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From intraoral scan to final custom implant restoration

Four-unit BruxZir Solid Zirconia fixed bridge cemented in place. (DTI/Photo Glidewell Laboratories)
Perry E. Jones, USA

Perry E. Jones, USA

Fri. 28 December 2012

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This case demonstrates the optical scanning of Inclusive Scanning Abutments (Glidewell Laboratories; Newport Beach, Calif.) utilizing the iTero digital scanning system (Align Technology; San Jose, Calif.) with software version 4.0. Digital data was used with laboratory CAD/CAM planning to fabricate custom all-ceramic implant abutments and a four-unit fixed prosthesis.

The abutments and fixed prosthesis were fabricated using advanced computer-aided milling technology.

Dental history

The patient was a 52-year-old healthy Hispanic male who sustained a traumatic avulsion and lost his maxillary incisors in an automobile accident. Following healing, a four-tooth transitional removable partial denture was constructed. He was seen by the oral and maxillofacial surgery service of Virginia Commonwealth University for dental implant therapy.

Treatment plan

The patient was informed of the alternatives, benefits and potential complications of various treatment options before deciding to pursue implant restoration of his missing 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-ceramic custom abutments and a four-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 implant placement protocol. Placement angulation and depth were verified and deemed satisfactory. Standard RP 5 mm healing abutments were placed, and the fully reflected tissue flap was closed with interrupted sutures.

Restorative procedure

Following six months of healing post-implant placement, intraoral photos were taken to record and confirm the healthy remaining dentition. Osseous integration was confirmed with a panoramic X-ray, followed by resonance frequency analysis (RFA) using an Osstell ISQ implant stability meter with SmartPeg attachment (Osstell Inc.; Linthicum, Md.), 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.

The implant fixtures were considered acceptable for restoration.

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The 5 mm healing abutments were removed, Inclusive Scanning Abutments were placed on the implants and the accompanying titanium screws were tightened (Fig. 1).

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 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, providing 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; New Providence, N.J.) and the Glidewell Digital Abutment Library (Fig. 2).

From this, the corresponding physical Inclusive All-Zirconia Custom Abutments (Glidewell Laboratories) were milled. Similarly, a BruxZir Solid Zirconia four-unit fixed bridge (Glidewell Laboratories) was designed and milled using 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. 3).

In the same visit, the final four-unit all-ceramic milled BruxZir Solid Zirconia bridge was tried-in and examined for proper occlusion. 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. 4). Further, the occlusal view demonstrates an optimal incisal edge arch form. The soft-tissue lip position and speech phonetics appeared to be optimal.

Following the trial seating, 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 PLUSTM (GC America; Alsip, Ill.).

Cadent (Carlstadt, N.J.) was acquired by Align Technology (San Jose, Calif.) in May 2011.

Note: This article was published in Implant Tribune U.S. Edition, Vol. 7 No. 8, August 2012. References are available upon request from the publisher. Photos were provided by Glidewell Laboratories.

 

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