587
A Digital Approach to Immediate-Load, Full-Arch
Implant Dentistry: A Case Report
Mark Bishara, DDS1 Traditional approaches to full-
Richard J. Miron, DMD, MSc, PhD2 arch implant dentistry require an
Gregori M. Kurtzman, DDS3 initial accurate impression using
Naif Sinada, DMD4 vinyl polysiloxane.1 This can pres-
David T. Wu, DMD5 ent its own challenges, including
ensuring that the impression cop-
ings are fully seated intraorally,
Conventional approaches to full-arch implant dentistry require a verified to inherent limitations caused by
master model created by luting together impression jigs. This process involves the impression material itself and
numerous steps and is sometimes prone to errors that require subsequent insertion of lab analogs correctly
correction. A novel approach involving an extraoral scanning technique using an
to fabricate the working model.
Imetric 4D Imaging system demonstrates an alternative for same-day delivery
of printed full-arch prosthetics. Advantages include the ability to offer a same- Advances with intraoral scanning
day provisional restoration without needing to verify an analog master cast. Int utilizing scanbodies allow for an
J Periodontics Restorative Dent 2022;42:587–593. doi: 10.11607/prd.6048 improvement in the process us-
ing a digital approach. However,
scanning multiple adjacent scan-
bodies has proven to be a clinical
challenge.2 This is especially true
in the case of multiple splinted
implants, as found in typical hy-
brid full-arch implant cases.3,4 The
following case presentation ex-
emplifies an improvement from
traditional approaches whereby a
full digital approach is used to de-
liver a same-day temporization op-
tion without needing a traditional
analog-based model or subse-
quent master model verification.
1
Private Practice, Bowmanville, Ontario, Canada.
2
Department of Periodontology, University of Bern, Bern, Switzerland.
3
Private Practice, Silver Spring, Maryland, USA.
4
Private Practice, Fayetteville, Arizona, USA. Conventional Digital
Division of Periodontology, Department of Oral Medicine, Infection, and Immunity, Harvard
5
Approach
School of Dental Medicine, Boston, Massachusetts, USA.
Correspondence to: Dr Mark Bishara, 17 Mackey Drive, Whitby, Ontario, Canada, L1P 1P5. In a conventional digital approach,
Fax: 905-436-2401. Email: [email protected] implant scanbodies are connected
to the implants for digital scanning.
Submitted October 14, 2021; accepted February 11, 2022.
©2022 by Quintessence Publishing Co Inc. Typically, the scanbodies used for
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588
Fig 1 Capturing the 3D implant positions using the ICam4D Fig 2 An example clinical scenario using ICamBodies to capture
system. implant positions in a full-arch case.
full-arch implant cases are connect- ating a verification jig (stent) that Photogrammetry
ed to multi-unit abutments (MUAs). ensures that the implants are cap-
This increases the passivity of the tured in an accurate relationship Photogrammetry is a technique that
final prosthesis by ensuring paral- to each other. Then, the model is generates 3D coordinates of spe-
lelism of the implants through the created via a “corrected cast.”9 The cific points identified from multiple
angle correction provided by the process involves an initial accurate images of the same object obtained
MUA.5 Similar to a panoramic im- impression, fabrication of a verifica- at different angles.11 The ICam4D
age, an intraoral scan consists of tion jig and custom tray, repouring unit (Imetric 4D Imaging) is a hand-
multiple images that are stitched the model if necessary, or cutting held camera unit that consists of
together using common overlap- the verification jig if any distortion four cameras and one projector.12
ping data between one image and or misfits are apparent during the By combining photogrammetry
the next. That process of data ex- try-in. The verification jig is then and structured-light scanning tech-
trapolation introduces slight errors captured in an open-tray impres- niques, this unit can capture 3D
that can add up as the number of sion, and a soft tissue model is fab- data for an accurate representation
images needed for full-arch scan- ricated.10 of implant positions relative to each
ning increases.6 The literature is Once this model is verified, other (Fig 1). By using the equivalent
unclear on the accuracy of full-arch scanbodies can be inserted and of implant scanbodies in the form of
intraoral scanning in edentulous scanned on a benchtop lab scanner. ICamBodies, which have a unique
cases; this is especially important As previously mentioned, the ability target arrangement (Fig 2), the unit
because most testing is done us- to scan extraorally without accom- can determine the position and ori-
ing benchtop models that do not modating for saliva or patient move- entation of the implants.13
replicate the difficulty of capturing ment makes this approach advanta- Another critical component of
accurate data in the intraoral envi- geous. Further, a lab scanner can the ICam 4D system is the ICam-
ronment due to the present blood capture more data per shot, thus Refs, which are placed directly on
and saliva.7,8 limiting (1) the number of images the MUAs. These are similar to tra-
Currently, the gold standard that need to be stitched together ditional healing abutments but with
for restoring adjacent implants is to and (2) the potential magnitude of a smaller profile height, which facili-
lute together impression jigs, cre- error. tates soft tissue capture either by a
The International Journal of Periodontics & Restorative Dentistry
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589
a b
Fig 3 (a) Initial patient clinical and (b) panoramic radiographic presentation with a failing maxillary long-span fixed prosthesis.
a b
Fig 4 Preoperative intraoral scan imported into Exocad software. Green highlighted areas illustrate the temporary design scan overlaying
the original scan.
traditional impression of the gingiva involves placing constant reference able options, a provisional restora-
or by capture with an intraoral scan- points (such as palatal screws) at tion solution using implants was of-
ner. Imetric 4D software then allows the start of the procedure, subse- fered and accepted by the patient.
the user to transform the captured quently scanning them or recording Diagnostic records included smiling
implant positions into the coordi- them through physical impression. photos, intraoral scans (Medit i500,
nate system of the gingiva using By maintaining a constant reference Medit), and CBCT scans (CS 8100
ICamRefs. This information is then point, the clinician can refer to the 3D, Carestream) were taken, and
exported into a design software, temporary design in Exocad without temporary designs in Exocad were
such as Exocad, which was used in losing reference of the orientation. printed on the same day of surgery
the present case. using temporary resin (Freeprint
To maintain a constant refer- Temp, Detax) on a MAX printer (Asi-
ence point between the temporary Same-Day Provisional ga) (Fig 4).
design and mouth, one of two strat- Restoration Case Grand Morse implants (Neo-
egies can be utilized. One approach dent) were placed in a free-handed
involves keeping two or three teeth A 72-year-old healthy woman (Fig fashion based on the surgical plan
until the end of the procedure, 3a) presented to the first author’s designed in coDiagnostiX software
which can be subsequently extract- (M.B.) private practice with a failing (Dental Wings; Fig 5); in this case, the
ed once the implant positions have maxillary long-span partial denture presence of artifacts from the exist-
been confirmed. The other strategy (Fig 3b). After discussing the avail- ing metallic partial denture would
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590
Fig 5 Virtual surgical planning in coDiagnostiX software for the planned implant posi- Fig 6 Intraoral scan of the patient with pre-
tions relative to the present anatomy. treatment presentation. A palatal reference
screw and the two posterior molars were used
as reference points prior to initiating the surgi-
cal procedure.
detached from the stacks and pol-
ished (Fig 11), then inserted intra-
orally (Fig 12). Screws were placed
and tightened by hand, and the oc-
clusion was checked and adjusted
as needed.
Two months elapsed to allow
osseointegration to occur, and
Fig 7 After implant placement, MUAs were Fig 8 ICamBodies were attached to the then the final prosthesis records
inserted on each implant to achieve paral- MUAs intraorally in preparation for scan- were completed by capturing any
lelism and have a base to fix the temporary ning.
screw-retained prosthesis. soft tissue changes underneath the
temporary restoration and confirm-
ing implant osseointegration. One
implant in the maxillary molar area
have made it difficult to merge the the suggested temporary design did not osseointegrate and was
DICOM (Digital Imaging and Com- created prior to surgery. The im- subsequently removed prior to
munications in Medicine) data for plants achieved a minimum insertion fabrication of the final monolithic
a fully guided approach. A palatal torque of 35 Ncm each, allowing for zirconia partial denture. Because
screw and bilateral second molar placement of the MUA (Fig 7). ICam- the verified implant positions were
implant crowns were used to main- Bodies were attached to the MUAs captured at the surgical appoint-
tain the orientation of the design intraorally in preparation for scanning ment, a final Imetric 4D record was
relative to the temporary partial for Imetric 4D records (Fig 8). taken to include the single maxil-
denture design prior to surgical im- Once the Imetric 4D records lary second molar implant crown
plant placement (Fig 6). Once the were captured (Fig 9), the pala- in the second quadrant, where an
anterior teeth were extracted, tent- tal screw could be removed while MUA was placed instead. Figure 13
ing screws helped orient the ridge waiting for the printing and design shows the final monolithic zirconia
to the preoperative condition in the processes to be completed (Fig 10). partial denture in place, and Fig 14
design software. This is a crucial step Once printing was complete, the shows the panoramic radiographic
in aligning the implant positions with temporary partial restoration was view.
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591
a b c
Fig 9 The Exocad design shows the captured implant positions on the MUAs. The green area highlights the temporary prosthesis design
with positions for screw access holes.
Fig 10 ICamRefs healing abutments were Fig 11 The final printed temporary pros- Fig 12 The printed maxillary immedi-
placed prior to taking a soft tissue impres- thesis, after removing the supports and ate temporary prosthesis was intraorally
sion. polishing, is ready for intraoral placement. placed.
a b
Fig 13 Clinical view of the soft tissues (a) prior to placing the final monolithic zirconia partial denture and (b) after restoration placement.
Discussion cess.14 This can be achieved only by Photographs and video scan-
ensuring a passive fit by minimiz- ners share some of the advantages
The ability to provide a tension-free ing inherent margins of error while of photogrammetry. Scanners gen-
(passive) connection between the eliminating any stress on the individ- erate 3D images by stitching multi-
implants and the prosthetic struc- ual implants when connecting them ple images together using a best-fit
ture is critical for long-term suc- with the temporary prosthesis. algorithm. However, the reliability
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592
accuracy. Future trends include im-
proving the material strength of the
printed provisional restorations to
allow for a longer temporization pe-
riod, if needed.
Acknowledgments
The authors declare no conflicts of interest.
Fig 14 Panoramic radiographic view of the final prosthesis after intraoral placement. References
1. Kurella KS, Thiyaneswaran N, Abhinav
RP. Comparison of accuracy/dimen-
sional stability of high-rigid vinyl poly-
siloxane, polyvinyl siloxane, and poly-
diminishes as the number of im- saves both the clinician and patient
ether impression materials in full arch
plants involved increases, which a number of appointments, short- implant-supported prosthesis: In vitro
increases the number of images ens the overall treatment time, and study. J Long Term Eff Med Implants
2020;30:179–186.
stitched together. In contrast with ensures that a passive fit is achieved 2. Griseto NT, Gallucci GO. Digital maxil-
intraoral scanners, photogrammetry on the final prosthetic restoration. lomandibular relationship registration
for an edentulous maxilla: A dental
generates direct vectors of the ex- Registering the implant posi-
technique. J Prosthet Dent 2021;125:
act position of the implants in rela- tions with the Imetric 4D workflow 858–861.
tion to one another. This information improves patient comfort in com- 3. Giménez B, Özcan M, Martínez-Rus
F, Pradíes G. Accuracy of a digital im-
makes it possible to calculate the parison with conventional impres- pression system based on active trian-
implant positions without superim- sion techniques. By eliminating gulation technology with blue light for
implants: Effect of clinically relevant
posing photos. Therefore, the ac- physical impression materials, the
parameters. Implant Dent 2015;24:
curacy is increased, and potential practitioner can avoid patient nau- 498–504.
errors are eliminated. sea and discomfort, which is also a 4. Ciocca L, Meneghello R, Monaco C, et
al. In vitro assessment of the accuracy
The clinical evaluation of pas- critical issue in those with a strong of digital impressions prepared using a
sivity between the implants and gag reflex. single system for full-arch restorations
on implants. Int J Comput Assist Radiol
the prosthetic components is chal-
Surg 2018;13:1097–1108.
lenging. The Sheffield test has been 5. Zhang YJ, Qiao SC, Qian SJ, Zhang CN,
shown to be an efficient clinical test Conclusions Shi JY, Lai HC. Influence of different fac-
tors on the accuracy of digital impres-
of passive fit, especially in cases sions of multiple implants: An in vitro
with multiple implants.15 The screw- The clinical application of a novel study. Int J Oral Maxillofac Implants
2021;36:442–449.
resistance test has the disadvantage photogrammetry system for regis-
6. Andriessen FS, Rijkens DR, van der
of introducing subjectivity into the tering multiple implant positions at Meer WJ, Wismeijer DW. Applicability
evaluation but is considered a pre- the time of surgery allows for pa- and accuracy of an intraoral scanner for
scanning multiple implants in edentu-
cise way of detecting discrepancies. tient rehabilitation using the same- lous mandibles: A pilot study. J Prosthet
In the present case, the Imetric day delivery of a printed prosthesis. Dent 2014;111:186–194.
7. Camcı H, Salmanpour F. Effect of sa-
4D workflow allows for the same- As the cost of digital dentistry be-
liva isolation and intraoral light levels
day delivery of a temporary pros- comes more accessible for clini- on performance of intraoral scanners.
thesis without the need for a veri- cians, more patients can be treated Am J Orthod Dentofacial Orthop
2020;158:759–766.
fication jig or corrected cast. This with fewer clinical visits and better
The International Journal of Periodontics & Restorative Dentistry
© 2022 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
593
8. Chen Y, Zhai Z, Li H, et al. Influence of 11. Sánchez-Monescillo A, Hernanz-Martín 13. Molinero-Mourelle P, Lam W, Cascos-
liquid on the tooth surface on the ac- J, González-Serrano C, González- Sánchez R, Azevedo L, Gómez-Polo M.
curacy of intraoral scanners: An in vitro Serrano J, Duarte S Jr. All-on-four re- Photogrammetric and intraoral digital
study. J Prosthodont 2022;31:59–64. habilitation using photogrammetric im- impression technique for the rehabilita-
9. Silverstein LH, Kurtzman GM, Schneider pression technique. Quintessence Int tion of multiple unfavorably positioned
A, Shatz PC. The utilization of a prepro- 2019;50:288–293. dental implants: A clinical report. J Oral
sthetic extraoral verification stent for 12. Lee H, Fehmer V, Hicklin S, Noh G, Implantol 2019;45:398–402.
dental implant-supported reconstruc- Hong SJ, Sailer I. Three-dimensional 14. Yannikakis S, Prombonas A. Improving
tions. Dent Today 2002;21:88–91. evaluation of peri-implant soft tissue the fit of implant prosthetics: An in vi-
10. Schneider A, Kurtzman GM, Silverstein when tapered implants are placed: Pi- tro study. Int J Oral Maxillofac Implants
LH. Improving implant framework pas- lot study with implants placed immedi- 2013;28:126–134.
sive fit and accuracy through the use ately or early following tooth extraction. 15. Figueras-Alvarez O, Cantó-Navés O,
of verification stents and casts. J Dent Int J Oral Maxillofac Implants 2020;35: Real-Voltas F, Roig M. Protocol for the
Technol 2001;18:23–25. 1037–1044. clinical assessment of passive fit for
multiple implant-supported prostheses:
A dental technique. J Prosthet Dent J
2021;126:727–730.
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