CASE PRESENTATION
Immediate Premade
Provisional Bridge on
Implants Placed With Guide
The accuracy of implant placement has increased dramatically with the advent of guided surgical guides. The digital workflow offers the possibility of premade provisionals that can be delivered at the time of implant placement. Considering that precise data is the key to excellent outcomes, CBCT-based DICOM data can be file-merged with STL intraoral scan data to create a virtual planning platform. Planning software allows crown-down planning, with virtual representation of missing teeth and virtual placement of implants. This case will present the workflow used to plan and precisely place 3 implants to support an immediate placed 4-unit
anterior provisional bridge.
Following a bicycle accident in which he collided with a truck, this 28-year-old patient lost his 4 maxillary incisors. The patient presented with no contraindications to implant placement. After a discussion of alternatives, benefits, and complications, the patient consented to have 3 implants and a premade provisional placed.
Virtual Planning
Using implant planning software, CBCT-based DICOM data (PreXion) was file-merged with STL scan data (iTero Element scanner, Align Technology) to create a virtual planning platform. The 4 missing incisors were virtually created and placed in an optimal position to allow screw retention with the access hole lingual to the incisal edge. The implant locations were planned in relation to available bone as well as relationship to the position of the wax-up maxillary incisors.
As there was insufficient room for implant placement of tooth No. 10, three implants were planned with a cantilever 4-unit bridge resting on the implants. The access cylinders for the retention screws were precisely designed to be lingual to the incisal edges.
Using the planned bridge design, Glidewell Labs milled a PMMA Implant Provisional and cemented 3 titanium insert cylinders using Shofu luting cement. The planned surgical guide was created using an Objet30 3D printer (Stratysis) with FDA-approved MED610 translucent polymer.
Treatment
After administering 4% Septocaine (Septodont) local anesthesia, an anterior ridge incision with bilateral vertical releasing incisions was performed to allow observation of the implant to titanium insert fit for the premade provisional bridge. Using the 3D-printed surgical guide, sequential osteotomy drills implants were placed to shoulder stop depth. To ensure precision fit of the premade provisional, the Glidewell Direct Inclusive Tapered implants were placed with surgical guide in place and torqued to 35 Ncm. Close inspection of the PMMA provisional to the implant surface revealed a precise fit. No adjustment of implant depth or occlusal adjustment was necessary.
Outcome Summary
The patient was extremely happy with the immediate esthetic result, and the healing after 6 months was excellent. Superior outcomes can result from the use of accurate scan data for file merge and virtual planning. In this case, precise accuracy was achieved using a guided surgical guide sufficient to place 3 implants and immediately seat a premade provisional with no adjustment necessary.
ITERO ELEMENT 2
The iTero Element 2 scanner is equipped with next-generation computing power that enables 2X faster start-ups and 25% faster scan processing time, as compared to the iTero Element. The iTero Element 2 provides improved screen resolution while minimizing scanner footprint due to its slim 21.5” monitor and 16:9 widescreen viewing format. The integrated lithium-ion battery provides easy mobility from operatory to operatory without the need to plug in for power or reboot.
Following a bicycle accident in which he collided with a truck, this 28-year-old patient lost his 4 maxillary incisors. The patient presented with no contraindications to implant placement. After a discussion of alternatives, benefits, and complications, the patient consented to have 3 implants and a premade provisional placed.
Virtual Planning
Using implant planning software, CBCT-based DICOM data (PreXion) was file-merged with STL scan data (iTero Element scanner, Align Technology) to create a virtual planning platform. The 4 missing incisors were virtually created and placed in an optimal position to allow screw retention with the access hole lingual to the incisal edge. The implant locations were planned in relation to available bone as well as relationship to the position of the wax-up maxillary incisors.
As there was insufficient room for implant placement of tooth No. 10, three implants were planned with a cantilever 4-unit bridge resting on the implants. The access cylinders for the retention screws were precisely designed to be lingual to the incisal edges.
Using the planned bridge design, Glidewell Labs milled a PMMA Implant Provisional and cemented 3 titanium insert cylinders using Shofu luting cement. The planned surgical guide was created using an Objet30 3D printer (Stratysis) with FDA-approved MED610 translucent polymer.
Figure 1—Anterior view of missing incisors following accident
Figure 2—iTero Element intraoral digital scan, used for file merge with PreXion CBCT scan
Figure 3—3shape Implant Studio planning software; crown-down planning with virtual teeth and implant location
Figure 4—Occlusal view anterior ridge incision with releasing incisions
Figure 5—Surgical guide in position with sequential drills in place
Figure 6—Implant placed with implant mount using surgical guide; implant placed with depth guide of implant mount shoulder to guide cylinder sleeve
Figure 7—Flap reflected to allow close inspection of implant to provisional titanium insert fit
Figure 8—One week after placement of implants and screw-retained PMMA BruxZir provisional
Figure 9—Occlusal view of implant healing after 6 months with provisional removed
After administering 4% Septocaine (Septodont) local anesthesia, an anterior ridge incision with bilateral vertical releasing incisions was performed to allow observation of the implant to titanium insert fit for the premade provisional bridge. Using the 3D-printed surgical guide, sequential osteotomy drills implants were placed to shoulder stop depth. To ensure precision fit of the premade provisional, the Glidewell Direct Inclusive Tapered implants were placed with surgical guide in place and torqued to 35 Ncm. Close inspection of the PMMA provisional to the implant surface revealed a precise fit. No adjustment of implant depth or occlusal adjustment was necessary.
Outcome Summary
The patient was extremely happy with the immediate esthetic result, and the healing after 6 months was excellent. Superior outcomes can result from the use of accurate scan data for file merge and virtual planning. In this case, precise accuracy was achieved using a guided surgical guide sufficient to place 3 implants and immediately seat a premade provisional with no adjustment necessary.
GO-TO PRODUCT USED IN THIS CASE
The iTero Element 2 scanner is equipped with next-generation computing power that enables 2X faster start-ups and 25% faster scan processing time, as compared to the iTero Element. The iTero Element 2 provides improved screen resolution while minimizing scanner footprint due to its slim 21.5” monitor and 16:9 widescreen viewing format. The integrated lithium-ion battery provides easy mobility from operatory to operatory without the need to plug in for power or reboot.
MICHAEL DAVID SCHERER, DMD, MS, FACP
Dr. Scherer is an Assistant Clinical Professor at Loma Linda University, a clinical instructor at University of Nevada – Las Vegas, and maintains a practice limited to prosthodontics and implant dentistry in Sonora, CA. He has published articles, DVD training series, and online courses related to implant dentistry, clinical prosthodontics, and digital technology with a special emphasis on implant overdentures (learndental3d. com). Dr. Scherer also maintains the YouTube channels: “LearnLOCATOR,” “LearnLODI,” “LearnSATURNO,” “LearnLOCATOR F-Tx” and “The 3D Dentist,” popular channels on standard and narrow-diameter implant procedures and digital dentistry. Visit michaelschererdmd.com.
Dr. Scherer is an Assistant Clinical Professor at Loma Linda University, a clinical instructor at University of Nevada – Las Vegas, and maintains a practice limited to prosthodontics and implant dentistry in Sonora, CA. He has published articles, DVD training series, and online courses related to implant dentistry, clinical prosthodontics, and digital technology with a special emphasis on implant overdentures (learndental3d. com). Dr. Scherer also maintains the YouTube channels: “LearnLOCATOR,” “LearnLODI,” “LearnSATURNO,” “LearnLOCATOR F-Tx” and “The 3D Dentist,” popular channels on standard and narrow-diameter implant procedures and digital dentistry. Visit michaelschererdmd.com.
