Compendium ABGlS - Periodontal Concepts...osseoiintegrated implants and thai Fig r Electronic...

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Compendium B_ ofCantimiinfi Kdticiititm in Ih'ntiatry . *. * ABGlS CASE SERIES REPORT DIGITALIZING IMPLANTS The Digitalizing of Implant Dentistry; A Clinical Evaluation of 15 Patients Munib Derhalli, DMD, MS, MBA Abstract: This article introduces intraoral scanning technology as it applies to custom-fabricated implant abutments. The author discusses its use and clinical applications, and provides an overview of the bcnelils of such a system in the clinical setting. In this clinical evaluation of 1.1 patients, the BellaTek™ Encode11 Impression System was combined with iTero™ intraoral scanning technology to demonstrate the technical feasibility of combining these two CAD/CAM technologies. The BellaTek'" Encode impression system protocol was established to allow the clinician to digitally impress special codes embedded on the occlusal surface of the BellaTek™ Encode" healing abutment. Once a digital iile was prepared tor CAD/CAM pro- cessing, a duplicate STL file could be sent to iTcro tor fabrication of apolyurethane model of the definitive UellaTek 1 " abutment, from which an implant restoration could be created. This definitive prosthesis was able to be fabricated simultaneously while the definitive BellaTek"' abutment was being milled. he digital era for implant and tooth-supported prosthctics based on computer-aided design and computer-aided manufacturing (CAD/CAM) has progressed in the past two deeades, mainly due to market-driven development of various generations of visible light impressions. 1 Integration and ap- plication of this technology within the realm of implant den- tistry has been limited, as a greater emphasis has been placed on conventional crown and bridge applications. In 19-94 Jemt and Lie2:< described a technique called photogrammetry, which uses a series of 3-dimensional (3-D) photographs to record im- plant positions for manufacturing implant frameworks. They deter- mined that photograminelry was a valid opt ion for recording implanl positions and had a precis ion com- parable to that of conventional im- pression techniques. 4 Del Corso' demonstrated that optical ;j-l> scanning acquisition could be used to determine the position of osseoiintegrated implants and thai Fig r Electronic impression image-acquiring technology could be used as an alternative to traditional impression techniques. The entire manufacturing process begins with the correct impression procedure and de- pends on the accuracy of the master cast. Digital impression systems have offered the possibility of better-fitting restorations and greater productivity for Ihe gen- eral dentist/' These systems otter users the ability to capture a digital image of the preparation and submit that informa- tion electronically, resulting in lubrication of a working model and die system for fabrication of the restoration. A comparison of crowns made with a digital scan versus those created with a tradi- tional impression found thai Ihc scanned restorations showed a greater number of perfect in- terproximal eon tacts, better marginal fit, and more accurate occlusion.7'* The iTcro™ digital impression device (Align Technology, Inc., www.alignteeh.com) has been developed a.s an office-based in- device with scan camera wand. traoral scanning system, which is AKTICLK IIKI'HINT March 2013 COM 1'KMll U M

Transcript of Compendium ABGlS - Periodontal Concepts...osseoiintegrated implants and thai Fig r Electronic...

Page 1: Compendium ABGlS - Periodontal Concepts...osseoiintegrated implants and thai Fig r Electronic impression image-acquiring technology could be used as an alternative to traditional impression

CompendiumB_ ofCantimiinfi Kdticiititm in Ih'ntiatry

. * .*

ABGlS

CASE SERIES REPORT

DIGITALIZING IMPLANTS

The Digitalizing of Implant Dentistry;A Clinical Evaluation of 15 PatientsMunib Derhalli, DMD, MS, MBA

Abstract: This article introduces intraoral scanning technology as it applies to custom-fabricated implant

abutments. The author discusses its use and clinical applications, and provides an overview of the bcnel i l s

of such a system in the clinical setting. In this clinical evaluation of 1.1 patients, the BellaTek™ Encode11

Impression System was combined with iTero™ intraoral scanning technology to demonstrate the technical

feasibility of combining these two CAD/CAM technologies. The BellaTek'" Encode impression system

protocol was established to allow the clinician to digitally impress special codes embedded on the occlusal

surface of the BellaTek™ Encode" healing abutment. Once a digital iile was prepared tor CAD/CAM pro-

cessing, a duplicate STL file could be sent to iTcro tor fabrication of apolyurethane model of the definitive

UellaTek1" abutment , from which an implant restoration could be created. This definitive prosthesis was

able to be fabricated simultaneously while the definitive BellaTek"' abutment was being milled.

he digital era for implant and tooth-supportedprosthctics based on computer-aided design andcomputer-aided manufacturing (CAD/CAM)has progressed in the past two deeades, mainlydue to market-driven development of various

generations of visible l ight impressions.1 Integration and ap-plication of this technology within the realm of imp lan t den-tistry has been limited, as a greater emphasis has been placedon conventional crown and bridge applications. In 19-94 Jemtand Lie2:< described a techniquecalled photogrammetry, whichuses a series of 3-dimensional(3-D) photographs to record im-plan t positions for manufacturingimplant frameworks. They deter-mined that photograminelry was avalid opt ion for recording implanlpositions and had a precis ion com-parable to that of conventional im-pression techniques.4 Del Corso'demonstrated that optical ; j - l >scanning acquisit ion could beused to determine the position ofosseoiintegrated implants and t h a i Fig r Electronic impression

image-acquiring technology could be used as an alternative totraditional impression techniques. The entire manufacturingprocess begins with the correct impression procedure and de-pends on the accuracy of the master cast.

Digital impression systems have offered the possibility ofbetter-fitting restorations and greater productivity for Ihe gen-eral dentist/' These systems otter users the ability to capturea digital image of the preparation and submit that informa-tion electronically, resulting in lubrication of a working model

and die system for fabrication ofthe restoration. A comparison ofcrowns made with a digital scanversus those created with a t radi-tional impression found tha i Ihcscanned restorat ions showed agreater number of perfect in-te rproximal eon tacts, bettermarginal fit, and more accurateocclusion.7'*

The iTcro™ digital impressiondevice (Align Technology, Inc.,www.alignteeh.com) has beendeveloped a.s an office-based in-

device with scan camera wand. traoral scanning system, which is

A K T I C L K I I K I ' H I N T March 2013 COM 1 'KMll U M

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CASE REPORT I DIGITALIZI NG IMPLANTS

connected by the Internet to a ft-ntnili/c'd m i l l i n g center andto I he partnering dental laboratory. The system's enhaneed vi-sualization and real-time analy t ica l tools enable c l in ic ians toadjust measurements before completing the i n l r a o r a l d i g i t a lscanning of patients.' " Digital scanning technology has signifi-cantly enhaneedclinicalaccuracy and productivity in compari-son to conventional impression techniques. Slandard impres-sions ean be prone to the following shortcomings: pulls andteal's; bubbles and voids; distortion; tray to-tooth contact; poortray bond; de-lamination; sensitivity to temperature, technique,time, and chemistry; varying shrinkage; stone model pouring;and die t r imming discrepancies. D i g i t a l scanning technologyeliminates these issues,12 consistently displaying highly accuratedigital impressions.

The iTero intraoral scanning device used in this case seriesconsisted of a mobile cart (central processing u n i t fCl ' l ' l de-vice) on castors equipped with a wireless mouse and keyboard,hands-free navigation using a wireless toot control • pedal, and ahandheld scanning wand (electronic impression device | I'M I)])that is used to obtain the scan data. The scanner head houses theanalog-digital converter, video camera, focusing mirrors 'mo-tor, and light source, which projects 10O.OOO beams of parallelred laser at focal depth intervalsofSO um.Thc reflected l igh t isconverted into digital data, through the use of analog-to-digitalconverters; therefore, the entire event takes approximately onet h i r d of a second. The iTero digital impression device does notrequire opaque powder to provide uniform l ight distribution,and the surface registration and accuracy are w i t h i n 15 urn.'1 '

Clinical EvaluationThe case series included 13 patients with single implant sites andtwo patiente with multiple implant sites (two) in both the maxillaryand mandibular arches. All patients were healthy and nonsmok-ers. Cone-beam computerized tomography (CHCT) scans wereobtained preoperalively. Prior to surgeiy. all patients received aloading dose ofamoxicillin. 4 nig Medrol Dosepak (methyl pred-nisone), and O.I 2% chlorhexidine mouthrinse. Local anesthesiawas delivered using local infiltration and nerve blocks with 29carticaine, lidocaine (1:100,OOO epinephrine). Where possible, aHapless surgical procedure was used wi th a biopsy punch (Ace Sur-gical Supply, www.acesurgical.com). I ('guided hone regenerationwas anticipated, aftill-thicknessmucoperiosteal flap was raised fordirect visibil i ty and true analysis of hard tissue.

ho l lowing ridge exposure, implan t osteotomies were pre-pared according to the manufacturer's drilling specifications.Seventeen NanoTite'" Certain implan t s (Hiomel ,'>'/, www.bio-mct:Ji.com) were placed in l f> patients usingconr beam analy-sis and a surgical guide fabricated on study casts from an idealwax-up or computerized software (Anatomage", Anatomage,www.anatomage.eom). The i m p l a n t diameters and lengthsranged from :{.25 mm to 5 mm l)x 10 mm to l.'l mm I.. All im-plant insertion torque values were set at 50 Nem to achieveadequate pr imary stability. Primary stabil i ty was achievedwi th all implants and verified with the Osstell™ resonance fre-quency analysis (RFA) device (Osstell™ Device, Integration

„ - - . . - .

Fig 2. Preoperativo radiograph of tooth. No. A in the No. 4 posi-tion (recurrent caries). Fig 3. Six-month post implant placementwith BellaTek Encode healing abutment. Fig 4. BellaTek Encodehealing abutment—buccal view. Fig 5. BellaTek Encode healingabutment—occlusal view (note occlusal codes). Fig 6. iTero digitalscan of BellaTek Encode healing abutment.

Diagnostic AB. www.osstell.com).Hir' Following It FA slahil-ity verification, the implants had BellaTck'" Encode"" heal ingabutments (Hioniet 3/) placed for single-stage healing. Theful l - th ickness mucoperioslcal Haps were closed ushig4-Oand5-0 Vicryl (Klhicon, www.ethicon.com) interrupted sutures.

Patients were placed on a 1-week antibiotic regimen (amoxi-cillin),chlorhexidine 2 t imes daily, a low-dose steroid, and an-algesics as needed. Strict oral hygiene ins t ruct ions were givenin writing and orally, and specific dietary protocols were given.After 14 days, the sutures were removed and each pat ient's oralhygiene instructions were modified and the pat ients reinstrucl-ed. The implants were allowed lo heal for approximately 3 to5 months prior to definitive restoration. A d ig i t a l scan of theBellaTek Encode healing abutment using the iTero intraoral

( . • O M I ' K N D I U M March2013 - AH'I ICI.I-: H U I ' H I N T Voluini- H'i. Niiinhcr

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scanner (Figure 1) was taken to include the opposing arch and"-O-degrcc occlusal registration. All scanning data was sent toiTiTo I n he processed and ron verted tn s tandard t r i angu la t ionlanguage (STL) files in preparation for definitive abutment fab-rication. The data was forwarded to the BellaTek™ ProductionCenter at Biomet«?/, where the virtual BellaTck abutment wasdesigned in preparation for the CAD/CAM mil l ing process. Forfurther modification and approval, ajpeg file can be sent to therestorative dentist to approve the design (eg, margin location)prior to final manufactur ing.

The new STL file with the patient-specific abutment(BcllaTek™ Abutment, Biomet 3f) in place and the healingabutment removed was sent back to iTero for fabrication of apolyurethane master cast (working model) for completion ofthe de f in i t ive restoration. The crown was then fabricated onthe iTero model and delivered to the restoring clinician withmodel, abutment, and abutment-specific screw in preparationfor the final seating. Once seating verification was complete, theBellaTek final abutment was torqued down with a gold screw(Gold-Tite' abutment screw, Biomet 3i) to 20 Ncm with theindicated torque driver. The crowns were then seated using acement-retained protocol indiv idual ized to each clinician. Apost-sea t i n g radiograph was taken to assess marg ina l l i t and tocheck for retained cement.

CaseIn a sample case among the pa t i en t s treated in this evaluationthat depicts a typical application of the technology, a 28-year-old woman presented with recurrent caries associated w i t h I hemesial aspect of tooth No. A in the No. 4 posi tion (Figure 2). Therestorative dentist determined this tooth should not be re ta ined

and recommended extraction. The tooth was extracted approxi-mately 6 months prior to implant placement. A 4.1/3.25-mm xi;S-mm implant (NanoTite Certain, Biomet 3/) was placed in theNo. 4 area with the aid of a surgical guide (Figure 3). The implantinsertion torque value was set at 50 Ncm to achieve adequateprimary stability. Primary stabili ty was achieved and verifiedwith the Osstell™ KFA device prior to the final restorative phase.The BellaTek Kncodc heal ing abutment was cheeked for mo-bility, and torque was verified at 20 Ncm (Figure 4 and Figure5). A radiograph was taken for seating verification prior to thedigital scan. A digital scan of the heal ing abutment using theiTero intraoral scanner was taken to include the opposing archand 90-degree occlusal registration (Figure 6),

The crown was then fabricated on the iTero model and de-livered to the restoring clinician with the model, abutment, andabutment-specific screw in preparation for the final seating(Figure 7 and Figure 8). Once seating verification was complete,the BellaTek abutment was torqued down with the gold screw(Gold-Tite) in place to 20 Ncm with the indicated torque driver(Figure 9 and Figure 10). The crowns were then seated using acement-retained protocol (Figure 11 and Figure 12).

ConclusionsDigital scanning technology is changing the face of implant den-tistry. Compared to elastomeric impression materials digitalscanning results in less expense, increased productivity, andmore ellicient clinical systems. Digital scanning technologyhas s ign i f i can t ly enhanced clinical accuracy and productivity incomparison to conventional impression techniques. A variety ofimpression materials can be prone to inherent challenges thatdecrease their overall accuracy. Scanning technology such as

Fig 7. Final crown on polyurethane model die—buccal view. Fig 8. Final crown on polyurethane model die—palatal view. Fig 9. DefinitiveBellaTek abutment (titanium) with hex orientation mark—buccal view. Fig 10. Definitive BellaTek abutment—palatal view.

A H T f C L J : l i l U ' F U N T M ; , r d i 2 U I H C O M P K N U I U M

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CASE REPORT | D1GITALIZING IMPLANTS

I hat used in this evaluation eliminates these issues and consis-tently produces highly accurate digit;!I impressions.

Today in dentistry, specific implant abutments can bescanned and the information digitally transferred directly toa five-axis milUng center. This technology saves additional timeand money for all parties. The introduction of digital impres-sion systems provides clinicians the opportunity 1'or better-fitting restorations and greater general dent is t ry productivity.These digital systems are now being utilized together to serveclinicians and patients more effectively. The design technicianis also given more information, improving the design of theCAD/CAM abutments with the aid of computerized virtualprograms.

Undoubtedly, digital impression devices are going to be asignificant part of the future of implant dentistry. The indus t rywill see continued development w i t h i n the digital markets,which will increase market competition, and with more clini-cians implementing the technology into their practices, thetechnology wi l l likely become more affordable.

DISCLOSURE

This project was partially supported by BiometS/.

ACKNOWLEDGMENTS

The author would like to thank Mrs. Amy Dcrhalli and Dr. Richard Mounee for their critical review, and Dr. Steven Hopmannfor the restoration shown in Figure 11 and Figure 12. In addi-tion, he would like to thank O'Brien Dental Lab, Inc.,Corvallis,Oregon.

Fig 11. Final crown cementation—buccal view. Fig 12. Final crowncementation—palatal view.

ABOUT THE AUTHOR

Munib Dcrhalli, DM I), MS, MtiAPrivate Practice, Vancouver, Washington

REFERENCES

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