760 MPabefore plastic deformation occurs compared to the 480 MPa minimum yieldstrength of grade 4 commercially pure titanium used for many abutments. Forceramic materials such as zirconia, flexural strength is used to measure thestrength of the material in bending. Inclusive All Zirconia Abutments are ma-chined from high strength zirconia with a flexural strength of 1500 MPa.Glidewell Laboratories uses titanium abutment blanks that are manufacturedon Swiss-style CNC automatic lathes utilized throughout the implant industry.The zirconia abutment blanks are manufactured on five-axis CNC mills. Theentire manufacturing process is tightly controlled, from material issue to finalinspection, to ensure quality and consistency.Rigorous testingAbutment-to-implant compatibility requires manufactur-ing the prosthetic components to very close tolerances.Further, the mechanical function and performance of theabutment/implant assembly should be determined byfatigue testing that approximates actual-use conditions.Fatigue-strength testing based on the ISO 14801 protocolwas conducted on the implant/abutment assemblies todetermine fatigue strength. Fatigue-strength testing wasperformed at an independent laboratory on both Titaniumand All Zirconia Inclusive Custom Abutments for everyimplant system offered.The fatigue strength is the maximum force that the as-sembly can withstand after cyclical loading at a frequencyof 14Hz. Testing is typically done on the smallest, andtherefore the weakest, diameter implant. In this test, 3.5mm (Narrow Platform) Inclusive Zirconia Abutments had a fatigue strength of 289 – 333 N after 5 million cycles. To putit in perspective, the bite forces in the anterior region where zirconia would be primarily indicated have been reportedin the range of 109 to 299N.1,2The clear choiceInclusive Custom Abutments provide an array of benefits that ultimately lead to superior final restorations. A variety ofoptions including All Zirconia, Titanium and Zirconia with Titanium Insert allow you to work with a material that bestmeets the needs of you and your patients. Mechanical testing results show that you can count on a dependable abut-ment that maintains long-term prosthetic function.1. Helkimo E, Carlsson GE, Helkimo M. Bite forces used during chewing of food. J Dent Res 1959;29:133–136.2. Waltimo A, Könönen A. A novel bite force recorder and maximal isometric bite force values for healthy young adults. Scand J Dent Res 1993;1001:171–175.Inclusive is a registered trademark of Glidewell Laboratories.Mechanical Testing of Inclusive Custom Abutments 23
  24. 24. Screw-RetainedBruxZir®CrownThe Screw-Retained BruxZir Crown pro-vides a one-piece alternative to cement-ed implant restorations. This restorationcombines the abutment and crown intoone solid restoration. The benefits in-clude: no crown margin, and thereforeno concerns about excess cement; easyretrievability; and because it is all zirco-nia, there is no possibility of porcelainfracturing off. Inclusive Custom Abut-ments, as well as the Screw-RetainedBruxZir Crown, are compatible with thefollowing implant systems:• Neoss • NobelReplace • NobelActive• Biomet 3i Certain • Branemark System RP• Straumann Bone Level • Zimmer Screw-Ventby Richard L. Seberg, DDS, and Bradley C. Bockhorst, DMDBruxZir®Solid ZirconiaCrown and Inclusive®Custom Titanium AbutmentWhy should you be interested in themonolithic concept of a solid zirconiacrown? As you know, when you fuseporcelain to a metal or zirconia sub-structure, there is always the possibil-ity that the two layers could separate.The best-case scenario is a small chipof the porcelain that you might be ableto polish off. The worst-case scenario isthat the porcelain completely fractures,exposing the substructure and requiring replacement.A key benefit of monolithic restorations is that nothing can chip off, aswe don’t have two materials fused together. The restoration is made ofone homogeneous material. BruxZir is a full-contour zirconia restora-tion with no porcelain veneer.More brawn than beauty, the BruxZir Solid Zirconia crown has rap-idly gained popularity for posterior restorations thanks to the preci-sion milling of CAD/CAM technology. With the increasing price of goldfor porcelain-fused-to-metal restorations, the proven strength of zirco-nia gives you a viable option for your posterior implant crowns andbridges.Inclusive®Custom Titanium Abutments provide ideal support for therestoration and the soft tissue. This CAD/CAM-designed abutment ex-hibits a natural-looking emergence and provides strength and durabil-ity. The laboratory virtually designs your abutment and mills a tailor-made solution of the highest quality. Also available in the Inclusive lineof products is the Inclusive All-Zirconia Abutment and the InclusiveZirconia Abutment with Titanium Insert.BruxZir and Inclusive are registered trademarks of Glidewell Laboratories.Inclusive®Titanium Abutment BruxZir®Solid Zirconia Crown Screw-Retained BruxZir®Crown Sealed screw access openingProduct Spotlight– www.inclusivemagazine.com –24
  25. 25. My First ImplantAs featured in the last issue ofChairside®magazine, “My FirstImplant” showcases the selection, work-upincluding digital treatment planning, andplacement of a single-tooth implant utiliz-ing guided surgery. The restoration consistedof an Inclusive®Custom Titanium Abutment(Glidewell Laboratories; Newport Beach, CA) anda PFM crown.Below is an excerpt from the article detail-ing the experience of seating my first implantcase. You’ll find the complete article, a photoessay, video of the procedure and more atwww.inclusivemagazine.com.I’ve always known that patients would ratherstay in my office than be referred to anotheroffice, but I was afraid to surgically place animplant. Up to this point I had been restoringimplants for some time and had taken numer-ous implant courses. However, when our im-plant department convinced me that DigitalTreatment Planning technology would elimi-nate the guesswork, I decided I was ready togive it a try.I can honestly say it was the most fun I havehad in a long time, and it was easier than al-most any crown prep I’ve recently done. I wishthere was this much technology available towalk me through molar endo, wisdom toothextractions or multiple-unit bridge preps.With the patient anes-thetized, we begin theprocedure by insertingthe Surgical Guide andusing the start drill. Thetip of the start drill creates a countersink in the bone, while theupper part of the start drill acts as a tissue punch. Since nografting was necessary, no flap was utilized as part of the pro-cedure. Note how the large diameter of this drill fills the sleevein the Surgical Guide.A close-up view of the Surgical Guide on the model. It shouldseat into place, much like an occlusal splint. The guide will havesome inspection windows from which cusp tips will stick out sothat you can verify that the guide is completely seated. The metalsleeve in the Surgical Guide controls the angle and the depth ofthe implant drills.by Michael DiTolla, DDS, FAGD– www.inclusivemagazine.com –26
  26. 26. Guided Surgerywith Grafting and Ridge ExpansionGuided Surgery and GraftingFIGURE 1: After fabrication of a Radiographic Guide, the patienthas a CT scan taken and the case is virtually planned. Note: Thepatient’s buccal defect can be seen in the cross-sectional slice. ASurgical Template is fabricated based on the digital plan.FIGURE 3: Next, the Surgical Template is seated.FIGURE 2: At the time of surgery, a full thickness flap is re-flected.FIGURE 4: The drills are guided through the Surgical Templateto create the osteotomy.ne of the most exciting recent advancements in implant dentistry is digital treatment planning and guided sur-gery. In some cases ancillary procedures may be required. This photo essay showcases grafting and the use ofosteotomes in conjunction with guided surgery.Here, you will see the step-by-step process, from planning the case to the final restoration.Oby Richard L. Seberg, DDSGuided Surgery with Grafting and Ridge Expansion 27
  27. 27. FIGURE 5: The implant is threaded into place. FIGURE 6: The buccal graft is placed and the flap closed.FIGURE 7: Once the implant has had time to osseointegrate, animplant level impression is made.FIGURE 8: The model is scanned and an Inclusive®TitaniumCustom Abutment is virtually designed.FIGURE 9: An Inclusive®Titanium Custom Abutment is deliv-ered.FIGURE 10: After adjustments are made, the PFM crown iscemented into place.Guided Surgery and Ridge ExpansionFIGURE 11: The patient’s old bridge is removed and the prepsare cleaned up. Note the typical saddle defect in the edentulousarea.FIGURE 12: The patient had a CT scan, and the implant wasvirtually planned. The SurgiGuide®is fabricated based on the digi-tal plan.– www.inclusivemagazine.com –28
  28. 28. FIGURE 13: The SurgiGuide is seated and used to direct thepilot drill.FIGURE 14: Osteotomes are used to expand the ridge andcreate the osteotomy.FIGURE 15: The implant is threaded into place. FIGURE 16: An implant level impression is made.FIGURE 17: Note the improved labial contour due to the ridgeexpansion.FIGURE 18: A BioTemps®bridge is modified to seat over theHealing Abutment during the osseointegration period.FIGURE 19: An Inclusive All-Zirconia Custom Abutment is seat-ed.FIGURE 20: Individual Prismatik Clinical Zirconia™crowns aredelivered.BEFOREAFTERPrismatik Clinical Zirconia is a trademark of Glidewell Laboratories. Inclusive and BioTemps are a registered trademark of GlidewellLaboratories. SurgiGuide is a registered trademark of Materialise.To see two videos related to this article, go to www.inclusivemagazine.com.Guided Surgery with Grafting and Ridge Expansion 29
  29. 29. A key to the success of any implant case, from the simplest to the most advanced, involves the teamconcept in which the surgeon, restorative dentist and laboratory are all in sync. Here, we will outline apractice concept in which the surgeon, working closely with the laboratory, can support his or her referral base througha restoratively-driven approach. That support can be offered at various levels, from the traditional approach-to a hybridthat includes immediate loading-to digital dentistry.Utilizing technologies such as cone beam scanners with digital treatment planning and guided surgery allows the caseto be focused on the prosthetic side from the start, providing a more predictable end result. The surgeon can differenti-ate himself or herself and provide superior treatment to the patient by incorporating this concept into daily practice.The restorative dentist, no matter his or her level of experience, can benefit from working closely with the surgeon whohas incorporated this practice approach to achieve simple, esthetic solutions.The first thing I think we need to discuss is: “What is the restorative-driven surgical practice?” Is there a definition, orhow is it applied. For me, the definition that I like is: It is a dentist, a specialist, a laboratory that uses a menu of servicesto provide patients and referrals with their implant procedures. This menu will vary depending on your philosophy,your understanding of the literature and your clinical experience.With any menu, we need to think about our basic philosophy of implant dentistry. My menu has been shaped much bymy colleagues and mentors. The present philosophy I have on implant dentistry is that it is a laboratory procedure witha surgical and a prosthetic component. It’s my belief that because in implant dentistry, for the most part we’re workingwith prefabricated machine parts or CAD/CAM parts, that everything should fit, and we should not dedicate a lot ofchairtime to making things fit, when in fact the laboratory can get things to fit for us.My experience in traveling across the United States is that depending on what group you’re talking to, they will tell youthat their part of implant dentistry is the most important. So if I’m talking to restorative dentists, they’ll tell you their partis most important; if I’m talking to surgeons, they’ll tell you why what they have to do in placing implants is so critcal;and finally, somebody has to make the teeth – dentists don’t make their own teeth, so to speak — so the laboratorieswill be owning implant dentistry. We’ll discuss this further in the section on digital dentistry.To see Dr. Duello’s complete lecture on the Restorative-Driven Practice, go to www.inclusivemagazine.com. You’ll also find a photo essay on this piece online.The Restorative-Driven Surgical Practice■by George V. Duello, DDS, MS– www.inclusivemagazine.com –30
  30. 30. Recent advancements in Cone Beam (CBCT) scanners have resulted in much greater utilization of thistechnology as a diagnostic and treatment planning tool. Three-dimensional imaging is rapidly becoming astandard of care in dentistry. The online presentation by Dr. Parish Sedghizadeh includes:❖ A brief introduction to conventional CT and CBCT scanning technology.❖ An overview of the use of CBCT scans in various fields of dentistry including diagnosis and treatment planning for implants.❖ A brief refresher on common pathology, including osteonecrosis of the jaw secondary to bisphosphonate use.❖ A discussion on medical-legal liability and CT scans.Conventional CT works in slices. Cone Beam CT, as the name implies, is a cone through the tissue. This volume is thenreconstructed into various slices such as axial, coronal and sagittal views. The software can also create a 3D renderingof the anatomy. While both types of CTs are similar, the applications and uses for Cone Beam CT are better in dentaluse, as you’ll see.The applications of CBCT are increasing right now in dentistry, and pretty soon it’s going to become a standard of carefor radiology and for radiographic diagnosis – not just digital planning for implants, but for many disciplines.The standard of care is shifting to Cone Beam CT, and it’s happening now. It’s not going to be a very long time beforein dentistry and dental-related procedures and treatment planning, it is the standard of care over any other imagingstudies. The reasons for that: The radiation from CBCT, in one volume, is very low. So if you just do one Cone Beam CT,that’s your baseline imaging for anything you need for that patient. Right now we don’t do it because it’s not as sensi-tive and specific for caries detection and periodontal disease detection. But that’s changing because oral radiologists areon the cutting edge of research and fine-tuning this technology and the software associated with it to allow us to startlooking at things like caries and periodontal disease and pocketing, two dimensionally and three dimensionally withthese different slices. So it will become the standard of care in the very near future for probably any dental imagingprocedure that needs to be done.To see Dr. Parish Sedghizadeh’s complete presentation, including specific examples of Cone Beam CT applications and detailed images, along with a discussion onpathology and medical-legal liability, visit www.inclusivemagazine.com.by Parish P. Sedghizadeh, DDS, MSCone Beam Computed Tomography:Applications in Diagnostic Oral and Maxillofacial Radiology and PathologyCone Beam Computed Tomography: Applications in Diagnostic Oral and Maxillofacial Radiology and Pathology 31
  31. 31. Implant Removable Instructions for Use Digital Treatment Planning Instructions for UseStep-by-step guides for procedures used during the implant reconstruction are availablefrom Glidewell Laboratories. These informational pieces will guide you through the entireprocess, from the initial appointment to delivery of the final prosthesis. In addition, theseguides will help you schedule appointments with your patients thanks to a list of laboratoryturnaround times. Go to www.glidewelldental.com to obtain copies, or call 800-839-9755.Digital Treatment Planning and guided surgery are rapidly becoming a standardof care in implantology. This technology allows you to plan implant cases fromboth surgical and prosthetic perspectives in a 3-D environment. Glidewell Labo-ratories can help you easily integrate this technology into your practice withouthaving to spend extensive time training on, or investing in, expensive software.■ Locator®OverdentureGet information on restoring an edentulous arch with an overdenture and free-standingattachments.■ Locator Bar OverdentureInstructions on restoring an edentulous arch with a CAD/CAM bar overdenture.■ Screw-REtained Denture (Implant Level)Find technical information on restoring an edentulous arch with a fixed prosthesis, di-rectly to the implants. This piece features a CAD/CAM titanium framework with dentureteeth and pink acrylic.■ Screw-Retained Denture (Abutment Level)See step-by-step instructions on restoring an edentulous arch with a fixed prosthesis, onabutments. Device features a CAD/CAM titanium framework with denture teeth and pinkacrylic.■ Screw-Retained Denture (Glidewell Selects Abutments)Get information on restoring an edentulous arch with a fixed prosthesis that features a CAD/CAM titanium frameworkwith denture teeth and pink acrylic. Impressions are taken at the implant level. The laboratory determines the abut-ments, if necessary, based on the positions of the implant analogs in the model and the trial denture tooth set-up.■ Premium Bar HybridRestore an edentulous arch with a fixed prosthesis that features a CAD/CAM titanium framework with individual all-ceramic crowns and pink composite to simulate the soft tissues.■ NobelGuide™ Fully and partially EdentulousThese guides offer specific instructions on how to plan cases for fully andpartially edentulous patients. Get detailed information on Digital TreatmentPlanning and Guided Surgery using the Nobel Biocare system.■ SimPlant®fully and Partially EdentulousThese convenient guides offer all you need to know about utilizing SimPlant on your fully and partially edentulouspatients. This system has an open architecture. Most implant systems available today can be planned with the Sim-Plant software.For a complete step-by-step guide detailing how to utilize Glidewell Laboratories’ Digital Treatment Planning Services, visit www.inclusivemagazine.com. Here, you candownload the full IFU for future reference on how to take advantage of this cutting-edge technology.– www.inclusivemagazine.com –32
  32. 32. Beyond learning the techniques and procedures for successful completion of im-plant prosthetics lays the problem of fee determination. This can be a thorny issue with manyclinicians unless a rational method for analysis of the case can be identified. In order to deter-mine a fair fee for any implant case, we must first know our total costs involved to produce theprosthesis. I suggest breaking down the total case cost figure into three components:■ Lab costs ■ Implant component costs ■ Overhead costsLearn how to calculate your costs and determine the fee you should be charging for these types of cases in a comprehensive articleavailable exclusively at inclusivemagazine.com.by Samuel M. Strong, DDSFee Determination...Fee Determination for Implant Cases 33
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