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FALL 2011 ISSUE
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From Intraoral Scan to Final Custom Implant Restoration

video photo essay continuing education

Perry E. Jones, DDS, FAGD

Overview

Digital technology continues to revolutionize the methods of modern dentistry, benefitting every phase of treatment from diagnosis to final restoration. Implant cases in particular rely heavily on accuracy and predictability, both of which can be greatly enhanced using computer-aided techniques. In this multimedia presentation, Dr. Perry Jones demonstrates the use of an intraoral optical scanning system, followed by the CAD/CAM design and milling of all-zirconia custom abutments and a monolithic zirconia bridge, to precisely restore a historically problematic anterior case. After reading the article, viewing the photo essay and watching the video, take the short CE test to earn two free hours of credit.

Perry E. Jones, DDS, FAGD

bockhorstDr. Perry Jones received his DDS from Virginia Commonwealth University School of Dentistry, where he has held adjunct faculty positions since 1976. He maintains a private practice in Richmond, Va. One of the first GP Invisalign® providers, Dr. Jones has been a member of Align's Speaker Team since 2002, presenting more than 250 Invisalign presentations. He has been involved with Cadent optical scanning technology since its release to the GP market and is currently beta testing the newest software from Align Technology. Dr. Jones belongs to numerous dental associations and is a fellow of the AGD. Contact him at inclusivemagazine@glidewelldental.com.

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From Intraoral Scan to Final Custom Implant Restoration

Introduction

This case demonstrates the optical scanning of Glidewell Laboratories' purpose-made Inclusive® Scanning Abutments utilizing the iTero™ digital scanning system (Align Technology; San Jose, Calif.) with software version 4.0. Digital data was used in conjunction with laboratory CAD/CAM planning to fabricate custom all-ceramic implant abutments and a final 4-unit fixed prosthesis. The abutments and fixed prosthesis were fabricated using advanced computer-aided milling technology.

Dental History

The patient in this case was a 52-year-old healthy Hispanic male who sustained a traumatic avulsion and loss of his maxillary incisors in an automobile accident. Following healing, the patient reported that a 4-tooth transitional removable partial denture was constructed. He was seen by the oral and maxillofacial surgery service of Virginia Commonwealth University, as he desired dental implant therapy. The patient reported multiple incidents of a "broken" provisional denture (Fig. 1).

Treatment Plan

The patient was informed of the alternatives, benefits and potential complications of various treatment options before confirming his desire to pursue implant restoration of his missing anterior teeth. The treatment plan included placement of two Replace® Select Straight RP 4.3 x 13 mm implants (Nobel Biocare; Yorba Linda, Calif.) with 5 mm healing abutments, followed by a six-month healing period and restoration with all-zirconia custom abutments and a 4-unit all-ceramic fixed prosthesis to restore the anterior incisors to form and function.

Surgical Procedure

Using local anesthesia, two Replace Select Straight RP implant fixtures were placed in the area of tooth #7 and #10 using standard Nobel Biocare implant placement protocol. Placement angulation and depth were verified and appeared to be satisfactory (Fig. 2). Standard RP 5 mm healing abutments were placed, and the fully reflected tissue flap was closed with interrupted sutures (Fig. 3).

Restorative Procedure

Following six months of healing post implant placement, intraoral photos were taken to record and confirm the healthy remaining dentition (Fig. 4, Fig. 5, Fig. 6, Fig. 7, Fig. 8). Osseous integration was confirmed with a panoramic X-ray (Fig. 9), followed by resonance frequency analysis (RFA) using an Osstell® ISQ implant stability meter with SmartPeg™ attachment (Osstell Inc. USA; Linthicum, Md.) (Fig. 10), which displayed an implant stability quotient (ISQ) of 78 on a minimum-to-maximum scale of 1-100. Counter rotation with a torque wrench confirmed no rotation to 35 Ncm. Based on this evidence of stability, the implant fixtures were deemed to be acceptable for restoration.

The 5 mm healing abutments were removed (Fig. 11) and purpose-made Inclusive Scanning Abutments (Fig. 12) were placed and hand-tightened over the implants with the accompanying titanium screws (Fig. 13, Fig. 14).

Using the iTero scanner with updated software (version 4.0), a full maxillary arch scan, full mandibular arch scan and centric bite in maximum intercuspation were completed. A three-dimensional digital record of the patient's anatomy was created from these scans (Fig. 15) and electronically submitted to Glidewell Laboratories to be used in the CAD/CAM restoration process.

At Glidewell Laboratories, the virtual scan was registered to the scanning abutments (Fig. 16, Fig. 17). This provides the dental technicians with the implant system, size, axis, position relative to the adjacent anatomy and locking feature orientation. A virtual zirconia abutment was designed using 3Shape's DentalDesigner™ software (3Shape Inc.; New Providence, N.J.) and the Glidewell Digital Abutment Library (Fig. 18, Fig. 19, Fig. 20, Fig. 21).

From this, the corresponding physical Inclusive All-Zirconia Custom Abutments (Glidewell Laboratories) were milled. Similarly, a BruxZir® Solid Zirconia 4-unit fixed bridge (Glidewell Laboratories) was designed and milled using this state-of-the-art CAD/CAM technology.

The custom zirconia abutments were trial-fitted in the patient's mouth with some slight tissue blanching noted (Fig. 22). The individual close-up views demonstrate how close the labial path of insertion passed to the head of each abutment's titanium screw (Fig. 23, Fig. 24).

In the same visit, the completed 4-unit all-ceramic milled BruxZir Solid Zirconia bridge was trial-fitted and examined for proper occlusion (Fig. 25, Fig. 26). There was "tight" anterior coupling for this case as evidenced by the history of provisional denture fracture. The occlusion was checked and presented as so precise that no adjustment was required. The anterior view of the final prosthesis demonstrates optimal mesial-distal width proportion, incisal edge proportion, pontic-tissue contact and excellent shade/esthetics (Fig. 27). Further, the occlusal view demonstrates an optimal incisal edge arch form (Fig 28). The soft tissue lip position and speech phonetics appeared to be optimal (Fig. 29). Following the trial fitting, the fixed bridge was removed, the zirconia abutment retention screws torqued to 35 Ncm, the abutment screws covered with cotton/Cavit™ Temporary Filling Material (3M™ ESPE™; St. Paul, Minn.), and the prosthesis cemented with GC Fuji PLUS™ (GC America; Alsip, Ill.).

The final full-face photo demonstrates the pleasing smile achieved with the restorative result (Fig. 30).

References

  • Baldissara P, Llukacej A, Ciocca L, Valandro FL, Scotti R. Translucency of zirconia copings made with different CAD/CAM systems. J Prosthet Dent. 2010 Jul;104(1):6-12.
  • Birnbaum NS, Aaronson HB. Dental impressions using 3D digital scanners: virtual becomes reality. Compend Contin Educ Dent. 2008 Oct;29(8): 494, 496, 498-505.
  • Chang YB, Xia JJ, Gateno J, Xiong X, Zhou X, Wong ST. An automatic and robust algorithm of reestablishment of digital dental occlusion. IEEE Trans Med Imaging. 2010 Sep;29(9):1652-63.
  • Christensen GJ. Will digital impressions eliminate the current problem with conventional impressions? J Am Dent Assoc. 2008 Jun;139(6):761-3.
  • Drago C, Saldarriaga RL, Domagala D, Almasri R. Volumetric determination of the amount of misfit in CAD/CAM and cast implant frameworks: a multicenter laboratory study. Int J Oral Maxillofac Implants. 2010 Sep-Oct;25(5):920-9.
  • Ender A, Mehl A. Full arch scans: conventional versus digital impressions – an in-vitro study. Int J Comput Dent. 2011;14(1):11-21.
  • Fasbinder DJ. Digital dentistry: innovation for restorative treatment. Compend Contin Educ Dent. 2010;31(4):2-11.
  • Garg AK. Cadent iTero's digital system for dental impressions: the end of trays and putty? Dent Implantol Update. 2008 Jan;19(1): 1-4.
  • Jones PE. Cadent iTero digital impression case study: full-arch fixed provisional bridge. DC Dentalcompare. 2009 Jul 8 [cited 2011 Jul 28]. Available from: http://www.dentalcompare.com/Featured-Articles/2082-Cadent-iTero-Digital-Impression-Case-Study-Full-Arch-Fixed-Provisional-Bridge/.
  • Jones PE. Cadent iTero optical scanning digital impressions for restorative and invisalign. Dental Product Shopper. 2011 Jun 28 [cited 2011 Jul 29]. Available from: http://dentalproductshopper.reachlocal.net/articles/cadent-itero-optical-scanningdigital-impressions-restorative-and-invisalign.
  • Kurbad A. Impression-free production techniques. Int J Comput Dent.2011;14(1): 59-66.
  • Priest G. Virtual-designed and computer-milled implant abutments. J Oral Maxillofac Surg. 2005 Sep;63(9 Suppl 2):22-32.
  • Smith R. Creating well-fitting restorations with a digital impression system. Compend Contin Educ Dent. 2010 Oct;31(8):640-4.
  • Touchstone A, Nieting T, Ulmer N. Digital transition: the collaboration between dentists and laboratory technicians on CAD/CAM restorations. J Am Dent Assoc. 2010;141 Suppl 2:15S-9S.
  • Zweig A. Improving impressions: go digital! Dent Today. 2009 Nov;28(11):100, 102, 104.
From Intraoral Scan to Final Custom Implant Restoration
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  • Figure 1: Patient presents with broken RPD. Note tight anterior coupling.

  • Figure 2: Osteotomies for implants #7 and #10 with guide pins

  • Figure 3: Post placement with 5 mm healing abutments and sutures

  • Figure 4: Healing abutments at six months post implant placement

  • Figure 5: Right buccal view

  • Figure 6: Left buccal view

  • Figure 7: Maxillary occlusal view

  • Figure 8: Mandibular occlusal view

  • Figure 9: Panoramic view of implants at six months

  • Figure 10: Osstell ISQ implant stability meter

  • Figure 11: Replace Select Straight RP implants (Nobel Biocare) with healing abutments
  • animate_postcard
    Figure 12: Inclusive Scanning Abutment with attachment screw

  • Figure 13: Inclusive Scanning Abutments attached to implants (occlusal view)

  • Figure 14: Inclusive Scanning Abutments attached to implants (labial view)

  • Figure 15: iTero virtual scan (Align Technology)

  • Figure 16: Registering scanning abutment library to iTero virtual scan

  • Figure 17: Scanning abutments registered to iTero virtual scan

  • Figure 18: Abutment planning (labial view) with 3Shape's DentalDesigner software and Prismatik CZ add-on module

  • Figure 19: Abutment design (occlusal view)

  • Figure 20: Abutment design (profile view)

  • Figure 21: Abutment design (lingual view)

  • Figure 22: Inclusive All-Zirconia Custom Abutments #7 and #10

  • Figure 23: Inclusive All-Zirconia Custom Abutment #7

  • Figure 24: Inclusive All-Zirconia Custom Abutment #10

  • Figure 25: 4-unit BruxZir Solid Zirconia fixed bridge (labial view)

  • Figure 26: 4-unit BruxZir Solid Zirconia fixed bridge (internal abutment view)

  • Figure 27: 4-unit BruxZir Solid Zirconia fixed bridge (labial view)

  • Figure 28: 4-unit BruxZir Solid Zirconia fixed bridge (occlusal view)

  • Figure 29: Final all-zirconia restoration

  • Figure 30: Happy patient!

Course Objectives (2 CE Credits)

Implant cases rely heavily on accuracy and predictability, both of which can be greatly enhanced using the latest computer-aided techniques. In his written case report and accompanying video, Dr. Perry Jones utilizes an intraoral optical scanning system, followed by the CAD/CAM design and milling of all-zirconia custom abutments and a monolithic zirconia bridge, to restore a historically problematic anterior case. His presentation demonstrates the following concepts and technologies:
  • Evaluating implant stability
  • Inclusive® Scanning Abutments
  • iTero™ Digital Scanning System
  • CAD/CAM abutment design utilizing 3Shape DentalDesigner™
  • CAD/CAM fabrication of monolithic BruxZir® Solid Zirconia anterior bridges

CE Summary

Digital technology continues to revolutionize the methods of modern dentistry, benefitting every phase of treatment from diagnosis to final restoration. As the long-term success of any implant faces threat from masticatory function, it is critical not only to ensure proper placement, but also to relieve or eliminate undue mechanical stresses that may result from a poorly planned restoration. Taking full advantage of the latest computer-aided techniques as demonstrated here can help to ensure the optimal design of, and precise fit between, the full chain of restorative components, thereby reducing the risk of failure.

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