This case demonstrates the high level of accuracy and predictability we achieve with implants and premade provisionals placed at the time of implant placement. A healthy 61-year-old female presented in pain with a failing tooth No. 8 (Figure 1). She reported a previous endodontic procedure in Colombia, her native country. Examination revealed internal/external root resorption with pain and swelling. An i-CAT (Imaging Sciences International) CBCT image confirmed a hopeless maxillary right central incisor. After discussion, the patient agreed to removal of the tooth with implant restoration.
Treatment and Virtual Planning
An iTero Element (Align Technology) intraoral digital scan was taken prior to tooth removal (Figure 2). The open source STL fi le was sent to my Netfabb software to prepare the fi le, and a model was 3D-printed in-house using my Stratasys Objet 30 OrthoDesk 3D printer. Essix ACE .040 thermoplastic material from Dentsply Sirona Prosthetics was used to fabricate a “pontic appliance” directly on the 3D-printed model (Figure 3). After trimming and polishing the appliance, Dentsply Sirona Restoratives’ TPH3 composite resin material was used to fill the “pontic” area and create an optimal ovoid tissue side pontic shape (Figure 4).
Atraumatic removal of tooth No. 8 was performed and the extraction site augmented with Zimmer Biomet’s Puros grafting material and sutured with Ethicon suture material. The site healed well with tissue mimicking the ovate pontic shape and excellent interproximal tissue (Figure 5).
After 4 months of healing, i-CAT CBCT DICOM data and iTero Element STL data fi le merge was performed using 3Shape Implant Studio software to create a virtual planning platform (Figure 6). Virtual “wax up” helped determine a precise location for a screw retained implant restoration in relation to the available bone. Design software was used to create a guided surgical guide directly on the digital rendering, which was then 3D-printed.
Glidewell Labs designed and milled a titanium screw-retained single-unit provisional crown out of PEEK (polyether ether ketone) BioTemps material with a titanium “engaging” cylinder to be delivered at the time of implant placement (Figure 7).
Surgery
The guided surgical guide was placed intraorally and inspection windows were checked to ensure precise fit (Figure 8). A tissue removal drill was followed by a sequential series of osteotomy drills. A Glidewell Direct Inclusive 3.7 mm x 16 mm implant was placed and torqued to 35 Ncm with the guided surgical guide in place (Figure 9). The depth was determined with the shoulder-to-shoulder fi t of the guide to placement tool. The labial orientation marker on the guide allowed for precise rotation (Figure 10). The premade provisional had an optimal fi t and no adjustment was necessary in rotation, depth, or occlusion (Figure 11). After suture removal, both the patient and I were pleased with the nice adaptation of the tissue to the premade provisional (Figure 12).
Conclusion
Working in a 100% digital virtual environment, planned guided surgery has proved to be a precise and predictable method for the placement of implants and delivery of excellent-fitting premade provisional restorations in the esthetic zone.
