Digital workflow of immediate implant-supported restoration for atrophic edentulous patients

doi:10.12016/j.issn.2096-1456.2020.12.001

Abstract

Abstract:

Rehabilitation and reconstruction of atrophic edentulous predicament represents significant challenges for implant dentists due to the anatomical conditions of the edentulous jaw. Implant-supported fixed complete dental prostheses represent a scientifically and clinically validated treatment for recovering patients, masticatory function and esthetic effect. However, the highly demanding implant surgical techniques and complex rehabilitation procedures for immediate functional reconstruction make it difficult to achieve the desired treatment outcomes. The application of digital and CAD/CAM technology in various stages of the treatment process is logical for patients and dentists. This article summarizes the workflow of digital-assisted implantation with immediate functional reconstruction of atrophic edentulous combined with a clinical case. Digital-assisted diagnosis, design, implantation, immediate reconstruction and final rehabilitation can optimize the implant surgery and immediate rehabilitation workflow, improve the accuracy of implant-supported immediate functional reconstruction, reduce the demand for a large amount of bone graft, and achieve higher patient satisfaction. The “prosthetic-oriented, begin with the end in mind” concept of edentulous jaw implant prosthetics can accurately and efficiently restore the patient,s beauty and chewing function in a minimally invasive manner, and is worthy of clinical promotion.

Key words: atrophic edentulous jaw, bone insufficiency, implant restoration, digital workflow, immediate functional reconstruction, digital surgical guide, digital impression, digital smile design, prosthodontic oriented, CAD/CAM material

摘要：

萎缩无牙颌由于颌骨解剖条件因素给修复重建带来了巨大挑战,种植支持式全口固定义齿修复因为可以很好地恢复患者咀嚼功能和美观效果而广受推崇。然而,萎缩无牙颌种植即刻功能重建手术要求高,修复治疗程序复杂,往往很难达到理想治疗效果。数字化辅助萎缩无牙颌种植即刻修复功能重建的工作流程对于无牙颌患者和种植修复医生都具有重要意义。本文结合临床病例总结了数字化辅助萎缩无牙颌种植即刻修复功能重建的工作流程,通过数字化手段进行辅助诊断、设计、植入、即刻修复重建和最终修复,可优化种植手术和即刻修复工作流程,提高萎缩无牙颌种植即刻修复的精度,减少大量植骨需要,获得更高的患者满意度,实现“修复导向,以终为始”的无牙颌种植修复理念,精准、微创、高效地恢复患者的美观和咀嚼功能,具有较高的临床推广应用价值。

关键词: 萎缩无牙颌, 骨量不足, 种植修复, 数字化工作流程, 即刻功能重建, 数字化导板, 数字化印模, 数字化微笑设计, 以修复为导向, CAD/CAM材料

CLC Number:

R783.4

GU Xinhua. Digital workflow of immediate implant-supported restoration for atrophic edentulous patients[J]. Journal of Prevention and Treatment for Stomatological Diseases, 2020, 28(12): 749-758.

顾新华. 萎缩无牙颌患者数字化种植即刻修复工作流程[J]. 口腔疾病防治, 2020, 28(12): 749-758.

Figures/Tables 8

Figure 1 Intraoral images and X-ray examination images before implant surgery a： intraorthodontic image of removable partial denture before implant surgery; b： intraorthodontic image before implant surgery; c：maxillary occlusal image before implant surgery; d： panoramic image before implant surgery; e： CBCT indicated an inverted impacted tooth located on the apical side of 21 and 22

Figure 2 Mark and collect intraoral digital information of the patient a&b: 4 mark points were diffusely made by fluid resin on the mucosa of the edentulous area and remaining teeth; c: light curing finished; d&e: collection of digital intraoral information; f: intraoral digital information of the patient was obtained

Figure 3 Digital teeth prearrangement a: merge the intraoral scan of soft tissue and occlusion status with CBCT bone tissue information; b: virtual dentition reconstruction

Figure 4 Digital implant design a： implant plan design （implanting Straumann BLT 3.3 mm × 10 mm is planned for 12 and 22, and obliquely implanting BLT 4.1 mm × 14 mm is planned for 15 and 25）; b： temporary denture design; c-f： a digital-assisted plan was selected for each implant abutment transgingival height, angle and direction

Figure 5 Designing and manufacturing of the frame using digital cut-back technology, temporary denture, 3D printed research model and surgical guide a&b: digital design of enhanced bracket; c: fabrication of CAD/CAM resin wax pattern; d: fabrication of cobalt-chromium bracket; e: 3D printed research model, surgical guide and temporary denture

Figure 6 Digital-assisted implant surgery, immediaterestoration and image evaluation a: preparation of implant hole with a surgical guide during the surgery; b: the prefabricated temporary denture was worn and relined with self-curing resin immediately after implant surgery; c: panoramic image after implant surgery and fixation with abutments; d: matching diagram of 15, 12, 22 and 25 CBCT implant positions after implant surgery (dark green) and preoperative digital design (white)

Table 1 Deviations of the implants between postoperative CBCT implants and preoperative digital design

Implant position	Deviations of different parts of implant
Implant position	Cervical（mm）	Apex（mm）	Space angle（°）
12	1.6	1.3	2.0
15	0	0	0
22	2.0	2.2	5.4
25	0.7	0.8	2.0

Figure 7 Revisits for final restoration 6 months after implant surgery a: digital images 6 months after implant surgery; b: making impression; c: taking the bite record; d: transferring the jaw position; e: the CAD/CAM-fabricated integrated pure titanium bracket was tried on; f: the implant supported fixed permanent restoration was completed; g&h: comparison of screw channel positions before and after surgery

References 38

[1]	Papaspyridakos P, Chen CJ, Chuang SK, et al. Implant loading protocols for edentulous patients with fixed prostheses: a systematic review and meta-analysis[J]. Int J Oral Maxillofac Implants, 2014,29(suppl):256-270.
[2]	Gallucci GO, Benic GI, Eckert SE, et al. Consensus statements and clinical recommendations for implant loading protocols[J]. Int J Oral Maxillofac Implants, 2014,29(suppl):287-290.
[3]	Malo P, de Araujo NM, Lopes A, et al. The All-on-4 treatment concept for the rehabilitation of the completely edentulous mandible: a longitudinal study with 10 to 18 years of follow-up[J]. Clin Implant Dent Relat Res, 2019,21(4):565-577. URL PMID
[4]	Lopes A, Malo P, de Araujo NM, et al. The NobelGuide^® All-on-4^® treatment concept for rehabilitation of edentulous jaws: a retrospective report on the 7-years clinical and 5-years radiographic outcomes[J]. Clin Implant Dent Relat Res, 2017,19(2):233-244. URL PMID
[5]	Weinstein R, Agliardi E, Fabbro MD, et al. Immediate rehabilitation of the extremely atrophic mandible with fixed full-prosjournal supported by four implants[J]. Clin Implant Dent Relat Res, 2012,14(3):434-441. DOI URL PMID
[6]	Kattadiyil MT, Goodacre CJ, Lozada JL, et al. Digitally planned and fabricated mandibular fixed complete dentures. Part 2. Prosthodontic phase[J]. Int J Prosthodont, 2015,28(2):119-123. DOI URL PMID
[7]	Pommer B, Mailath-Pokorny G, Haas R, et al. Patients′ preferences towards minimally invasive treatment alternatives for implant rehabilitation of edentulous jaws[J]. Eur J Oral Implantol, 2014,7(suppl2):91-109.
[8]	Maló P, Nobre MA, Lopes A, et al. Five-year outcome of a retrospective cohort study on the rehabilitation of completely edentulous atrophic maxillae with immediately loaded zygomatic implants placed extra-maxillary[J]. Eur J Oral Implantol, 2014,7(3):267-281. URL PMID
[9]	Najafi H, Siadat H, Akbari S, et al. Effects of immediate and delayed loading on the outcomes of all-on-4 treatment: a prospective study[J]. J Dent (Tehran), 2016,13(6):415-422.
[10]	Cassetta M. Immediate loading of implants inserted in edentulous arches using multiple mucosa-supported stereolithographic surgical templates: a 10-year prospective cohort study[J]. Int J Oral Maxillofac Surg, 2016,45(4):526-534. URL PMID
[11]	Sannino G. All-on-4 concept: a 3-dimensional finite element analysis[J]. J Oral Implantol, 2015,41(2):163-171. DOI URL PMID
[12]	An X, Yang HW, Choi BH. Digital workflow for computer-guided implant surgery in edentulous patients with an intraoral scanner and old complete denture[J]. J Prosthodont, 2019,28(6):715-718. DOI URL PMID
[13]	Oh JH, An X, Jeong SM, et al. Digital workflow for computer-guided implant surgery in edentulous patients: a case report[J]. J Oral Maxillofac Surg, 2017,75(12):2541-2549. URL PMID
[14]	Papaspyridakos P, Gallucci GO, Chen CJ, et al. Digital versus conventional implant impressions for edentulous patients: accuracy outcomes[J]. Clin Oral Implants Res, 2016,27(4):465-472. DOI URL PMID
[15]	Lewis RC, Harris BT, Sarno R, et al. Maxillary and mandibular immediately loaded implant-supported interim complete fixed dental prostheses on immediately placed dental implants with a digital approach: a clinical report[J]. J Prosthet Dent, 2015,114(3):315-322. URL PMID
[16]	Correa LR, Spin-Neto R, Stavropoulos A, et al. Planning of dental implant size with digital panoramic radiographs, CBCT-generated panoramic images, and CBCT cross-sectional images[J]. Clin Oral Implants Res, 2014,25(6):690-695. DOI URL PMID
[17]	Amornvit P, Sanohkan S. The accuracy of digital face scans obtained from 3D scanners: an in vitro study[J]. Int J Environ Res Public Health, 2019,16(24):5061.
[18]	Mangano F, Mangano C, Margiani B, et al. Combining intraoral and face scans for the design and fabrication of computer-assisted design/computer-assisted manufacturing (CAD/CAM) polyether-ether-ketone (PEEK) implant-supported bars for maxillary overdentures[J]. Scanning, 2019: 4274715.
[19]	Cervino G, Fiorillo L, Arzukanyan AV, et al. Dental restorative digital workflow: digital smile design from aesthetic to function[J]. Dent J (Basel), 2019,7(2):30.
[20]	Stanley M, Paz AG, Miguel I, et al. Fully digital workflow, integrating dental scan, smile design and CAD-CAM: case report[J]. BMC Oral Health, 2018,18:134. DOI URL PMID
[21]	Battista G. Face scanning and digital smile design with an intraoral scanner[J]. J Clin Orthod, 2019,53(3):149-153. URL PMID
[22]	Rawal S, Tillery DJ, Brewer P. Robotic-assisted prosthetically driven planning and immediate placement of a dental implant[J]. Compend Contin Educ Dent, 2020,41(1):26-30.
[23]	Marlière D, Demètrio MS, Picinini LS, et al. Accuracy of computer-guided surgery for dental implant placement in fully edentulous patients: a systematic review[J]. Eur J Dent, 2018,12(1):153-160. DOI URL PMID
[24]	Lanis A, Álvarez DO. The combination of digital surface scanners and cone beam computed tomography technology for guided implant surgery using 3Shape implant studio software: a case history report[J]. Int J Prosthodont, 2015,28(2):169-178. URL PMID
[25]	Tan PLB, Layton DM, Wise SL. In vitro comparison of guided versus freehand implant placement: use of a new combined TRIOS surface scanning, implant studio, CBCT, and stereolithographic virtually planned and guided technique[J]. Int J Comput Dent, 2018,21(2):87-95.
[26]	Panchal N, Mahmood L, Retana A, et al. Dynamic navigation for dental implant surgery[J]. Oral Maxillofac Surg Clin North Am, 2019,31(4):539-547. URL PMID
[27]	Joda T, Katsoulis J, Bragger U. Clinical fitting and adjustment time for implant-supported crowns comparing digital and conventional workflows[J]. Clin Implant Dent Relat Res, 2016,18(5):946-954. URL PMID
[28]	Marghalani A, Weber HP, Finkelman M, et al. Digital versus conventional implant impressions for partially edentulous arches: an evaluation of accuracy[J]. J Prosthet Dent, 2018,119(4):574-579. DOI URL PMID
[29]	Cappare P, Sannino G, Minoli M, et al. Conventional versus digital impressions for full arch screw-retained maxillary rehabilitations: a randomized clinical trial[J]. Int J Environ Res Public Health, 2019,16(5):829.
[30]	Tan MY, Yee SHX, Wong KM, et al. Comparison of three-dimensional accuracy of digital and conventional implant impressions: effect of interimplant distance in an edentulous arch[J]. Int J Oral Maxillofac Implants, 2019,34(2):366-380. URL PMID
[31]	Gherlone E, Cappare P, Vinci R, et al. Conventional versus digital impressions for "all-on-four" restorations[J]. Int J Oral Maxillofac Implants, 2016,31(2):324-330. DOI URL PMID
[32]	Miyoshi K, Tanaka S, Yokoyama S, et al. Effects of different types of intraoral scanners and scanning ranges on the precision of digital implant impressions in edentulous maxilla: an in vitro study[J]. Clin Oral Implants Res, 2019,31(1):74-83. DOI URL PMID
[33]	Menini M, Setti P, Pera F, et al. Accuracy of multi-unit implant impression: traditional techniques versus a digital procedure[J]. Clin Oral Investig, 2018,22(3):1253-1262. DOI URL PMID
[34]	Abduo J. Fit of CAD/CAM implant frameworks: a comprehensive review[J]. J Oral Implantol, 2014,40(6):758-766. DOI URL PMID
[35]	Luo Q, Ding Q, Zhang L, et al. Analyzing the occlusion variation of single posterior implant-supported fixed prostheses by using the T-scan system: a prospective 3-year follow-up study[J]. J Prosthet Dent, 2020,123(1):79-84. DOI URL PMID
[36]	Madani AS, Nakhaei M, Alami M, et al. Post-insertion posterior single-implant occlusion changes at different intervals: a T-Scan computerized occlusal analysis[J]. J Contemp Dent Pract, 2017,18(10):927-932. DOI URL PMID
[37]	Radke JC, Kull RS. Comparison of TMJ vibration frequencies under different joint conditions[J]. Cranio, 2015,33(3):174-182. DOI URL PMID
[38]	Stavness IK, Hannam AG, Tobias DL, et al. Simulation of dental collisions and occlusal dynamics in the virtual environment[J]. J Oral Rehabil, 2016,43(4):269-278.