Accurate Down to the Micron by Dr. Cory Glenn with Dr. Danny Domingue

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Categories: Implant Dentistry; Restorative Dentistry;

The digital advantage in full-arch implant dentistry

by Dr. Cory Glenn with Dr. Danny Domingue

In recent years, there has been tremendous growth in full-arch implant dentistry, offering patients the option to have fixed implant-supported restorations.

FP1 implant restorations—replacing just teeth, not gingiva—are extremely underutilized, in my opinion. They generally require little or no bone reduction; I guarantee you every dentist on Dentaltown would prefer this restoration over an FP3 hybrid if they had to be edentulated, because we all know removing all that bone can severely limit your options down the road if or when those implants fail. An FP1 maintains most of the bone architecture, and if it ever needs revision, you could still go to FP2 or FP3.

When done properly, FP1s are by far the most natural-looking and most aesthetic option; pink porcelain or composite cannot compare to natural gingiva. And, finally, FP1 restorations feel more natural to the patient; it’s basically like still having your original teeth, only in the form of a bridge on implants.

No margin for error in FP1 restorations
So, why don’t more dentists do FP1 restorations? Because they’re hard! I think a maxillary FP1 is likely the hardest treatment to pull off in implantology. Hybrids are easy because you chop away enough bone for restorative space, flatten the ridge and place your implants. FP3s are much more forgiving when the implants are not placed in ideal positions because all that space allows for a lot of options for angle correction.

But with FP1s, you have to be meticulous in how you manage the gingiva to maintain papillae and get a natural-looking emergence profile. Your implant positions also need to be perfect, because you’re not going to have nearly as many options for angle correction and not nearly as much running room to develop emergence.

When you opt to do immediate loading, you increase the difficulty even more. I’ve done these freehand and gotten good results, but that’s a lot more stressful and more difficult, in my opinion. I find it much easier to use a serial extraction staged approach, but that does equate to longer treatment time and requires having some teeth that can be kept long enough to support a temp. [Editor’s note: Click here to see a case by Dr. Cory Glenn that illustrates the serial extraction staged approach. This content is viewable by verified members of Dentaltown only.]

But that’s not always an option, so when it’s not, the challenge becomes how to manage the gingiva if you’re not going to immediate-load. If you just place implants and bury them, you’ll either need to go with no prosthesis or a short-term denture. In both cases, you lose all the gingival architecture and will have to go to great lengths to get it back at a later step.

Case presentation
This case was difficult: The tooth positions were all over the place because of the collapsed vertical dimension of occlusion (VDO) and supereruption. The patient refused to go without teeth and we didn’t want to lose the gingival architecture, so that left us with the option of placing the implants and immediately loading them with an FP1 temp.

Again, this is hard stuff, so if you’re just venturing into full-arch implants, this is not the place to start! Danny makes this stuff look easy, but he’s also one of the best implant surgeons, does hundreds of implants a month, has 18 years of experience, does 80% of all his implants as immediates, and also has his own lab with all the fun toys. I’d definitely suggest working up to these types of cases very slowly. Start with a staged approach such as in the case linked above.

Notice in the preoperative photos (Fig. 1), the anteriors are periodontally involved and very flared. The occlusal plane is a roller coaster, the VDO is collapsed and there is supereruption of UR and LL. The first step should always be to take a lot of pictures, a complete diagnostic workup, and models or scans in centric, preferably at the desired VDO.

One of the most powerful things you can do for patient motivation is use the full-face photo to create smile simulations (Fig. 2). I can’t stress enough how powerful this is! It also serves another purpose that’s even more important for me as I tap into my lab tech mode: It defines for me an ideal end goal that will dictate my wax-up.

I always like to really analyze the smile in PowerPoint by doing simple stuff like bringing in a horizontal line and aligning the pupils to it. Then I’ll duplicate it and pull one down around the incisal edge to give me a visual reference on tooth length and occlusal plane. I’ll also do a facial midline line. I also like to use a little golden proportions gauge (Fig. 3), which I can overlay and scale up and down as necessary.

Fig. 1

Fig. 2

Fig. 3

Scanning for success
For any complex full-arch implant case, unless you’ll be treating them in maximum intercuspation (MI), I suggest taking the CT scan in centric and at the desired VDO (Fig. 4). Use a leaf gauge or Lucia jig to get them there and then take your CT scan. (You’ll need to use a chin rest as opposed to the bite fork for positioning.) This will help you avoid a lot of extra work and duplicate files. If I’d taken the CT scan at her collapsed MI, I’d have to bring in her intraoral scans and then have duplicates of all the mandibular files—one to be stitched to the CT and another imported at the desired VDO. Otherwise, how do you know where to set the teeth and occlusion? Just take my word for it and scan them in centric at the final desired VDO.

The next step is to import and stitch in the IO scans to the Blue Sky Bio plan (Fig. 5). Danny also captured some facial scans using the Shining 3D MetiSmile (Fig. 6). This is one of the scanners I recommend because of its affordability and ease of use. It does bring in full color, so don’t let the monotone here distract you; personally, I don’t really care for the color and have the feature turned off because I’m only using the facial scan to orient me to facial planes, midline, etc.

It’s impossible to screw up if you have a well-stitched facial scan. I see a lot of people using them for patient presentations, and while it’s cool to be able to rotate their head around and see your wax-up underneath, it looks terrifying to the patient; they always look like death masks. I think a 2D simulation is much better for that task.

Fig. 4

Fig. 5

Fig. 6

Planning and positioning
I knew my guides would be bone-supported, so I performed bone segmentation. This is now done automatically with artificial intelligence within Blue Sky Plan (Fig. 7). If you haven’t tried it, you absolutely need to. Because it’s a new release, I don’t even think it charges you an export currently. Furthermore, because it’s all being done within Blue Sky Bio, you won’t need to do all that importing, exporting, downloading and stitching. Just give it three to four minutes per arch and it perfectly segments the jaws and the teeth and gives you the opportunity to edit the segmentation before finalizing, which is a feature I love.

Similar to the 2D lines I use in PowerPoint, I like to do the same in 3D. I import a plane shape of roughly 100 mm by 100 mm by 0.2 mm thick, orient one side to the midline, then duplicate it and orient that one to parallel the ala tragus and interpupillary line. Then I’ll duplicate that again and pull down to the occlusal plane (Fig. 8). This is super useful because I can now turn off all the other stuff while doing my wax-up and simply orient the teeth to my planes. It really simplifies the waxup design. Again, you can analyze the wax-up under the facial scan, but I don’t find that to be all that helpful (Fig. 9). I was meticulous about how I designed the apical portion of the pontic, too, because used that pontic shape to know how the bone needs to be contoured to accept the temp (Fig. 10).

Only at this point did I start positioning implants (Fig. 11). Again, with an FP1, we have to be super precise with implant locations and angulations, so there’s no point in bothering until I have determined where the teeth belong. I want to come right through occlusal tables or cingulums wherever possible.

The final positions were decided upon given the available bone and for the best AP spread: six implants in second molars, premolars and laterals. These would be restored with straight multiunit abutments, which makes life really simple (Fig. 12). Cross-sections of implant positions indicate #15 will need some bone expansion (Fig. 13).

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

Fig. 13

Designing the guides
Now I was ready to design guides. Remember, tissue follows bone, so if we want to have natural-looking tissue around the temp, we need to properly contour the bone. This patient’s UL quad didn’t even have teeth, so we needed to create some pontic sockets, and several of the other teeth were shifted out of ideal position, so they needed recontouring.

How do you know where to contour? One way is to create a scalloping guide. I did this by first deleting all the sockets in the maxilla and closing them up. I then made a 2-mm-thick “guide” on the maxilla with no tubes or anything (Fig. 14)—basically, a bone night guard.

Because I’d already determined exactly how I wanted the teeth/pontic apex to be shaped, I could turn on the wax-up and view where it penetrated through this. I could use this to know where bone should be adjusted (Fig. 15). However, remember, we need 1.5–2 mm of space (Fig. 16) between the temp and bone for the tissue to reside, so I “off set” the apical part of each pontic by 1.5 mm, creating a new STL file. I then Boolean-subtracted that 1.5 mm off set surface from the guide, which creates a bone scalloping guide (Fig. 17).

In the bone contour photo (Fig. 18), the left side is the guide on the bone before contouring and the right is what it should look like after contouring. Once the bone was contoured, we were going to need to guide the implants, so I opted to make a stackable drill guide (Fig. 19) that would drop on top of the scalloping guide. This was pretty easy, honestly—it took 12 minutes. This is more of a telescopic stackable design type and it uses small 3 mm magnets to provide retention between the drill guide and the scallop guide.

Fig. 14

Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

Fixated on quality
Normally we use guide fixation pins, but they’re kind of big and it can be dificult to find a spot to put them when working around your implant positions and existing teeth. So instead, I’ve begun using small guide fixation screws from GDT in some cases (Fig. 20). These are nice because they don’t require any predrilling, and they’re really small so you can sneak them into almost any little chunk of interproximal bone. They just drive in with an 0.048-inch hex screw driver or a uni driver like Nobel’s.

To create the pin holes, I positioned some custom pins where I’d want them in the software, then booleaned them away from the guide (Fig. 21). Fig. 22 illustrates the final section of the scalloped base guide featuring apertures for secure attachment by screws, as well as components designed to be stackable. After this, Fig. 23 presents the drill guide, which is to be placed on top once the bone has been shaped.

I usually prefer printed metal for these types of guides, but because of time constraints we had to print these in resin (Figs. 24–26), all in SprintRay Surgical Guide 3 resin. The tradeoff with resin printing is it will be much weaker, and given that these were kept thin to avoid excessive flapping, it’s wise to print some extras in case one breaks or gets dropped. I always recommend printing the jaw model, too, to test the fit and to have it as a reference during surgery. The little magnets are available from Apex Magnets and they are small cylinders: 3 by 3 mm.

Fig. 20

Fig. 21

Fig. 22

Fig. 23

Fig. 24

Fig. 25

Fig. 26

Marked for success
For the surgery, the first thing Danny did was screw in some palatal scanning reference markers (Fig. 27). This is because he was going to use his Imetric iCam4D photogrammetry system to digitally capture the implant positions after surgery. Without that reference marker, it would be very difficult to stitch the final scan back in place because you’ve lost all the common data—the teeth are going to be gone and the tissue will be flapped and edentulous. The markers serve as a common landmark that allow him to stitch the photogrammetry-corrected postoperative scan back into the right orientation with the preop models.

With the teeth extracted and the tissue flapped enough to seat the scallop guide directly on bone (Fig. 28), fixation screws were placed and bone contouring was completed (Figs. 29 and 30). In several places it coincided with the sockets, but in many others he had to contour the bone where the guide indicated. This way, we knew the temp would have the correct emergence. After bone contouring, Danny seated the magnetic stackable drill guide (Fig. 31). Danny packed the socket with his graft before placement, then used the implant to fully compress the graft into the buccal gap (Fig. 32). Fig. 33 shows the result: dead-on perfect.

Once the surgery was done, we needed to take new scans to create the temporary (Fig. 34). You could try to pick up a premade temp in the mouth, but it’s really tough to do and they end up very weak because you don’t have nearly as much thickness in an FP1 temp to accommodate some big 5-mm pickup holes. The better option is to capture a verified old school impression and make the temp on the model or, if you have photogrammetry, do it all digitally and design a direct-to-multiunit-abutment (MUA) temp.

Fig. 27

Fig. 28

Fig. 29

Fig. 30

Fig. 31

Fig. 32

Fig. 33

Fig. 34

Creating the bridge
With 6-mm cylinder healing/scan bodies in place (Fig. 35), Danny took an intraoral scan, being sure to pick up the palatal screws. The model we got was pretty close, but wasn’t exact enough to make a final restoration from. Intraoral scanning just can’t achieve that kind of accuracy, particularly in a scan like this where there’s lots of blood and no hard tissue for the scanner to track along. So we knew this model was not completely accurate.

Once that’s complete, remove the cylinder scan bodies, put on the photogrammetry scan bodies and do the Imetric scan. Photogrammetry scanners are designed to capture only the positions of the domino scan bodies, and they do so with remarkable precision. They don’t record details such as tissue, blood or teeth. The way the process works is that you bring those scans into Exocad and stitch them together. The highly accurate photogrammetry implant positions end up replacing the intraoral scan implant positions, which creates a digitally verified model. Now, we can make a perfectly passive restoration with just digital data.

The conversion in Exocad happens really fast. Because we already had the wax-up completed, it was brought in and Exocad built in the MUA interface into the wax-up (Fig. 36), creating a screw-retained roundhouse FP1 bridge. It’s certainly possible to do this same day if you keep the patient there for a couple of hours, but most dentists tend to send the patient home for the day and get them back the following day to deliver. This way, you’re not under the gun trying to design, mill and print with the patient in the chair. It’s not like they’re going to go party at the club that night after their surgery anyway.

Fig. 35

Fig. 36

The final reveal
The bridge was set for next-day delivery. Danny created it using the SprintRay On X printer, and interestingly, no Ti-Bases were incorporated; it was solely the printed bridge that attached directly to the MUA, and it was fastened with specialized Vortex screws (Fig. 37) that Danny created and are available through his Louisiana Dental Implant Lab. This method results in an economical and durable temporary solution. Although you could also mill this in PMMA if you have access to a milling machine, Danny opted to 3D-print it because it’s quicker.

Observe how well the temps reflect the simulation (Fig. 38). It’s not an exact match because, as you might remember, in the patient’s preoperative simulation, she was at a collapsed VDO, whereas now, with the temps, she’s been adjusted correctly. Nonetheless, that resemblance is remarkably close. The patient was thrilled with the result (Figs. 39 and 40), as you’d imagine. To be able to provide such a dramatic smile overhaul (Fig. 41) in 24 hours is incredible!

Take a look at the postoperative X-ray, displaying the precision placement of the implants (Fig. 42). The alignment correlates seamlessly with the preoperative design, despite the initial discrepancy because of the collapsed VDO. This final image exemplifies the precise execution of our plan, from simulation to the placement, and reveals the true-to-life results we can achieve—even down to the micron—with contemporary implantology techniques. The symmetry and integration with the surrounding bone structure highlight the level of detail that is achievable, ensuring not only aesthetic delight but also long-term functional stability.

Fig. 37

Fig. 38

Fig. 39

Fig. 40

Fig. 41

Fig. 42

Conclusion
There are various methods for tackling cases like these, yet the workflow outlined here consistently yields excellent results. Clearly, there’s a substantial amount of technology involved in this approach, but technology is merely a tool that anyone can master. More critical than the tools themselves is the comprehensive understanding of surgical implants, occlusion, aesthetics, treatment planning and periodontics that’s required before taking on a case like this, whether you’re working digitally or using traditional analog techniques.

I owe much of my understanding of these topics to many of the legends on Dentaltown, including Drs. Jerry Smith, Lane Ochi, Howard Chasolen, Julio Maya, Emil Verban, John Nosti, Lambert Stumpel, master dental technician Uwe Mohr, and many others whom I’ve inadvertently omitted. I am deeply grateful to each of them and I highly recommend that others read through their posts on Dentaltown’s online message boards.

Author Bios

Dr. Cory Glenn attended dental school at the University of Tennessee Health Science Center. After graduation in 2008, he went on to do an additional Advanced Education in General Dentistry residency with a focus on comprehensive care and dental implants. He lectures frequently across the world on the topics of CAD/CAM, cone beam technology and guided dental implants, dental photography, digital smile design, complete dentures and complex full-mouth rehabilitation. Website: coryglenn.org

Dr. Danny Domingue received his bachelor’s degree from Louisiana State University in Baton Rouge and his DDS from the LSU School of Dentistry in New Orleans. Domingue was awarded the Certificate of Achievement from the American Academy of Implant Dentistry and a fellowship from the International Congress of Oral Implantologists, and received an associate fellowship from the American Academy of Implant Dentistry. He also was also awarded Diplomate from the American Board of Oral Implantology, the highest award possible for a general dentist practicing implantology. In addition, Domingue is a member of the American Dental Association, the Acadiana District Dental Association and the American Academy of General Dentistry.

View Comments (8) More by Dr. Cory Glenn (2)More by Dr. Danny Domingue (2)

September 2025

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The digital advantage in full-arch implant dentistry

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