PUBLISHED IN DUBAI www.dental-tribune.me September-October 2018 | No. 5, Vol. 8 SUBSCRIBE NOW https://me.dental-tribune.com/e-paper/ issn 1868-3207 • Vml. 19 • Issue 3/2018 3/18 implants international magazine of oral implantology case report Minimally invasive implant dentistry industry Implant retreatment interview Measuring implant stability deem the complex ones. Even the most experienced implant clinician can miss a potential treatment plan- ning hazard, especially during a busy day. Accurate study model casts are an essential part of this; how- ever, we can now use intraoral scans preoperatively to begin the digital workﬂow. We take a scan rather than impressions to form digital models. Our laboratory can then use these to create digital wax-ups of proposed treatment outcomes. We are routinely used to 2-D radio- graphic imaging techniques in den- tistry, but with the availability and access to CBCT scanning devices now, we are able to assess bone quan- tity and quality of proposed implant surgical sites. ith ever-reducing doses of 3-D imaging and improving accu- racy, we are able to use CBCT scans, combined with clever software pack- ages such as coDiagnostiX (Dental Wings), to plan safe and accurate implant placement and restoration. We are able to preoperatively plan precise implant placement with safe surgical margins away from impor- tant anatomical structures, such as the inferior alveolar nerve or max- illary sinus. From this, we are then able to design and either mill or print a surgical guide to use for precise im- plant placement. ÿPage 2 Mastering the implant digital workﬂow Fig. 1: Dental Wings intraoral scanner Fig. 2: Printed models Fig. 3: 2-D X-ray Fig. 4: 3-D X-ray By Dr Ross Cutts, UK Whether we like it or not, we are em- bracing the digital era in our brave new world. Many dental practices are now becoming paper-free – a digital innovation – and even using tablet computers to record patient details and medical histories. We are continually surprised by the rising age of the technologically savvy pa- tient, particularly those of a certain generation who perhaps we assume would be less so than the perceived iPhone generation. This change in the patient demo- graphic and attitude towards tech- nology is ﬁltering through to us in the dental profession. The nuts and bolts of implant dentistry tends to lend itself more readily to the digi- tal revolution of dentistry in the UK and now globally. Many practitioner opposed to or reluctant to embrace it are actually being inﬂuenced by it through shifting workﬂows in dental laboratories, even where more tradi- tional clinical practices are followed chairside. Quite often, wet impres- sions are poured and stone models are scanned to produce STL ﬁles for laboratories to process during crown and bridge unit manufacturing. As an implant clinician, one does not have to invest in a CT scanner or chairside intraoral scanner—there are ways that other centers and labo- ratories can provide these services. However, having these tools at one’s disposal greatly increases one’s ef- ﬁciency and means one is not reli- ant on external services for one’s patients. So how do we begin the implant digital workﬂow? Successful implant treatment begins with thorough case assessment and planning of the proposed restoration. This is impor- tant for all cases, not just what we Fig. 5: CodiagnostiX Fig. 6: CodiagnostiX surgical guide Fig. 7: Printed guide and sleeves Fig. 8: Postoperative radiograph of implant placement
2 ◊Page 1 IMPLANT TRIBUNE Dental Tribune Middle East & Africa Edition | 5/2018 Fig. 9: Surgical placement of LL67 implants Fig. 10: Scanbodies in situ Fig. 11: Tissue level implants Fig. 12: Crowns on printed model Fig. 13: Implant crowns in situ Fig. 14: Scanbodies with composite ﬂow material to increase scan accuracy Fig. 15: Veriﬁcation jig locked in situ to gain implant passivity Fig. 16: Createch framework ﬁt surface Even with assisted surgery or guided surgery, there are sometimes certain restrictions that prevent us from achieving the most ideal implant placement, such as this case shown where posterior access in the second molar region was reduced, so achiev- ing the perfect parallel was extreme- ly difﬁcult. There are fully guided systems avail- able that allow for absolutely pre- cise implant placement, but these ar fraught with complexities and should be reserved for experienced clinicians. The accuracy of surgical guides should not be used to make up for a lack of surgical competency however. There are many factors to be consid- ered when using surgical guides, in- cluding whether the guide is tooth- ,soft tissue- or bone-supported. Tooth-supported allows the greatest degree of accuracy. If tooth-supported, · are there win- dows in the guide that direct full seating of the guide? · are the teeth that support exact po- sitioning of the guide mobile? Any mobility adds a degree of inaccuracy. · is the guide made from a direct intraoral scan or a scan of a study model? If scanning a study model, is this an accurate stone model rep- resentation? Otherwise, there is the risk of poor seating and inaccuracy of the guide. Fig. 17: Finished screw-retained bridge in situ If soft tissue-supported, mobility completely negates any accuracy of the guide, so it should only be used for a pilot drill and then a more con- ventional surgical protocol adopted. If bone-supported, · raising of a very large surgical ﬂap is likely. · it is very difﬁcult to ensure accu- rate full seating of a bone-supported guide in the precise planned posi- tion and this relies upon external ﬁxation. Once the implants are placed in situ and fully integrated, we then have a choice of conventional wet impression techniques versus digi- tal intraoral scanning. For the ma- jority of cases, intraoral scanning is extremely predictable and reli- able—more so than conventional techniques—with milled (and lately printed) models having excellent properties and less accumulation of processing errors. However, deeply placed implants relative to adjacent teeth with deep contact points are very difﬁcult to scan and pick up. Straumann tissue level implants of- fer a very straightforward restorative platform to scan from. With greater numbers of implants and fewer teeth to act as reference points, intraoral scanning becomes less reliable—particularly across the arch—so we need to exercise caution and be aware of its limitations. We have used composite ﬂow stuck to the soft tissue to increase reference points for our scanners, increasing their ability to stitch images more ac- curately together. With this in mind, we cannot assume the scan is accu- rate and any framework fabricated would be non-passive; therefore, we must use other methods to verify the scan’s accuracy. We have found locking temporary abutments with- in a composite framework intraoral- ly the easiest and most reproducible way to do this. It then allows us to de- sign and mill a truly passive frame- work by Createch and a temporary acrylic bridge. Conclusion There are many opportunities to opt in and out of using technology regarding the digital implant work- ﬂow. For anyone considering capital investment, the most important question to ask is, how will or can this improve the outcomes I provide to my patients, and then determine whether that warrants the expendi- ture. Too often are we subjected to sales pitches of the next biggest thing by company sales representa- tives and gadgets and gizmos end up by the wayside. Acknowledgements to Andy Morton and Ian Murch, the fantastic labora- tory technicians at Borough Crown and Bridge that I work closely with. Editorial note: This article was published in the 2/2018 issue of CAD/CAM_interna- tional magazine of digital dentistry. Dr Ross Cutts He is the principal dentist at Cirencester Dental Practice in Cirencester in the UK. He can be contacted at firstname.lastname@example.org.
Dental Tribune Middle East & Africa Edition | 5/2018 IMPLANT TRIBUNE 3 Astra Tech Implant System and Atlantis Case report By Prof. Clark M. Stanford, USA & Ass. Prof. Gustavo Avila-Ortiz, USA Single tooth immediate placement using the Astra Tech Implant Sys- tem EV and Atlantis Abutment. The patient presented with a fractured maxillary right lateral incisor (#12) with a dislodged endodontic post. Due to crown-to-root ratio and short remaining root, extraction and im- mediate implant placement was elected. Care was provided with an OsseoSpeed EV 3.6 diameter implant placed towards the palate following the 3x2 rule. Following eight weeks of healing, stage-II was performed and the ﬁnal restoration completed within six weeks using an Atlantis Abutment in gold-shaded titanium with concave emergence shape se- lected. The ﬁnal crown was an all- ceramic zirconia crown. Fig. 1: Clinical pre-treatment situation. Root fracture on maxillary right lateral incisor. Fig. 2: Radiographic image of the pre-treatment situation. Fig. 3: Immediate implant placement after tooth extraction starting with the Twist Drill EV Ø1.9. Fig. 4: Direction Indicator EV showing the forthcoming position of the implant. Fig. 5: Implant placement using Implant Driver EV 3.6. Fig. 6: OsseoSpeed EV 3.6 S x13mm placed in the correct position. Fig. 7: Radiographic image after implant placement showing the Osse- oSpeed EV 3.6 S x13mm placed epicrestally with a Cover Screw EV 3.6. Fig. 8: Stage-II was performed after eight weeks of healing. A triangular HealDesign EV 3.6 Ø5-3.5mm is placed in the implant. Fig. 9: The triangular design pre-shapes an esthetic proﬁle for the ﬁnal restoration. Fig. 10: The self-guiding Im- plant Pick-Up EV 3.6 is used for impression taking. Fig. 11: Implant Replica EV 3.6 is connected to the Implant Pick-Up in the impression material. Fig. 12: An Atlantis Abutment in gold-shaded titanium is ordered through Atlantis WebOrder. Fig. 13: Atlantis Abutment in situ after six weeks of ad- ditional healing. The one- position-only indexing fea- ture simpliﬁes the abutment placement. Fig. 14: Radiographic image after placement of the Atlantis Abutment and the crown. Fig. 15: All-ceramic crown (ZrO2) after three months. Fig. 16: Anterior incisal plane and ﬁnal clinical appearance three months after installation.