Arts de Dimension Vertical e Implantes Sobredentadura

Inclusive
Restorative Driven Implant Solutions
Vol. 1, Issue 4
A Multimedia Publication of Glidewell Laboratories
Caring
for the
Edentulous
Patient
Dr. A. Burton Melton and
Dr. J. Jeffrey Melton
Page 26
Vertical Dimension
of Speech: The
Pilot of Occlusion
Dr. Earl Pound
Page 6
Finding Lost
Vertical Dimension
Dr. Anthony LaVacca
Page 15
Demographics, Destiny
and Dentistry
Locator Attachment: Your

Top Questions Answered
Dr. David Schwab

Page 35
Paul Zuest
Page 30
On the Web
Find bonus content at inclusivemagazine.com
ONLINE Video Presentations
Dr. Anthony LaVacca expands on his instruction for
finding the vertical dimension in full-mouth rehabilitations. Also, learn about vertical bar design in our
online R&D Corner.
Online Lectures
Another informative installment of the gIDE Lecture-on-Demand series features a presentation by
Dr. Edward Bedrossian, who offers guidance on implementing a systematic restorative plan for treatment
of the edentulous patient with a fixed prosthesis.
ONLINE Photo Essays

View clinical photos from Dr. Timothy Kosinskis presentation on CT scanning for implants. Plus, learn
even more about utilizing optical scans with Digital
Treatment Planning software in a photo slide show
that accompanies Dr. Bradley C. Bockhorsts article
on the subject.
ONLINE Educational Animations

An animation illustrating the four stages of bone resorption that occur over time supplements an article
on treating the edentulous patient by Drs. Burton and
Jeffrey Melton.
ONLINE Free CE credit

Earn CE credit for the material youve seen in Inclusive
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two hours for each test you complete.
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Contents
6
15
The Vertical Dimension of Speech:

The Pilot of Occlusion
In this classic article, Dr. Earl Pound discusses the various problems
of vertical dimension, including those of the face, of occlusion and
of speech. He emphasizes the value of applying the vertical dimension of speech as a protective and esthetic guide for all forms of
prosthetic restorations. The vertical dimension of occlusion is one
of the most researched phases of denture prosthodontics, Pound
writes.
Where Is the Vertical?

Basic Principles to Find Lost Vertical Dimension
for Full-Mouth and Implant Rehabilitation
Dr. Anthony LaVacca, using the guidelines set forth in Dr. Earl
Pounds Let S Be Your Guide, explains how to find the true vertical dimension of occlusion and how it relates to full-mouth rehabilitation, implant rehabilitation and denture cases. He argues that
Dr. Pounds article will provide the clinician with the information
necessary to find the vertical component using sibilant sounds.
26
Caring for the Edentulous Patient
30
Top Questions About the Locator Attachment
35
Demographics, Destiny and Dentistry
Features
38 Clinical Tip: Vertical Opening
and Guided Surgery Drills
43 CT Planning for Implants:
Dont Let a Panoramic Fool You
52 Merging Technologies:
Utilizing Optical Scans with
Treatment Planning Software
Cover photo courtesy of

Daniel DAmour, RT
Drs. Burton and Jeffrey Melton write that caring for the edentulous
patient is one of the most critical and life-altering services clinicians
can provide. Instead of following the traditional approach to treatment achieving an acceptable outcome, rather than a superior
result they advocate a doctor-patient relationship that includes
co-diagnosis and co-treatment planning.
There are a number of attachments to choose from when prescribing an implant overdenture. A low profile, ease of use and
retention options make the Locator attachment one of the most
popular. Paul Zuest, president of Zest Anchors, answers the five
most common questions asked by Locator users.
Dr. David Schwab uses demographic data to argue that the destiny
of dentistry is positive for at least the next two decades. This is
largely due to the aging baby boomer generation, which will significantly increase the demand for dentistry because of a potential
future need for comprehensive dental care.
Contents
Letter from the Editor

The fourth issue of Inclusive magazine is dedicated to treating the edentulous patient.
While the rate of edentulism in the U.S. decreases, the population continues to age, so
the total number of adults who are missing all their teeth is actually growing. As you
will read in Dr. David Schwabs article, the demographics of this group represent a huge
potential future need for comprehensive dental care.
Our featured reprint is a truly classic article by one of the pioneers of removable prosthodontics, Dr. Earl Pound. His article on utilizing s sounds to determine proper positioning of the anterior teeth is as pertinent today as when it was originally written in 1978.
Whether you are fabricating a new conventional denture, an overdenture or a screwretained denture, the set-up is the same.
Putting Dr. Pounds principles into practice, Dr. Anthony LaVacca discusses obtaining the
proper vertical dimension of occlusion. Visit inclusivemagazine.com to see his presentation and watch as he dials in the VDO with the provisional restoration.
Also included in this issue are two feature articles related to treating edentulous patients.
In a case report, Dr. Tim Kosinski illustrates how a two-dimensional image, such as a
panorex, can be deceiving and how a 3-D CBCT provides a superior diagnostic and
treatment-planning tool. He then transfers the digital treatment plan to the clinical setting through the use of a Universal SurgiGuide. The other feature is the first article in
a series by Dr. Burton Melton and his son, Dr. Jeffrey Melton, in which they discuss the
critical role the patient interview plays in properly setting up a case and determining the
appropriate layers of care.
If an overdenture is your treatment option of choice, there are a number of attachments
available. The Locator attachment is one of the most popular thanks to its low profile,
ease of use and retention options. Paul Zuest, president of Zest Anchors, reviews the five
most common questions related to this attachment.
Rehabilitating fully edentulous cases with implant-retained or implant-supported restorations can truly be a life-changing event for patients, as well as one of the most
rewarding experiences for the clinician. After reading the various articles contained in
this issue, be sure to check out the online version of Inclusive magazine for expanded
lectures on demand as well as clinical and procedural videos.
Regards,
Dr. Bradley C. Bockhorst

Editor-in-Chief, Clinical Editor
inclusivemagazine@glidewelldental.com
Letter from the Editor
Contributors
Publisher
Jim Glidewell, CDT
Editor-in-Chief
Bradley C. Bockhorst, DMD
senior Copy Editor

Kim Watkins
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, Academy of Osseointegration, International Congress of Oral Implantologists and American Academy of Implant Dentistry, Dr. Bockhorst lectures internationally
on an array of dental implant topics. He maintains a private
practice focused on implant prosthetics in Mission Viejo, Calif.
Contact Dr. Bockhorst at 800-521-0576 or inclusivemagazine@
glidewelldental.com.
copy editors
Jennifer Holstein, Melissa Manna
Earl Pound, DDS (19011979)
Managing Editors
Jim Shuck; Mike Cash, CDT
Creative Director
Rachel Pacillas
Clinical Editor
Contributing editors
Dzevad Ceranic, Greg Minzenmayer
Graphic Designers/Web Designers

Jamie Austin, Deb Evans, Joel Guerra,
Lindsey Lauria, Phil Nguyen
Photographers/Clinical Videographers
Jennifer Brunst, RDAEF; Sharon Dowd;
James Kwasniewski
Illustrators
Kevin Greene, Phil Nguyen
coordinatorS/AD Representatives
Vivian Tsang, Teri Arthur
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.
2010 Glidewell Laboratories
Neither Inclusive magazine nor any employees involved in its publication (publisher) makes any warranty, express or implied, or assumes
any liability or responsibility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or
represents that its use would not infringe proprietary rights. Reference
herein to any specific commercial products, process, or services by
trade name, trademark, manufacturer or otherwise does not necessarily constitute or imply its endorsement, recommendation, or favoring
by the publisher. The views and opinions of authors expressed
herein do not necessarily state or reflect those of the publisher and
shall not be used for advertising or product endorsement purposes.
CAUTION: When viewing the techniques, procedures, theories and materials that are presented, you must make your own decisions about
specific treatment for patients and exercise personal professional judgment regarding the need for further clinical testing or education and
your own clinical expertise before trying to implement new procedures.
Inclusive is a registered trademark of Glidewell Laboratories.
Dr. Earl Pound, renowned researcher, clinician and lecturer of complete denture esthetics and function, graduated from the University of Southern California School of Dentistry
in 1923. He developed a celebrity practice in
Hollywood, Calif., which he put on hold to
volunteer for the Navy during World War II.
Dr. Pound was assigned to treat facial war injuries and was awarded a Navy commendation for his outstanding achievements in service. After the war, Dr. Pound returned
to West Los Angeles and began a lifetime in private practice,
dental research, writing and teaching. His many achievements
include: being honored by Evita and Juan Pern in Argentina,
receiving the Key to the City in Paris and achieving the Masters
rank in the International College of Dentists. Dr. Pounds teachings and numerous published works continue to inspire generations of dentists.
EDMOND BEDROSSIAN, DDS, FACD, FACOMS

Dr. Edmond Bedrossian graduated from University of the Pacific Arthur A. Dugoni School
of Dentistry in 1986, then completed a residency in Oral and Maxillofacial Surgery
at the Alameda County Medical Center. He
maintains a private practice in San Francisco
and is director of Surgical Implant Training
at the Alameda County Medical Center and
a leading researcher on the use of the zygomatic implant. Dr.
Bedrossian is a diplomate of the American Board of Oral and
Maxillofacial Surgery and a fellow of the American College
of Oral and Maxillofacial Surgeons. He is also on the board
of the Pacific Dugoni Foundation and the Brnemark Institute
and is current president of the Brnemark Foundation North
America. Contact Dr. Bedrossian at info@gidedental.com.
TIMOTHY F. KOSINSKI, DDS, MAGD, MS
Victor Rodriguez, CDT
Dr. Timothy Kosinski graduated from the University of Detroit Mercy School of Dentistry and
received a M.S. degree in biochemistry from
Wayne State University School of Medicine. An
adjunct assistant professor at the Mercy School of
Dentistry, he serves on the editorial review board
of numerous dental journals and is a Diplomate of ABOI/ID, ICOI and AO. Dr. Kosinski is a
Fellow of the American Academy of Implant Dentistry, receiving
his Mastership in the AGD, from which he received the 2009 Lifelong Learning and Service Recognition award. Contact him at
248-646-8651, drkosin@aol.com or smilecreator.net.
Victor Rodriguez studied Dental Technology

at Orange Coast College and Southern California College of Medical and Dental Careers. In
1994, he achieved certification in the Swissedent
Technique and passed the national CDT exam
in Dental Technology in the area of Full Dentures. Victor has 25 years experience as part of
a restorative team focused on reconstruction as
the in-house technician for a group of prosthodontists in Newport
Beach, Calif. He is active in local dental study groups and is a
member of the Osseointegration Study Club of Southern California
and American Prosthodontic Society. In 1995, Victor received his
Credential of Mastership in the Technology section of the American
Academy of Implant Prosthodontics. He is manager of the Removable Implant Department at Glidewell Laboratories and lectures
on removable and fixed-removable prosthetics from the lab perspective. Contact him at inclusivemagazine@glidewelldental.com.
Anthony LaVacca, DMD

Dr. Anthony LaVacca is a graduate of Temple
University Kornberg School of Dentistry. He
has served as director of the General Practice
Residency program and as interim director of
the postgraduate program in prosthodontics at
Montefiore Medical Center/Albert Einstein College of Medicine, where he is an assistant professor. Dr. LaVacca is a member of the American
College of Prosthodontists, ADA, AO and International Association
for Dental Research. He has lectured internationally on implantrelated topics. Contact him at 630-848-2010 or alavacca@aol.com.
A. Burton Melton, DDS

Dr. Burton Melton has practiced dentistry in
Albuquerque and Santa Fe, N.M., since 1972.
He received his undergraduate degree from
Brigham Young University, his DDS from Baylor
College of Dentistry and his Diploma in Prosthodontics from the University of Missouri School
of Dentistry. He has lectured in the U.S., Japan,
Korea, Mexico, Taiwan and England. He has
also appeared as a guest lecturer at dental schools across the U.S.
Contact Dr. Melton at 505-883-7744 or abmeltonnm@aol.com.
J. Jeffrey Melton, DDS, MS

Dr. Jeffrey Melton graduated from Baylor College of Dentistry in 2003. He received graduate
diplomas in periodontics and prosthodontics
as well as a masters degree from the University
of Texas Health Science Center at San Antonio.
Dr. Melton recently completed his board certification in periodontics and is preparing for
completion of his board certification examination in prosthodontics. He practices in Albuquerque and Santa Fe,
N.M., and lectures extensively. Contact him at 505-984-8300 or
meltondds@gmail.com.
David Schwab, Ph.D

Dr. David Schwab presents practical, userfriendly seminars and in-office consulting sessions for the entire dental team. Fast-paced,
filled with humor and overflowing with
pearls, Dr. Schwabs seminars are as popular
as they are useful. An internationally known
seminar speaker and practice management
consultant who works exclusively with dental
professionals, Dr. Schwab has served as Director of Marketing
for the ADA and as Executive Director of the American College
of Prosthodontists. He currently works closely with Straumann
to educate doctors and team members about practice management trends to help them reach their full potential. Contact him at
407-324-1333, 888-324-1933 or davidschwab.com.
Paul t. zuest
Paul Zuest earned a bachelors degree in biology at California State University, San Diego.
He is president of Zest Anchors Inc., headquartered in Escondido, Calif. Founded by his
father, Max Zuest, in 1972, Zest Anchors Inc.
is one of the worlds leading dental attachment manufacturers. The company developed
and manufactures the Locator dental attachment for implant and root-retained overdentures. Paul, who has
more than 30 years experience in dental manufacturing, is an
Associate Fellow of the American College of Oral Implantology,
American Society of Osseointegration and International Congress of Oral Implantologists. He lectures nationally and internationally and has published several articles on a variety of dental
topics. Contact him at 800-262-2310 or zest@zestanchors.com.
Contributors
The Vertical Dimension of Speech:
The Pilot of Occlusion
by Earl Pound, DDS
Introduction........................................
This article discusses the various problems of vertical dimension, namely those of the face, of occlusion and of
speech. It stresses why the vertical dimension of speech
should be used as the primary guide for establishing the
vertical dimension of occlusion and when performing restorative procedures. The control for the vertical dimension of speech is the repetitive position the mandible
assumes when a person is enunciating s sounds at conversational speed.
The Face................................................
The vertical dimension of the face is related primarily
to esthetics. It is defined as a vertical measurement of
the face between any two arbitrarily selected points located one above and one below the mouth, usually in the
midline.1
This measurement is useful for comparing various vertical dimensions of occlusion and relating them to the
vertical dimension of the rest position. Its importance is
of secondary value, however, because the vertical dimension of occlusion cannot be established from this measurement alone.
Vertical Dimension of Occlusion.........
Figure 1: Procedure used to develop the vertical dimension of occlusion

by simple retrusion to a comfortable hinge position and closure to contact,
illustrating a classic s position with a Class I occlusion.
The vertical dimension of occlusion is probably one of

the most researched phases of complete denture prosthodontics, and the search for more valid controls continues. It is defined as a vertical dimension measurement of
the face when the teeth or occlusion rims are in contact
Figure 2: The ball on the lower ridge represents the repeatable

mandibular level of the s position and the vertical dimension of
speech. The three balls indicate the area in which different dentists
might place incisal edges of upper centrals. If lower centrals are
set to corresponding s positions, the effects on esthetics and the
vertical dimension of occlusion are very minor.
Figure 3: A classic s position of a Class II patient. Note the visibility and the wide posterior speaking space created by gross horizontal and vertical overlaps.
in centric relation. Many techniques are available for obtaining this level of occlusal contact, and the results vary
considerably. J. Landa has stated that the determination
of the maxillo-mandibular opening is, to a great extent,
work of an imaginative nature.2
dimension of speech, have a specific protective bearing

on the vertical dimension of occlusion and in determining the interocclusal posterior space required for different
classes of occlusion.
The vertical dimension of

speech should be used as
the primary guide for
establishing the vertical
dimension of occlusion.
Vertical Dimension of Speech..............
Such wide variations of these former results are completely unnecessary if the vertical dimension of speech is incorporated into the development of the occlusal scheme, as
it always indicates the most open and most closed usable
vertical dimension of occlusion, regardless of the degree
of ridge resorption or age. A recent article discussed that
the vertical dimension of occlusion can be developed by
setting the upper and lower anterior control teeth to the
s positions and then retruding and closing the mandible
until the lower anterior teeth are in contact (Fig. 1). These
same anterior controls, which are the key to the vertical
Although the s position can be considered either mandibular or dental, it is the mandibular position that is the
key to the vertical dimension of speech (Fig. 2). When s
sounds are being enunciated at conversational speed, the
mandible moves to the most forward and upward (closed)
position it ever assumes during speech. This spatial position is repetitive and recordable to within 1 mm of accuracy. The operational platform the dentist uses is the
anterior ridge of the mandible. Through this he relates
the teeth he places upon it to the static position of the upper central incisors, making this mandibular s position
visible and usable in establishing both the vertical dimension of speech and the clarity of the s sounds (Fig. 2, 3).
These replacements should theoretically restore the size
and angle of the lost teeth and the approximate amount
of lost bone structure.
All languages studied have visible and audible s positions.
The Vertical Dimension of Speech: The Pilot of Occlusion
Classic S
Position and Space
Atypical S Position
Figure 4: This classic s anterior speaking space can occur labial,

edge-to-edge or slightly lingual to the upper incisors.
Mechanics of the S Position .............

It is the muscles that control the mandibular movements
of speech that can move the mandible and its teeth into
the s position. When this occurs, if natural teeth exist,
the lower incisors are carried to within 1 to 1.5 mm of the
incisal edges or lingual surfaces of the upper central incisors. The resulting s sound is actually a subtle whistle created when air is forced between these two hard surfaces.
It is this clearance (or space between these teeth) and the
subtle whistle that permit the operator to clearly identify
the s level of the mandibular bone. If the tongue intervenes, as it does with tongue thrusters and in some difficult Class II situations, the s position cannot be identified as easiIy. However, the mandibular bone still has a
specific s level, and this can be ascertained and used
for developing the vertical dimension of speech for these
types of patients.
The s position is constant because the muscles controlling this level are programmed to this activity during a
persons formative years. The muscular activity of natural speech is effortless and nontraumatic. Thus, even if
a tooth is extracted, the comfortable muscles continue
to operate to this same level; in other words, the s position of the mandible is the same whether the patient is
dentulous or edentulous.
Figure 5: In atypical s positions, sharp enunciation is possible as

far lingual as the gingival tissues.
If age or lack of tonicity affects the muscles, all principles still apply, but the vertical dimension of speech and,
therefore, of occlusion, may be less than what previously
existed, and this is what must be used.
The s position of the

mandible is the same
whether the patient is
dentulous or edentulous.
There are two types of sharp s sounds. The classic type,
and by far the most common, occurs when the s clearance exists around the incisal edges of the upper and
lower central incisors (Fig. 4). The atypical type occurs
when the s clearance exists at any point on the lingual
surfaces of an upper central incisor (Fig. 5). Both types
permit a clear s sound; they always identify the vertical
dimension of speech.
The third type of s sound is considered abnormal and
occurs when the tongue intervenes between the lower
anterior teeth when s sounds are made. Such abnormal
s sounds occur with tongue thrusters, and they pose a
problem as to how to determine where to position the
Classic S Class I
Lingualized Occlusion
Anterior Occlusions
Verti-Centric
Classes I, II and III
Posterior S Space
23 mm Forward Movement
Slightly Variable Verti-Centrics
Figure 6: Normal incisal positions for the three basic classes of
occlusion
lower anterior teeth and how to identify their vertical dimension of speech and, therefore, their vertical dimension of occlusion.
Relating Speech to Occlusion..............

There are three basic classes of anterior occlusion:
Class I, for which the incisal edges of the lower anteriors rest in or anterior to the cingulum area of the upper central incisors; Class II, in which the lower anterior teeth contact distal to the cingulum and sometimes
on the palatal tissues; and Class III, or the edge-to-edge
type, which make their contact directly labial to or on the
incisal edges of the upper teeth (Fig. 6).
All three types must open to disclude the posterior teeth
in order to allow a person to speak, and when s sounds
must be made, 1 to 1.5 mm of clearance must be developed between the upper and lower central incisors.
The amount of discussion depends on the degree of
forward movement of the teeth from centric relation
to their s position. These movements define the incisal guide angle and represent the vertical and horizontal overlaps of the teeth. Thus, the greater the forward
movement, the greater the amount of posterior disclusion
and the resultant s space
or posterior speaking space.
Figure 7: This shows the posterior speaking space in a Class I

occlusion and how it is influenced by varying horizontal and vertical
overlaps. The lesser the forward s movement, the smaller the
space.
Vertical Dimension of Occlusion.........

The teeth should never contact during speech. In fact, the
closest contact that ever occurs is when s sounds are
enunciated, and this s clearance should be established
when a patient is reading at conversational speed and is
unaware of the dentists interest in the s sounds.
Since the posterior teeth must never contact during
speech, the greatest vertical dimension of occlusion for
any person must be 1 mm less than the vertical dimension
of speech. Otherwise, speech contacts will occur.
Therefore, the vertical dimension of speech should be located first and can be used as a protective guide to determine what the vertical dimension of occlusion should be.
Posterior Speaking Space....................

The posterior speaking space which exists between posterior teeth when s sounds are being used can be used
to great advantage in determining the appropriate vertical
dimension of occlusion. The size of this space is largely
controlled by the distance the mandible moves forward
from centric relation to its s position. By ascertaining the
amount of this movement, the class of occlusion a patient
originally had can also be determined.
Classic S Class II
S Positions Class I, II and III

With No Forward Movement
Posterior S Space
410 mm Forward Movement
Variable Verti-Centrics
Figure 8: Class II patients have greater horizontal and vertical overlaps and, therefore, a larger posterior speaking space, which also
varies as shown.
If classic s positions exist in Class I occlusions, the

forward movement can create a vertical overlap of 1.5 to
5 mm with a corresponding posterior speaking space
of 1.5 to 3 mm (Fig. 7). This vertical overlap in Class II
patients can vary from 1.5 to 10 mm, and the posterior
speaking space can vary from 2 to 8 mm (Fig. 8).
Class III edge-to-edge occlusions have no forward movement, no incisal guide angle and practically no vertical
overlap; the posterior speaking space is only a fraction less
than the anterior s clearance, which is never more than
1.5 mm (Fig. 9).
The time to confirm

established tooth
positions, speech patterns
or jaw relations is at the
try-in stage.
Occasionally, a Class l or Class II patient has no or very
little forward movement in speech, which can prove very
disturbing if not recognized. Such variations never have
a classic s position, as they are atypical or palatal. Since
10
Posterior Speaking Space

Minimum-Maximum Verti-Centric
Figure 9: A Class III occlusion showing minimal posterior speaking space. These occlusions, and very rarely some for Class I
and Class II patients, have no forward movement and this same
minimal space.
there is no forward movement, their posterior speaking

space and their vertical dimension of occlusion should
be studied and managed in the same manner as that of
Class III patients (Fig. 9); they exhibit the same minimal
posterior speaking space.
Another unusual situation occurs with the Class III occlusion, in which the lower anterior teeth are labial to
the upper anterior teeth and have a severe labial overlap
(Fig. 10). As with all Class III occlusions, these, too, exhibit
the classic s position; however, the s space is labial to
the incisal edge of the upper centrals instead of lingual as
in Class I and II occlusions.
Patients exhibiting this type of Class III occlusion will
also have a gross posterior speaking space. Thus, it is at
times advantageous to open the former vertical dimension of occlusion; this will improve appearance during
mastication and swallowing and, because masticating and
speaking activities are always in centric relation, no temporomandibular joint problems will develop.
Extensive experimentation with diagnostic dentures as
problem solvers has indicated that the vertical dimension of occlusion is a more flexible entity than has been
assumed, especially in severe Class II and labial version
Class III occlusions.
Atypical Anterior Occlusion
Sharp Upper
Cusps
Occurs Only in
Class III Occlusions
Nonfunctional
Buccal Cusps
Shallow
Fossae
Figure 10: A Class III occlusion with a labial overlap. A classic s

position always exists in these patients with gross corresponding
posterior speaking space.
Operative Procedures..........................
It is the dentists responsibility to ensure that clarity of
speech remains after all restorative procedures and that
no teeth contact during speech. The space for the subtle
whistle of the s is the key to success.
When using, as most do, occlusion rims to establish the
vertical dimension of occlusion, one has little opportunity to work with speech. The lower anterior teeth,
for example, must be positioned primarily by judgment;
however, the dentist can change this position at the tryin stage to improve phonetics and then relate the new
s clearance to the vertical dimension of occlusion that
has been established and correct it if necessary. But this
may become a very time-consuming procedure.
In contrast, operators who first set the upper and lower
anterior control teeth to s positions and then obtain
the verti-centric registration by retrusion to centric relation and closure to contact3 (Fig. 1) have automatically
related the anterior setting to the vertical dimension of
occlusion and can usually limit their try-in time to mainly
esthetic considerations. To aid in this procedure method,
an Analytical Control Chart (page 13) was developed to
help control these earlier procedures in relation to the
s position and occlusion.4
Establishing the vertical dimension of occlusion for patients
Figure 11: In Iingualized occlusion, the efficiency of the lower buccal cusps is eliminated and all sharp upper lingual cusps operate in
open lower fossae. This reduces lateral stresses and centralizes
the power of chewing for complete dentures.
with normal speech patterns and jaw relations poses no

great problem, but serious difficulties can be encountered
with some Class II and Class III patients, as well as tongue
thrusters and lispers. For these patients, a very visible
guide for developing a safe vertical dimension of occlusion
is available that uses the vertical dimension of speech.
Let S Be Your Guide ............................

The time to confirm established tooth positions, speech
patterns or jaw relations is at the try-in stage. The Analytical Control Chart, sections CD, C15, C16 and C18, can be
used to this end by any operator, regardless of how teeth
were positioned, who positioned them and what the tentative jaw relations are. The chart recommends that, using
an articulator, all teeth except the lower posteriors be set
up; a flat wax rim contoured to the width and position of
the future lower teeth is to be used in place of the lower
posteriors. Here, a lingualized occlusion is strongly advocated because, in addition to other advantages, this will
permit only the tips of the lingual cusps to touch the wax
rim. Any contacts or the amount of the posterior speaking space will be, thus, clearly visible when the patient is
reading at conversational speed (Fig. 11).
If contacts exist, or if there is an insufficient posterior
speaking space, the wax can be reduced as necessary. If
11
When s sounds are

being enunciated at
conversational speed, the
mandible moves to the
most forward and upward
(closed) position it ever
assumes during speech.
controlled s position should be developed. This will

produce a more accurate incisal guide angle, and the balancing walls of the lower fossae will be in harmony with
these more natural controls. A comfortable and esthetic
occlusal scheme will then result.
When anterior restorations of any type are being made,
s controls should be monitored and prematurities of
speech cleared. In ceramo-metal procedures or any type
of anterior restoration, the framework should be cleared
and the biscuit bake should be refined to accommodate
the entire range of the mandibular movements of speech.
summary..............................................
the space is larger than needed, the vertical dimension
of occlusion can be opened by adding layers of wax on
the lower rim. In this manner an acceptable vertical dimension of occlusion can be safely coordinated with a
satisfactory posterior speaking space (Fig. 79). The lower
posterior teeth can then be placed and balanced using
the condylar controls already established and the refined
incisal guide angle.
This article has emphasized the value of applying the

vertical dimension of speech as a protective and esthetic
guide for all forms of prosthetic restorations. It has also
reviewed how to use posterior speaking spaces as a control when developing the vertical dimension of occlusion
for all types of patients.
Reprinted by permission of the California Dental Association. "The Vertical Dimension of Speech: The Pilot of Occlusion" by Earl Pound, DDS: CDA Journal, Feb.
1978, pp 4247.
Restorative Procedures ......................

These concepts also apply in restorative procedures. In
full-mouth rehabilitation, where the operator is required
to rebuild the entire occlusal scheme on the articulator,
condylar and incisal guide angles are usually established
via pantographic writings made by excursions on rather
flat surfaces. Such techniques will not, however, record as
true an incisal guide angle as the patient had.
During these procedures (before wax-ups and tooth positions or lingual contours are completed), more natural
relations between the upper and lower incisors as
dictated by the mandibular movements of speech and a
12
references...........................................
1. Glossary of Prosthodontic Terms. Education and Research Foundation, Detroit,
Michigan.
2. Landa, JS. The freeway space and its significance in the rehabilitation of the
masticatory apparatus. J Pros Dent 1952;11:757.
3. Pound E, Murrell GA. An introduction to denture simplification. J Pros Dent
1971;26:57080.
4. Pound E. Controlling anomalies of vertical dimension and speech. J Pros Dent
1976;36:12435.
ANALYTICAL CONTROL CHART

Set-up maxillary anterior teeth
C1
Determine the position of the lower anterior teeth

by adjusting the speaking wax to the classic s position
C2
20
C3
Wax acceptable
anatomically
Wax is
too short
Wax assumes an
unusable angle
Wax is
too long
No s is possible
Tongue thruster
75%
5%
Try to correct wax by altering upper teeth
Successful
C5
Not successful
Reset wax to a normal angle and a length equal to lost bone

and tooth structure. Try to develop an atypical "s" position.
C7
Short and angled waxes usually

develop an atypical s positition
with minor changes in the
upper teeth
C8
C10
C16
No s is possible on the long wax and

a few of the short and angled ones
(tongue thrusters)
Replace speaking wax with 2 incisors
Use speech and esthetics

to refine tooth position
Refine s clearance
Determine retruded contact
C12
C14
C9
If on palatal tissues
If on upper teeth
Record verti-centric by retrusion and closure,

by the swallowing technique or by any desired
method. None is dependable.
Record verti-centric by
retrusion and closure
Mount casts in articulator of choice

Set-up all teeth except the lower posteriors. Use a flat wax rim in their place.
C6
C9
C8
C11
C13
C15
C16
Have a try-in
C17
Refine esthetics
Refine s clearance
Set articulator controls
Use lingualized occlusion
With patient reading, study posterior speaking space to

refine vertical dimension by altering height of wax rim. Space
will vary in direct proportion to mandibular forward movement.
More movement, more space, varying from 110 mm.
C18
C19
Linear or diagnostic dentures

may now be completed for this
type of patient
Making diagnostic dentures is strongly advised for these types

of occlusions. This permits refining, through use, of their
existing problems. Linear dentures might perpetuate them.
C20
Earl Pound, DDS 1975

13
Where Is the Vertical?
Basic Principles to Find Lost Vertical

Dimension for Full-Mouth and
Implant Rehabilitation
by Anthony LaVacca, DMD

One of the most common questions that arises with larger cases is: Where
is the vertical dimension? How did you find
the vertical dimension? How did you transfer
the vertical dimension to the final prosthesis?
It seems like all of us struggle with this concept, and we try to use a significant amount
of classic laboratory information to fit our patients into a generic tooth set-up. But all our
patients are not the same. In this article, I will
present principles from a classic article by
Dr. Earl Pound, Let S Be Your Guide,1 to
help you determine where the correct vertical
dimension is located. This technique may help
you, as it did me, to find where a true vertical
dimension is and how it relates to your fullmouth rehabilitations, implant rehabilitations,
denture cases and cosmetic dentistry patients.
You can read a similar article by Dr. Pound,
The Vertical Dimension of Speech: The Pilot
of Occlusion, on page 6 of this issue.
I have a study club in Naperville, Ill., where
my practice is located. Basically, its a group of
doctors who get together on a monthly basis
to review some of the problems that arise in
Where is the Vertical?
15
our practices. During our discussions, we describe the

complications encountered during the past month and
work together to resolve them.
Sometimes we get caught

up in the esthetic component
of our cases and forget about
the functional part.
Figure 1: Patient with advanced periodontal disease
Routinely, when I conduct lectures about vertical dimension, I ask the question, Who here likes to treat
full-mouth rehabilitations? If I have an audience of
100, Ill see 30 or 40 hands go up. Then I lead into,
Who likes to treat veneers? Every hand in the audience goes up. Then I throw a little curveball and ask,
Who really likes to fabricate dentures? Literally, four
or five hands out of 100 will go up. Its really interesting that no one likes to do dentures anymore, yet
the foundation for our full-mouth rehabilitations and
many of our cosmetic veneer cases is developed from
basic denture principles.
Sometimes upper and lower full dentures are the hardest full-mouth rehabilitation cases to treat, unless we
have implants in place. Dentures allow patients who
are edentulous to have teeth, smile and have a feeling that they are whole again. Can you imagine what
it is like to have dentures? But dentures also need to
be functional, and so do our full-mouth rehabilitation and veneer cases. Sometimes we get caught up in
the esthetic component of our cases and forget about
the functional part. One of the key functional parts is
vertical dimension and occlusion. When youre starting from nothing, meaning you have two edentulous
arches, and maybe the case was referred to you (the
restorative doctor), and you have no teeth to guide
you, no diagnostic casts, no wax-up, you need to find a
starting point. Or your patient comes in with dentures
and his or her face looks terrible. The solid starting
points to help you treat your patient come from our
basic denture principles.
Figure 2: Patient restored with complete dentures
16
Using these solid denture principles, we can take a

patient who comes in with significant advanced periodontal disease, as demonstrated in Figure 1, and bring
her back to a youthful appearance, as demonstrated
in Figure 2, by providing proper facial esthetics and
tooth position for a smile that is harmonious with the
patients face.
Proper facial esthetics and tooth position must be built

within the boundaries of the patients vertical dimension and occlusion. When treating large implant reconstructive cases, the question always becomes: How
did you do that? Did you treat the patient with five
implants, 10 implants? The number of implants doesnt
really matter. Its actually the positioning and length of
the abutments that establishes resistance and retention
form of your prosthesis (Fig. 3).
If we are replacing hard and soft tissue on implants,
its critical to understand where the vertical dimension
is and how to find that position, because that is going to be our starting point for developing esthetics
and function. When the vertical component is overclosed, the typical result is a Class III or witchs chin.
This usually leads to poor facial esthetics and lack of
lip support. But this is only the esthetic component.
Functionally, it is difficult to chew because the occlusal plane is low, making it difficult to bring the food
back onto the plane due to its lower position. The patient also needs to be able to speak properly and smile
in a way that is attractive and complements his or her
facial characteristics.
Proper facial esthetics

and tooth position must be
built within the boundaries
of the patients vertical
dimension and occlusion.
Figure 3: The abutments establish the resistance and retention

form of the prosthesis.
For patients who have been edentulous for a considerable amount of time and have lost a significant amount
of bone, one of our concerns within the vertical component is the loss of gingival tissue and the alveolus. If we
are replacing the gingival tissue, the alveolus and the
teeth, its critical to know where this vertical position
is when were designing our substructure. These cases
become significantly expensive in the laboratory if we
dont have the vertical properly set along with the proper tooth position.
So what does it matter? The vertical component will
allow us to make the patients teeth within the muscular component and within the physiological component of his or her musculature, lip support and
speech. That will give us a final result that is proper
in form, function and esthetics. The patient in Figure 4
Figure 4: This patient demonstrates basic denture principles.
17
demonstrates several basic denture principles. The

mandibular tooth plane bisects the corners of his
mouth. His smile line follows the lower lip. If you could
hear him speak, he would be able to demonstrate how
his sibilant sounds function within the arena of his
maxillary-mandibular rehabilitation. We would know
that his fricative sounds are something that we are
going to utilize to establish maxillary anterior tooth
length. But, once again, all of these factors need to
function within the muscular realm of our patient for a
successful functional and esthetic result.
Now lets take a look at real life. In Figure 5, we have
a midline that properly divides the face through the
center of the nose and the lips. A horizontal line can
be drawn through the pupils. Two additional parallel
lines can be drawn to break the face into thirds.
In Figure 6, we have a patient whose interpupillary
line is even. If we look at her face for vertical symmetry, we see that it is divided into equal halves. One of
the things that really jumps out with this patient, however, is that her lower third is significantly larger than
her middle third. This makes her look, as she stated,
like a witch or very old.
Figure 5: Cosmetic model demonstrating midline and horizontal
planes.
Figure 6: This patient exhibits a lower third that is significantly

larger than the middle third.
18
What the patient really wants is to look young again.

She wants to look the way she did when she was
20-some-odd years old. We have all encountered this
type of patient. When we look at our patient from a
lateral view (Fig. 7), you can really see that the lower
third is exacerbated. One of the things with the lower
third being exacerbated is, if we take a closer look
with the closed vertical dimension, youll notice a significant number of lines or wrinkles in her mid-face
(Fig. 8). You would never want to tell a female patient
that her lips look wrinkly, but this patient demonstrates an overclosed vertical dimension and subsequent deepening of the nasolabial folds. With this also
comes a loss of the vermilion border or an inversion
of the wet-dry line. When we retract her lips, we can
see the reason for the above characteristics and the
related prosthesis (Fig. 9).
When a patient has had a denture for many years, we
have a loss of bone in the maxilla, a loss of bone in
the mandible and a significant loss of vertical dimension, or supposed loss of vertical dimension. We have
to get back to our starting point. Why would we want
to follow traditional laboratory denture guidelines
and set the teeth over the ridge after there has been
a significant amount of bone loss? It really doesnt
make sense. If were going to set teeth over the ridge
and the bone has resorbed, are we setting the teeth in
the right position? And if we do this, will it make our

patient look old?
The panoramic view in Figure 10 demonstrates the patient before implant placement. You can see how much
bone loss shes had over the years. How do I know
shes had a significant amount of bone loss? We had
the mental nerve sitting on the crest of the ridge and
the maxillary arch is severely atrophic.
Stabilizing the mandibular

denture allows us to increase
the vertical dimension and
bring the maxillary and
mandibular teeth forward
to fill out the mid-face.
The patients primary goal is to look younger. So she had
five implants placed in the mandible (Fig. 11). Why the
mandible? Stabilizing the mandibular denture allows us
to increase the vertical dimension and bring the maxillary and mandibular teeth forward to fill out the midface, developing superior esthetics. How, you may ask?
Stabilizing the mandibular denture with implants also
removes the ability of the muscular component to lift
the denture while the patient performs normal actions.
In summary, with the prosthesis now anchored, we can
bring the teeth forward, past the crest of the ridge on
the mandible, allowing us to bring our patients maxillary teeth past the crest of the ridge, creating a fuller,
more esthetic look and enabling our patient to smile
with confidence.
Figure 7: Lateral view
Figure 8: Pronounced wrinkles due to collapsed vertical and loss

of mid-face support
Figure 9: Patients existing denture
Our patient presented to an oral surgeon and had implants placed in the hopes of achieving a more youthful appearance. But with the way the initial dentures
were constructed over the ridge, with a significant
loss of vertical dimension, they made her look old. She
was not happy.
Figure 12 shows the final result, which made the patient happy and met her expectations. To achieve your
patients desired result, I advise conducting an interview to develop a rapport to determine your patients
expectations prior to treatment. Have the patient
bring in pictures and photographs of when they were
younger, of how they looked, how their teeth looked.
The end result that really made this patient happy was
Figure 10: Preoperative panoramic film
19
restoring her smile filling out her smile and making

her look youthful again. I knew from the start I would
be successful with her treatment because of all the
deficiencies with her previous prosthesis.
Figure 11: Post-operative radiograph
Figure 12: New dentures at correct VDO
Figure 13: The distance from the incisal papilla to the incisal
edge was increased to 13 mm.
Figure 14: New versus old mandibular denture
20
Utilizing the incisal papilla

as a stable point, I was
able to measure from the
distal aspect of the incisal
papilla to the incisal edge
of the old denture.
When I look at our patient, one of the things I see
is an older woman who takes good care of herself.
How do I recognize that? She goes to the beautician
frequently; she colors her hair; she manicures her eyebrows. Whats interesting about her eyebrows is she
manicures them so they are higher and thinner than
her existing eyebrows, which gives her eyes a brighter,
more youthful appearance. She also wears mascara and
lip liner. Lip liner is especially important to create the
illusion of larger lips. By lining the lips up over their
natural border, it gives them a fuller look. When our
patient presented to me, as seen in Figure 6, she was
very unhappy with the way her dentures looked. She
showed me pictures and demonstrated to me how she
routinely looks and wants to look, so we were able to
find her vertical dimension. We worked on esthetics,
tooth size, shape and color from her pictures and from
her diagnostic information, and then we gave her back
her smile.
Now, Ill explain how this was achieved. I transferred
her denture information to the master cast. By utilizing the incisal papilla as a stable point, I was able to
measure from the distal aspect of the incisal papilla to
the incisal edge of the old denture. This demonstrates
the incisal edge tooth position is 9 mm from the incisal papilla. For the new denture, I took the position
from the incisal papilla and measured the same way
and had a total distance of 13 mm (Fig. 13). What will
this do for our patient facially? It begins to unfold
and rejuvenate the maxillary mid-face by reducing
wrinkles on her maxillary lip. Subsequently, it will
fill out the nasolabial folds and give our patient a
more youthful appearance. Once we couple that with
the vertical dimension component, well be able to
establish that vertical and maintain the mandibular
denture in place by stabilizing the lower denture with

the implants. This will then give our patient the functional esthetic and look she desires.
Were finally getting to the point of explaining where
the vertical dimension is and how we find it. If we
look at the two dentures in this case side by side, you
can see theres about a 10 to 15 mm increase in our
patients final denture, versus the denture she came
in with (Fig. 14). With the final denture, we have also
included lifelike tissue modification. You can see the
amount of soft and hard tissue being replaced with
our denture acrylic to give us that increased vertical
dimension (Fig. 15).
Figure 15: New mandibular overdenture
But how do you know where the vertical dimension is?

Lets take a look at our starting point. In Figure 16, I
measured the patients vertical dimension with her existing dentures in place and, using a tongue depressor,
made two marks on the depressor and some marks on
her face. Then I measured her vertical dimension with
the new denture in place. I have actually opened the
vertical dimension a full centimeter (Fig. 17).
What Dr. Pound considered

to be a great starting point
for vertical dimension was
to use phonetics.
This is where we get into why Dr. Pounds article is
so important. What I want to drive home is where
that vertical dimension is and how we find it. What
Dr. Pound considered to be a great starting point for
vertical dimension was to use phonetics, or as in the
title of his article, Let S Be Your Guide. Dr. Pounds
article gives you the information you need to find the
vertical component by using the sibilant sound or the
s sound. When you say s, a number of things happen. The lateral borders of your tongue will go up
and touch the inner aspect of the pre-molars. As the
lateral borders of the tongue touch the inner aspect of
the pre-molars, the tongue forms a groove. When the
tongue forms a groove, air is expelled; that s sound
goes over the maxillary central incisors and through
the mandibular lower incisors. So with the sound s,
youre getting a lot of information.
Figure 16: VDO of existing dentures as a starting point
The s sound will give you something called the closest speaking space. The closest speaking space is
21
where the mandibular plane and the maxillary plane

are as close as they possibly can be to allow for your
restoration, your full-mouth rehabilitation or your denture to function in the closest space that it can function
within the patients muscular realm. When the patient
says s, the mandibular teeth are approximately 1 mm
from the maxillary posterior teeth. The sibilant sound,
or the s sound, is your guide for vertical dimension.
With the sibilant sound, we discussed how the tongue
braces against the pre-molars to say s you can feel
that. That s and the lateral border of the tongue will
give you the patients maxillary posterior tooth position by allowing it to fill out the buccal space. If the
maxillary arch is too constricted, your patient may say
s and come up with a shushy type sound. This also
makes it very difficult for the patient to eat and chew.
Figure 17: New VDO
Figure 18: VDO was increased approximately 1 cm.
So the s sound has to be a function of a vertical component Dr. Pounds closest speaking space and a
horizontal component, allowing the tongue to fit into
where the teeth should be. For a functional s sound,
the maxillary anterior teeth and mandibular anterior
teeth need to be positioned in approximately 1 mm
vertical and 1 mm horizontal overjet, so that with the
s sound the air is expelled over those teeth to give
the patient a proper s sound.
If we look at the tongue depressor in Figure 18, we
see about a complete centimeter. This brings us to the
mystery of how I opened the patient up that much in
the quick timeframe. I argue I didnt really open her
up that much. To me, this patient was overclosed for
too long, and by fabricating her new prosthesis utilizing Let S Be Your Guide, I really just restored her to
her original position. So I really didnt open the vertical. I just found the proper position for her vertical
dimension that was within the functional guidelines of
her speech and desired esthetics.
Looking back at our patients lateral view, we can see a
loss of vertical dimension (Fig. 19). There are increased
nasolabial folds and a long lower third. In Figure 20,
with the vertical dimension opened up a full centimeter, look at what happens. She looks beautiful again. We
have increased her middle third; we actually brought
her middle third out to be almost parallel with her chin.
We have rolled her lip out to give her an appearance
of youthfulness. Her lower third has not really changed
much; weve done all of the adjustments in the maxillary third. But with that increase of vertical dimension,
notice her chin point. Something that comes up with
increasing the patients vertical dimension is, as you
open it the mandible follows the arch of closure and
22
swings posteriorly, bringing the chin back automatically. And thats what was created to give our patient a
smile. If we look again at the red line on the facial in
Figure 19, it completely demonstrates how she looked
with her old dentures. Now if we draw the same line
(Fig. 20), we have close to a vertical appearance, and it
gives our patient the facial esthetics she desired.
By fabricating her new

prosthesis utilizing
Let S Be Your Guide,
I really just restored her
to her original position.
But with all that said, theres a big negative here. With
an increase in vertical dimension, one of the things that
develops as the mandible swings downward is that the
patient will gather an excessive amount of skin in the
neck area. So once again, as you increase the vertical,
the tissue underneath the patients chin will begin to
bunch up. Remember, our patient is very conscious of
the way she looks. She spoke to me about this and I
told her there is nothing I can do about that; she needs
to see her plastic surgeon.
Figure 19: Mid-face profile with old denture
So lets recap. The patients existing denture with an

overclosed vertical, teeth set over the ridge provided
her with an older appearance, which she was not
looking for when she had her dental implants placed.
She thought implants would give her a more youthful appearance.
With the new denture, we were able to give our patient
the tooth size and shape she wanted. We were able
to bring the maxillary anterior teeth forward from the
ridge approximately 13 mm, by the incisal papilla. We
utilized Dr. Pounds Let S Be Your Guide to develop
and find where the vertical should be through her sibilant sounds, and that allowed us to develop the buccal
corridor because our pre-molars were in the right position. So our sibilant sounds were fabricated through
Let S Be Your Guide 1 mm vertical and 1 mm
horizontal overjet of the maxillary and mandibular anterior teeth. This gave our patient the look she wanted.
Figure 20: Improved profile with increased VDO and mid-face

support
If we take that tooth position and we look at where

our patient wanted to be, using the cosmetic guidelines, and looking at her where her existing denture
23
was (Fig. 21), and then the final with her lips together,
you can see in Figure 22 theres a decrease in that
nasolabial fold. She looks great, and now our patient
is happy. We have met her expectations through the
use of dental implants and have given her the superior
smile she wanted and deserved (Fig. 23).
References
1. Pound E. Let s be your guide. J Prosthet Dent 1977;38:48289.
Figure 21: Appearance with old denture
Figure 22: Patient restored at proper VDO
Figure 23: Final restoration
24
by A. Burton Melton, DDS and J. Jeffrey Melton, DDS, MS

One of the most critical and life-altering services we provide as clinicians is caring
for the edentulous patient. The functional and esthetic concerns the edentulous patient confronts are unique and challenging. A traditional approach to treatment frequently provides only an
acceptable outcome, rather than a superior result. This article will address a better way to go about patient
care. A future article will expand on providing treatment for the edentulous patient once a treatment plan
has been developed.
When a patients teeth are removed, alveolar bone immediately begins to resorb and continues to do so over
the lifetime of the patient. The degree of resorption has everything to do with the difficulty and, sometimes,
marked limitations of what a clinician can do to restore a patient to function with good support and satisfactory
appearance. Clinically, there are two ways to go about providing patient care. Typically, the clinician describes
the problem(s) to the patient, gains case acceptance, makes financial arrangements and then starts treatment.
Starting treatment involves applying the techniques or tricks the clinician has learned to produce a result:
prosthesis, denture or plate. The clinician hopes the new result will be better fitting and more attractive than
or at least as good as the patients previous prosthesis or dentition.
However, there is another, better way to go about this process. Decades ago, during an epochal time in dentistry, Dr. Robert F. Barkley, the father of preventive dentistry, revolutionized the dental profession with his
innovative approach. Redefining the doctor-patient relationship, he stressed the need for doctor-patient codiagnosis and co-treatment planning.
Building on Dr. Barkleys philosophy, we advocate that proper patient care must begin with a thorough dual
interview, during which the doctor interviews the new patient, and vice versa, to gain a better understanding of the patients needs, desires and expectations. During this interview, the doctor and patient should
discuss the patients health and life circumstances (i.e., limited time, limited finances, inadequate health).
This initial interview is used to create provisional and definitive treatment plans, offering the patient levels, or
layers, of care. Price ranges for these treatment plans should also be discussed, in order to help the patient
select the appropriate layer of care. These layers of care enable the patient to accept treatment beyond what
is acceptable or satisfactory. Instead, an appropriate, definitive treatment will be achieved that will include excellent esthetics, a secure and truly functional prosthesis or restoration, clear speech and an enhanced quality
of life. The selected treatment plan should marry the patients wants and wishes to what is clinically possible
and affordable. Working within these layers of care allows the patient to decide, level by level, whether they
need or want a more advanced layer of care.
This more comprehensive approach enables the patient to fully understand his or her current dental health
and what he or she can achieve. Under this model, the doctor and lab work together to fulfill the patients
expectations in a way that is affordable for the patient. This allows everyone involved the patient, the
doctor and the laboratory technician, who have been charged with making the impossible or improbable a
clinical reality to achieve the desired result.
26
How It All Begins: Data Gathering and Analysis

There is an axiom in dentistry: Never treat a stranger. The idea is
the doctor should spend time talking to the patient to understand
his or her desired result and decide whether he or she is going to
be able to help the patient. The patient interview should, at the very
least, cover the patients wants, needs and expectations, followed by
the doctor asking the patient, Have you thought of a budget for your
dental care?
One of the most

critical and lifealtering services
we provide as
The patient should also undergo an orofacial examination as well

as a review of his or her health history. Photographs with and without the prosthesis should be taken and impressions made for diagnostic casts.
clinicians is
caring for the
A well-made maxillary denture is the perfect diagnostic tool for a

subsequent implant-supported overdenture, implant-supported fixed
prosthesis or hybrid prosthesis that is fixed as well as removable.
This diagnostic denture is the architectural model for the final result
and a stepping stone to the patients next layer of care.
edentulous patient.
At the time of the esthetic trial denture, both the patient and the
doctor should be satisfied with the prosthesis in terms of esthetics, phonetics and occlusal function. If the doctor has done his job
well, the initial prosthesis is the practice of fine dentistry, allowing evolution to the highest level of technicality and facilitating a
better quality of life. (Note: Several protocols are acceptable to make a
trial/diagnostic denture and/or a definitive denture. This will be the subject
of a future article.)
After the trial denture is made, the patient and the doctor each have
the opportunity to terminate treatment, if either or both believe the
continuation of treatment will not lead to patient success. (Dr. Earl
Pound was a leading proponent of the trial denture before the definitive or best treatment plan is provided.)
A
There is always a terminal point in care, at which the clinician

has done the best he or she can to please the patient. Anything beyond this only frustrates all parties, sometimes causing anger or, in
extreme cases, litigation brought by the unhappy patient. To avoid
this, the doctor and the patient should agree on an acceptable midtreatment termination fee before treatment begins.
Once the patient and the clinician accept the trial denture, it can
be processed into a Scan Appliance. The type of Scan Appliance
should be based on the type of radiology to be utilized. In the
past, a panoramic film was standard. Now we can use Cone Beam
Computerized Tomography (CBCT) to create 3-D images. The CT
data is imported into implant planning software and the case virtually designed.
The information gathered can then be utilized to develop a treatment plan for the patient. The case illustrated here will be used to
demonstrate fixed and fixed-removable prosthetic options.
B
Figure 1a, 1b: Digital plan for eight implants to be restored with
four 3-unit bridges
27
Case Study
The patient in this case is a young, attractive female. She is edentulous in the maxilla, with a full complement of mandibular teeth. She
desires a fixed ceramic restoration, if possible.
After the initial patient interview, the patients records are reviewed
and photos are taken. These images plus the digital plan and diagnostic casts are used to determine the limitations of treatment.
Digital Planning Options

A
a. The doctor can do his own treatment planning using a

CBCT scan and planning software.
b.
The doctor can send the scan of the patient to a third
party, who will do the treatment planning and the surgical
guides. (This frequently leaves the doctor out of the loop.)
c. The scan can be sent to a planning center, where the planning experts schedule a Web conference with the doctor to
co-diagnose and co-treatment plan the case. (The clinician
doesnt need his own software in this scenario.)
Treatment Options
Figure 2a, 2b: Digital plan for six implants
The selected
treatment plan
should marry the
patients wants
and wishes to
what is clinically
possible and
affordable.
28
The first treatment option is eight implants for a segmented restoration (eight implants supporting four 3-unit bridges) (Fig. 1a, 1b). It is
best for Stage I and Stage II ridge resorption patterns. This option
does not present any restrictions to the clinician or the laboratory,
but its high cost can be restrictive to the patient.
A second treatment option is six or more implants broken into one to
three fixed-bridge segments. The positions of the implants are based
on the arch form, the anterior-posterior spread and available bone.
For a square arch form, the most anterior implants are placed in the
canine positions (Fig. 2a, 2b). For a tapering or U-shaped arch, the
anterior implants are placed in the incisor region. This option offers
increased stability, especially where vertical bone loss exists. Permanent or removable bridgework can be used, and hard or soft tissue
grafting may be required. Splinting dramatically increases stability in
all three planes (X, Y and Z axes). With this option, porcelain fracture
can be catastrophic, unless there is an element of retrievability so the
units can be repaired versus having to be replaced.
The third option is All-on-4/6 (fixed bridgework on four to six implants) (Fig. 3a3c). This option is a splinted but removable restoration, usually screw-retained, that requires four implants maybe
more, if space allows. It has a titanium framework with denture teeth
and pink acrylic. No bone grafting is required. Often implants are
immediately loaded with a fixed provisional followed, after adequate
healing time, by a one-piece fixed restoration.
A variation of the third option is a Premium Hybrid (sophisticated
fixed-removable; titanium framework with individual all-ceramic
crowns) (Fig. 4a). This is the same as the first option listed, but all
Figures 3a3c: All-on-4 digital plan. The posterior implants are

angled distally to increase the A-P spread.
implants are connected by a CAD/CAM titanium framework that has a gingival mask (pink composite)
and individual ceramic crowns. More extreme bone loss requires creating the appearance of the patients
original hard and soft tissue. This option provides a high level of esthetics, but due to the advanced technology required, it is considerably higher in cost for the laboratory, doctor and patient. Typically, eight
implants would be required to support this type of prosthesis (Fig. 4b).
Figure 4a: Premium Hybrid prosthesis
Figure 4b: Eight implants strategically spaced
Conclusion
The doctor-patient relationship is critical. Doctor-patient co-diagnosis and co-treatment planning provide a method to determine the appropriate layers of care. Through proper case set-up, treatment
options can be developed to match the patients wants and wishes to what is clinically possible and
affordable to the patient.
29
Top Questions
About the Locator Attachment

by Paul T. Zuest
Q.
How should I choose the correct-fitting

Locator Implant Abutment?
A.
The three pieces of information needed to select the proper-fitting Locator Abutment (Zest Anchors;
Escondido, Calif.) are: type of implant, diameter of implant and tissue cuff measurement. Locator Abutments are available for all major implant systems and have tissue cuff heights ranging from 0 to 6 mm
in 1 mm increments. The tissue cuff height measurement must be taken at each implant site using the
deepest side of the tissue for measuring from the apical shoulder of the implant to the crest of the tissue.
If the measurement is 3 mm, choose a 3 mm tissue cuff height for the Locator Abutment. If the measurement is 3.5 mm, choose the next highest tissue cuff available, 4 mm. This will place the working portion
of the Locator Abutment at or slightly above the gingival level.
Editors note: Another option is to take an implant-level impression and allow the lab to select the
appropriate attachment using the master cast.
30
The tissue cuff height measurement

must be taken at each implant site using
the deepest side of the tissue for measuring
from the apical shoulder of the implant
to the crest of the tissue.
Q.
What torque value should be used to

tighten the Locator Abutment?
A.
The placement of a Locator Abutment into the implant should always start with the tactile feel of the
hand driver to avoid cross-threading. However, the torque value of a hand driver is only about half of the
final torque value of 30 to 35 Ncm that is necessary to avoid loosening of the abutment during function
and possible fracture when the abutment is no longer properly supported by the implant. Special torque
wrench insert tools are available to fit all dental torque wrenches and connect directly to the triangle
drive portion of the Locator Abutment.
Editors note: The Locator instrumentation can be purchased through Zest Anchors (800-262-2310,
zestanchors.com).
31
Q.
A.
Why is the Locator Denture Cap only

sold with the Processing Male inside?
The Locator Denture Cap is never sold with the final nylon
insert because the Locator Processing Male eliminates any
pivoting off center while the titanium denture cap is being
processed into the denture and is designed to position the
metal cap into the proper position of vertical resilience.
The black Processing Male places the Locator Denture
Cap in the upper position of vertical resilience so that the
gingival tissue surrounding the abutment can help support
the overdenture during mastication function. The yellow Processing Male is used with Locator Bar
Attachments and places the Locator Denture Cap in the lower position of vertical resilience because
the overdenture is solidly supported by the bar.
Editors note: For lab-processed cases, Glidewell provides the attachment with the processing cap
(black for freestanding attachments, yellow for bar overdenture attachments). A vial containing the
spacer, as well as clear, pink and blue caps comes with each attachment. The desired caps can then be
selected and inserted based on the desired retention and the patients ability to remove the prosthesis.
Q.
A.
32
How many Locator Male

Attachments should be
processed at one time?
When placing Locator Denture Cap

Males into the overdenture using a
direct chairside process, the most
conservative approach is to pick
up one at a time and no more than
two at a time. After curing the first
Locator Cap Male into place, leave
the Processing Male in the metal cap
and make sure the denture snaps in and out properly. Repeat this process for each additional Locator
Cap Male so that any fit problem can be identified at a single site. After all the Locator Cap Males have
been cured into place and correct fit of the denture has been verified, remove the Processing Males
from the metal caps and replace them with the appropriate final nylon male retention cap.
Q.
A.
What is the proper level of retention for a

Locator Overdenture?
A good rule of thumb is

to start the patient with
just 6 pounds of retention
for his or her overdenture. That means using
two 3-pound pink Locator
Males if the patient has two Locator Abutments, and dropping down to 1.5-pound blue
Locator Males if the overdenture is supported by four Locator Abutments. Use of the
new nonretentive gray male can reduce overall retention of multiple Locator Attachments while still providing rest support for the overdenture.
A good rule of thumb is to

start the patient with just 6 pounds
of retention for his or her overdenture.
33
by David Schwab, Ph.D

I recently lectured at a seminar at which topics included the economy (not doing
great) and demographics (could not be better). I was asked whether, if I could
choose only one, I would wish for a thriving economy or favorable demographics. I chose demographics. Its not even a close contest. The economy moves in cycles so complex that it is difficult
even for economic experts to predict peaks and valleys. Demographic data, however, is inexorable. Demographers can tell us not only where we have been, but, with remarkable certainty,
where we are headed. Demographics are destiny, and the destiny of dentistry is profoundly positive for at least the next 20 years.
The numbers are startling because people alive today are the
first in history who can reasonably live to be old. In 1215, when
King John signed the Magna
Carta, average life expectancy was
33 years. In more recent times, life
expectancy has zoomed upward.
Life expectancy in the U.S. was 49.2
years at the turn of the 20th century and 77.5 years at the dawn of
this century, according to the Congressional Research Service.
In the U.S., we also have a baby
boom generation, those 76 million individuals who were born
between 1946 and 1964. The first
baby boomer will turn 65 very
soon: Jan. 1, 2011. Over the next
20 years, all the other boomers will
turn 65. The over-65 population
will number roughly 72 million in
2030, more than double the number of the year 2000.
Figure 1: Age profile of the U.S. in 1960
These demographic changes are represented in age pyramids, courtesy of the University of
Southern California AgeWorks. Figure 1 shows the profile of the U.S. in 1960. Note the high numbers in the lower age ranges as boomers were being added to the population. Figure 2 shows
the U.S. in 2010. The U.S. is developing a middle-age spread, as boomers are now in their 40s
through 60s. This chart tapers at the top because there are relatively few elderly compared with
35
the bulge in the population in the middle-age groups. Figure 3 shows a dramatic change in 2030.
The representation starts to look more like a box than a pyramid because boomers, now in their
60s through 80s, are near the top of the chart.
Beyond the sheer numbers, the aging population will significantly increase the demand for dentistry for the following reasons:
1. There have been innumerable studies that document the dental needs of the older population. In addition to the partially and fully edentulous, patients who have had dental treatment
in the past will need increased maintenance
for bridges, partial dentures and complete
dentures that need to be relined or replaced
with other dentures or implants due to bone
atrophy. In fact, the demand for dental implants will be particularly strong, driven by
demographics. In the older population, there
are also issues of decay, periodontal disease,
worn natural dentition, failing restorations,
xerostomia and a continuing need for oral
cancer evaluation. In short, an older adult
population has greater dental needs than a
younger adult population, and the older population is surging. Every day, 10,000 people
in the U.S. turn 65.
The over-65 population will
number roughly 72 million in

2030, more than double the
number of the year 2000.
2. The scientific literature is also replete with articles showing interesting relationships between
periodontal disease and other systemic diseases, the so-called perio-medical interface. While it
is not possible to predict the results of future research, the literature suggests complex relationships between oral health and general health. As patients become more educated, and as additional information becomes available on the Internet and in the media, many older patients will
36
recognize the benefits of optimal oral health as it relates to their general well-being. For years,
dentists have talked to their patients about the benefits of dentistry in terms of quality-of-life
issues. Members of an increasingly sophisticated and informed elderly population, armed with
new scientific information that they are gleaning on their own and at the dentists office, are
more readily making this connection and demanding dental care as part of their attention to
overall health issues. Older people get it: Dentistry is not just about teeth.
3. Because of recent difficult economic times, many dental practices have noticed a drop in patient visits. Here is the nexus of economics and demographics: While the economy has slowed,
demographic trends march on relentlessly. Some patients who have deferred needed treatment
are elderly; all patients are aging and
heading toward a rendezvous with
old age. When dental issues are ignored, they do not spontaneously
improve. Periodontal disease, in particular, is progressive. All individuals,
especially the elderly, who have been
putting off dental treatment since the
economy started to deteriorate in late
2007, have even greater dental needs
now. They will eventually seek care,
either when their perceived financial
situations improve, or more immediately if they experience discomfort
they cannot ignore. There is great
pent-up demand for dentistry. When
the dam bursts, the elderly will flood
dental offices.
While economists confound
even one another, rest assured

demographers have clearly
charted the demographic destiny

of dentistry. It does not get
any better than this.
4. Demographers often classify the elderly in different groups: the young-old, ages 6574; the
old, ages 7484; and the oldest-old, age 85 and older. The oldest-old is the fastest-growing
group, but the young-old are the individuals most likely to remain active and seek regular dental
care. In fact, if one looks at the soon-to-be old, those individuals who are approaching 55, the
numbers are even more impressive. Each year, more than 3.5 million Americans turn 55. By 2012,
the 50-plus population in the U.S. will reach 100 million one-third of the total population.
We know the last few years have caused economic hardships for many people. This lamentable
fact has also caused a behavioral shift: Many have delayed retirement so they can rebuild their
retirement portfolio. Social Security laws are complicated, but suffice to say that often people
over 65 can collect a monthly Social Security check while they continue to work and earn a salary. The net result is increasing numbers of young-old (who have greater dental needs than
their younger counterparts) with more disposable income. More people with more needs with
more money equals more demand for dentistry.
Harry Truman once complained that he wanted to hire a one-armed economist so that person
could not say, On the one hand this, and on the other hand that. While economists confound
even one another, rest assured demographers have clearly charted the demographic destiny of
dentistry. It does not get any better than this.
37
Clinical Tip:
Vertical Opening and

Guided Surgery Drills
by Bradley C. Bockhorst, DMD

The primary purpose of the surgical guide (aka Surgical Template, SurgiGuide, etc.) is
to transfer the virtual implant plan to the clinical setting. A few of the benefits include:
Implants are placed in a more ideal position based on a restorative-driven treatment plan.
Allows flapless procedures, if indicated, to be performed in a more precise manner.
Implant placement can be performed with a higher degree of safety, as vital structures have
been identified pre-surgically.
However, the surgeon must be aware that guided drills are longer than standard drills, as they
will be going through the surgical guide and soft tissue into the bone. This can be an issue if the
patient has limited vertical opening, particularly for posterior implants.
Figure 1: Cross section of mandible for implant in the area of

#19 (SimPlant)
38
Figure 2: SimPlant Drill Guideline
The total drill length for Materialise SurgiGuides (cases planned with SimPlant software) varies
and is based on the addition of three numbers: the length of the planned implant, the height of
the guidance sleeve and the prolongation length (Fig. 1). The prolongation length is the distance
from the top of the implant to the bottom of the sleeve. If a Mucosa Level SurgiGuide is ordered,
the prolongation length will be slightly greater than the thickness of the soft tissue. A Bone Level
SurgiGuide would obviously have a shorter prolongation length than a Mucosa Level SurgiGude.
The prolongation length may also be affected if the sleeve collides with an adjacent crown. A Drill
Guideline listing the total drill length for each osteotomy (Fig. 2) is supplied with the SurgiGuide.
Other guided systems, such as NobelGuide (Nobel Biocare; Zurich, Switzerland), have a fixed
distance from the top of the implant to the top of the sleeve in the Surgical Template. In Figure 3,
the distance is 9 mm. The drill guides that fit into the sleeve have a 1 mm flange. Therefore,
the total depth is the length of the implant plus 10 mm. The parallel-walled NobelGuide Twist
Drills are 10 mm longer than the companys standard drills (Fig. 4). The overall length of the
NobelGuide Tapered Drills is approximately 6 mm more than the standard drills. NobelGuide
Tapered Drills have built-in depth stops (Fig. 5).
The surgeon must

be aware that guided
drills are longer than
standard drills.
Figure 3: Cross section of mandible for implant in the area of
#19 (NobelGuide)
10 mm
Figure 4: Standard vs. Guided Twist Drills (NobelGuide)
Figure 5: Guided Tapered Drills (NobelGuide) with built-in depth

stops
Clinical Tip: Vertical Opening and Guided Surgery Drills
39
If you are considering

guided surgery, the
vertical opening can
easily be evaluated at
the consultation
Evaluating Vertical Opening at the

Consultation Appointment
If you are considering guided surgery, the
vertical opening can easily be accessed at the
consultation appointment. A quick visualization can be made by placing a guided drill in
the handpiece, asking the patient to open wide
and determining whether you can fit the drill
over the intended implant site (Fig. 6a, 6b).
appointment.
Figure 6a: Evaluating vertical opening with a standard 2 mm

Twist Drill.
Figure 6b: Evaluating vertical opening with a 2 mm Guided Twist

Drill.
40
Dealing with Limited Vertical

Opening During the Procedure
First do the obvious: If the patient has a removable prosthesis on the opposing arch, it should
be removed after the anchor pins/horizontal fixation screws have been placed. If the drill is too
long, you may want to start with a shorter drill
(Fig. 7a), then place the longer drill through
the surgical guide into the osteotomy. Next,
attach the handpiece to the drill and continue
to the desired depth (Fig. 7b).
A key to success with guided surgery is becoming familiar with the components and understanding their uses and limitations. Evaluating the patients vertical opening at the start
can eliminate surprises and help the case go
smoothly.
Figure 7a: Start with a shorter guided drill.
Evaluating the patients

vertical opening at the
start can eliminate
surprises and help the
case go smoothly.
Figure 7b: Continue with a longer guided drill to depth.
Clinical Tip: Vertical Opening and Guided Surgery Drills
41
CT Planning for Implants:
Dont Let a Panoramic Fool You

by Timothy F. Kosinksi, DDS, MAGD, MS
CT scanning software is fast becoming a viable
tool in the diagnosis and treatment of dental
implant position and placement. In areas where contours
and width and height of bone are difficult to determine with
conventional radiographic techniques, CT scanning software
allows diagnostic determination if bone quantity and quality
exists and can be used to virtually place dental implants using
the computer program before surgical intervention. This is an
outstanding tool in discussing the risks involved in surgical
implant procedures and can help the clinician and the patient
visualize the case. Used in critical anatomic situations and for
placing the implant in an ideal position in bone, CT planning
software, such as SimPlant (Materialise Dental, Glen Burnie,
Md.), eliminates possible manual placement errors and matches planning to prosthetic requirements. This innovative tool
makes surgical placement of implants less invasive and more
predictable, increasing treatment acceptance and reducing patient anxiety. Prosthetic reconstruction is thus made simpler
because the implants are appropriately positioned to allow for
fabrication of the final prosthesis.
Preoperative CT scan
43
Simple two-dimensional
images created using
conventional radiographic
techniques may no longer
Figure 1: A preoperative properly fabricated conventional maxillary complete denture is shown.
be an adequate and
predictable technique for
proper implant placement.
Fabrication of a stable, comfortable maxillary removable
complete denture using dental implants as the support
mechanism begins with careful diagnosis and case planning. Simple two-dimensional images created using conventional radiographic techniques may no longer be an
adequate and predictable technique for proper implant
placement. The surgeons experience and manual placement techniques greatly influence the final functional and
esthetic result. Any laboratory technician can tell you that
implants often are placed in poor position or angulation,
making prosthetic fabrication difficult or compromising
retention.
Figure 2: The preoperative panoramic radiograph appears to

illustrate good height of bone to accept dental implants in the
pre-maxillary area.
Dental implants provide an outstanding treatment option,

demonstrating dramatic improvement in denture stability
and increased chewing efficiency. There is an increase in
quality of life that is rewarding to the dentist and gratifying for the patient. The use of endosseous implant
designs, such as the Sybron dental implant system, has
proven to have an outstanding prognosis and are reliable
as retainers for overdentures.
The patient treated in the case illustrated in this photo
essay is a 57-year-old African American female who has
worn a conventional maxillary complete denture opposing an old IMZ (IMZ GmbH; Schwbisch Gmnd, Germany) implant-retained overdenture for the past 14 years
(Fig. 1). There were no medical contraindications to dental
implant therapy. After maxillary tooth removal years ago,
several maxillary complete dentures were fabricated over
time. The dentures were not completely acceptable to the
patient because of functionality and esthetic concerns.
Form and function diminished over the years, and the
patient was anxious for a stable maxillary dentition.
Several options were discussed with the patient, including
fabrication of a new conventional denture or a possible
44
Figure 3, 4: Occlusal and facial view of edentulous ridge. Again,

it appears there is adequate bone width and height to accept
dental implants in preparation for an implant-retained maxillary
overdenture.
Figure 5: Underside of a properly fabricated, well-fitting conventional maxillary denture, which will be duplicated to fabricate the
Scan Appliance and eventually the Universal SurgiGuide.
Figure 6: A Scan Appliance fabricated from the conventional

denture. Note gutta-percha placed in at least eight planes.
Figure 7: The CT digital plan illustrates panoramic cross-sectional

and axial views, as well as a 3-D rendering of the patients maxilla.
Simple panoramic radiographs or periapicals do not produce the
3-D image achieved with CT scanning. Note the thinness of bone
in the pre-maxillary area; this is not acceptable for conventional
implant placement. Without CT diagnosing, we would have flapped
the gingival and found inadequate bone for implant placement.
Figure 8: Using the planning software from SimPlant allows for

fabrication of a stable SurgiGuide that will allow us to precisely
place the dental implants where we virtually determined the best
position to be.
implant-retained prosthesis. Initial diagnosis of the maxillary ridge determined by palpitation and panoramic
radiographic evaluation appeared to indicate adequate
bone height and width to strategically place four implants in the pre-maxilla to support an implant-retained
overdenture, likely using individual Locator attachments
(Zest Anchors; Escondido, Calif.) (Fig. 24). The posterior
vertical bone was minimal because of the large maxillary
sinuses. The amount of anterior pre-maxillary bone was
difficult to precisely determine by radiographic interpretation alone but looked adequate. The ridge was thin, but
how thin would need to be determined by reflecting the
soft tissue and visually evaluating the crest of the ridge at
the time of implant placement.
The patients main concern was that the existing maxillary case was not stable, and her ability to chew and function had diminished. Her quality of life had been compromised by the loss of her upper teeth. Discussion of
the use of CT technology to determine the exact amount
of bone available and the use of CT planning software
to determine the precise position of potential implants
helped motivate the patient to consider dental implant
reconstruction. It also allowed for another tool to determine the size, type and position of implants to be surgically placed.1
There was significant facial resorption in the maxilla,
so it was determined that an implant-retained maxillary
overdenture with proper lip support would best serve the
patient. Sybron dental implants were chosen because of
their innovative design. This system improves the dentist and patients access to superior and more effective
treatment. The SybronPRO XRT (Sybron International;
Orange, Calif.) implant design incorporates micro-threads,
a mount-free delivery system and self-tapping threads.
The implant is a self-threading system. A placement tool
is firmly seated into the implant body and is used for
the insertion using a handpiece reduced to 35 rpm and
25 Ncm of torque. An internal hex or octa pattern allows
for great stability of the platform-switching abutments.
The reliability and innovation demonstrated in the Sybron
surgical and prosthetic techniques made this the implant
of choice for the case.
There are concerns with any surgical procedure, especially
those in the sinus area or in bone where nerves are located. These concerns have popularized a newer concept in
implant dentistry: digital treatment planning. We are now
able to utilize software to quickly visualize the patients
anatomy in three dimensions. The computer software
allows us to simulate the placement of implants accurately before ever touching the patient. A surgical guide,
created from the 3-D images, helps us place the dental
CT Planning for Implants: Don't Let a Panoramic Fool You
45
implants in the proper predetermined positions, often in

a flapless procedure. This technique is proving to be a
cost-effective solution to assist the implant dentist in planning an esthetic and functional final result and minimizing any possible surgical challenges.
It is critical to make sure

that the final tooth positions
Figure 9: The Universal SurgiGuide is placed into the mouth and

the stabilizing pins positioned. This SurgiGuide does not move
once the stabilizing pins are placed, allowing for accurate guided
placement of the dental implants.
are established before there is

any surgical intervention.
The technology behind digital treatment planning and
guided surgery is based on planning algorithms used
clinically for years. CT scans and 3-D planning software
can really improve the clinicians predictability and safety.
Guided surgical techniques can be used for:
Figure 10: Universal SurgiGuide in place with a 2 mm drill key
Single-tooth edentulous spaces

Single-tooth immediate extractions
Partially edentulous spaces

Fully edentulous maxillary and mandibular overdenture cases
Fully edentulous maxillary or mandibular full-arch
permanent restorations
The surgical cases are, therefore, driven by the final esthetic and functional result. It is important to listen to
your patients carefully to determine their goals and desires and design the implant reconstruction accordingly.
It is critical to make sure that the final tooth positions are
established before there is any surgical intervention. Placing the dental implants in the jaw before understanding
tooth/implant position can be disasterous.2,3,5
Figure 11: The first drill used to initially determine angulation is

the Lindemann Guide. The total depth is measured and marked
on the drill.
A CT planning and placement system like SimPlant provides a high level of comfort and safety for the patient
by reducing surgical and restorative time. This is done by
utilizing an accurate 3-D plan prior to implant placement.
There are obvious advantages, including:
Easy visual understanding for clear case presentations
Reduced surgical chairtime
Reduced restorative chairtime in certain cases because of ideal implant positioning
46
Figure 12: The Lindemann drill is positioned to the predetermined depth through the 2 mm drill key.
Reduced stress for the clinician and the patient

Avoidance of surprises during surgery
Optimal implant placement for long-term implant
and prosthetic success
An improved esthetic result
Figure 13, 14: A 2.2 mm key is positioned and the 2.2 mm

diameter Twist drill is used to the established depth. Soft tissue
thickness is included in the total drill depth.
Before the CT scan, a Scan Appliance is fabricated by

the laboratory. This aids in visualization of the optimal
prosthetic outcome. The teeth are positioned properly in
wax and then processed into a hard appliance to illustrate
what the case will look like when its finished before its
even started. In this case, the proper-fitting conventional
maxillary complete denture was duplicated (Fig. 5). All appropriate dental anatomy is included. The Scan Appliance
is placed in the mouth during the CT scan (Fig. 6). This
allows the clinician to see the ideal position of the teeth
on a 3-D model. The entire 3-D image is analyzed and
the implant planning and simulation of implant placement
completed using the computer. The surgical placement of
the implants can be done in a conventional manner using
the newly created surgical guide to help direct the implants in the ideal position, often in a flapless procedure
(Fig. 7). The implants are placed in the desired depth using
the computer software and the surgical guide.
The use of CT planning

software to determine the
precise position of potential
implants helped motivate the
Figure 15: Periapical of 2.2 mm Twist drill illustrating the predetermined depth and angulation
patient to consider dental

implant reconstruction.
In this case, we utilized the Universal SurgiGuide (Materialise Dental). It consists of a single SurgiGuide. Keys,
based on the drill diameters, are placed in the sleeves in
the SurgiGuide to guide each drill.
Figure 16: A 2.8 mm key guide positioned and 3.3 mm Twist

drill used to depth. The actual diameter of this Twist drill is
2.8 mm.
It is imperative that the implants be placed as nearly parallel as possible in all three dimensions to the long axis
of the bone and to each other. The implants in the right
maxilla are parallel to each other, as are the implants in
the left maxilla. A clear Universal SurgiGuide was fabricated using the information created with the CT scanning
47
software (Fig. 8). The guide is used to correctly position the

implants in the first molar and cuspid areas to maximize
stability of the final implant-retained prosthesis. No retraction of the soft tissue was needed because the CT indicated
in three dimensions the length, width and position of the
implants to be used.
We are now able to

utilize software to quickly
Figure 17: Periapical radiograph of 3.3 mm Twist drill in position
visualize the patients

entire mouth anatomy in
three dimensions.
Figure 9 illustrates the stable Universal SurgiGuide in the
mouth with the stabilizing pins positioned. This Universal
SurgiGuide does not move once the stabilizing pins are
placed, allowing for accurate guided placement of the dental implants. Figure 10 illustrates the Universal SurgiGuide
in place with the 2 mm key.
Figure 18: Drilling the distal osteotomy with a 2.2 mm key
The Sybron system is simple and precise. The first drill

used to initially determine angulation is the 2 mm Lindemann drill. This is a very sharp drill with a point (Fig. 11).
The Lindemann drill is positioned to the predetermined
depth through the 2 mm drill key (Fig. 12).
Figure 13 and 14 illustrate the 2.2 mm drill key guide
in position and the 2.2 mm diameter Twist drill used to
establish depth. The black lines are clearly delineated:
7 mm, 9 mm, 11 mm, 13 mm and 15 mm. Soft tissue thickness is incorporated in the drill depth. Figure 15 shows
the periapical radiograph of the 2.2 mm Twist drill at the
proper depth and angulation as determined by the CT
scanning software. A 2.8 mm key is positioned in Figure 16, and a 3.3 mm Twist drill is used to depth. The
actual diameter of the 3.3 mm Twist drill is 2.8 mm. Figure 17 illustrates the periapical radiograph of the 3.3 mm
Twist drill to proper predetermined depth. Note the proximity of the maxillary sinus.
The remaining three implant sites were then prepared.
Figures 1821 show the identical steps listed above but
with an increased osteotomy size for a 4.8 mm diameter
Sybron dental implant. The actual diameter of the 4.8 mm
Twist drill is 4.2 mm, which is the osteotomy size used
for a 4.8 mm dental implant (Fig. 22). The Sybron implants
48
Figure 19: A 2.8 mm key in position for the 3.3 mm Twist drill
(actual drill diameter 2.8 mm).
Figure 20: A 3.5 mm key in position. The 4.1 mm Twist drill is

used (actual drill diameter 3.5 mm).
In this case, splinting

the implants in the maxilla
will improve the long-term
prognosis of the
Figure 21: A 4.2 mm key is seen in position. The 4.8 mm Twist
drill is used (actual drill diameter 4.2 mm).
implants themselves.
are self-tapping, so the osteotomy preparation is slightly
smaller than the final implant diameter. This allows for
excellent initial stability and retention.
Figure 22: After the osteotomies are completed, the SurgiGuide

is removed. A tissue punch removes any soft-tissue tags.
Figure 23: A 3.3 x 13 mm SybronPRO XRT dental implant is

threaded into the tooth #5 position.
Figure 23 and 24 show threading into bone of a 3.3 x 13

mm SybronPro XRT dental implant in the tooth #5 area
and a 4.8 x 9 mm implant in the #3 area. On the contralateral side, a 3.3 x 13 mm implant was placed in the #12
area and a 4.8 x 11 mm in the #14 area. Figure 25 shows
the occlusal view of the four Sybron implants placed
using this flapless technique. Note there is little or no
bleeding from the site, and no sutures are necessary. The
final periapical radiographs show the positioning of the
maxillary right and left posterior implants (Fig. 26, 27).
The patients existing conventional maxillary complete
denture was seated during the entire healing process.
A final CT scan was taken to document and confirm the
placement of the implants as compared to the virtual
preoperative placement using the SimPlant CT scanning
software (Fig. 28a, 28b).
When selecting an appropriate attachment for the overdenture, it is important to consider the amount of interocclusal space available. Retention requirements, ease of
use and lifespan of attachment should also be considered.
Conventional denture and implant impression techniques
will be used to create the final esthetic contours. We will
create an outstanding functional and esthetic result, meet
the patients expectations and eliminate the gagging reflex
caused by the old full-palate conventional complete denture. It is this authors opinion that splinting the implants
in the maxilla will improve the long-term prognosis of the
implants themselves.
Figure 24: A 4.8 x 9 mm SybronPRO XRT dental implant is

threaded into the tooth #3 position.
The dentist has an obligation to provide his or her patients

with the most innovative, proven techniques available.
CT scans and scanning software like the SimPlant program
make surgical placement of dental implants rather routine.
Anatomical anomalies are virtually determined before ever
touching the patient. With better implant placement comes
49
more routine and predictable prosthetic reconstruction.

The dentist must educate himself or herself with treatment
modalities in order to best serve patients. Many surgical
therapies can be performed by the trained general dentist,
and certainly all general dentists should be able to restore
these cases simply and easily. The predictable results only
reinforce the modality. Maintenance is rather routine, with
a design of the bars that allows easy access with a proxy
brush. As with any other dental appliance, professional
evaluations and periodic radiographs are mandated.
Figure 25: Occlusal view of the four Sybron implants placed

using a flapless technique. Note there is little or no bleeding from
the site; no sutures were required.
REFERENCES
1. Overdenture construction of implants directionally placed using CT scanning
techniques. Dental Implantation and Technology. Nova Science Publishers
2010;197208.
2. Provided a reliable preoperative assessment of implant size and anatomic complications. Int J Oral Maxillofac Implants 2003;18(6).
3. Point of care: how do I select an attachment for use in a removable partial denture or overdenture. JCDA 2007;73(8).
4. Precision of transfer of preoperative planning for oral implants based on cone
beam CT scan images through a robotic drilling machine: an in vitro study. Clinical Oral Implants Res 2002;13.
Figure 26: Periapical of maxillary right posterior implants in

place
5. Minimally invasive procedures may be requested by patients to reduce anxiety

and the pain experienced. Int J Oral Maxillofac Implants 2006;21(2).
Figure 27: Periapical of maxillary left posterior implants in place
Figure 28a: Preoperative virtual plan
50
Figure 28b: Post-operative CT scan. Note the precise positioning of the implants, which were virtually positioned using planning
software and placed through a guided procedure.
A Merging of Technologies:
Utilizing Optical Scans with

Implant Treatment Planning Software
by Bradley C. Bockhorst, DMD
From intraoral scans used to create virtual impressions to scanning models for custom implant abutments,
the use of scanning technologies in dentistry is rapidly expanding and gaining acceptance. There is now
a movement to merge these scans with other technologies. One example is implant planning software. These planning
programs provide a tremendous treatment-planning tool, utilizing the DICOM files from Cone Beam or Spiral Beam
CT scans. While hard tissues such as bone and teeth are well differentiated, soft tissue is not. The intaglio surface of a
well-fitting Scan Appliance provides an indication of the soft tissue thickness and contours.
Another way to incorporate the soft tissue is to optically scan the stone model and merge it into the digital plan. The
case can then be worked up virtually from hard and soft tissue perspectives through a restorative-driven plan. The following two cases illustrate the use of an optical scan of the model within the implant planning software.
1A
Figure 1: The space between the crest of the alveolar ridge and the intaglio surface of the Radiographic Guide represents the soft tissue.
Another way to incorporate the soft tissue

is to optically scan the stone model and
merge it into the digital plan.
52
1B
Case 1
Treatment Planning to Replace Tooth #6 and #11

(Case courtesy of Dr. Jeffrey LaFuria)
5A
Figure 2: A dual scan was performed: one scan of the patient wearing
the Scan Appliance and another of the appliance alone. The two scans are
merged using SimPlant (Materialise Dental; Glen Burnie, Md.) software. The
Scan Appliance (green) shows the ideal positions of the teeth to be replaced.
5B
5C
Figure 5: The implants are virtually planned based on the hard tissue, soft
tissue and prosthetic information. Note: The teeth (yellow) are segmented to
provide easy visualization of the adjacent roots.
Figure 3, 4: The model is optically scanned and merged into the plan (salmon),
providing an accurate representation of the soft tissue contours.
A Merging of Technologies: Utilizing Optical Scans with Implant Scanning Software
53
6A
7A
6B
7B
Figure 6: Abutments can be added based on the soft tissue contours and the
trajectory of the implants.
The implants are virtually

planned based on the
hard tissue, soft tissue and
prosthetic information.
54
Figure 7: Virtual teeth can be inserted as an additional diagnostic aid.
8
Figure 8: Once the digital plan is finalized, a preview of the SurgiGuide
(Materialise Dental) can be generated. The SurgiGuide can then be ordered
and utilized to transfer the virtual plan to the clinical setting.
Case 2
Treatment Planning to Place Six Implants for a Screw-Retained

Denture (Case courtesy of Dr. Todd Engel)
The clinicians plan was to extract the remaining teeth and place six implants in preparation
for a screw-retained denture. A Scan Appliance
was fabricated based on an approved Diagnostic Wax-Up. A dual scan was done (a scan of
the patient with the Scan Appliance, then the
appliance alone). The data for the two scans
was then imported into the SimPlant software. Optical scans of the stone model as well
as the Diagnostic Wax-up were merged into
the program.
9
10
12
11
13
Figures 911: The patient CT scan is imported into the SimPlant software.
The mandibular canal is identified and the remaining teeth segmented. The
Scan Appliance (pink) shows the ideal positions of the missing teeth. An optical scan of the Diagnostic Wax-Up (green) provides an additional treatmentplanning aid.
Figure 12, 13: The planned surgical sequence is to extract all remaining
teeth except for canines. They will be used to help stabilize the SurgiGuide.
Once the implants are placed, the canines will be extracted. The stone model
was modified per the sequencing plan, optically scanned and imported into the
planning software (salmon).
A Merging of Technologies: Utilizing Optical Scans with Implant Scanning Software
55
14
16
Figure 16: A preview of the SurgiGuide is digitally generated based on the
virtual plan and optical scan of the modified model.
15
Figure 14, 15: The implants are virtually planned. The yellow rods illustrate
the trajectory of the implants from a prosthetic perspective. Abutments are
selected based on soft tissue thickness.
The stone model was

modified per the sequencing
plan, optically scanned
and imported into the
planning software.
Conclusion
There are a number of diagnostic and treatment-planning tools at our disposal. As new technologies gain acceptance
from the dental community, we will continue to see them merged. Importing CT scans of the patient and optical scans
of the model into planning software provides an excellent example, allowing us to work up implant cases from hard
tissue, soft tissue and prosthetic perspectives.
56

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The Vertical Dimension of Speech:

Where Is the Vertical?

Caring for the Edentulous Patient

Top Questions About the Locator Attachment

Demographics, Destiny and Dentistry

Cover photo courtesy of

Letter from the Editor

Dr. Bradley C. Bockhorst

Letter from the Editor

Bradley C. Bockhorst, DMD

senior Copy Editor

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David Schwab, Ph.D

The Vertical Dimension of Speech:

The Pilot of Occlusion

by Earl Pound, DDS

Vertical Dimension of Occlusion.........

Figure 1: Procedure used to develop the vertical dimension of occlusion

The vertical dimension of occlusion is probably one of

Figure 2: The ball on the lower ridge represents the repeatable

dimension of speech, have a specific protective bearing

The vertical dimension of

Vertical Dimension of Speech..............

The Vertical Dimension of Speech: The Pilot of Occlusion

Figure 4: This classic s anterior speaking space can occur labial,

Mechanics of the S Position .............

Figure 5: In atypical s positions, sharp enunciation is possible as

The s position of the

Relating Speech to Occlusion..............

Figure 7: This shows the posterior speaking space in a Class I

Vertical Dimension of Occlusion.........

Posterior Speaking Space....................

The Vertical Dimension of Speech: The Pilot of Occlusion

S Positions Class I, II and III

If classic s positions exist in Class I occlusions, the

The time to confirm

Posterior Speaking Space

there is no forward movement, their posterior speaking

Atypical Anterior Occlusion

Figure 10: A Class III occlusion with a labial overlap. A classic s

with normal speech patterns and jaw relations poses no

Let S Be Your Guide ............................

The Vertical Dimension of Speech: The Pilot of Occlusion

When s sounds are

controlled s position should be developed. This will

This article has emphasized the value of applying the

Restorative Procedures ......................