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ePaper created 2014-10-07, 09:31:41 | version 1.30.01
case report _ smile design combined with guided implantology I carious lesion. The patient presented with severe caries in the remaining teeth. She had no contra- indications for dental treatment (Figs. 1–4). After complete diagnostic evaluation, including clinical, radiographic and photographic analyses, maxillaryandmandibularimpressionsweretakenfor study model fabrication and triplication (Tropicalgin andEliteRockFast,bothZhermack).Usingamaxillary wax rim, the vertical dimension of occlusion was de- termined based on anthropometric and phonetic methods. A facebow was utilised to set and transfer the maxillary 3-D orientation. After the use of an oc- clusaljigforthreedays,aninterocclusalrelationwas registered utilising a bite impression material (Zeta- labor, Zhermack) and the wax rim, establishing the mandibular centric relation and keeping the vertical dimension of occlusion determined previously. The castmodelswerepositionedinanarticulator(Fig.5). The triplication of the models allowed the modifica- tionoftwopairsofcastswithlaboratoryprocedures, while maintaining the initial information in the re- maining pair (Model 2340 Articulator, Whip Mix). The intra-oral and extra-oral photographs were imported into Keynote (Keynote 5.0, Apple) and a complete DSD analysis was performed following the concept’s protocol (Figs. 6–9). The digital restorative simulation was presented to the laboratory techni- cian with the specific indications for preparation of awax-up(Fig.10).Thewax-upwasfabricatedonone of the articulated study models replicating the orig - inal DSD information. On the second pair of casts, a translucent acrylic template of 2 mm in thickness wasfabricatedspanningonlythepalateandedentu- lous regions of the maxillary model. Using a silicone index, acrylic teeth were added to the template in the edentulous regions based on the wax-up model. A1mmroundburwasutilisedtocreateperforations and gutta-percha marks were placed in the palatal region. In order to avoid any movement of the radiopaque material, the perforations were sealed withatranslucentlight-curedresin(Triad,DENTSPLY; Figs. 11 & 12). The radiographic guide was then checkedonthepatientforstabilityandaninitialCBCT scanwasperformed.Thetemplatewasthenremoved andasecondCBCTscanwasperformed,butthistime only of the radiographic template in accordance with the double-scanning protocol described by Verstreken and Van Steenberghe.15–20 The DICOM files obtained from both CBCT scans wereimportedintotheNobelCliniciansoftware(Nobel Biocare). The surgical planning was then performed accordingtoanaestheticallyandprostheticallydriven approach, following the DSD and the NobelGuide conceptandprotocol(NobelBiocare;Figs.13–15). At the next appointment, the DSD analysis and the guided surgical plan were presented to the patient. A virtual superimposition of the implants and the digital restorative simulation was done to give the patient a more comprehensible treatment explanation (Fig. 16). After discussion of the thera- peutic options, a non-invasive surgical approach was selected based on the patient’s requirements. In the maxillae, the proposed treatment entailed pre-operative periodontal treatment, extraction of Fig. 13_NobelClinician virtual surgical planning. The double-scanning protocol allows superimposition of the radiographic template over the virtual reconstruction of the partially edentulous patient. Fig. 14_NobelClinician virtual surgical planning. Note how the implants are virtually placed based on the radiographic template. Fig. 15_Superimposition of the virtual implant surgical planning over the digital restorative simulation. Fig. 16_Superimposition of the implant surgical planning over the extra-oral photograph with the digital restorative simulation. Fig. 17_Occlusal view of the virtual design of the surgical guide. I 25cone beam3_2014 Fig. 14 Fig. 17Fig. 16Fig. 15 CBE0314_22-28_Lanis 30.09.14 15:11 Seite 4