Vol. 3, No.

5 – October 2011
 Contents and Contacts

Publisher:
Ettore Palmeri, MBA, AGDM, B.Ed., BA
Palmeri Publishing Inc.
Toronto, Canada
ettore@palmeripublishing.com

Editor-in-Chief: Dr. Robert Zena

4 6
Clinical Editor: John A. Sorensen, DMD, Ph.D

Technoclinical Editor: Ed McLaren, DDS

Office Administrators:
Sanaz Moori Bakhtiari, B.SC –
Editorial Implant supported bar work sanaz@palmeripublishing.com
Ettore Palmeri, MBA, AGD, B.Ed., BA – Part 1 Tina Ellis – accounting@palmeripublishing.com
Bahar Palmeri, B.SC – bahar@palmeripublishing.com
Hans-Peter Vögtle, MDT Adriana Palmeri – adriana@palmeripublishing.com

Sales/Marketing:
Mark Behar Bannelier – mark@palmeripublishing.com
Mona Mohammadzadeh, MBA –
sales@palmeripublishing.com
Gino Palmeri – gino@palmeripublishing.com

Editorial Director:
Frank Palmeri, H.BA, M.Ed –
frank@palmeripublishing.com

Production Manager:
Samira Sedigh, Design Dip. –
production@palmeripublishing.com

14
Red or White? – Part 1
22
Aesthetic assistance
Design & Layout:
Tim Faller – tim@palmeripublishing.com
Sophie Faller

Internet Marketing Director:

Ambianz Inc., Rashid Qadri
MDT Haristos Girinis Dr. Bruno R. Chrcanovic and DT Rolf Ankli
Event Coordinators:
Casandra Brown – casandra@palmeripublishing.com
Roya Safari – roya@palmeripublishing.com
events@palmeripublishing.com

Canadian Office:
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dental labor international plus is published six times a

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continuing education for dental laboratories in order

30
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dental labor international plus – Vol. 3 No. 5 – October 2011 3

Editorial
Internet an open book
eorge Orwell in his famous book 1984
G invented Big Brother, a dictator of the
imaginary country known as Oceania, whose
objective was total control and total suppression.
Since then the saying “Big Brother is watching
you” has become a common saying that indicates
Angelika when we talk about the state or private control in
Schaller, Ph.D. front of which the individual has no say.
The concept of Big Brother is present today when
we deal with the internet; here however we are not
totally impotent as long as we are very careful and we
do not make any mistakes.
Individuals that use the internet negligently, risk
a lot: personal data while one’s privacy can be
compromised by YouTube, Facebook and other social
media. Here personal data is made available to third
party.
One should be not surprised by the careless use of
your personal information on the internet. It is a huge
4 dental labor international plus – Vol. 3 No. 5 – October 2011
shock for users when the ignorance on the web
becomes a boomerang of negative information for
them: a real bad awakening.
For example in the job market area — laboratory
owners and managers have discovered, like other
business owners the internet for personal research. In
the past the procedure for a job applicant was simple:
you applied, you were invited to attend an interview,
and perhaps you were offered a job.
Today, employers are very interested to know who
is “John Smith?” Is there something about him on the
web? So, we Google him and a world of information
opens up on our screen. So, we can see the job
applicant half dressed and drunk at an office party.
In blogs people talk openly about their political
tendencies, hobbies, number of weddings, and sexual
preferences. Nothing is sacred anymore. We relate
everything with no inhibition whatsoever. We become
an open book for everyone to read.
What is evil about the web? Often it is the
intentional character assassination of individuals: the
ex-employee wants revenge on the employer, the
ex-husband wants to tarnish the ex-wife reputation
and students can attack the unpopular or strict
teacher. Nothing is so easily available for this type of
carrying on the web.
So, who wants to experience success professionally
has to be careful about his reputation on the internet,
it extremely difficult to delete non desired information
especially when we are not experts.
But, everywhere we have a deficit, new business
ideas develop very rapidly.
So if you want to delete personal information that
one way or another has found its way to the web
there are now reputation repair services that exists
online that know how to delete inappropriate and
embarrassing information from the web.
I feel it is better to control our communication and
enjoy the return to the real conversations with real
friends (do they exist anymore?)
Serious self-promotion through one’s profile on the
web is modern and might be advantageous to the
individual however one should be careful not to let
our narcissistic side takes us out of control. n
Digital Realities 2011
Digital Restorative Symposium
The ACP’s 41st Annual Session is a must-attend meeting for dental technicians
Packed with three full days of revealing and engaging programming, you can’t afford to miss this valuable educational opportunity
in Scottsdale, Arizona on November 2-5 at the Westin Kierland Resort & Spa.

Bringing together expertise from the clinical and technical worlds of prosthodontics in a collegial and educational setting, the
ACP’s 41st Annual Session is aimed at helping prosthodontists, dental technicians, residents and other dental professionals realize
their own individual excellence in prosthodontics as well as how we can collectively achieve excellence for the specialty.

T H U R S D AY, N O V E M B E R 3
Implant Care: Today’s Perspective – Stephen D. Campbell, D.D.S., M.M.Sc.
Regenerative and Esthetic Techniques in Implant Surgery: Clinical Applications with Recombinant
Growth Factors – Mark Nevins, D.M.D., M.M.Sc.
The Significance of Traditional Removable Prosthodontics in the Age of Implants – Peter F. Johnson, A.B.,
D.M.D., F.A.C.P.
The Future of Implant Dentistry – Steven Eckert, D.D.S., M.S.D.

F R I D AY, N O V E M B E R 4
Digital Realities for Dental Laboratories
Register now online. Scan this
Moderator: Frank Tuminelli, D.M.D. Quick Response code using your
U Recreating Nature: The Harmony of Function and Esthetics with Digital Technology – Lee Culp, C.D.T.
smart device.
U Restoring Maxillary Anterior Implants: Appropriate Steps and Design Principles to Achieve
the Highest Esthetic Results – Brahm Miller, D.D.S., F.R.C.D. (C)
Ê U The Art, Science and Digital Dentistry in Modern Implant Dentistry – Dominico Cascione, C.D.T., B.S.
Ê U Digital Implant Dentistry: New Technology for Teeth and Implants – Frank Higginbottom, D.D.S.
U Metal-Free Prosthodontics: The Power of Zirconia – Michael Moscovitch, D.D.S.

S AT U R D AY, N O V E M B E R 5 www.prosthodontics.org/AS
Digital Restorative Symposium
Moderator: J. Robert Kelly, D.D.S., M.S.
U Balanced Smile Design: All-Ceramic Solutions on Diverse Conditions – Jurgen Seger, M.D.T.
U Aesthetic Approach with Bonded Ceramic Restorations: A Distinctive Approach to Nature – Michel
Magne, M.D.T.
U Zirconia-Based Restorations: What Have We Learned – Ariel Raigrodski, M.S., D.M.D., F.A.C.P.
U The “New Age” Digital Dental Office and Dental Lab: “The Digital Dental Team” – Edward McLaren,
D.D.S., M.D.C.
 Implant supported
bar work
– Part 1
Within the series of lectures for implant prosthetics, reviewed by
the GBOI, all important aspects of implant prosthetics from
anatomy and preprosthetics planning to the integrated implant
superstructure are taught and verified. Dentists and dental
technicians work closely together to assure that oral implantology
Hans-Peter Vögtle, MDT and prosthetics manufacturing harmonize even more in the future.
The GBOI curriculum has an excellent reputation because of the
consensus conference of oral implantology. Hans-Peter Vögtle
Contents: demonstrates in a two-part article the necessary steps for the
manufacturing of the practical assignment.
Curriculum implantology,

GBOI, Status and planning

• Four Straumann-implants regular neck, 4.8 mm diameter
Dolder bar, • Bar work with four milled crowns and bars
• Three dolder bars
Implant prosthetics, • Matrix distal on 35 and 34
• Multicon attachment
• Secondary parts individually produced from precious metal
Combination work,
In the above-mentioned planning stage, set-up and wax-up are created, copied and
Bar converted to plaster (Figs. 1 to 4). Now I am able to visualize what the reconstruction
might look like.

6 dental labor international plus – Vol. 3 No. 5 – October 2011

 Impression
After the teeth exposure, the dentist sends us a pre-impression
(Figs. 5 and 6). Once the model is produced, an individual
impression tray for an open implant impression (Figs. 7 to 10)
in the mandibula is created. It is important that the impression
posts do not interfere with the functional impression to avoid
a fitting inaccuracy later on. In the case of multiple implants it

Fig.1

Fig.2

Figure 5 — Mandibula with implants

Fig.3

Figure 6 — Impression posts on the mandibula model

Fig.4

Figures 1 to 4 — Planning model, set-up and wax-up

Figure 7 — Wax-out with wax

dental labor international plus – Vol. 3 No. 5 – October 2011 7

 Figures 8 to 10 — Individual impression tray from different angles

is advisable to interlock the impression posts in the patient’s

mouth before the impression taking; it ensures a considerably
higher degree of stability.
We use the individual impression supplied by the dentist to
create the master model. This is done with or without the
gingiva mask.

Bite-taking
Back in the laboratory the next step is bite-taking (Fig. 11),
which is produced with bite registration aids or impression
posts so that a stable fit in the mouth is guaranteed. The
dentist marks the midline and cuspidline (Fig. 12). With this
information, the work is transferred to the semi-adjustable
Figure 11 — Bite-taking articulator.

Figure 12 — Bite situation with maxilla Figure 13 — Teeth set-up

Figures 14 and 15 — Mandibula set-up

8 dental labor international plus – Vol. 3 No. 5 – October 2011

 Set-up
Now we start with the actual work by choosing the proper
teeth and doing a set-up of the teeth on the adjustable bite
plate, which is then placed in the patient’s mouth and
corrected if needed. This step is absolutely necessary to ensure
proper planning and to reach the desired goal (Figs. 13 to 15).
If the patient and dentist are pleased with the set-up and all
functions work properly, a 1/1 silicone precast is prepared
in the laboratory. It is used for design, bar positioning,
attachment and spacing purposes (Fig. 16).
Figure 16 — Lay-out of the mandibula with silicone wall

Figures 17 and 18 — Secondary parts milled in wax

Figures 19 and 20 — Adding of the attachment

Figures 21 and 22 — Attachment of the bars

dental labor international plus – Vol. 3 No. 5 – October 2011 9

 Figures 23 and 24 — Casted gold bar

Primary construction
We are ready to choose the implant
elements: synOctasecondary parts
1.5 and the matching attachable
gold cap for better fitting results
(Figs. 17 to 20). For non-conical
Figures 25 and 26 — Lasered bar implant systems, we usually suggest
a sealant like Gebsil for our clients.
We begin with the modellation
of the bar and the milled posts.
We then place the attachments
(Figs. 21 and 22) and invest the
cast piece. These pieces are created
in wax in two-parts or multi-parts.
After the casting, the work is fitted,
secured with a laser and soldered
(Figs. 23 and 24).

Figures 27 and 28 — Finishing of the bar

Figure 29 — Finished bar with rider Figure 30 — Manufacture of the secondary part

10 dental labor international plus – Vol. 3 No. 5 – October 2011

 Secondary construction
Once the bar fits tension-free the structure is milled, polished
(Figs. 25 to 29) and the secondary construction is modeled.
The prefabricated bar matrices dolder macro are integrated
tension-free and polymerized into the acrylic later on. It is
important that the bar riders can be activated and deactivated
freely and are not covered with acrylic. We polymerize instead
of soldering; this way we eliminate the tempering of the riders.
The modellation should offer sufficient retention for the teeth
and the acrylic and yet be delicate enough. We model metal
occlusal surfaces over the attachment boxes due to space and
stability requirements (Figs. 30 to 33).

Figure 31 — Space verification with precast

Figures 32 and 33 — Modellation

Figures 34 and 35 — Cast result

Figures 36 and 37 — Set-up

dental labor international plus – Vol. 3 No. 5 – October 2011 11

 Figure 38 — Preparation for the finishing Figure 39 — Precast with acrylic teeth

Figures 40 and 41 — Work unprocessed

Fig.42 Fig.43

Fig.44
After casting the secondary parts, (please note: a good cast
result is very important) we finish the secondary structure and
prepare it for the set-up (Figs. 34 and 35). The transfer is easy
because we work with a precast and the metal occlusal
surfaces integrate well into the prosthesis. We insert a thin
gold strip to our work on the lingual side, which adds a
delicate touch (Fig. 36). Once more function and aesthetic are
verified in the articulator (Fig. 37) we followed with a
complete wax-up, embedding and boiling process.

12 dental labor international plus – Vol. 3 No. 5 – October 2011

Fig.45 Fig.46

Finishing
Finally the work is prepared for the finishing
process. The frameworks are opaquered and the
structure is waxed-out in all undercut areas
(Figs. 38 and 39). It is important that a thin wax
layer is applied in the small opening between the
prefabricated matrix and cast piece. It ensures an
easy activation and deactivation of the bar in the
future. With the acrylic finishing the final stage of
our work is reached. For the finishing we use the
cuvette technique by Candulor. We opt for a cast
Fig.47 acrylic by Merz Dental (Figs. 40 and 41). It flows
well and has minimal shrinkage. After the acrylic
work is done we attach a composite veneer on
tooth 34 and 45 followed by polishing and
functional tests. The very last step is the polishing
of the precious metal parts and the implant pieces,
which is a time-consuming process that has to be
done very meticulously (Figs. 42 to 49).

Conclusion
This type of removable prosthesis is a solid and
above all durable solution and is manageable for
an elderly person as well. It can be activated easily
and the specific adjustment of friction, which is
matched to the patient individually, is easily
Fig.48 obtained.
With regard to price, it is a reasonable and
contemporary solution compared to a fixed
restoration consisting of six to eight implants. The
aesthetic’s compromise compared to a fixed
option is definitely acceptable mainly because we
are dealing with a technique that has proven itself
for years.

Acknowledgement
Special thanks to MDT Volker Weber who
inspired me as a highly competent course
instructor and as a person. n

Figures 42 to 49 — The finished work

from different angles
Fig.49

dental labor international plus – Vol. 3 No. 5 – October 2011 13

 Construction, function and aesthetics

Red or White?
Part 1
For a complex implant supported restoration like the one discussed in
this article, the dental technician has to apply all his capabilities:
Construction, function and aesthetics. MDT Haristos Girinis
MDT Haristos Girinis,
demonstrates how to solve such a challenging case.
Nagold

removable combination work challenges the dental technician on many levels, from

A the smallest ceramic veneer to the largest implantological reconstruction. From the
wax set-up and the casting technique to the milling process, this specific task faces a
variety of difficult challenges. Furthermore, the handling of different materials like acrylic,
ceramic and metal has to be mastered, quite a challenge in our profession. Our goal is to find
Contents: clinical long-term solutions for the patient. Even though we are considered craftsmen and have
to master all required procedures, it is equally important that the communication between
aesthetics, dentist, technician and patient remains open. Especially in implantology, a close relationship
between laboratory and dental clinic is essential. The main focus is the patient and restoring his
function, quality of life. Comfort is an important factor for the patient functionally and aesthetically, and
has to be part of the reconstruction so that he can lead and enjoy an active life. Once all these
implant prosthetics requirements have been fulfilled it is always a welcome surprise when the feedback for a job
well done is the big smile on the patient’s face.

14 dental labor international plus – Vol. 3 No. 5 – October 2011

 Figures 1 to 3 — Initial situation

Figure 4 — The occlusion needs strong corner posts Figure 5 — Progenic positioning

Initial situation and analysis

A 74 year old quite skeptical patient presented himself (Figure
1). We noticed right away that he was missing a lot of teeth.
After a closer look we discovered additional defects (Figure 2).
Before any new restoration work it is vital to look at the
person as a whole. We look at the tooth axes, arches and
Figure 6 —
Anatomic curves and try to get as much information as possible. Initially
impression the patient had difficulties opening his mouth, thus hiding his
fairly new prosthesis, which did not live up at all to its quality
seal “Made in Germany” (Figure 3). Cusps and fossas were
barely visible and a proper occlusion was non-existent. The
existing tilted position was a clear indication that acrylic was
not a suitable material for a longterm accurate occlusion.
Strong corner posts, like ceramic teeth, were needed for a
proper occlusion (Figure 4).
Furthermore we noticed a slight progenic bite (Figure 5).
Figure 7 — The bar How this happened is unknown, in this case it was not clear,
is cut after the which one was the maxilla or mandibula restoration, despite
connecting joint the fact that they were both 5 years old.

dental labor international plus – Vol. 3 No. 5 – October 2011 15

 Design
We informed the patient that work needed to be done in the
maxilla as well. In the mandibula two canine teeth were
present. Our patient wanted a stable, removable restoration,
similar to his wife’s. The two canines in the mandibula were
left for the temporary phase. Afterwards two implants were
placed in the area of the number two and number four teeth.

Preparation in the dental clinic

Figure 8 — “Wings” serve as retentions for the impression material
First we took an anatomic impression with the impression
posts in place, which we will then replace with the implant
posts (Figure 6). These were individualized with Pattern resin
and connected with a bar. We cut the bar in several places and
attached small wings (Figure 7), which serve as retentions
for the impression material in the closed tray impression
(Figure 8). The dentist applied those Pattern aids orally before

Fig.9 Fig.10

Fig.11 Fig.12

Figures 9 to 12 — Removable gingival mask made of pu-acrylic

Figure 13 — Acrylic control key with metal support Figure 14 — Verification of the control key

16 dental labor international plus – Vol. 3 No. 5 – October 2011

 Fig.16

Figure 15 — Figures 16 and 17 — The wax set-up with positioning screws

The old prosthesis aids with the maxillomandibular relationship record

Fig.17

Figure 18 — Try-in
Screws serve as static stabilizers during try-in

Figures 19 and 20 — Lengthening of the anterior teeth in wax

Figures 21 and 22 — Set-up of the mandibula

dental labor international plus – Vol. 3 No. 5 – October 2011 17

 Figure 23 — Modelled gingival

Figures 24 to 26 — Orange peel effect

Figures 27 and 28 — Cleaned and polished ready for duplicating

taking the impression and – very important – connected

the bars with Pattern resin.

Removable gingival mask

After taking the impression, we created a removable
gingival mask made of pu-acrylic (picodent) in the
implant area (Figures 9 to 12) to individually design the
emergence profile on the implants. It is very important to
leave enough space for the plaster material to ensure that
the model abutments of the implants are properly
positioned, therefore creating needed stability. That is
how we fabricated our working model.

Control key
Then we created an acrylic control key with metal
support on the working model (Figure 13) and connected
the abutments with Pattern resin. We then checked the Figure 29 — Matrix to capture the situation
positioning of the control key with an x-ray (Figure 14)

18 dental labor international plus – Vol. 3 No. 5 – October 2011

and concluded that the model was accurate. The old 25) followed by the use of an alcohol torch on low flame. The
prosthesis, serving as a maxillomandibular relationship result was the typical orange peel effect (Figure 26). Once
record, was placed in the articulator (Figure 15). cleaned and polished (Figures 27 and 28) the work was ready
for duplicating.
Wax set-up and try-in
We did a wax set-up with acrylic teeth to visualize the
dimensions. The wax set-up had positioning screws (Figures
16 and 17) to keep the set-up statically stable in situ during
try-in so that we were able to take the bite. We realized during
try-in (Figure 18) that functional and aesthetic adjustments
were needed in the maxilla. The try-in is an important design
platform that offers much information.

Final set-up
We started with the lengthening of the anterior teeth in wax
(Figures 19 and 20), followed by a set-up with the mandibula
(Figures 21 and 22) – from function to aesthetics.

Modelling of the gingival

Once everything was verified and approved, we began with
the modelling of the gingival (Figure 23). We started by Figure 30 — The capillary effect forces the embedding material
pressing a prosthesis brush hard into the wax (Figures 24 and into the channels thus avoiding metal penetration

Figure 31 — Transformed into a precious metal alloy Figure 32 — Premilling along the gingival line

Figures 33 and 34 — Plastic wrap protects the model from debris

dental labor international plus – Vol. 3 No. 5 – October 2011 19

 The red and white areas were designed perfectly and we were
able to capture the situation with matrices for our work later on
(Figure 29). We were now ready to visualize our next step.

Abutments
The castable HSL-abutments were attached with wax and milled
then sprued for the casting process and embedding aids were
applied, thus creating a capillary effect that guides the embedding
material into the channels (Figure 30) to avoid metal penetration
later on. This is a very important step!
The transformation was done in a precious metal alloy (Figure
31) followed by milling with a parallel milling bur along the
Figure 35 — Master model

Figures 36 and 37 — Figures 38 and 39 — Precise fit

Minimal clearance fit of the silver conductive lacquer

Figures 40 and 41 — The primary component is positioned with a template

20 dental labor international plus – Vol. 3 No. 5 – October 2011

Figure 42 — Laboratory abutments…
Figures 45 and 46 — Duplicated model
Figure 47 — Design model
Figures 43 and 44 — …with base
gingival line (Figure 32). Plastic foil was used to protect the
model from oil and milling debris (Figure 33) and to prepare
the surface (Figure 34). We were able to forego the milling
model and could check the abutments directly on the working
model (Figure 35).
Secondary components
For the fabrication of the secondary components, we chose
the galvano electroforming technique with a thickness of
0.2 mm. Because of the minimal clearance fit of the silver
conductive lacquer (Figures 36 and 37) we achieved a very
accurate fit (Figures 38 and 39).
Reinforcement with a metal-supported structure is
advisable, but more on that subject later.
With the aid of a template (Figures 40 and 41) the primary
component was fitted in the mouth and placed with the
laboratory abutments (Figure 42) using a base stone with
minimal expansion (Figures 43 and 44). This was our
“precious precision model” on which we would glue the
secondary component, the structure, in the end.
Now we returned to our duplicated model (Figures 45 and
46), the design model with maxilla (Figure 47) for which we
chose ceramic teeth, to be exact pressed ceramic veneers, that
needed to be individualized with colour, as initially discussed
with the patient and dentist. n
…to be continued in the next issue
dental labor international plus – Vol. 3 No. 5 – October 2011 21
Fabrication of a
gingival mask
Aesthetic assistance
Contents:
aesthetics,
smile,
Dr. Bruno R. DT Rolf Ankli, periodontal disease,
Chrcanovic Beto Horizonte,
Brazil gingival mask
eriodontal disease is one of the second biggest dental
P diseases worldwide 1,2. Periodontal disease is not an
age-related disease, it starts earlier in adolescence and
worsens with age. The final stage, the complete loss of teeth,
is often present in the elderly 3. Periodontal recession or
gingival atrophy with exposed root surface creates many
therapeutical challenges. The loss of gingival papillas creates
hypersensitivity 4 and “black holes” 5.
Minor or major surgery procedures are one way to replace
missing gingival but besides soft tissue manipulation they
often require bone grafts for tissue support 6 . Luckily
prosthetic alternatives for missing gingival and papillas are
available:
a) fixed gingiva-coloured ceramic in combination with
ceramic bridge restorations
b) removable restorations that are kept in place by
precisely constructed components
c) removable restorations held in place by adhesives 7-10
Gingival masks are made of acrylic or silicone. Both
materials are characterized by a high colour stability 5. Gingival
masks serve as a support for the lips but can also obstruct the
lips, resulting in food particles getting stuck 11. On the other
hand, this kind of prosthesis can solve phonetic issues7.
22 dental labor international plus – Vol. 3 No. 5 – October 2011
For patients with gingival atrophy who want
to avoid periodontal surgery, various prosthetic
options exist to improve aesthetics. For
example gingival masks offer simple prosthetic
solutions and aesthetic enhancement by
covering the so-called black holes between
the anterior teeth and making long teeth
appear shorter in the cervical area.
Discussion
In the posterior region of the mouth periodontal recession and
gingival atrophy are less reason for concern but in the anterior
area soft tissue loss causes aesthetic defects, which can lead to
psychological problems. Renggli and Curilovic 12 point out that
the gingival of the maxilla is mostly visible during talking
and smiling. Gingival defects of the mandibula are seldom
noticeable and therefore gingival masks are rarely needed.
Nevertheless in some rare cases defects of the mandibula are
clearly visible (Figures 1 to 4). Every ten years the mouth area
sags about 1 mm. That explains why we notice the lower
anterior teeth in elderly persons more than the upper ones
when they speak and smile. In addition the incisal edges of the
upper anterior teeth are worn due to natural abrasion.
Indications
After the loss of hard tissue often soft tissue recession is
unavoidable, which in turn offers nearly hopeless starting
conditions if the bone loss caused by periodontal disease leads
to interdental gingival recession. For the last decades, it
has been clinically proven that a variety of regenerative
procedures, like width and height enlargement of the attached
gingival, achieve satisfactory results. The majority of these
surgeries are based on plastic periodontal surgery methods
(mucogingival) and transplant techniques, either by
themselves or in combination with guided bone regeneration
(gbr-therapy).
If the patient decides against periodontal surgery as a
corrective method for gingival atrophy he has a variety of
prosthetic options to choose from. Even if the size of the
alveolar ridge can be reconstructed, it is very difficult to
re-create an optimal gingival- papilla anatomy 13.
Gingival prostheses have been around since historic times
to correct tissue loss (caused by gingival surgeries, trauma,
alveolar ridge surgery or traumatic tooth extraction 6 and
cancer) when other methods (for example surgery or
regenerative procedures) are unpredictable, unforeseeable or
inaccessible. A gingival prosthesis easily replaces large
amounts of tissue.
From a prosthetic perspective either fixed or removable
prostheses can be used for the reconstruction of certain areas
in the mouth. The prosthetic margins are defined from the
cervical side by the movement of the mucosa while for the
teeth aesthetic preferences determine the margin. The lip
support is adjustable. Extensive gingival prostheses (Figures 5
to 7) are suitable to cover large defects, for example, after
periodontal flap surgery in the anterior tooth region. A small
prosthesis (Figures 8 to 10) is used to cover minor
Figures 1 to 4 — The gingival of the maxilla is usually visible during talking and smiling.
Defects of the mandibula are rarely noticed and after being vibrated.
imperfections. The fabrication of this prosthesis has to be very
precise in terms of stability, as we have to take lip pressure
into consideration 12.
Material and processing
A variety of materials can be used for the production of
gingival masks, for example pink acrylic resin (self or hot
polymerizing), thermoplastic acrylic resin, ceramic, light
polymerizing composites and silicone 6. The materials have to
be non-toxic, hypo-allergenic, non-carcinogenic, cleanable,
resistant to micro organism growth, colourfast to nasal
discharge, sweat, saliva and sebaceous secretion and resistant
to atmospheric agents when not inside the mouth 14.
During fabrication it is important that the prosthesis does
not turn out too thick because it is uncomfortable to wear and
noticeable and it should never extend into the movable
mucosa 12. The fracture risk of large gingival masks is relatively
high. These fractures occur mostly during cleaning, oral
hygiene and during removal and integration of the prosthesis.
It is important to copy the orange-peel effect, the frenulum
labii and the transition between attached gingival and the
margin of the natural gingival. The margin of the prosthesis
has to be uneven. Regular and straight margins are noticeable
and look unnatural. The lip pressure guarantees evenly
distributed stability in the interdentium.
dental labor international plus – Vol. 3 No. 5 – October 2011 23
 tray does not rest on the soft tissue (deformation risk). To
create a uniform material thickness, the spacing between the
individual impression tray and gingival needs to be uniform
(Figure 27).

The impression
The impression tray is placed in the mouth, checked for
interferences with the alveolar mucosa, the frenulum labii and
the lips and cut if necessary. The insertion of the impression

Figures 5 to 7 (above) —
Large gingival masks are suitable for clearly noticeable gingival defects

Indication
For patients with poor oral hygiene (Figure 11) and high
caries incidence regardless of age, occupation or aesthetic
preference, the gingival mask is contraindicated. This is a very
important factor and should not be ignored, otherwise the
failure rate is very high 12,15. The big question now is should
patients with loose teeth use gingival masks or not? The daily
integration and removal might put additional strain on the Figures 8 to 10 (above) —
Small gingival prosthesis for minor defects
already loose teeth. It is advisable to look for a better solution,
especially in cases with a high degree of tooth mobility 12.
We believe that gingival masks can also serve as splints and
interlocks. Images 12 to 24 show some examples.

Fabrication
To achieve best results we need to produce an individual
impression tray. We start by using an accurate model (Figure
25). On this plaster model we create an individual labial
impression tray. The individual impression tray can be
supported only by the labial cusps and the incisal edges
(Figure 26) and it should be a little larger than the projected
gingival mask. It is extremely important that the impression Figure 11 — Patient with bad oral hygiene

24 dental labor international plus – Vol. 3 No. 5 – October 2011

tray should be practiced several times beforehand. We mark
the teeth with a fine pencil line to indicate the exact tray
position. These markings facilitate the tray insertion with the
impression material. To avoid having the material seep
through the interdentium, a splint made of silicone or wax is
placed on the palatal side. This barrier needs to be cut if
necessary. If impression material gets between the teeth it can
cause fissures and deformation during the removal of the
impression tray, which forces us to repeat the impression step.
The impression is taken with a strong non-tearable material.
Our material of choice is Impregum (3M Espe, Seefeld). The
material is applied to the impression tray and inserted
horizontally. Once the material has hardened we check if any
of it seeped between the teeth into the oral cavity and remove
it with small scissors. The impression tray has to be removed
very carefully and again horizontally.
The most common defects are shown in Figure 28. The red
arrow points to a pressure sore and the green one to saliva
bubbles. Both are defects that will lead to failure.
Wax-up and try-in
We start by casting the working model in hard plaster (Figure
29) followed by outlining the to-be-covered area with a fine
pencil and then we insulate the model for the wax-up (Figure
30). For the production of the impression tray it is helpful if
the dentist outlines the projected gingival mask size on the
first model. We insert the wax-up in the mouth, check the fit
and verify the aesthetic horizontal gingival margin and the lip
support (Figure 31). The colour of the gingival mask is
selected with the help of a self-made gingival shade guide
(Figure 32).

Figures 12 to 17 —
Gingival masks for different defects

dental labor international plus – Vol. 3 No. 5 – October 2011 25

 Gingival masks serve also as splints and interlocks

Figures 18 to 24 —
Aesthetic gingival mask in the maxilla
Pressing
We glue the mask to the model and treat the surface with a
brush to imitate natural gingival. Now the model is trimmed
as required and with white plaster embedded in a cuvette. The
counterbite is cast with hard plaster (Figure 33) to withstand
the pressure during pressing. Now we proceed by boiling out
the wax and insulating the plaster. We then apply the acrylic
(Figure 34), pre-press with cellophane foil and re-open the
cuvette to remove thin press threads. This step might have to
be repeated several times.
The cuvette is left in the press for twelve hours set at a
pressure of 500 kg, afterwards it is polymerized for one-and-a-
half hours at 75˚C and an additional one-and-a-half hours at
95˚C. After the pressing procedure and slow cooling to room
temperature, the gingival mask is carefully removed to avoid
fracturing then finished and polished (Figures 35 and 36).

26 dental labor international plus – Vol. 3 No. 5 – October 2011

 Figure 25 — Fig.26
Individual impression tray
for accurate results

Fig.27

Figures 26 and 27 — Figure 28 —

The individual Common defects:
impression tray is The red arrow points
supported only to a pressure sore and
by the labial cusps the green one to a
and the incisal edges saliva bubble

Important: the uniform

gap between individual
impression tray and gingival

Figure 29 — The working model is cast with hard plaster Figure 30 — The model is insulated for the wax-up

Finishing and try-in Conclusion

During the try-in we look for interferences and flaws in the
alveolar mucosa, the frenulum labii and the lips. The shine can
be enhanced with soft, elastic polishing discs and felts. Please
note: the shine depends on the viscosity of the saliva!
Usually two gingival masks are produced and both are tried
in the mouth, the integration and removal is practiced with
the patient. Finally the patient receives written handling
instructions: the gingival mask needs daily cleaning with a soft
brush as well as the covered gingival in the mouth. A visual
check lets the patient verify if the hygiene is adequate.
Gingival masks improve the anterior aesthetics. They are easy
to produce, inexpensive, easily replaceable and the results are
fairly predictable.
Replacing gingival with a prosthesis is a sensible method to
replace missing tissue architecture. They are especially
suitable in cases where large amounts of tissue need replacing
or to hide implants that are not completely buried in the
gingival. The optimal tissue contour is easily created and
refined on the wax-up model and at the same time lets the
patient perceive the look of the future prosthesis. There is no
need for additional surgical procedures.

dental labor international plus – Vol. 3 No. 5 – October 2011 27

 Figure 31 — The aesthetic horizontal gingival margin and lip support
Figure 33 — Figure 34 —
The counterbite made of hard plaster Acrylic powder is applied
The dental technician has to possess impeccable knowledge
of clinical and surgical techniques to be an active member of
the patient’s treatment team. Practice is of great importance to
reproduce accurate aesthetic gingival and tooth anatomy.
Material knowledge and colour skills are a prerequisite.
We fabricated numerous prostheses and received a lot of
praise. Many patients confirmed that they do not leave the
house without their prosthesis and the majority wears them
24 hours and only removes them for cleaning. n
References
1 Papapanou PN. Epidemiology of periodontal diseases: An update. J Int Acad
Periodontol 1999;1:110-116.
2 Petersen PE. TheWorld Oral Health Report 2003: Continuous improvement of
oral health in the 21st century - The approach of the WHO Global Oral Health
Programme. Community Dent Oral Epidemiol 2003;31(Suppl.1):3-24.
3 Ingle JI. The health, economic and cultural impact of periodontal disease on an
aging population. Presented at NIH Conference on Aging, Louisville, Ky., 1975.
4 Kassab MM, Cohen RE. Treatment of gingival recession. J Am Dent Assoc
2002;133:1499-1506.
28 dental labor international plus – Vol. 3 No. 5 – October 2011
Figure 32 — Self-made gingival shade guide to select
the gingival mask colour
Figures 35 and 36 —
The finished and polished work
5 Lai YL, Lui HF, Lee SY. In vitro color stability, stain resistance, and water sorption
of four removable gingival flange materials. J Prosthet Dent 2003;90:293-300.
6 Barzilay I, Tamblyn I. Gingival Prostheses – a review. J Can Dent Assoc
2003;69:74–78.
7 Worthington P, Bolender CL, Taylor TD. The Swedish system of osseointegrated
implants: Problems and complications encountered during a 4-year trial period.
Int J Oral Maxillofac Implants 1987;2:77-84.
8 Brygider RM. Precision attachment-retained gingival veneers for fixed implant
prostheses. J Prosthet Dent 1991;65:118-122.
9 Morgano SM, Verde MA, Haddad MJ. A fixed-detachable implant supported
prosthesis retained with precision attachments. J Prosthet Dent 1993;70:438-442.
10 Ankli R. Zwischen allen Stühlen. Sonderdruck. Quintessenz Zahntech
2006;32:248-258.
11 Taylor TD. Fixed implant rehabilitation for the edentulous maxilla. Int J Oral
Maxillofac Implants 1991;6:329-337.
12 Renggli HH, Curilovic Z. The gingival prosthesis. Quintessence Int (Berl)
1971;2:65-68.
13 Costello FW. Real teeth wear pink. Dent Today. 1995;14(4):52-55.
14 Lewis DH, Castleberry DJ. An assessment of recent advances in maxillofacial
prosthetic materials. J Prosthet Dent 1980;43:426-432.
15 Greene PR. The flexible gingival mask: an aesthetic solution in periodontal
practice. Br Dent J 1998;184:536-540.
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 Information event held by implant prosthetic specialist E.S. Healthcare

Compartis
ISUS:
Precision and flexibility
Modern dental laboratories increasingly take advantage of today’s CAD/CAM technologies. It allows
the technician to efficiently fabricate restorations made of high quality ceramic or suitable complex
metallic materials, using new processing strategies. As an alternative to the completion in one’s
own laboratory, the integration of external milling centers offers a convenient access to the
CAD/CAM processing with minimal investment cost. The industrial manufacturing center Compartis
with ISUS recently also offered complete design and fabrication service for even extremely complex
implant-supported suprastructures that are manufactured according to the design projects of the
laboratory. Wolfgang Weisser visited E.S. Healthcare in Belgium.

Figure 1 — Screwed-in bars and bridge frameworks made of titanium or cobalt-chrome on

Paul Delee, implants offer excellent conditions for secure mounting of the prosthetic
Director of Technical Sales at E.S. Healthcare restoration. Unfortunately, conventional methods like casting, lasing or soldering
do not guarantee the desired precision needed for the fabrication process. The
CAD/CAM milling technique introduced significant progress.
Under the brand name Compartis ISUS, DeguDent together with its sister
company E.S. Healthcare offers an industrial manufacturing service for dental
laboratories that deal with sophisticated implant prosthetics. Recently, Wolfgang
Weisser, master dental technician and manager of a dental laboratory, visited E.S.
Healthcare in the Belgian town of Hasselt. During an information event for
technical journalists he gained a first-hand impression of the complex technology
in the fabrication of suprastructures.

30 dental labor international plus – Vol. 3 No. 5 – October 2011

Figure 2 — Left to right: Dr. Sven Rinke, Paul Delee, MDT Alexander Drechsel and Andreas Maier of DeguDent

High-tech at DeguDent and E.S. Healthcare

The company was originally founded 1996 under the name E.S. Tooling as a company specializing in
highly precise custom pieces for NASA and known Formula-1 racing teams. Since 2002 the company
has offered solutions for the dental industry. In 2007 E.S. Healthcare was founded, becoming a sister
company of the Dentsply group one year later. The distribution of their products and services is
handled by DeguDent GmbH in Hanau. The main focus of E.S. Healthcare is the design and the
fabrication of milled suprastructures (made by Compartis ISUS) that are screwed onto the implants.

Easy workflow, high-quality results

During a tour of the production departments, Paul Delee, Technical Director at E.S. Healthcare,
introduced the 5- and 7-axis milling machines and robots.
Mr. Delee pointed out that the workflow of the Compartis ISUS method differs significantly from
conventional processes. First, a master model and a wax-up are created in the laboratory. They are sent
to the ISUS design center where the model is scanned and using a special CAD design software a
digital construction draft of the suprastructure is created. The data is immediately forwarded to the
laboratory along with an online viewer, which helps the technician evaluate the construction and make
adjustments if necessary. Only after a firm approval by the technician does the milling of the
suprastructure commence.
The Compartis ISUS method allows work on implants and abutments. The materials used in this
process, mainly titanium or cobalt-chrome, are a cost-effective alternative to zirconium oxide or alloys
with a high gold content.

Conclusion
After coordinating with the laboratory, Compartis ISUS manages the CAD design and the CAM
production. The laboratory keeps complete control of the design while the specialized industrial
service provider handles the technological and financially quite challenging fabrication of framework
structures. All other steps are still done in the laboratory. n

dental labor international plus – Vol. 3 No. 5 – October 2011 31

 TEST FOR NBC & RDT CREDITS
dental labor international plus – Vol. 3 No. 5
Each article in this continuing education series is worth 0.5 credit from the NBC. To get your Scientific CE credit for this article,
circle the correct answers to the questions on the short test below. The correct answers can be found within the text of the article.
Then simply complete the form and submit it to Palmeri Publishing Inc., to receive your credit. It’s that easy!

Questions for: Questions for:

Implant supported bar work – Part I Red or White – Part I
— Hans-Peter Vögtle, MDT — MDT Haristos Girinis
1. During the finishing stage … 1. After the initial analysis it was felt that …
A. the frameworks are opaquered. A. neither acrylic nor ceramic were ideal materials to use.
B. the structure is waxed out in all undercut areas. B. acrylic was not a suitable material for a long term
C. a thin wax layer is applied between the prefabricated accurate occlusion
matrix and cast piece. C. strong corner posts, like ceramic teeth, were needed
D. all of the above for a proper occlusion.
D. B and C
2. To finish why does the author opt for a cast acrylic by
Merz Dental? 2. As step one the dentist …
A. it is of high quality yet economical A. took several X-rays of the patient’s mouth.
B. it is extremely durable. B. took an anatomic impression with the impression
C. it flows well and has minimal shrinkage. posts in place.
D. though it does not flow well it has minimal shrinkage. C. had to consult with a dental technician.
D. none of the above
3. When is a 1/1 silicone precast prepared?
A. After the patient and dentist are pleased with the 3. The removable gingival mask is …
set-up. A. made of pu-acrylic.
B. After all functions work properly. B. made in the implant area.
C. A and B C. used to individually design the emergence profile on
D. none of the above the implants.
D. all of the above.
4. The 1/1 silicone precast is used by the dentist …
A. for design. 4. How were the abutments connected in the acrylic
B. for bar positioning. control key?
C. for attachment and spacing purposes. A. with silicone.
D. All of the above B. with Pattern resin.
C. were soldered.
5. Why are bite registration aids or impression posts
D. by using a laser
used?
A. To guarantee a stable fit in the mouth. 5. To fabricate the secondary components the galvano
B. To assist with the modellation of the bar. electroforming technique was chosen with a thickness of …
C. To facilitate the activation and deactivation of the bar. A. 0.2 mm.
D. none of the above. B. 0.02 mm.
C. 0.1 mm.
D. 0.2 cm

Once you have completed the questionnaire, fill out the information below. You can photocopy this form. Then simply complete the form
and submit to Spectrum dialogue online at www.spectrumdialogue.com or by fax to 905-489-1971. It’s that easy!
In order to receive credits, you must be a subscriber to dental labor international Plus.
NOTICE: All tests are time sensitive and will expire by the end of the calendar year.
You must complete all tests within the current calendar year to receive the credit.

Subscriber Name: __________________________________________________ Phone #: _______________________________________

Address: ___________________________________________________________________________________________________________

Email: ___________________________________ CDT or RDT #: _______________________ Signature: __________________________

32 dental labor international plus – Vol. 3 No. 5 – October 2011

 TEST FOR NBC & RDT CREDITS
dental labor international plus – Vol. 3 No. 5
Each article in this continuing education series is worth 0.5 credit from the NBC. To get your Scientific CE credit for this article,
circle the correct answers to the questions on the short test below. The correct answers can be found within the text of the article.
Then simply complete the form and submit it to Palmeri Publishing Inc., to receive your credit. It’s that easy!

Questions for: Questions for:

Aesthetic assistance Compartis ISUS: Precision and flexibility
— Dr. Bruno R. Chrcanovic and DT Rolf Ankli
1. Periodontal disease … 1. E.S Healthcare …
A. is not an age-related disease. A. was founded in 2007.
B. starts in adolescence. B. is the sister company of DeguDent.
C. worsens with age. C. focuses in on the design and fabrication of milled
D. all of the above suprastructures.
D. all of the above
2. The loss of gingival papillas … 2. The laboratory …
A. often requires a surgical intervention (bone graft). A. is responsible to provide the CAD design software.
B. creates hypersensitivity and “blackholes”. B. initially creates a master model and a wax-up.
C. is considered part of the normal aging process. C. will evaluate and make adjustments if they wish.
D. A and B D. B and C
3. The ISUS design centre …
3. Ginival masks … A. scans the laboratory model.
A. can solve phonetic issues. B. uses a special CAD design software.
B. rarely serve as a support for the lips. C. creates a digital construction draft of the
C. are made of acrylic and silicone. suprastructure.
D. A and C D. all of the above.
4. What materials are used in the process?
4. Gingival atrophy and periodontal recession are less A. zirconium oxide
reason for concern … B. aluminum oxide
A. in the anterior area. C. alloys with high gold content
B. in the posterior region. D. titanium or cobalt-chrome
C. for gingival defects of the mandibula.
5. In this process …
D. B and C
A. DeguDent handles the distribution of products and
services.
5. Large gingival masks … B. ISUS now offers design and fabrication services for
A. are suitable to cover all kinds of defects. sophisticated implant prosthetics.
B. have a relatively high risk of fracturing. C. conventional methods like casting, soldering
C. are seldom used after periodontal flap surgery. etc… guarantee the same desired precision.
D. none of the above. D. A and B

Once you have completed the questionnaire, fill out the information below. You can photocopy this form. Then simply complete the form
and submit to Spectrum dialogue online at www.spectrumdialogue.com or by fax to 905-489-1971. It’s that easy!
In order to receive credits, you must be a subscriber to dental labor international Plus.
NOTICE: All tests are time sensitive and will expire by the end of the calendar year.
You must complete all tests within the current calendar year to receive the credit.

Subscriber Name: __________________________________________________ Phone #: _______________________________________

Address: ___________________________________________________________________________________________________________

Email: ___________________________________ CDT or RDT #: _______________________ Signature: __________________________

dental labor international plus – Vol. 3 No. 5 – October 2011 33

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34 dental labor international plus – Vol. 3 No. 5 – October 2011

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