Dr. David Little maintains a multidisciplinary, state-of-the-art
dental practice in San Antonio, Texas, where he dedicates himself
to developing and refining his knowledge skills – as well as those
of his colleagues and peers – through extensive continuing
education and product research. As a clinical researcher
focusing on implants, restorative materials, and technology,
Dr. Little develops predictable procedures for successful
functional and esthetic outcomes. His passion for helping others
drives him to share this expertise in emerging restorative
techniques and materials, as evident in the following interview.
Dr. Bradley Bockhorst: Your practice
is a little different from the typical practice
out there. Tell us how you're set up.
Dr. David Little: My practice is in a little
town called China Grove, which the
Doobie Brothers made famous. It's a
sleepy little town around San Antone,
but you can see downtown from my
office. I built the office around a lake,
so all the treatment rooms look out on
the water. One half of the office is a
specialty wing. I have a fully equipped
surgical suite and orthodontic bay,
and every specialist in dentistry rotates
through my practice. We have
CBCT technology, intraoral scanners,
lab support – just about everything
under one roof. And they're not part
of my practice, they just rent from me.
Together we provide many services.
BB: So you can refer a case and still
keep it in-house?
DL: Exactly.
BB: You're a general dentist. You place
and restore implants. How do you decide
which ones you're going to place
and those you're going to refer out?
DL: First of all, you look at medical
history. Also, in our office, we can do
everything from just local anesthesia
all the way to IV sedation, depending
on what patients want along those
lines. Then, the key is to determine
the factors necessary for success: Is
it great bone? Is it good occlusion? Is
everything set up to make it successful?
If so, then it's one that I'm going to do.
If the patient needs a sinus lift or bone
augmentation, I'm going to refer it. We
do really well referring together. The
oral surgeon will do the bone grafts,
we'll do the implants, or if we need
periodontal plastic surgery, we'll bring
in the periodontist. It actually works
very well.
BB: Sounds like it's a truly interdisciplinary
practice.
DL: Absolutely. We're really blessed to
be able to jump in and take care of
things, especially trauma cases.
BB: You mentioned medical considerations
as a determining factor when deciding
what you might refer out. What
are red flags for you when you're looking
at a patient's medical history?
DL: Uncontrolled diabetes, blood disorders,
the use of bisphosphonates –
those are things that we shy away
from. Essentially anything that makes
us uncomfortable. If I wouldn't do an
extraction, then I'm probably not going
to do an implant on them. So, I use
that as my guideline.
BB: Do you have any advice for aspiring
implantologists – how they should
get started, and what they should look
for in first cases?
DL: First of all, I think you need to
have an eye for implants. I think you
have to start looking for cases where
implants will be the best solution for
the patient. Second, get educated.
Go out and really learn your craft.
And then use mentors. Mentors are a
really good thing. Today, by using a
team approach, you can work with a
laboratory like Glidewell, and sit down
and plan out the case, looking at it
from the restorative aspect backward,
so that everything is planned out. By
using CBCT and surgical guides, you
can do it very predictably and get
great results. The bottom line is: It's
better for our patients.
BB: You mentioned earlier that you have
a cone beam scanner in your office.
DL: I do. Even before I had one, I
would send it out to get that done
because I think it's really valuable information.
Sometimes all you need is
a scan to say, "Yes, OK, I've got this
much bone – great." Sometimes I
look at it and go: "Wow, I'm glad I did
that. I didn't want to do that case." But the real key is not just the CBCT.
It's putting it in the software and being
able to manipulate it. I call it virtual
planning. I want to be able to show
my patient that I'm going to put in
this size implant, and this is why, and
this is how it's going to be contoured
and shaped, all the way to the final
restoration. Because I think the key to
success is treatment planning from the
restoration backward.
BB: What is your favorite planning software?
There are several on the market.
DL: I use SimPlant® (Materialise Dental
Inc.; Glen Burnie, Md.), mostly
because you can use every implant
system. But with whatever implant
you're using, there is going to be a
system that will work with you. So,
again, I think you've got to look at the
total picture.
BB: We've had the same experience. We
do a lot of SimPlant cases here because it
has an open architecture. Let's talk about
guided surgery and level of guidance.
DL: Obviously, you can have the lab
make a guide for you from a wax-up.
That will kind of give you the position,
but it doesn't really give you the angle,
doesn't give you the depth. It just gives
you a guide to stay within that area.
Or you can go all the way to where
you can actually control depth, angle,
and position; you can even place the
implant through the guide (Figs. 1, 2a, 2b).
Everything is planned out. I like that
the best because it gives me the perfect
emergence profile. The software helps
me establish what my abutment is
going to be like, so the laboratory can
work with me to create a provisional
that stays in that same position –
everything is worked through.
I'll also say that using even the
patient's denture as a guide is huge
because that makes sure that you keep
those implants in the neutral zone,
and you're going to get a great result
as well (Fig. 3). There are a lot of guide
techniques, but I like using the one
that controls all of it, if I can.
BB: At the California Dental Association
(CDA) meeting in Anaheim last
May, you spoke on the topic of overdentures.
Can you talk a little bit about how
you approach your edentulous patients?
DL: A lot of denture patients are dental
cripples. They really can't function
and they can't eat. So, one of the
things I do is I ask them, "Do you want
to eat what you want, or eat only what
you can?" Then I talk about what the
different solutions are. I ask questions
like, "At the end of this, would you just
like it that your denture stays in a little
better, or are you looking for something
that you never have to take out?"
Their answers will tell you the direction
they want to go. Then I look at
implant-retained, soft tissue-supported
as a solution. You can do that with
mini implants, or you can do that with
two or four conventional implants,
with different attachments such as Orings
and Locator® attachments (Zest
Anchors; Escondido, Calif.) (Figs. 4a, 4b, 5).
Or, you could go to implant-retained,
implant-supported. The ANKYLOS®
SynCone® (DENTSPLY Friadent) is what
I use for that particular one. It is implant-
retained and implant-supported,
but still removable. And, finally, we
have the option to go screw it in and
either use processed denture teeth,
which are very esthetic today, or make
it out of porcelain.
So, you have that whole range of solutions.
And I really like what Glidewell
has done in establishing one fee. If you
ask a dentist how much an implant
costs, they know the surgical fee off the
top of their head. But if you ask them
how much a crown is, they go: "Uh, it
depends." On what? Well, it depends
on abutments, etc. So it's having a
solution – a two-implant solution, a
four-implant solution. If you include
everything in that, it's just a whole lot
better when you present it to patients.
BB: And you understand all your costs
as a dentist. Talking about the edentulous
patient, how do you make that
decision between a screw-retained denture
and a crown & bridge procedure?
DL: I look at the situation and treat
it four ways: First, I look at it and
treat it in my mind. Second, I wax it
up so I can see if what I'm thinking
can work. Then I sit down with the
lab and we discuss how this is going
to work out. Then we ask the patient
because they're most important. That's
who we're doing it for. Do they want it
fixed? Hopefully, if they want it fixed,
they have enough bone to do it. That's
usually what we have to deal with. If
they do have enough bone, then I tell
them, "Look, if you have a lower denture,
you're eating at about 10 percent
efficiency." If I put in two or four implants
– implant-retained, soft-tissue
supported – you'll be at about 40 to
60 percent. But if you really want to get back to the way you were chewing,
we can do this screw-retained, or
porcelain, and then I can get you back
to functioning even better than you
were before. So, those are the things
I look at. And I really ask that question
of my patients: "Do you want to
eat what you want, or eat only what
you can?
BB: Regarding screw-retained dentures
versus porcelain, how do you make a
decision on which way to go?
DL: That's a good question. What do
patients think? They all think porcelain
is better. Well, porcelain is better
if you have the space for it. And
lip support is the number one thing.
You've got to do a wax rim and make
sure your lip support is proper because
I think you can do a better job
with acrylic a lot of times. So, it's all
in the diagnosis – looking at it and
seeing what is best for that individual
patient. Because the cost on those is
not as much as you'd think, when you
get to that point. A lot of factors are involved,
but really, listen to the patient.
I think that's the main thing.
BB: A suggestion I've heard you give in a past presentation is, "Treat the patient
as you'd treat yourself." Can you expand
on that treatment approach?
DL: When I talk to young dentists
who are coming out of dental school,
I tell them, "Don't biopsy wallets."
Treatment plan what you would do
for yourself, for your mom. Don't
make value judgments. Tell them what
you'd recommend. You can always
back off and sequence it, but always
do what's best. They want what's right.
I think that's my best advice: Don't
biopsy wallets.
BB: I also know you're a big proponent
of education and the importance of
educating the team. What are your
thoughts along those lines?
DL: Here's the truth: As dentists, we
spend more time with our team than
we do with our family during waking
hours, so we've got to be on the
same page. So many times you go to
a seminar and you're all fired up, but
when you come back to the office, after
a couple weeks, things are back
to normal. Unless you take it back
and implement it, nothing happens.
And the key to that is, when you do bring implants into your practice, you
have to have systems, strategies, and
everybody talking the same language
because the very first part of case acceptance
is the phone call. Sometimes
I'll actually do random care calls. I'll
call offices and say, "I need implants,"
and see what they say because everybody
needs to be on the same page.
BB: We were talking about different
technologies – guided surgery, cone
beam scanning. Another is intraoral
scanning. Are you involved in that?
DL: Absolutely, and I've been involved
with that from the beginning. Looking
at the different technologies out there,
I definitely get better fits when I use
an intraoral scanning device. I definitely
get less chairtime when I seat
them, so that's the real value for the
dentist. There's also that wow factor.
Patients love it, there's no gagging. But
I really think it also makes you a better
dentist. If we take an impression
and look at it and go, "It looks pretty
good, the lab will make that work"
versus blowing it up and looking at it
and saying, "Wow, I can't see that," it
really makes us prepare teeth better,
and see things more accurately. Key,
though, is still tissue management.
The holy grail would be when we can
scan it and that's no longer a factor.
But I think that's going to be the future
of dentistry, where we're headed.
I'm a big believer of doing the scanning
yourself and letting the lab do
the work. That's just not my type of
practice, where I'd plan it and mill it
right there in the office. I think it's a
great service and a great technology,
but I prefer to use the lab because my
chairtime is more valuable to me.
BB: Regarding tissue management with
intraoral scanning, do you have a particular
technique that you like to use?
DL: Tried and true, the gold standard
is still the double-cord technique –
I can teach that all day long – and
I've gotten into diode (AMD) and CO2
(DEKA) soft tissue lasers (Figs. 6a, 6b). I think lasers
have really made a big difference
in being able to manage tissue. And
there are lots of products out there
that help that. I think doing whatever
you need to do to be able to see that
margin is the key.
BB: As far as the different materials
that are out there right now, is there
anything you're experimenting with or
starting to work with?
DL: We've seen a growth in monolithic
restorations, which is probably the
biggest thing happening right now.
When we first thought about that, we
said: "Oh my goodness, that material
is so hard. How is it going to wear
the opposing?" Concerns like that. But
there are companies out there, like
Glidewell, that have done all the tests,
and I now know it's not going to wear
the opposing enamel. And you're not
going to have to worry about it breaking.
Also, the esthetics continue to get
better and better. That goes back to
CAD/CAM, and using that technology
to its finest. But I don't think there's a
single perfect solution for every case.
You've got to evaluate each case individually.
Lithium disilicate is good in
some areas, zirconia is good in other
areas. I think you need to look at the
case and the technologies available
and make the best decision.
BB: Going back to implant placement,
are you immediately provisionalizing
your cases?
DL: I'm very conservative in that respect.
There are a lot of things I look
at to make sure I can do that. Let's
look at single-tooth for a minute, upper
anterior (Figs. 7a, 7b). If I can get the
tooth out atraumatically, that's number
one. I have to have the buccal plate
solid and in good shape. Two is if I
can place the implant and get a little
bit of bone apical. So if I have apical
stability, place it a little bit more
toward the palate to get a little palatal
stability. And the most important
thing is that I can have it in disclusion
so there's no pressure on it.
Doing that, our success rate in our
office – and we track everything –
is just as good as if we don't provisionalize.
And our papillae are better.
So, I'm seeing great results doing that.
But if those things don't match, I don't
do it. There are some great provisional
techniques we can apply to wait out
that healing period.
Now, let's talk full arch. There's a
big trend, especially among baby
boomers, where they want it now.
They don't want to wait. So, if we can
extract, place the implants, and seat an
immediate screw-retained provisional,
I think that's a beautiful service for
patients. Patients are really enjoying
that (Figs. 8a, 8b, 8c).
BB: And are you doing everything in
one surgery?
DL: We are. But again, not for every
case. We don't promise it, either. I always
start out with a full denture. And
if it's not the bone that I want to see,
if I don't have the torque I want, then
we just reline it. But I usually know
because I've used the planning CBCT,
and I know exactly what I have. I've
measured my vertical. I know every
detail about it. So we are doing cases
where we're doing upper and lower
immediate extractions and immediate
placement and immediate screwretained
provisionalization, and then
coming back later with CAD/CAM and building the final prosthesis. And
that's a great service to patients.
BB: Have you worked much with All-on-4™ (Nobel Biocare; Yorba Linda, Calif.)
when you're doing screw-retained restorations?
DL: I have. That's been around now
for 10 years, so we've got some track
record to look at. And for patients
who don't have adequate bone, that's
a great solution. Honestly, if I have a
choice, I'd rather have six straight. But
a lot of times I can't. So, in situations
where you don't want to do bone
grafts and other things, it is a solution.
We mentioned SynCone earlier. One
of the things I like about SynCone in
the lower is that I can put four implants
in between the mental foramen, I can load that immediately, and the
costs are a lot less, so it opens that
treatment solution up to more patients.
Sometimes I even use that as
a provisional technique, and then
graft and come back later in the other
areas. Again, you've got to look at
what is best for the patient and make
the diagnosis.
BB: Going back to single teeth and
immediately provisionalizing, in what
percentage of your cases do you think
you're actually doing that?
DL: If I do that in that upper anterior
area, I plan on doing it every time I
can. Now, the truth is, that's probably
only about 80 percent of the time because
there are some times when we
just don't. We always have the lab fabricate
some type of provisional for me.
BB: Have that flipper ready.
DL: Always have that ready. Like an Essix® appliance (Raintree Essix Inc.;
Wilmington, Del.) or something that
I can put in there so that we have
something for the patient to wear
without any worry and without compromising
their care. And, obviously,
patients want it now. If you can do it
now, patient acceptance goes up. With
the technology we have today, we can
do that.
BB: Once you provisionalize at the time
of placement, how long are you waiting
until you do the final restoration?
DL: There are a lot of different opinions
on that, a lot of different research
out there. I'm still waiting three
months. Truthfully, if they're in a good
provisional that looks great and you
have to wait longer, it's not a problem.
They're happy. So, it's not as big an
issue from that standpoint.
BB: How about full-arch cases? If you
immediately provisionalize, how long
are you waiting?
DL: With those cases we're actually
waiting a little bit longer – about four
months on most of those cases. It depends.
When I put that in, I can tell
right then how long it's going to be. If
I have any concerns, I'll wait longer.
There's no rush because you have a
good provisional for them to work with.
It goes back to working with the lab
and having everything in proper order.
It's to the point now where we've become
so good at the provisionals that
we can use that as part of our diagnostics
for our final, and even eliminate
some appointments. The more planning
you do, the better your results
are going to be.
BB: Right. It gives you that ideal prototype
to work from. Are there any future
technologies you see coming to the fore
in dentistry?
DL: I think implants are going to
continue to grow. More dentists
are going to be able to get into that
technology, and more patients are
going to be able to afford it. In our practice, it's one of the most successful
things that we do, so there's a bright
future for that. As I said before, a lot
of people who are edentulous are
dental cripples, and we can really help
with the use of implant overdentures.
Those treatment options are going to
become more and more popular.
Scanning technologies are also going
to change things, even if it's just with
diagnostic impressions. We're going to
be able to do more and more things
digitally, and anything we can do
digitally, I think, is going to help us
all the way through a given procedure
to final restoration. We're looking at
doing dentures digitally now, which
is something else becoming more
prevalent in our field and that will
continue to evolve. It's a great time to
be in dentistry. And the best thing is,
the people who benefit the most are
our patients.
Dr. David Little received his DDS at the University of Texas Health Science Center at San Antonio Dental School and now maintains a multidisciplinary, state-of-the-art dental practice in San Antonio, Texas. An accomplished national and international speaker, professor, and author, he also serves the dental profession as a clinical researcher focusing on implants, laser surgery, and dental materials. As a professional consultant, he shares his expertise on emerging restorative techniques and materials with industry peers. Highly respected for his proficiency in team motivation, Dr. Little's vision, leadership, and experience are recognized worldwide. Contact him at 
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
