App

lication of digital diagnostic

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Brandon M. Stap

aResident, Advanced Education in PbAssistant Professor, Department ofcAssistant Professor, Department ofdAssociate Professor, Department ofeProfessor, Chair and Director, Adva

The Journal of Prosthetic

ession, virtual planning, and

puter-guided implant surgery for a

/CAM-fabricated, implant-supported

d dental prosthesis: A clinical report

leton, DMD,a Wei-Shao Lin, DDS,b

Athanasios Ntounis, DDS, MS,c Bryan T. Harris, DMD,d andDean Morton, BDS, MSe

University of Louisville School of Dentistry, Louisville, Ky

This clinical report demonstrated the use of an implant-supported fixed dental prosthesis fabricated with a contemporarydigital approach. The digital diagnostic data acquisition was completed with a digital diagnostic impression with an intraoralscanner and cone-beam computed tomography with a prefabricated universal radiographic template to design a virtualprosthetically driven implant surgical plan. A surgical template fabricated with computer-aided design and computer-aidedmanufacturing (CAD/CAM)was used to perform computer-guided implant surgery. The definitive digital data were then used todesign the definitive CAD/CAM-fabricated fixed dental prosthesis. (J Prosthet Dent 2014;112:402-408)

Computer-guided (static) implantsurgery is defined by the use of a staticsurgical template that reproduces a vir-tual implant surgical plan from com-puted tomographic data and doesnot allow intraoperative modificationof implant position.1-3 The benefit ofcomputer-guided surgery is a morepredicable implant placement witha surgical template fabricated withcomputer-aided design and computer-aided manufacturing (CAD/CAM) basedon a prosthetically driven treatmentplanning process in a virtual implantplanning software.4,5 The conventionalcast-based implant planning and surgicaltemplate fabrication approach does notallow visualization of all prosthetic andanatomic parameters simultaneouslyduring the planning process, and theresulting surgical template does notprovide exact 3-dimensional guidanceduring implant placement.6 Most of theavailable systems for computer-guidedimplant surgery share a similar treat-ment protocol. A radiographic templatewith fiducial markers represents thedesired prosthetic treatment plan. Cone-beam computed tomography (CBCT)

rosthodonOral HeaOral HealOral Heanced Edu

Dentis

is performed with the patient wearinga radiographic template. The resultingCBCT data are imported into virtualimplant planning software to formulatea prosthetically driven implant surgicalplan.7 Although concerns about theaccuracy of computer-guided implantsurgery still exist,1 it may help the clini-cian to perform successful implant sur-gery without flap elevation, causing lessdiscomfort to the patient.8

SIM/Plant (Columbia Scientific Inc)was the first commercially availablevirtual dental implant planning software.Introduced in 1993, it allowed cliniciansto interactively plan implant place-ment with CBCT images.9,10 Modernvirtual implant planning software, suchas NobelClinician (Nobel Biocare),coDiagnostiX (Dental Wings GmbH),and VIP Software (BioHorizons), allowsa virtual implant surgical plan to be sentto a processing center for a CAD/CAMfabricated surgical template.9,10 A dif-ferent process can then be used tofabricate CAD/CAM surgical templates,such as additive manufacturing technol-ogies (stereolithography) or computer-driven drilling.2,6,11,12

tics, Department of Oral Health and Rehabilitalth and Rehabilitation.th and Rehabilitation.lth and Rehabilitation.cation in Prosthodontics, Department of Oral H

try

The use of digital impression for thefabrication of definitive prostheses onnatural dentition and dental implantshas become available,13-16 and it offerssome advantages over conventionalimpression techniques. A clinical studyfound that overall patient preferencewas significantly in favor of the digitaltechnique.17 The iTero System (AlignTechnology) has been used to acquiredefinitive implant-level impression forimplant-supported prostheses with theoption of milled definitive cast withremovable implant analog (Reposition-able Implant Analog; Straumann).14-19

Although the accuracy of digital dataacquisition at the implant level and ofthe resulting cast has not been widelystudied, it may provide clinicians with analternative workflow and improve clin-ical efficiency.20,21

This clinical report demonstratedthe use of an implant-supportedfixed dental prosthesis fabricatedwith a digital workflow. Digital diag-nostic impression, virtual planning,computer-guided implant surgery, andan immediate provisionalization pro-tocol were used to complete treatment

tion.

ealth and Rehabilitation.

Stapleton et al

1 Pretreatment condition, occlusal view. 2 Diagnostic data acquisition with intraoral digital scanner.

3 Virtual diagnostic waxing created in CAD/CAM software. A, Occlusal view. B, Buccal view.

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with a CAD/CAM-fabricated, implant-supported fixed dental prosthesis.

CLINICAL REPORT

A 55-year-old white woman pre-sented at the Graduate ProsthodonticsClinic, Department of Oral Healthand Rehabilitation, School of Dentistry,University of Louisville, for the replace-ment of missing right maxillary canineand premolars. The teeth had beenpreviously removed with a simultaneousridge preservation procedure. A clinicalintraoral and radiographic examinationfound no contraindications for dentaltreatment (Fig. 1). The patient wantedto have her missing dentition restoredwith a fixed dental prosthesis, and atreatment option with 2 dental im-plants and an implant-supported fixeddental prosthesis was presented, which

Stapleton et al

she accepted. A digital treatmentpathway with computer-guided implantsurgery and an immediate provisionali-zation protocol was chosen. It requiredthe use of 2 dental laboratories, the firstfor the virtual planning and CAD/CAM-fabricated surgical template and thesecond for the interim and definitiveprosthesis.

An intraoral digital scanner (iTero;Align Technology) was used to makedigital diagnostic impressions forboth the maxillary and mandibulararches with an interocclusal registration(Fig. 2). The approved scan data wereforwarded to the selected dental labo-ratory (ProPrecision Guides), wherevirtual diagnostic casts and virtualdiagnostic waxing were created (Fig. 3).CBCT for the maxillary anterior regionwas recommended for preoperativeassessment, and the patient was

scanned with a prefabricated universalradiographic template with fiducialmarkers (Keybite; ProPrecision Guides)(Fig. 4). The radiologic report from theCBCT confirmed that there was no ev-idence of pathosis and minimal atrophyof the edentulous ridge (in width) withevidence of bone grafting materials.However, the remaining ridge heightnecessitated simultaneous sinus graft-ing and implant placement. Digitalstereolithography files (STL) generatedfrom the virtual diagnostic casts andwaxing were imported into virtualimplant planning software (coDiag-nostiX; Dental Wings GmbH). TheDigital Imaging and Communicationsin Medicine data (DICOM) from theCBCT was also imported into the vir-tual implant planning software andmerged with the STL files. A virtualprosthetically driven implant surgical

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plan was completed in the virtualplanning software (Fig. 5). The ap-proved surgical plan was transmittedto the selected dental laboratory (Pro-Precision Guides), where a CAD/CAM-fabricated surgical template (Fig. 6)was created for subsequent computer-

4 Prefabricated universal radiofiducial markers.

5 A, Demonstration of virtual prosthetfiles generated from virtual diagnostic cacanine. C, Detailed prosthetically driven

The Journal of Prosthetic Dentis

guided implant surgery and CAD/CAM-fabricated diagnostic casts (Fig. 7A, B).An immediate provisionalization proto-col was planned. The interim implant-supported fixed dental prosthesis wasmade in the dental laboratory (RoyDental Laboratory) on the CAD/CAM

graphic template with

ically driven implant placements merged wsts and waxing. B, Detailed prostheticallysurgical plan for right maxillary second p

try

fabricated cast from autopolymerizingacrylic resin (Jet Tooth Shade Acrylic;Lang Dental) and provisional abutments(RN Temporary synOcta Post, Bridge;Straumann) (see Fig. 7C).

The computer-guided implant sur-gery was performed under local anes-thesia. An intrasulcular full-thicknessflap was raised to facilitate the plannedosseous recontouring and sinus graftingprocedure. Graft material containingmineralized cortical particulate (GuidorAllograft; Sunstar Americas Inc) wasused for the sinus grafting procedure toprepare the site for the simultaneousimplant placement at the maxillary sec-ond premolar location. Two implants(Straumann standard Plus, SLActive,guided 4.1 mm � 10 mm; InstitutStraumann AG) were placed with theguidance provided by the CAD/CAM-fabricated surgical template (Fig. 8).The flapwas coronally repositioned, andprimary closure of the flapwas obtained.

ith DICOM file from CBCT and STLdriven surgical plan for right maxillaryremolar.

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September 2014 405

Because of the concerns of passivity ofthe interim restoration,1 the laboratory-fabricated interim implant-supportedfixed dental prosthesis was separatedwith a diamond disk (911.11.220 DSDIAM DISC; Brasseler USA) and

6 CAD/CAM fabricated surgicguided surgery.

7 CAD/CAM fabricated casts. A, Diagnwith implant analogs (RN synOcta analointerim implant-supported fixed dental p

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reconnected with autopolymerizingacrylic resin (Jet Tooth Shade Acrylic;Lang Dental).

The patient was observed for 8weeks with uneventful healing beforethe definitive impression appointment.

al template for computer-

ostic cast representing result from virtualg; Straumann USA) representing plannedrosthesis.

An intraoral digital scanner (iTero;Align Technology) was used to acquirethe definitive digital data with thescannable impression copings (ScanBody; Straumann AG) (Fig. 9). Themilled definitive polyurethane cast wasthen fabricated by the manufacturer(iTero; Align Technology). The soft tis-sue profile at the periimplant area andthe pontic site was transferred to themilled definitive polyurethane cast withthe interim implant-supported fixeddental prosthesis and polyvinyl siloxanematerial (Softissue Moulage; KerrDental Laboratory Products) (Fig. 10).12

The modified definitive cast with thedesired soft tissue profile was digitizedwith a laboratory-based scanner (CS2scanner; Institut Straumann AG) andused to design the definitive fixed dentalprosthesis framework (Fig. 11). The ap-proved framework design was sent tothe production facility (StraumannUSA)

diagnostic waxing. B, Diagnostic castimplant placements. C, Completed

8 CAD/CAM fabricated surgical templatewas used to completecomputer-guided surgery for 2 dental implants.

9 Definitive digital data acquisition made with intraoraldigital scanner and scannable impression copings.

10 Modified milled definitive polyurethane cast with desiredsoft tissue profile at periimplant area and pontic site.

11 Design of CAD/CAM-fabricated definitive fixed dentalprosthesis framework.

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for fabrication from cobalt-chromiumalloy (Coron; Straumann USA).

The framework was evaluatedintraorally, and the definitive castsand framework were returned to thedental laboratory for completion. Atthe insertion appointment, all thenecessary adjustments were made toachieve a satisfactory clinical outcome.The definitive metal ceramic fixed dentalprosthesis was secured to the implantswith a 35-Ncm preload (Fig. 12A). Ahigh-resolution localized CBCT scan(60�60 mm, 90 kV, 3 mA, 180-degreeStandard mode; effective doses, 23 mSvper CT image; 3D Accuitomo 170; J.Morita USA) of the implants was used forposttreatment assessment. The radiologicreport showed that both implants were

The Journal of Prosthetic Dentis

well integrated and that the boneaugmentation material in the right sinuswas homogeneous (see Fig. 12B, C).

DISCUSSION

The advantages of the workflowpresented were reduced treatmenttime and cost. The digital diagnosticimpression and a CBCT scan werecompleted in a single visit. Becausea prefabricated universal radiographictemplate (Keybite; ProPrecisionGuides) was used, the cost of acustomized radiographic template waseliminated. The proposed workflowhas several limitations. The CAD soft-ware may not permit a highlycustomized virtual diagnostic waxing,

try

and the completed virtual diagnosticwaxing cannot be transferred to thepatient for a trial insertion. Theselimitations may limit the estheticoutcome of the definitive prosthesis.The CAD/CAM-fabricated diagnosticcast with the implant analogs (RNsynOcta analog; Straumann USA) isan additional cost of the proposedworkflow. However, this cast can beomitted if an immediate provisionali-zation protocol is not planned or if aninterim implant-supported fixed dentalprosthesis is fabricated intraorally.Furthermore, both the clinician and thedental laboratory technician requireadditional system-specific training andexperience with the proposed digitalworkflow.

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12 Definitive metal-ceramic fixed dental prosthesis. A, Occlusal view. B, Posttreatment CBCT at right maxillary caninearea. C, Posttreatment CBCT scan showing implant at right maxillary second premolar area.

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SUMMARY

This clinical report proposed a digitalworkflow to provide a CAD/CAM-fabricated, implant-supported fixeddental prosthesis with a digital diag-nostic impression, virtual planning,computer-guided implant surgery, andimmediate provisionalization.

REFERENCES

1. Bornstein MM, Al Nawas B, Kuchler U,Tahmaseb A. Consensus statements andrecommended clinical procedures regardingcontemporary surgical and radiographictechniques in implant dentistryInt J Oral Maxillofac Implants 2014;29:78-83.

2. D’haese J, Van De Velde T, Komiyama A,Hultin M, De Bruyn H. Accuracy andcomplications using computer-designedstereolithographic surgical guides fororal rehabilitation by means of dentalimplants: a review of the literature.Clin Implant Dent Relat Res 2012;14:321-35.

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3. Cassetta M, Stefanelli LV, Giansanti M,Calasso S. Accuracy of implant placement witha stereolithographic surgical template. Int JOral Maxillofac Implants 2012;27:655-63.

4. Schneider D, Marquardt P, Zwahlen M,Jung RE. A systematic review on theaccuracy and the clinical outcome ofcomputer-guided template-based implantdentistry. Clin Oral Implants Res2009;20(suppl 4):73-86.

5. de Almeida EO, Pellizzer EP,Goiatto MC, Margonar R, Rocha EP,Freitas AC Jr, et al. Computer-guidedsurgery in implantology: review of basicconcepts. J Craniofac Surg 2010;21:1917-21.

6. Ramasamy M, Giri P, Raja R,Subramonia N, Karthik MM,Narendrakumar R. Implant surgicalguides: from the past to the present.J Pharm Bioallied Sci 2013;5(suppl 1):S98-102.

7. Orentlicher G, Abboud M. Guided surgery forimplant therapy. Dent Clin North Am2011;55:715-44.

8. Sicilia A, Botticelli D. Working Group 3.Computer-guided implant therapy andsoft- and hard-tissue aspects: the ThirdEAO Consensus Conference 2012.Clin Oral Implants Res 2012;23(suppl 6):157-61.

9. D’Souza KM, Aras MA. Types of implantsurgical guides in dentistry: a review. J OralImplantol 2012;38:643-52.

10. Azari A, Nikzad S. Computer-assistedimplantology: historical background andpotential outcomesea review. Int J MedRobot 2008;4:95-104.

11. Jabero M, Sarment DP. Advanced surgicalguidance technology: a review. Implant Dent2006;15:135-42.

12. Jung RE, Schneider D, Ganeles J, Wismeijer D,Zwahlen M, Hämmerle CH, et al. Computertechnology applications in surgical implantdentistry: a systematic review. Int J OralMaxillofac Implants 2009;24(suppl):92-109.

13. Lin WS, Harris BT, Ozdemir E, Morton D.Maxillary rehabilitation with a CAD/CAM-fabricated, long-term interim and anatomiccontour definitive prosthesis with a digitalworkflow: a clinical report. J Prosthet Dent2013;110:1-7.

14. JodaT,Wittneben JG,BräggerU.Digital implantimpressions with the “Individualized ScanbodyTechnique” for emergence profile support. ClinOral Implants Res 2014;25:395-7.

15. Lin WS, Harris BT, Morton D. The use of ascannable impression coping and digitalimpression technique to fabricate acustomized anatomic abutment and zirconiarestoration in the esthetic zone. J ProsthetDent 2013;109:187-91.

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16. Lin WS, Harris BT, Morton D. Useof implant-supported interimrestorations to transfer periimplant softtissue profiles to a milled polyurethanedefinitive cast. J Prosthet Dent 2013;109:333-7.

17. Wismeijer D, Mans R, van Genuchten M,Reijers HA. Patients’ preferences whencomparing analogue implant impressionsusing a polyether impression material versusdigital impressions (Intraoral Scan) of dentalimplants [published online August 14,2013]. Clin Oral Implants Res.http://dx.doi.org/10.1111/clr.12234.

Notewort

A retrospective analysis of 800 Br

Balshi TJ, Wolfinger GJ, Slauch RWJ Prosthodont 2014;23:83-8

Purpose. The purpose of this study was tAll-on-Four� protocol according to eden

Materials and Methods. All Brånemark Sprivate practice were separated into multiretrospective patient chart review. Inclusioprotocol from the clinical inception (Mayimplant survival rates (CSR). The arches,

Results. One hundred fifty-two patients,were included in the study. Overall implanand 489 of 500 mandibular implants sur256 implants (98.1%) remain in functionorientation, 389 of 400 tilted implants anAll comparisons were found to be statisti

Conclusions. The results from this study sparameters when formulating an All-on-FAll-on-Four� treatment as a viable alternmandible.

Reprinted with permission of the America

The Journal of Prosthetic Dentis

18. Lee SJ, Macarthur RX 4th, Gallucci GO. Anevaluation of student and clinician percep-tion of digital and conventional implant im-pressions. J Prosthet Dent 2013;110:420-3.

19. Lin WS, Harris BT, Zandinejad A, Morton D.Use of digital data acquisition and CAD/CAM technology for the fabrication of a fixedcomplete dental prosthesis on dental im-plants. J Prosthet Dent 2014;111:1-5.

20. Ramsey CD, Ritter RG. Utilization of digitaltechnologies for fabrication of definitiveimplant-supported restorations. J EsthetRestor Dent 2012;24:299-308.

21. Lee SJ, Gallucci GO. Digital vs. conventionalimplant impressions: efficiency outcomes.Clin Oral Implants Res 2013;24:111-5.

hy Abstracts of the Current Li

ånemark System implants followin

, Balshi SF

o retrospectively evaluate implant survivaltulous jaws, gender, and implant orientati

ystem implants placed in patients followinple classifications (maxilla vs. mandible; mn criteria consisted of any Brånemark Syste2005) until December 2011. Life tables wegenders, and implant orientations were st

comprising 200 arches (800 implants) fromt CSR was 97.3% (778 of 800). Two hundrvived, for CSRs of 96.3% and 97.8%, respewhile 527 of 544 implants (96.9%) in femad 389 of 400 axial implants osseointegracally insignificant. The prosthesis survival r

uggest that edentulous jaws, gender, andour� treatment plan. The high CSRs for eative to more extensive protocols for rehab

n College of Prosthodontists.

try

Corresponding author:Dr Wei-Shao LinDepartment of Oral Health and RehabilitationRm 310School of Dentistry, University of Louisville501 S Preston St, Louisville, KY 40292E-mail: WeiShao.Lin@Louisville.edu

AcknowledgmentsThe authors thank Roy Dental Laboratory, NewAlbany, Ind, and ProPrecision Guides, Gainesville,Fla for assistance in this study.

Copyright ª 2014 by the Editorial Council forThe Journal of Prosthetic Dentistry.

terature

g the All-on-Four� protocol

rates in patients treated with theon (tilted vs. axial).

g the All-on-Four� protocol in a singleale vs. female; tilted vs. axial) by

m implant placed with the All-on-Four�re constructed to determine cumulativeatistically compared with ANOVA.

May 2005 until December 2011,ed eighty-nine of 300 maxillary implantsctively. In male patients, 251 ofle patients survived. Regarding implantted, for identical CSRs of 97.3%.ate was 99.0%.

implant orientation are not significantach variable analyzed demonstrate theilitating the edentulous maxilla or

Stapleton et al