Digital implant planning in combination with a conventional prosthodontic workflow
Dr Mats Wernfried Heinrich Böse & Andrea Rosinski, Germany

Introduction

It is expected that the trend towards digitalisation will continue within dentistry. For practising dentists, this may give rise to the question of economic efficiency and the consideration of which aspects of a workflow can be advantageously digitised first. Implementing digitalisation in a specific clinical case should always be analysed according to the question of how digitalisation can improve existing workflows for both the practitioner and the patient. This analysis may also be influenced by the experience of the dentist and his or her team in using specific techniques.

However, the correct 3D placement of a dental implant is one of the most important prerequisites for long-term treatment success. It can reduce the risk of possible technical and biological complications. Therefore, specific options within digital dentistry for the placement of implants in a prosthetically driven way should be implemented whenever possible. Applying implant planning software is an example of this and can be chosen independently of the following treatment steps.

In my opinion, digitalisation within dentistry is a great tool. However, it does not inevitably simplify everything, but enables more predictable outcomes. It does not always require investments in costly equipment. Sometimes a smart combination of new possibilities and proven techniques add value to an individual case and experience. The following clinical case is intended to illustrate this.

Clinical case

A 72-year-old female patient presented to the Department of Prosthodontics, Geriatric Dentistry and Craniomandibular Disorders at Charité–Universitätsmedizin Berlin. The pretreating dentist had referred her with a view to the expected complexity of the case. She required extensive prosthetic rehabilitation (Figs. 1–6) and had discomfort in her left temporomandibular joint. Her expectations of the treatment result were high, and she wanted to be restored with single crowns and fixed dental prostheses only. After three months of therapy with an adjusted splint in the lower jaw to adjust the occlusal height and centric condylar position, prosthetic rehabilitation was planned.

Owing to the temporomandibular joint discomfort and compromised residual teeth, care was taken to plan an adequate number and position of dental implants. During the discussion with the master dental technician (MDT), Andrea Rosinski of Dental-Concept Berlin, it was decided to place one implant in region #13, one implant in region #23 and one implant in region #36 to achieve satisfactory function and aesthetics. Consequently, the prosthetic treatment goal was defined with a conventional wax-up and mock-up (Fig. 7). The mock-up helped to manage the patient’s expectations regarding her new smile in close consultation with the MDT.

A digital wax-up and mock-up would have been an option; however, a conventional way of working without additional digital equipment was chosen to elaborate the possibilities of combining new and established techniques. Furthermore, the MDT is highly specialised in this type of workflow and the equipment required for a digital wax-up and mock-up was not available. This may also represent a problem among practitioners broadly regarding implementation of digital workflows.

Therefore, the first step was digitalisation of the situation model and prosthetic treatment goal. Matching with the CBCT data set was performed in the planning software SMOP (Swissmeda; Figs. 8–10). This ensured ideal alignment of the implants regarding function and aesthetics (Fig. 11).
Subsequently, a drilling guide was designed and delivered by the manufacturer (Fig. 12). Guide sleeves for a fully guided implant placement protocol were inserted.

After preoperative try-in of the guide (Fig. 13), the implants (CAMLOG) were placed as planned (Fig. 14). The drilling guide and screw-mounted insertion posts were removed, and the implants were left to heal for three months (Fig. 15). After uncovering, the implants were supplied with prefabricated healing abutments for an additional two weeks for softtissue management. A panoramic radiograph of the situation with the healing abutments in place was taken (Fig. 16). A combination of digital—in this case utilisation of implant planning software—and conventional techniques can lead to highly satisfactory results. The restoration of the edentulous sites of regions #13 and 23 demanded a detailed consultation with the MDT. A conventionally manufactured wax-up and mock-up were helpful to integrate the patient’s expectations and the functional and aesthetic demands when planning the treatment. Malpositioning of dental implants (especially in regions #13 and 23) could have led to compromised prosthodontic results, additionally risking long-term results. This was avoided by consequent utilisation of backward planning. Apart from the SMOP fee for planning and manufacturing of the guide, there was no need for any investments in additional digital technology for treatment implementation or equipment for performing part of the treatment steps digitally. Therefore, this workflow is easy to implement for any practitioner and has little additional cost for the patient, resulting in a predictable outcome.

After the additional healing period, impressions were taken with an open-tray technique and polyether impression materials (Impregum and Permadyne, 3M ESPE; Fig. 17). After definitive restoration of the idealised maxilla with lithium disilicate (IPS e.max, Ivoclar) and multilayer zirconia (Eos, Orodent; Fig. 18), the lower jaw impression was taken (Fig. 19). Bite registration was performed step by step and subsequently checked with a bite registration plate (Fig. 20).

The definitive mandibular prosthetic restorations were manufactured from lithium disilicate and multilayer zirconia and seated and a final panoramic radiograph taken (Figs. 21–25.)

 

Conclusion                                        

This case demonstrates that predictable functional and
aesthetic restoration with implant-retained prostheses is possible even without costly investments in digital equipment.

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Editorial note: A list of references is available from the publisher.