Digital technology in the dental industry has grown rapidly in the post-COVID world, constantly reaching new heights of achievement. Besides its extensive use in prosthetic dentistry, digital technology has a wide application in dental surgery. Owing to increased federal funding and corporate investment during the pandemic, the current digital dentistry market size of US$4.2 billion is expected to grow to US$16.3 billion by 2032.2 Many solo practices have much to gain from application of digital technology in surgical dentistry, but this is yet to be fully realised. This is reflected in research databases. A PubMed search regarding research in digital dentistry yields more than 16,000 results for the term “restorative digital impressions”, while the term “dental 3D printing” yields 2,188 results. In contrast, the term “digital dental implants” yields only 1,174 results.
The success of surgical treatment is dependent on clinicians’ thorough understanding of key principles of wound healing, as well as on effective preparation and application of the chosen treatment modality. It is important to understand what digital technology can do for clinicians in dental surgery. This article will provide an overview of how digital technology can improve the success of crown lengthening, immediate implant placement, bone augmentation and full-mouth restoration.
Aesthetic crown lengthening
Although digital photography and renderings of predicted aesthetic outcomes are able to help us in planning for aesthetic crown lengthening, they are not always able to predict soft-tissue response after surgery. Therefore, surgical accuracy remains a challenge.
Soft-tissue rebound occurs when there is thick buccal bone and thick overlying gingiva. Merging of an intra-oral scan with CBCT imagery for planning of an aesthetic crown lengthening procedure can achieve two goals: it allows for a full understanding of the patient’s periodontium and its bony and soft-tissue relation and architecture and for digital planning and fabrication of 3D-printed surgical guides for precise resective surgery. If the patient has thick buccal bone and thick overlying gingiva, we can predict greater soft-tissue rebound after healing, and therefore we can plan for more aggressive resective therapy. We can also inform the patient of the possible need for secondary surgical procedures in the future, reducing the risk of disappointment or dissatisfaction. In this case, we determined the issue early on (Figs. 1–3). We decided to execute an open-ap approach, reduce the buccal plate and stabilise the soft tissue, resulting in an aesthetic and sustainable result (Figs. 4 & 5).
Immediate implant placement
The immediate implant placement procedure has been successful in both the anterior and posterior areas. However, the implant must be positioned lingual to the buccal plate with a minimum 2mm gap. Additionally, the platform must be positioned 3–4mm apical to the gingival margin and anchored in 3–4mm of native bone to achieve primary stability. The implant planning and eventual position must be prosthetically driven, to allow for fabrication of a screw-retained restoration.
Prerequisites for successful immediate implant placement include adequate interproximal bone, thick phenotype and an apical topography of the extraction socket that is amenable to implant anchorage. For precise implant placement, guided surgery utilising digital planning software and a 3D-printed surgical guide can be excellent tools. Immediate provisionalisation preserves the gingival scallop. Digitally synchronising virtual implant placement with prosthetic software will allow for fabrication of an accurate printed or milled resin provisional prosthesis, producing excellent aesthetic results and reducing dental chair time.
In the following case, tooth #21 exhibited external root resorption; therefore, it was planned to be extracted followed by immediate implant placement and provisionalisation with a 3D-printed screw-retained provisional prosthesis (Fig. 6).
The digital implant placement was planned using coDiagnostiX (Dental Wings) and synchronised with CARES prosthetic design software (Straumann). This extensive preparation resulted in two critical components: a 3D-printed surgical guide and a resin provisional prosthesis fabricated to t the exact implant position (Fig. 7). The tooth was extracted, and the implant was placed with the aid of the surgical guide, and the printed resin provisional prosthesis was luted to the temporary abutment and screwed on to the implant (Figs. 8–13). The patient was able to receive a final screw-retained restoration with a well-preserved gingival scallop in four months (Figs. 14 & 15).
Advanced bone augmentation
Whether the augmentation is to be horizontal, vertical or a combination of both, the criteria for successful bone augmentation are based on space creation, space maintenance and graft stabilisation. The surgical team must assess the defect in order to properly diagnose it, make a template of the area to establish the required volume, and determine where and how to stabilise that space for optimal success.
In 2019, we introduced the advantages of 3D printing in conjunction with a titanium mesh and augmentation entirely with allograft. We were able to reduce the average surgery time by more than 25 minutes thanks to 3D-printed models of the defect. Keep in mind that some cases in that study were completed by residents, which affected the length of time. With an experienced surgeon, however, this could be a great benet.
This procedure is demonstrated here by way of a case of an advanced bone augmentation scenario (Fig. 16). It was generated primarily using coDiagnostiX implant planning software. The volume was built with wax, and a template was created to aid in trimming the titanium mesh, which was eventually placed over the defect lled with a combination of mineral cancellous and cortical allograft layered on top (Figs. 17–19). After eight months of healing, the site was exposed, the titanium mesh was removed, and the dental implant was placed using a 3D-printed surgical guide. The process was prosthetically driven by rst designing the restoration in CARES, which was then synchronised with the coDiagnostiX planning, allowing for proper prosthetic contouring of the resultant restorations (Figs. 20–23). These efforts resulted in a successful aesthetic and functional prosthetic outcome (Figs. 24 & 25).
Full-arch implant-supported restoration
Traditionally, patients with terminal dentition were given options for fixed implant-supported restoration with a stage involving either a removable or xed provisional prosthesis. The former option is a delayed loading approach, in which all the hopeless teeth are extracted, implants are placed and a complete denture delivered while the implants osseointegrate. The latter option strategically maintains an adequate number of hopeless teeth with proper distribution to support a fixed provisional prosthesis while the implants osseointegrate underneath. All approaches required numerous dental visits and signicant laboratory fees and, importantly, presented emotional challenges to the patient. With digital technology and the all-on-X treatment modality, it is possible to provide an immediately loaded full-arch prosthesis in a predictable and precise manner that is streamlined. Digital technology has allowed surgical and prosthetic teams to plan treatment for such full-arch cases in a truly fully prosthetically driven manner (Figs. 26 & 27), allowing for planned smoothing of the different bony levels to create the proper prosthetic space (Fig. 28) and fabricating a milled xed provisional prosthesis that can be connected to the implants in a precise and effective manner at the time of surgery. This reduces the uncertainty and stress associated with such cases while also providing the patient with not only choice but also hope, making for a life-changing experience for the patient (Figs. 29–31).
Digital technology, whether utilised for surgical or prosthetic purposes, should be embraced and fully utilised in our daily practice. We must advocate for it to reap the benefits it provides to us, our patients, our ofces and our team. The overview of the possibilities of digital surgical workows provided in this article shows how digital technology can improve the success of crown lengthening, immediate implant placement, bone augmentation and full-arch restorations. This is just the tip of the iceberg. Technology is constantly evolving, and articial intelligence and robotic and navigation systems are making headway and becoming a more integral part of our daily practice. It is time to fully embrace digital technology and digital dentistry.
Drs Edgard El Chaar, Sherman Farahani & Yoonah Danskin, USA