Using an Integrated Digital Approach to Treatment Planning

INTRODUCTION
Several factors affect whether or not implant treatments are appropriate for replacing a single missing tooth, including bone quality and quantity at the implant site, space requirements, and the patient’s occlusion, among others.^1,2 These considerations and their potential implications also affect whether or not other treatments or procedures will be required prior to, or in conjunction with, dental implants.

For example, patients with impacted teeth may first be presented with the recommendation of orthodontics to move the affected tooth into a proper position, rather than extraction and implant placement.^3,4 Alternatively, if extraction and implant placement are desired by the patient, bony defects that remain following tooth extraction could negate the possibility of immediate implant placement and provisionalization. Instead, such cases could necessitate the need for bone and tissue grafting to ensure predictable stability and adequate soft-tissue aesthetics following delayed implant placement.⁵ These requirements demand further consideration, however, because different materials demonstrate varying healing properties that affect the timing of implant placement and, therefore, overall restorative treatment time.⁶

Therefore, successful implant treatments are predicated on thorough and accurate diagnosis, treatment planning that envisions the end result prior to undertaking any procedures, and communication among the entire dental team.^7-9 This inherently requires high-quality images (eg, 3-D, CBCT, or panoramic) that enable dentists to see beyond the scope of traditional radiographs.^10-13 However, because implant treatments involve a range of professional services, each with their own diagnostic, information transfer, and technology (ie, hardware and software) requirements, interoperability among technologies and treatment team members for planning and interoffice consultations is also essential.^7-9

Because diagnosis is the most critical step in the treatment planning process, it dictates the appropriateness of treatment alternatives in consideration of the individual case and patient characteristics. Every effort should be taken to ensure its accuracy, and when various forms of technology are integrated into the diagnostic workflow, the diagnostic process and communication among dental team members becomes more precise and efficient. In particular, 3-D imaging and CBCTs allow clinicians to determine if an implant is the most appropriate treatment; these are also are essential for implant placement, such as when creating implant surgical guides; planning the ideal implant length, size, and position; and ensuring predictable outcomes.^14,15

CASE REPORT
Diagnosis and Treatment Planning
A 58-year-old man presented with a fractured maxillary right primary tooth and impacted maxillary right cuspid, tooth No. 6 (Figures 1 and 2). A thorough clinical examination was performed, and preoperative digital photographs, as well as CBCTs (CS 9300 [Carestream Dental]), were taken (Figure 3). These technologies—along with digital impressions, study models, a virtual diagnostic wax-up, and treatment planning software, among others—formed the basis for educating the patient about his condition. Throughout the consultation, the technology-based information was shared with him to explain his treatment options, what they would involve, and what the expected outcomes would be.

Figure 1. Preoperative radiograph of a male patient presented with a fractured maxillary right primary tooth and impacted cuspid (No. 6).

Figure 2. Preoperative right lateral view of the fractured primary tooth.	Figure 3. CBCT image showing lingual position of impacted tooth (CS 9300 [Carestream Dental]).

The importance of managing patient expectations throughout the consultation and treatment planning process cannot be overstated. This process inherently requires actively listening to the patient and discussing the individual’s needs, concerns, and desires, including finances, aesthetics, time constraints, and compliance. In this case, orthodontics to move the impacted cuspid into position was recommended, and the patient was referred for consultation with an orthodontist and oral surgeon. However, given the patient’s age and immediate treatment desires, he was not interested in this option.

Therefore, even before any procedures began, technology was used to plan the patient’s treatment, and supporting image documentation was shared with other members of the treatment team. Planning began by first envisioning the completed implant case using diagnostic and treatment planning software SIMPLANT (Dentsply Sirona Implants) which enabled use of the diagnostic information for virtually planning the case.¹¹ After the restoration was envisioned, the case was sent to the dental laboratory team for creation of a virtual diagnostic wax-up to verify that the anticipated results could be achieved.

Extraction
In this particular case, CBCT analysis revealed that the patient’s maxillary right cuspid, tooth No. 6, was impacted, lingually and palatally displaced, and required extraction from a lingual approach followed by delayed implant placement and restoration. The ability to clearly view the exact location and angulation of the impacted tooth on the CBCT and radiograph illustrates an advantage of these technologies for facilitating precise surgical procedures. Although the impacted tooth was successfully extracted, a large bony defect remained with insufficient bone to support immediate implant placement.

Bone Graft and Tissue Membrane
Following extraction of the primary and impacted cuspids, alloplast cadaver bone graft material (BaseBone [Precision Allograft Solutions]) and a soft-tissue membrane (OraPlug collagen plug [Salvin]) were placed to enable implant placement in the ideal position after healing, as well as to ensure gingival aesthetics and long-term stability (Figure 4). The main reason for selecting the alloplast material was to facilitate a shorter healing period. Synthetic bone grafts can require up to 12 months of healing before implants can be placed, whereas alloplast materials can integrate and enable implant placement within 4 months.^16,17

Provisionalization
Because the implant could not be immediately placed and immediate loading was not possible, a removable snap-on provisional restoration (Snap-On Smile [DenMat]) was fabricated by the dental laboratory team based on 3-D digital intraoral scans and returned prior to the extraction procedure. This type of provisional restoration was extremely useful to the patient for aesthetics, allowing him to leave the office without concern about missing a tooth. However, this provisional in particular would avoid interferences with the occlusion of his adjacent natural teeth (ie, openings along occlusal surfaces) and would also be more comfortable since nothing was contacting the roof of his mouth (Figure 5).

Implant and Restoration Planning
The patient returned after 4 months of healing, at which time the radiographs and a CBCT scan were taken to confirm the presence of adequate bone for implant placement. Intraoral photographs were also taken to confirm soft-tissue healing. These images, combined with implant planning software, were used to plan implant placement, position, and restoration.

The CBCT was used with planning software (MavenPro [nSequence]) to develop a stereolithic model and surgical guide (Figure 6), which illustrated the exact position and angle needed for placing the implant in the ideal position. The ANKYLOS (Dentsply Sirona Implants) implant system was selected to enable the implant to be placed subcrestally, since its position in the anterior region would require an aesthetic emergence profile for a more pleasing restorative result.¹⁸

Additionally, using the digital design features of the implant treatment planning software, a custom-milled titanium healing abutment and ultimately a custom gold hue final abutment were designed by duplicating and mirroring the shape and anatomical characteristics of tooth No. 11. This enabled both abutments to be fabricated to the same dimensions, which would be ideal for soft-tissue shaping. Further, because gingival tissue and abutments should be shaped to accommodate each unique clinical case, using both custom healing and custom final abutments would help to ensure a natural emergence profile within the peri-implant soft tissue.¹⁹

Similarly, the treatment planning software was also used to design the final lithium disilicate crown restoration (IPS e.max [Ivoclar Vivadent]). To ensure fabrication of an accurate restoration and achieve maximal aesthetics and function, the crown was designed based on the planned and correct implant position.

Implant Surgery
The patient was placed on a non-narcotic relaxation system (NuCalm). A buffered anesthetic (Anutra [Anutra Medical]) was administered to make it more comfortable for the patient as well as for its quick-acting properties. The implant surgical guides were placed (Figure 7), and a fully guided surgery using a tissue punch technique was performed (Figure 8). This technique enables the dentist to punch the tissue to the exact size of the implant to be placed (Figures 9 to 11). Although an incision could have been used (or alternatively a laser), an entirely guided technique was preferred.

Following placement, implant scan bodies were placed, and close-up radiographs were taken to confirm ideal implant positioning. The scan bodies were removed, and the custom-milled titanium healing abutment was placed, which fit intimately with the surrounding soft tissue. Because the patient had been pleased with the aesthetics and function of the previously created snap-on and removable provisional, there was no reason to provide him with an immediately loaded restoration. Therefore, this provisional was used over the custom healing abutment, facilitating ideal soft-tissue healing.

Figure 9. Initial drill in the ANKYLOS ExpertEase guided surgery system (Dentsply Sirona Implants).

Final Abutment and Restoration
At the final restorative appointment, the custom healing abutment was removed (Figure 12), revealing that exceptional soft-tissue healing and contours had been achieved. Then, the customized gold hue abutment and crown restoration (Figure 13) were placed. This custom final abutment was designed to exactly mimic the shape of the healing abutment in order to maintain the same tissue contours and prevent any tissue resistance during final placement. The gold hue of the abutment also promoted a warmer and more aesthetic tissue color compared to zirconia abutments, particularly in the cuspid and premolar areas.²⁰

The contacts and occlusion were checked, after which the restoration was torqued down to 15 Ncm. The ANKY­LOS system has the torque built into the wrench, which makes the procedure simple. Several materials (eg, permanent cement, bonded resin cement, and provisional cement) could have been selected for cementing the crown to the abutment. In this case, Ceramir C&B (Doxa) luting cement was chosen due to its handling properties, easy cleanup, and radiopacity. Thorough cleanup was done, as care should be taken to remove all excess cement in implant cases. A periapical radiograph was taken to ensure all cement was removed (Figure 14). Ultimately, the definitive result was a highly aesthetic restoration with natural and healthy tissue contours (Figure 15).

Figure 14. Post-op periapical radiograph.

CLOSING COMMENTS
Advanced diagnostic imaging such as CBCTs, treatment planning tech­nologies such as stereolithic surgical guides, and an interdisciplinary collaborative team approach are helping to make implant treatments more predictable, beneficial, and satisfying for many patients. Visualizing the ultimate restorative result first, however, is essential for achieving ideal function, aesthetics, and oral health. In this case, doing so demonstrated the manner in which a delayed approach would enable extraction and grafting to ensure ideal implant position and stability. Equally important, however, was the planned use of a custom healing abutment to ensure a passive yet intimate fit of the final abutment with the soft tissues.

Acknowledgment
The author would like to thank the nSequence Center for Advanced Dentistry Dental Laboratory in Reno, Nev, for its work on this case.

References

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Dr. Little received his dental training at the University of Texas Health Science Center at San Antonio and now maintains a multidiscipline, state-of-the-art practice in San Antonio that provides patients with dramatic restorative treatment results. He is an accomplished international speaker, professor, and author and also a respected clinical researcher focusing on implants, laser surgery, and dental materials as well as a consultant on emerging restorative techniques and materials. His leadership and experience in team motivation and vision are recognized worldwide. He can be reached by phone at (210) 648-4411 or via the website professionalsindentistry.com.

Disclosure: Dr. Little reports no disclosures.