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Implant Q&A
An Interview with Dr. David Little


David A. Little, DDS, and Bradley C. Bockhorst, DMD


In this interview, a Texas-sized passion for excellence and a commitment to improving quality of life for edentulous patients shines through as Dr. David Little weighs in on several aspects of what makes today's progressive dental practice a success. Discover what this forward-thinking clinical researcher has to say on topics ranging from building a truly interdisciplinary practice, to incorporating advanced technologies, to educating the entire team, to treatment planning for patients as if they were family.

About Dr. Little

wiederholdDr. 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

About Dr. Bockhorst

bockhorstAfter 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, AO, ICOI and the AAID, Dr. Bockhorst lectures internationally on an array of dental implant topics. Contact him at 800-521-0576 or

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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.

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