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Inside Dentistry
September 2016
Volume 12, Issue 9
Peer-Reviewed

Case Type 5

Patients with significant dental and anatomical shortcomings fall into the final category, case type 5 (eg, an atrophic, completely edentulous ridge). These patients lack adequate tooth support to determine OVD, necessitating the fabrication of a trial tooth set-up. If the patient has an existing and well-fitting denture, the current prosthesis may either be duplicated into a differential barium gradient (30:10) scanning appliance or, more commonly, used as part of a dual-scan imaging technique.

Transferring Data From the Lab to the Scan

Traditionally, in order to transfer an ideal wax-up into 3D data, a scanning appliance would be fabricated, which is worn by the patient while the CBCT image is captured. This appliance typically is fabricated out of a radiopaque material so it can be visualized radiographically to enable case planning (Figure 6 and Figure 7). These scanning appliances can be fabricated using barium/acrylic teeth with a negative image center (Figure 6) or with acrylic teeth utilizing a positive image center (gutta percha or another radiopaque material).

More recently, 3D technology has evolved to allow the transfer of data from the wax-up without the use of a scanning appliance. With this technology, a CBCT image of the patient is first made without a scanning appliance in place. Then, a wax-up is duplicated into a stone cast, the cast is optically scanned, and this data can be merged with the original CBCT scan of the patient using planning software such as SIMPLANT® (DENTSPLY Implants, www.dentsplyimplants.com) (Figure 8 and Figure 9). Maven Pro by nSequence (www.nsequence.com) is another comparable treatment planning software that can be used in these types of cases. Patients who already have a well-fitting prosthesis can be scanned with the prosthesis in place in accordance with the dual-scan protocol. The prosthesis is then scanned alone and the two images are merged utilizing fiduciary markers attached to the prosthesis that allow for proper 3D alignment.

Conclusion

As implant dentistry has progressed, expectations have changed—of both the clinicians placing and/or restoring the implants and the patients receiving them. Implant survival is no longer the sole standard by which success is gauged; it is expected. Ideal replacement of the patient’s soft- and hard-tissue deficiencies should be the goal of anyone involved in implant dentistry. While 3D imaging has drastically increased the capability to evaluate head and neck anatomy, plan cases, and identify favorable sites for implant placement, its utility still requires “restorative leadership” for it to meet its full potential. Integration of digital technology, including implant planning software, is an emerging standard of care but is not a substitute for sound prosthetic fundamentals or biologic principles of wound healing.

Incorporating technological advances into clinical practice requires cooperative and collaborative input from all those responsible for patient care. However, it is the restorative dentist who must define and communicate the expected outcomes to the interdisciplinary team. While it is impossible to develop a one-size-fits-all approach to achieving ideal implant esthetics and function, organizing patients into case type patterns helps guide clinicians through the diagnostic phase of implant care and maximizes the potential benefits of CBCT imaging. The leadership of the restorative dentist, through an ideal wax-up or set-up, creates an environment of “collaborative accountability” by establishing and illustrating the performance standards for each case.

References

1. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants. 1986;1(1):11-25.

2. Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-submerged ITI implants. Part 1: 8-year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res. 1997;8(3):161-172.

3. Annibali S, Bignozzi I, Cristalli MP, et al. Peri-implant marginal bone level: a systematic review and meta-analysis of studies comparing platform switching versus conventionally restored implants. J Clin Periodontol. 2012;39(1):1097-1113.

4. Atieh MA, Ibrahim HM, Atieh AH. Platform switching for marginal bone preservation around dental implants: a systematic review and meta-analysis. J Periodontol. 2010;81(10):1350-1366.

5. Lang NP, Pun L, Lau KY, et al. A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Implants Res. 2012;23 suppl 5:39-66.

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