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JOBNAME: No Job Name PAGE: 1 SESS: 131 OUTPUT: Tue Sep 13 18:36:25 2011 SUM: 9309283C/v2503/blackwell/journals/jerd_v0_i0_newdesign/jerd_481_forzen
Utilization of Digital Technologies for Fabrication ofDefinitive Implant-Supported Restorationsjerd_481 1..11
CHRISTOPHER D. RAMSEY, DMD*, ROBERT G. RITTER, DMD†
ABSTRACT
The introduction 7 years ago of specially coded healing abutments dramatically simplified the task of obtaining implantimpressions. Such coded abutments eliminated the need for impression copings, instead enabling supragingivalimpressions to be made and sent to the laboratory for fabrication of patient-specific abutments and restorations.Combining this technology with digital oral scanning has the potential to further simplify the time betweenimpression-making and delivery of a definitive restoration, and it offers additional benefits to both patients andclinicians.This article explains how oral scanners can be used to obtain digital impressions of encoded healingabutments. A case report illustrating this approach is also presented.
CLINICAL SIGNIFICANCE
This article describes a new technological approach to implant dentistry utilizing intraoral scanning modalities.Theclinical workflow will highlight the digital transfer of necessary information to fabricate a patient-specific implantabutment and final prosthesis.
(J Esthet Restor Dent ••:••–••, 2011)
INTRODUCTION
Over the last 100 years, techniques and materials forrestoring compromised teeth have evolved dramatically.Nowhere has this been more pronounced than in thefield of implant dentistry. From its inception as aprotracted and unesthetic treatment of last resort forindividuals who had lost all their mandibular dentition,implant dentistry has been transformed into thestandard of care for many individuals with hopeless ormissing teeth. Clinicians now can provide patients withhighly esthetic restorations, often in a significantlycompressed time frame. As a result, the implant-dentalsector today is one of the fastest growing areas withindentistry.
Computer-aided design and computer-aidedmanufacturing (CAD/CAM) techniques have beentransforming the dental field in parallel with thesedevelopments. Introduced to dentists in 1971,CAD/CAM techniques were used to create the firstdental prototype in 1983, and the first crown wasmilled and installed in a mouth without any laboratoryinvolvement in 1985.1 By 1998, customized implantabutments were being created with CAD/CAMtechnology.2 Because these are patient-specific, suchabutments, like cast custom abutments, have thepotential to provide improved peri-implant soft-tissuesupport, essential to achieving an optimal estheticresult.3 The CAD/CAM process moreover eliminatesthe inherent dimensional inaccuracies of waxing,
*••†••, ••, Jupiter, FL, USA
ORIGINAL ARTICLE
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investing, and casting, as well as the subsequentneed for manipulation after machining. Suchabutments thus fit more precisely than stock or castones.
For several years, all CAD/CAM abutment fabricationbegan with removal of the healing abutment. Animpression coping then was connected to the implantand an implant-level impression was made along withan impression of the opposing arch. In 2004, a methodfor simplifying this part of the abutment-fabricationprocess was developed; it involved the use of speciallycoded healing abutments (BellaTek™ Encode®Impression System, BIOMET 3i, Palm Beach Gardens,FL, USA). Various arrangements of facets on theocclusal surfaces of the abutments identify theimplant-platform diameter, the healing abutmentheight, the hex position of the implant, and thediameter of the emergence profile.4 The use of such anabutment eliminates the need for impression copings.Instead, a supragingival impression can be made andsent to the laboratory for fabrication of a customizedabutment and crown.
Although the conventional elastomeric impressionmaterials used for such impressions have beendocumented to be accurate and safe,5–7 they still maypresent opportunities for error.8 When doneimproperly, tray selection, separation of the impressionmaterial from the tray, and material handling and/orstorage can compromise the restorative outcome.Materials such as polyvinylsiloxane and polyetherrequire messy mixing and clean-up, and many patientsfind the impression process unpleasant.
An alternative to making a conventional elastomericimpression is to record the intraoral geometry with adigital scanner. For at least 5 years, commerciallyavailable intraoral scanning systems have made itpossible to capture digital information about theprepared teeth, and from that data, three-dimensionalcomputer models are created. The models then canbe quickly, safely, and inexpensively conveyed to thelaboratory electronically,9,10 or they alternativelymay be used to design and mill crowns within thedental office.
Up to now, digital sensor technology has not beenapplied to the fabrication of implant restorations.However, in March of 2011, two manufacturersreceived 510 K Approval from the US Food and DrugAdministration for their intraoral scanners to be usedin making digital impressions of coded implant healingabutments. Obtaining such impressions digitally offersbenefits to both clinicians and patients. Patients arespared from the need for any contact with messyimpression material. Those with strong gag reflexesmay particularly benefit from the digital technologybecause the scanners do not touch the soft palate.These are used for a briefer interval than impressiontrays and allow patients to take a break, if necessary.Most scanners are comparable in size with othercommon devices such as curing lights and electrichandpieces.
Having a digital model of the BellaTek™ Encode®Healing Abutment in the patient’s mouth also has thepotential to reduce treatment expenses and compressthe interval between the making of the impressionand the delivery of the definitive restoration. The datafrom the three-dimensional digital model is sentelectronically to the BellaTek™ Production Center (PalmBeach Gardens, FL, USA). A dedicated techniciandesigns a virtual abutment with subgingival marginsthat conform precisely to the patient’s soft-tissuearchitecture. The steps of shipping a physicalimpression of the Encode Healing Abutment to thedental laboratory, having the laboratory pour mastercasts, mounting them on an articulator with specialplates, shipping the casts to BIOMET 3i, and having atechnician scan the casts, are eliminated.
Additional time savings are achieved by sending theabutment design simultaneously to the BellaTek™Production Center for milling of the abutment(s) and toa separate facility for fabrication of a rapid prototypemodel. The monolithic model, which includes aremovable die of a replica of the CAD/CAM abutment,is used by the lab to fabricate the restoration. As thedefinitive abutment or abutments are being milled(from zirconia or titanium), the rapid prototype modelis simultaneously sent to the dental laboratory for usein fabricating the definitive restoration. The restoration
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and definitive abutment can be shipped directly to therestorative office. Table 1 compares the workflow infabricating a definitive abutment and crown from atraditional impression versus a digital one.
The following clinical case illustrates the use of digitalimpression technology to obtain implant impressions
in order to fabricate a definitive implant-supportedrestoration.
CASE REPORT
A 34-year-old female presented with a missingmaxillary right first bicuspid, which had been previouslyextracted in the wake of failed endodontic therapy(Figure 1). A dental assistant, she was completingorthodontic therapy (Invisalign® System, AlignTechnologies, Inc., San Jose, CA, USA) and was readyto replace the missing tooth. A Certain® FOSS TaperedImplant (BIOMET 3i) (5.0 mm diameter ¥ 11.0 mmlength) was placed into the edentulous site, and primaryclosure was obtained. The patient’s final aligner/retainerwas used to provide temporization to replace themissing tooth during healing.
Six months after implant placement, the patientreturned for second-stage surgery. A tissue punch wasused to expose the implant, and a BellaTek EncodeHealing Abutment (5 mm diameter ¥ 3 mm height) wasplaced into the internal interface of the implant. Twoweeks later, the patient was seen for digital intraoralscanning (Lava™ Chairside Oral Scanner [C.O.S.], 3M,St. Paul, MN, USA).
TABLE 1. ••
Traditionalimpressions
Digitalimpressions
Remove healing abutment ✔
Place impression copings ✔
Radiographic verification ofabutment seating
✔ ✔
Make VPS impressions (of botharches)
Obtain an occlusal registration ✔
Replace healing abutment ✔
Send (mail) VPS impressions tolaboratory
✔
Lab fabricates a master cast andopposing arch
✔
Lab mounts the casts on a Stratosarticulator with Adesso plates
✔
Lab sends mounted casts toBellaTek Production Center
✔
Casts are scanned to createthree-dimensional models
✔
The definitive BellaTek Abutmentis designed virtually
✔ ✔
Abutment milling ✔ ✔
Robocast is fabricated frommaster cast
✔
Milled abutment is placed on theRobocast
✔
Robocast or SLA model and thedefinitive abutment(s) are sentto the lab
✔ ✔
Lab fabricates the restoration andsends it to the restorative dentist
✔ ✔
SLA = stereolithographic;VPS = ••.
FIGURE 1. The initial radiograph shows the site of themissing maxillary right first bicuspid, which had failedendodontically before being extracted.
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The restorative clinician confirmed that the BellaTekEncode Healing Abutment was securely connected tothe implant and properly seated, extending at least1 mm supragingival circumferentially. This is essentialfor the codes on the occlusal surface of the healingabutment to be transferred accurately. A periapicalradiograph was taken to confirm full seating of theabutment. An OptraGate® (Ivoclar Vivadent, Inc.,Amherst, NY, USA) retractor was placed to isolate thesite for scanning and create a dry field. A light dustingof a titanium dioxide powder was applied to the healingabutment and the adjacent teeth in the quadrant toafford higher resolution when scanning. The intraoralscanner was used to digitally capture the codes on theocclusal surface of the BellaTek Encode HealingAbutment, the surrounding soft tissue, and the adjacentteeth (Figures 2–4). The virtual image on the C.O.S.Monitor was evaluated for accuracy and accepted(Figure 5). Then the opposing arch was sprayed andscanned in similar fashion, followed by a scan of thebuccal aspect of the patient’s dentition in maximumintercuspation (Figure 6). The virtual images wereevaluated for accuracy of detail and correct occlusalrelationship.
Using the Lava C.O.S software, the appropriatelaboratory work order was completed and submittedelectronically to the BellaTek Production Center. Atechnician imported the data into a 3Shape three-dimensional scanner (3Shape A/S, Copenhagen,
FIGURE 4. View of the digitally scanned BellaTek EncodeHealing Abutment demonstrating that a minimum height of1 mm is supragingival, circumferentially.
FIGURE 2. The digital oral scan captured the codes on thesurface of the Encode Healing Abutment, as well as thecontours of the surrounding soft tissue and adjacent teeth.
FIGURE 3. Occlusal view of the digitally scanned BellaTek™Encode® Healing Abutment.
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FIGURE 6. Buccal view of the BellaTek Encode HealingAbutment in place along with the opposing dentition inmaximum intercuspation.
FIGURE 7. After being transmitted electronically to theBellaTek Production Center, the digital scan data was importedinto a 3Shape three-dimensional scanner, in which a specialsoftware was used to design the definitive abutment.
FIGURE 8. Buccal view of the virtual abutment design.
FIGURE 9. This cutaway view of the virtual abutment designshows that the abutment fits within the contours of theplanned definitive restoration.
FIGURE 5. Digital three-dimensional model of the maxillaryarch.
FIGURE 10. The patient-specific abutment was milled inzirconia, reproducing the dimensions of the virtual abutmentdesign.
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Denmark) (Figure 7), and the definitive abutmentwas designed virtually to fit within the confines ofthe planned definitive restoration (Figures 8and 9).
Once the abutment design was completed, the datawas transmitted to the milling machine for fabricationof a BellaTek Abutment in zirconia (Figure 10).Simultaneously, the data file was sent to 3M forfabrication of a stereolithographic (SLA) model(Figures 11–13). 3M sent the SLA model to thelaboratory, which concurrently received the zirconiaabutment from BIOMET 3i. Using the SLA model,the laboratory fabricated an all-ceramic restoration(Figure 14). Upon completion, the SLA model was
sent to the restorative clinician, along with theabutment and restoration.
On the day of delivery, the precision of fit of therestoration to the abutment was verified (Figure 15).The BellaTek Encode Healing Abutment was removed,and the definitive zirconia abutment was placed intothe implant and secured with an abutment screw. Aperiapical radiograph was taken to confirm completeseating, and the screw was tightened to 20 Ncm oftorque (Figure 16). The restoration was tried in toverify contacts and occlusion. The screw-accessopening was blocked with a cotton pellet. To ensureadequate bonding of the abutment to the restoration,zirconium primer (Monobond Plus, Ivoclar Vivadent)
FIGURE 11. A stereolithographic model was fabricated at3M from the digital data.
FIGURE 13. Buccal view of the articulated stereolithographicmodel.
FIGURE 12. Occlusal view of the stereolithographic model.
FIGURE 14. The definitive all-ceramic restoration on thestereolithographic model.
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FIGURE 15. The definitive all-ceramic restoration fitsprecisely on the zirconia BellaTek Abutment.
FIGURE 16. The zirconia abutment was seated and securedwith the specific abutment screw and tightened to 20 Ncm oftorque.
FIGURE 17. Zirconium primer was applied to the abutment. FIGURE 18. The all-ceramic restoration was cemented withresin cement.
FIGURE 19. Excess cement was spot-tacked with anlight-emitting diode curing light for 2 seconds on both thebuccal and palatal aspects.
FIGURE 20. The excess cement was removed easily in thegel state.
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was applied to the abutment (Figure 17), andthe restoration was secured with resin cement(Figure 18). Excess cement was spot-tacked with alight-emitting diode curing light for 2 seconds onthe buccal and palatal aspects (Figure 19) andthen removed (Figure 20). Final light-curing wasaccomplished (40 seconds buccal and palatal)(Figures 21 and 22). A periapical radiograph was taken(Figure 23), and the patient was given oral hygieneinstructions, then released. Figures 24 and 25, takenat the 6-month follow-up appointment, demonstratean esthetic and functional result. The patient was notonly very satisfied with the result of treatment, butas a dental professional, she was excited to havebenefited from the merging of these advancedtechnologies.
DISCUSSION
Since the first systems strictly intended for capturingdigital impressions appeared in 2006,11 severalcompeting products have emerged. They include theLava C.O.S, the Cadent™ iTero™ (Cadent, Inc., Carlstadt,NJ, USA), the CEREC Connect (Sirona Dental Systems,Charlotte, NC, USA), and the E4D Dentist® IntraOralDigitizer (D4D Technologies, Richardson, TX,USA). Whereas the CEREC and E4D scanners wereintroduced for chairside ceramic restoration fabrication,both the Lava and iTero Systems were created toelectronically transmit digital data to the dentallaboratory.12 These systems use different technologies,but either can be used to scan BellaTek Encode HealingAbutments.
FIGURE 21. Final light-curing was accomplished.
FIGURE 23. Radiograph taken immediately after delivery ofthe definitive restoration.
FIGURE 22. The restoration immediately after delivery andlight-curing.
FIGURE 24. The restoration 6 months after delivery.
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As is the case when making traditional impressions,digital impression scanners cannot capture imagesthrough the soft tissue. In order to ensure direct visualaccess for the scanner, the Encode Healing Abutmentsmust be at least 1 mm supragingival circumferentially.Otherwise, the codes will not be transferred accurately.Adequate control of the oral fluids also is essential asheavy saliva or blood can impair accurate capture of thedigital image.
CONCLUSION
Recent approval by the US Food and DrugAdministration of the use of intraoral digital scannersfor making digital impressions of coded implant healingabutments has the potential to simplify the task ofobtaining implant impressions. Combining digital scansof coded implant healing abutments with CAD/CAMtechnology enables a dramatic compression of the timerequired to deliver definitive crowns, bridges, andfull-arch restorations supported by implants andpatient-specific abutments that fit more precisely thanthose fabricated by traditional methods. The merging ofadvanced dental technologies eliminates the need forconventional elastomeric impression materials, the useof which is subject to error. Such materials also requiremessy mixing and clean-up and are repugnant to manypatients.
DISCLOSURE AND ACKNOWLEDGEMENTS
The authors have no financial interest in any of thecompanies whose products are included in this article.
Both Dr. Ramsey and Dr. Ritter have received honorariain the past as lecturers for BIOMET 3i.
Surgical colleague: Karina Leal, DMD, West PalmBeach, FL. Laboratory colleague: Frank Lavonia,CDT, Biotech Dental Prosthetics, Palm BeachGardens, FL.
REFERENCES
1. Duret F, Blouin J-L, Duret B. CAD-CAM in dentistry.J Am Dent Assoc 1988;117:715–20.
2. Kucey BK, Fraser DC. The Procera abutment—the fifthgeneration abutment for dental implants. J Can DentAssoc ••;66:445–9.
3. Papazian S, Morgano SM. A laboratory procedure tofacilitate the development of an emergence profile witha custom implant abutment. J Prosthet Dent1998;79(2):232–4.
4. Priest GF. Virtual-designed and computer-milled implantabutments. J Oral Maxillofac Surg 2005;63(Suppl2):22–32.
5. Clancy JM, Scandrett FR, Ettinger RL. Long-termdimensional stability of three current elastomers. J OralRehabil 1983;10(4):325–33.
FIGURE 25. An excellent esthetic result was achieved.
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6. Hondrum SO. Changes in properties of nonaqueouselastomeric impression materials after storage ofcomponents. J Prosthet Dent 2001;85(1):73–81.
7. Thongthammachat S, Moore BK, Barco MT, et al.Dimensional accuracy of dental casts: influence of traymaterial, impression material, and time. J Prosthodont2002;11(2):98–108.
8. Christensen GJ. The state of fixed prosthodonticimpressions. J Am Dent Assoc 2007;138(4):527–9.
9. Christensen GJ. Will digital impressions eliminate thecurrent problems with conventional impressions? J AmDent Assoc 2008;139(6):761–3.
10. Christensen GJ. Impressions are changing. J Am DentAssoc 2009;140(10):1301–4.
11. Avery DR. The maturation of CAD/CAM. CompendContin Educ Dent 2010;31(5):391–8.
12. Fasbinder DJ. Digital dentistry: innovation for restorativetreatment. Compend Contin Educ Dent 2010;31 Spec No4:2–11.
Reprint requests: Dr Christopher Ramsey, 500 University Blvd., Suite 109,
Jupiter, FL 33458, USA;Tel.: 561-626-6667; Fax: 561 627 7211; email:
This article is accompanied by commentary, Utilization of Digital
Technologies for Fabrication of Definitive Implant-Supported
Restorations,Thomas R, Mcdonald, DMD
DOI 10.1111/j.1708-8240.2011.00482.x
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