Integrating technologies leads to innovative solutions
by Dr. Grant Olson
Digital technologies have transformed the
practice of dentistry to offer clinicians a more
efficient and accurate means to diagnose and
plan how to treat their patients. Innovative
production technologies, high-performance
restorative materials and pioneering clinical technologies,
tools and techniques are converging in the digital
workflow space to expand patient treatment options and
offer clinicians new solutions for restorative treatment
from single-tooth to full-arch implant-supported cases.1,2
The ability to combine digital technologies with tools
and materials for restorative care opens up a host of new
possibilities for surgical and prosthetic treatments that
offer solutions for both patients and clinicians. Reduced
chair time, lower patient cost and fewer treatment phases
are all possible while improving the quality, fit and
aesthetics of the final outcome. This is particularly true
in the arena of full-arch, implant-supported prosthetics.
Although past advancements in technology and techniques
have resulted in 3D guided surgery protocols that can
deliver a full-arch short-term temporary in a single visit,
one of the biggest barriers to treatment acceptance is
the high cost of the permanent high-quality full-arch
prosthetic.3
It is estimated that 40 million Americans are missing
all of their teeth.4 Although most patients understand the
benefits of immediate-load implant-retained prosthetics,
the challenge today is to develop simplified restorative
protocols that are immediate, aesthetic and cost effective.5
The case presented here demonstrates how integrating
three patented technologies can result in a same-day
full-arch, implant-retained prosthetic solution that
not only is cost-effective but also offers the patient a
strong, longer-term, highly aesthetic fixed hybrid that
is not screw retained.
Case report
A patient in her 70s presented to the practice with
the chief complaint that her existing maxillary denture
had changed over time and was now slipping, which
triggered a gag reflex when swallowing. In addition,
she was dissatisfied with the aesthetics of the denture
and wanted her smile back (Fig. 1).
Fig. 1
She and the clinician discussed several restorative
options, from a new conventional denture to an
immediate-load, implant-retained prosthesis that would
eliminate the palatal aspect of a conventional denture.
Although she was pleased with a solution that would
eliminate the palatal aspect she found unbearable, the
final implant-retained solution was out of financial
reach for her.
The clinician then proposed a lower cost immediate-load,
implant-borne approach that included a long-term
solution—one that could be replaced after many years
or taken to a final zirconia solution if or when finances
allowed. In addition, the surgery and placement of
the prosthesis could be completed in a single two- to
three-hour visit with only one follow-up visit to finalize
the prosthesis.
The patient accepted this solution and was scheduled
for a record-taking appointment.
Treatment planning and record taking
To execute any digitally and prosthetically driven
full-arch case, the initial record-taking appointment is
critical to provide the dental team with the information
needed to treatment-plan the case and for the laboratory
to fabricate the surgical guidance system components
(Chrome GuidedSmile, Roe Dental Laboratory) and
the immediate-load, long-term, full-arch prosthesis for
delivery the day of surgery.6
X-rays and a CBCT scan (Axeos, Dentsply Sirona)
were taken to assess the patient’s bone quality and
density for 3D presurgical team planning (BlueSkyPlan,
BlueSkyBio) of optimal placement of six implants in
correct position in relation to the final prosthesis.
Digital photos with the patient wearing her existing
maxillary denture smiling, with an exaggerated smile,
and a full-face profile were taken, as well as retracted
views full center, left and right in occlusion (Figs. 2
and 3). The CBCT scan and digital photos were sent to
the dental laboratory and integrated for a review of the
comprehensive digital and clinical information for the
design and creation of an immediate-load, long-term,
full-arch prosthetic that would meet the form, fit,
function and aesthetics the patient expected.
Fig. 2
Fig. 3
To provide the patient with a strong, long-term, more
affordable full-arch solution, the team decided to use a
CAD/CAM-milled long-term monolithic provisional
material (Ivotion, Ivoclar) that would rely on a unique
retention mechanism (Smileloc Abutment System,
Rodo) to provide the patient with a fully functional
and aesthetic solution and eliminate the need for the
more conventional method of drilling holes through a
solid prosthesis for screw retention, which can weaken
the structure and lead to potential fracture.7
Surgery and implant placement
With the virtual plan confirmed, all components
for the guided surgical approach were delivered to
the practice. On the day of surgery, the patient was
administered local oral anesthesia and the labial tissue flap was reflected and sutured (Fig. 4).
Fig. 4
Because administering anesthesia may cause the
palate to swell, a 15-minute waiting period was instituted
before placing the palatal tissue-supported see-through
pin guide. The patient ensured correct indexing of the pin
guide to the palate by biting into the pin guide during
the pinning process. The pin guide fits intimately over
existing dentition or mucosa and guides the precise
anchoring of the surgical fixation base on the presurgical
anatomy (Figs. 5 and 6).
Fig. 5
Fig. 6
The upper edge of the patient-specific fixation base
for this case indicated that a bone reduction level of
15 millimeters would be necessary to accommodate
the full-arch restoration and implant components
(Figs. 7 and 8). Once bone leveling was accomplished
and confirmed by the system’s carrier guide (Fig. 9),
the osteotomy drill guide was secured to the fixation
base to guide placement of six implants (Ultimate,
Ditron Medical) to the proper angulation, trajectory
and depth (Figs. 10 and 11). The osteotomy guide also
ensured precise implant timing so the internal hex was
optimally positioned for receiving angled multiunit
abutments. With this no-hole, screwless protocol, implant
placement can be planned for the central portion of
the prosthesis or even along the incisal edge, which
not only provides added strength to the prosthetic but
also allows fabrication of a thinner, less bulky solution.
Fig. 10
Fig. 11
With the implants placed, the osteotomy guide was
removed and a carrier guide secured to the fixation base
(Figs. 12 and 13). The carrier guide provides an interface
to secure the placement and rotational position of the
multiunit abutments and to index it precisely to the
Rapid Appliance (Fig. 14). The appliance, a 3D-printed
replica of the final long-term prosthesis, is critical to
the conversion process.
The appliance was placed on the indexed carrier
guide, which is attached to the fixation base to verify
the bite, and impression cylinders were fitted onto the
implants and locked in place (Figs. 15 and 16) with a
dual-cure resin (Stellar, Taub Products). The resin was
light-cured, the impression cylinders unscrewed and
the appliance removed. Healing caps were placed on
the implants and the tissue sutured (Fig. 17).
Final prosthetic conversion
The extraoral conversion of the Rapid Appliance to
the provisional prosthetic was completed by a dental
assistant while the clinician grafted and sutured the tissue. The extraoral conversion process began by attaching
multiunit abutment analogs (Smileloc) to each of the
temp cylinders in the appliance (Fig. 18). The appliance
was then mounted onto the patient-specific 3D-printed
model articulator base (Smileloc Patient Model, Roe
Dental Laboratory) and locked into position (Fig. 19) with
acrylic (Stellar). After the material set, the appliance was
removed and fixed attachments and copings (Smileloc)
were placed on the multiunit abutment analogs. The
long-term prosthesis was then seated on the Smileloc
articulator to verify passivity over the copings (Fig. 20).
Once confirmed, acrylic (Stellar) was applied, half-filling
the predesigned wells in the prosthetic. The Smileloc
model was then connected back to the prosthesis to
connect the prosthesis to the temp cylinders (Fig. 21).
After the resin cured, the prosthetic was removed from the model using a unique activation device (Smilekey,
Rodo) for four seconds near each of the abutment
locations, unlocking the nickel titanium alloy of the
copings and allowing the prosthesis to release (Fig. 22). The acrylic housing areas in the long-term prosthesis
were finished, filling any voids and adjusting any flash. Then, the nickel titanium Smilelocs were placed on
the abutments in the mouth, following the seating
instructions, and the final prosthetic was seated, placing
downward pressure to engage the copings (Figs. 23–25).
Fig. 24
Fig. 25
The case was minimally equilibrated, and the patient
was dismissed, thrilled with her new smile (seen below).
Conclusion
The evolution of same-day, full-arch implant reconstruction
continues to improve as new and existing
technologies, materials and innovative techniques are
integrated to provide clinicians with a digital workflow
that is more efficient and accurate and, for patients, more
affordable. This case demonstrates how the use of three
different technologies provides a solution that offers a
stronger, narrower final prosthesis and a prosthetically
driven 3D treatment plan that can be equilibrated
throughout the process both in and outside the mouth.
For patients, it offers a more affordable, long-term, same-day,
full-arch solution, which can be easily maintained
and cleaned in the dental practice more efficiently than
screw-retained prosthetic alternatives.
Check out Dr. Grant
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References
1. Spagnuolo G, Sorrentino R. “The Role of Digital Devices in Dentistry: Clinical
Trends and Scientifi c Evidences.” J Clin Med. 2020 Jun 2;9(6):1692.
2. Culp, L. “Digital Dentistry: a New Era of Patient Care.” Compendium 2013
Nov/Dec; 34(10).
3. Russel, A. “How Much Do Implants Cost?” Forbes Health. https://www.forbes.
com/health/body/how-much-dental-implants-cost/ June 24, 2022. Accessed July
20, 2022.
4. Talking Points. Missing Teeth. American College of Prosthodontists. https://
www.prosthodontics.org/assets/1/7/ACP_Talking_points_for_Missing_
Teeth_1-12-15.pdf. Accessed July 20, 2022
5. Soto-Penaloza D, Zaragozí-Alonso R, Penarrocha-Diago M, Penarrocha-Diago
M. “The All-on-Four Treatment Concept: Systematic Review.” J Clin Exp Dent.
2017 Mar 1;9(3):474–e488.
6. D’ haese J, Ackhurst J, Wismeijer D, De Bruyn H, Tahmaseb A. “Current State
of the Art of Computer-Guided Implant Surgery.” Periodontology 2000. 2017
Feb;73(1):121–133.
7. Suarez-Feito JM, Sicilia A, Angulo J, Banerji S, Cuesta I, Millar B. “Clinical
Performance of Provisional Screw-Retained Metal-Free Acrylic Restorations in
an Immediate Loading Implant Protocol: A 242 Consecutive Patients’ Report.”
Clin Oral Implants Res. 2010 Dec;21(12):1360–1369.
Dr. Grant Olson is the owner of Innovative Dental and Rheostat
App & Consulting in Springfield, Missouri. As a dentist and
clinical director of Innovative Dental, he uses his experience
in cosmetic and implant dentistry to transform smiles for
patients traveling from all over the United States. As a Cerec
doctor mentor, he uses his knowledge and experience in
digital dentistry to train and deliver the latest in same-day
smile transformations. Most recently, he has been developing
advancements in Chrome GuidedSmiles utilizing Rodo Smile.