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Simplified digital workflow for dental implant restoration on a stock abutment using an intraoral scanner: A dental technique
DENTAL TECHNIQUE
Simplified digital workflow for dental implant restoration on a stock abutment using an intraoral scanner: A dental technique Jong-Eun Kim, DDS, MSD,a Ji-Hyun Park, DDS,b Hong-Seok Moon, DDS, PhD,c and June-Sung Shim, DDS, PhDd The use of intraoral scanning ABSTRACT in the fabrication of an implant A straightforward digital restorative method based on a library of stock abutments is presented. restoration requires a scanPrecisely scanned data of laboratory analog components of the stock abutment were obtained nable abutment, unlike a using a tabletop scanner to produce the library. The stock abutment and surrounding teeth, tooth-supported fixed dental opposing arch, and occlusal information were recorded using an intraoral scanner. After transprosthesis, where the prepared ferring the scanned data to computer-aided design software, an appropriate library file for the abutment connected within the mouth was matched in order to design the prosthesis. (J Prosthet tooth is scanned. Most manuDent 2016;-:---) facturers produce only a single size of scannable abutment for a given type of implant fixture. It is supplied as a thin, been milled. However, it may not exactly match the straight rod that extends evenly into the surrounding soft shape of the intaglio of the superstructure prosthesis, tissue. This feature may introduce errors in the soft tissue which may affect the fit of the restoration. The second profile of a custom abutment, because changes such as method should produce a restoration with a better fit soft tissue collapse may occur during connection of the because it is fabricated by scanning the abutment again scannable abutment and during the intraoral scanning after removing the residual titanium blank; however, process.1,2 Moreover, an incorrectly connected scansequential restoration fabrication complicates the pronable abutment lowers the accuracy of the implant cess. The consumption of additional material could also prosthesis.3,4 be disadvantageous.1,7,8 Because the scannable abutment is used to reproduce In the conventional process of dental implant restothe location of the fixture in the computer-aided design ration, a prefabricated stock abutment is first selected (CAD) software, a custom abutment and suprastructure based on the height of the surrounding soft tissues and are produced after that. Two main methods can be used the interarch space. The impression, made with an during the fabrication process, a customized abutment impression coping, is very reliable. This technique is and suprastructure are fabricated simultaneously; or after straightforward and can accurately produce a prosthesis the fabrication of a customized abutment, the abutment because only the suprastructure needs to be produced by is scanned again on the implant analog retrofitted to the using the recorded impression and the ready-made definitive cast or stereolithographic model, and a supracomponent. Furthermore, it can also reduce overall structure is produced on it.5,6 fabrication time and the cost relative to fabricating a In the first method, a laboratory technician must custom abutment.9 separate the area connecting the milled abutment from The purpose of this article was to introduce a 1-step the titanium blank after the customized abutment has prosthesis fabrication method that involves superimposing a
Clinical Research Assistant Professor, Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea. Graduate student, Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea. c Professor, Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea. d Professor, Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea. b
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Figure 1. Capturing process of library data of stock abutment. A, Die scanning jig of tabletop scanner used to scan analog components of stock abutment. B, Scanning process using tabletop scanner. C, Edit and confirm overall quality of all scanned data in computer-aided design (CAD) software.
library data of a stock abutment produced in advance after connecting the stock abutment and then scanning it with an intraoral scanner. TECHNIQUE 1. Scan the analog components of the stock abutment (Lab analog; Dentium Co). Obtain precisely scanned data by using a tabletop scanner to produce the library (Identica Hybrid; Medit Co). Use powder to avoid interference with the data-capturing
THE JOURNAL OF PROSTHETIC DENTISTRY
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process because of reflections from the metal surface. Use a die-scanning jig for convenience (Fig. 1A, B). Import the scanned abutment analog data into CAD software (Exocad DentalCAD; Exocad GmbH). Evaluate the integrity of the margin and confirm the overall quality of the scanned data. The scanned data must include the margin part of the abutment analog. Each file name should include the diameter and length of the abutment (Fig. 1C). Connect an appropriate stock abutment (Dual abutment; Dentium Co) to the implant fixture intraorally after selecting it based on parameters such as the height of the surrounding soft tissues, the distance from the opposite arch, and the distance from the adjacent tooth (Fig. 2). Fill the access hole of the abutment screw with composite resin. Scan the stock abutment and surrounding teeth and acquire the opposing arch and occlusal information using an intraoral scanner (TRIOS; 3shape A/S). Despite the gloss of the stock abutment, powder is not needed. The margin may not be scanned accurately where the stock abutment enters the subgingival portion. However, a prosthesis can be designed on the margin because this margin can be accurately reproduced during the matching process with the library (Fig. 3). After transferring the scanned data to the CAD software (Exocad DentalCAD; Exocad GmbH), match them to an appropriate library file for the abutment connected intraorally (Fig. 4). Design a definitive prosthesis based on the superimposed abutment data (Fig. 5).
DISCUSSION This workflow used the method of producing a superstructure through a digital workflow by using the library data of the stock abutment analog of the implant that was scanned in advance, like a scannable abutment. Even though the scannable abutment fabricated for the purpose of obtaining the location of the implant is not used, a library retrieved from the CAD software can play a role similar to that of the scannable abutment. Because the scanned data were used to produce the superstructure only while the stock abutment was connected to the implant intraorally and was not removed after the intraoral scanning procedure, the process is both convenient for patients and allows an accurate restoration to be fabricated within a short time.
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Figure 2. A, Intraoral occlusal view of stock abutment connected to implant fixture. Distal margin portion of abutment not visible clearly as located in subgingival area. B, Lateral view.
Figure 3. A, Occlusal view image of stock abutment and adjacent tooth scanned using intraoral scanner. B, Opposing arch and occlusal information.
This technique can reduce errors because it identifies the relationship with the surrounding teeth and the opposite arch at the abutment level, in contrast to the workflow using a scannable abutment at the implant fixture level. Moreover, even though the intraoral scanning does not record the margin exactly as for a tooth preparation, if the appearance of the stock abutment is scanned accurately, an accurate prosthesis can be produced because it uses the library data that were obtained by accurately scanning up to the margin in advance. Embedding the stock abutment library in the implant planning software or CAD software itself would reduce the effort required to produce a library. Diffuse reflection due to the high gloss level of the abutment analog can sometimes interfere with the process of producing the library. In such situations, powder should be applied, as in this report, or the surface of the abutment analog can be airborne-particle abraded. The procedure described has limitations for a fixed prosthesis supported by 2 or more implants with different
Kim et al
installation paths in that the abutment shape should be modified in order to align the axes of the abutments. Additionally, the accuracy of the scan can be reduced when a fixed prosthesis with a long edentulous span is produced and there are insufficient landmarks within the edentulous area.10 An intraoral scanner that operates as a closed system and does not extract scanned data in an open format such as stereolithography (STL) files cannot be used to design an implant prosthesis in the manner presented in this article. However, because most intraoral scanner software programs support data extraction to STL files, the dental techniques presented in this article can be used with CAD software such as Exocad or a 3-shape dental system (3Shape A/S). SUMMARY A digital workflow can simplify the process of fabricating an implant prosthesis after connecting a stock
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Figure 4. Matching intraoral scan data to appropriate library file in computer-aided design (CAD) software. A, Intraoral scan data imported in Exocad CAD software. Distal margin portion of stock abutment not captured clearly. B, Superimpose intraoral scan data and library data of stock abutment using scan registration option. C, Scan data of stock abutment portion replaced by library data of same shape and size after registration process. D, Occlusal view showing margin portion of library data replaced.
Figure 5. A, Designing definitive prosthesis based on superimposed abutment data. B, Intaglio of designed prosthesis and margin.
abutment to the implant and scanning it with an intraoral scanner. In this technique, a superstructure is produced by superimposing a stock abutment with a library that was fabricated in advance. An accurate prosthesis can be fabricated rapidly because only the superstructure needs to be made and the margin in the library data that was scanned in advance can be used.
THE JOURNAL OF PROSTHETIC DENTISTRY
REFERENCES 1. Monaco C, Evangelisti E, Scotti R, Mignani G, Zucchelli G. A fully digital approach to replicate peri-implant soft tissue contours and emergence profile in the esthetic zone. Clin Oral Implants Res 2016;27: 1511-4. 2. Joda T, Ferrari M, Braegger U. A digital approach for one-step formation of the supra-implant emergence profile with an individualized CAD/CAM healing abutment. J Prosthodont Res 2016;60:220-3. 3. Vandeweghe S, Vervack V, Dierens M, De Bruyn H. Accuracy of digital impressions of multiple dental implants: an in vitro study. Clin Oral
Kim et al
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4. 5.
6. 7. 8.
Implants Res 2016 May 6. http://dx.doi.org/10.1111/clr.12853. [Epub ahead of print]. Andriessen FS, Rijkens DR, van der Meer WJ, Wismeijer DW. Applicability and accuracy of an intraoral scanner for scanning multiple implants in edentulous mandibles: a pilot study. J Prosthet Dent 2014;111:186-94. Lin WS, Harris BT, Morton D. The use of a scannable impression coping and digital impression technique to fabricate a customized anatomic abutment and zirconia restoration in the esthetic zone. J Prosthet Dent 2013;109: 187-91. Telleman G, Raghoebar GM, Vissink A, Meijer HJ. The use of a coded healing abutment as an impression coping to design and mill an individualized anatomic abutment: a clinical report. J Prosthet Dent 2011;105:282-5. Brandt J, Lauer HC, Peter T, Brandt S. Digital process for an implantsupported fixed dental prosthesis: a clinical report. J Prosthet Dent 2015;114: 469-73. Ramsey CD, Ritter RG. Utilization of digital technologies for fabrication of definitive implant-supported restorations. J Esthet Restor Dent 2012;24: 299-308.
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9. Priest G. Virtual-designed and computer-milled implant abutments. J Oral Maxillofac Surg 2005;63:22-32. 10. Kim JE, Amelya A, Shin Y, Shim JS. Accuracy of intraoral digital impressions using an artificial landmark. J Prosthet Dent 2016. http://dx.doi.org/10.1016/ j.prosdent.2016.09.016.
Corresponding author: Dr June-Sung Shim Department of Prosthodontics College of Dentistry Yonsei University Seoul SOUTH KOREA Email: [email protected] Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY
Simplified digital workflow for dental implant restoration on a stock abutment using an intraoral scanner: A dental technique Jong-Eun Kim, DDS, MSD,a Ji-Hyun Park, DDS,b Hong-Seok Moon, DDS, PhD,c and June-Sung Shim, DDS, PhDd The use of intraoral scanning ABSTRACT in the fabrication of an implant A straightforward digital restorative method based on a library of stock abutments is presented. restoration requires a scanPrecisely scanned data of laboratory analog components of the stock abutment were obtained nable abutment, unlike a using a tabletop scanner to produce the library. The stock abutment and surrounding teeth, tooth-supported fixed dental opposing arch, and occlusal information were recorded using an intraoral scanner. After transprosthesis, where the prepared ferring the scanned data to computer-aided design software, an appropriate library file for the abutment connected within the mouth was matched in order to design the prosthesis. (J Prosthet tooth is scanned. Most manuDent 2016;-:---) facturers produce only a single size of scannable abutment for a given type of implant fixture. It is supplied as a thin, been milled. However, it may not exactly match the straight rod that extends evenly into the surrounding soft shape of the intaglio of the superstructure prosthesis, tissue. This feature may introduce errors in the soft tissue which may affect the fit of the restoration. The second profile of a custom abutment, because changes such as method should produce a restoration with a better fit soft tissue collapse may occur during connection of the because it is fabricated by scanning the abutment again scannable abutment and during the intraoral scanning after removing the residual titanium blank; however, process.1,2 Moreover, an incorrectly connected scansequential restoration fabrication complicates the pronable abutment lowers the accuracy of the implant cess. The consumption of additional material could also prosthesis.3,4 be disadvantageous.1,7,8 Because the scannable abutment is used to reproduce In the conventional process of dental implant restothe location of the fixture in the computer-aided design ration, a prefabricated stock abutment is first selected (CAD) software, a custom abutment and suprastructure based on the height of the surrounding soft tissues and are produced after that. Two main methods can be used the interarch space. The impression, made with an during the fabrication process, a customized abutment impression coping, is very reliable. This technique is and suprastructure are fabricated simultaneously; or after straightforward and can accurately produce a prosthesis the fabrication of a customized abutment, the abutment because only the suprastructure needs to be produced by is scanned again on the implant analog retrofitted to the using the recorded impression and the ready-made definitive cast or stereolithographic model, and a supracomponent. Furthermore, it can also reduce overall structure is produced on it.5,6 fabrication time and the cost relative to fabricating a In the first method, a laboratory technician must custom abutment.9 separate the area connecting the milled abutment from The purpose of this article was to introduce a 1-step the titanium blank after the customized abutment has prosthesis fabrication method that involves superimposing a
Clinical Research Assistant Professor, Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea. Graduate student, Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea. c Professor, Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea. d Professor, Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea. b
THE JOURNAL OF PROSTHETIC DENTISTRY
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Figure 1. Capturing process of library data of stock abutment. A, Die scanning jig of tabletop scanner used to scan analog components of stock abutment. B, Scanning process using tabletop scanner. C, Edit and confirm overall quality of all scanned data in computer-aided design (CAD) software.
library data of a stock abutment produced in advance after connecting the stock abutment and then scanning it with an intraoral scanner. TECHNIQUE 1. Scan the analog components of the stock abutment (Lab analog; Dentium Co). Obtain precisely scanned data by using a tabletop scanner to produce the library (Identica Hybrid; Medit Co). Use powder to avoid interference with the data-capturing
THE JOURNAL OF PROSTHETIC DENTISTRY
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process because of reflections from the metal surface. Use a die-scanning jig for convenience (Fig. 1A, B). Import the scanned abutment analog data into CAD software (Exocad DentalCAD; Exocad GmbH). Evaluate the integrity of the margin and confirm the overall quality of the scanned data. The scanned data must include the margin part of the abutment analog. Each file name should include the diameter and length of the abutment (Fig. 1C). Connect an appropriate stock abutment (Dual abutment; Dentium Co) to the implant fixture intraorally after selecting it based on parameters such as the height of the surrounding soft tissues, the distance from the opposite arch, and the distance from the adjacent tooth (Fig. 2). Fill the access hole of the abutment screw with composite resin. Scan the stock abutment and surrounding teeth and acquire the opposing arch and occlusal information using an intraoral scanner (TRIOS; 3shape A/S). Despite the gloss of the stock abutment, powder is not needed. The margin may not be scanned accurately where the stock abutment enters the subgingival portion. However, a prosthesis can be designed on the margin because this margin can be accurately reproduced during the matching process with the library (Fig. 3). After transferring the scanned data to the CAD software (Exocad DentalCAD; Exocad GmbH), match them to an appropriate library file for the abutment connected intraorally (Fig. 4). Design a definitive prosthesis based on the superimposed abutment data (Fig. 5).
DISCUSSION This workflow used the method of producing a superstructure through a digital workflow by using the library data of the stock abutment analog of the implant that was scanned in advance, like a scannable abutment. Even though the scannable abutment fabricated for the purpose of obtaining the location of the implant is not used, a library retrieved from the CAD software can play a role similar to that of the scannable abutment. Because the scanned data were used to produce the superstructure only while the stock abutment was connected to the implant intraorally and was not removed after the intraoral scanning procedure, the process is both convenient for patients and allows an accurate restoration to be fabricated within a short time.
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Figure 2. A, Intraoral occlusal view of stock abutment connected to implant fixture. Distal margin portion of abutment not visible clearly as located in subgingival area. B, Lateral view.
Figure 3. A, Occlusal view image of stock abutment and adjacent tooth scanned using intraoral scanner. B, Opposing arch and occlusal information.
This technique can reduce errors because it identifies the relationship with the surrounding teeth and the opposite arch at the abutment level, in contrast to the workflow using a scannable abutment at the implant fixture level. Moreover, even though the intraoral scanning does not record the margin exactly as for a tooth preparation, if the appearance of the stock abutment is scanned accurately, an accurate prosthesis can be produced because it uses the library data that were obtained by accurately scanning up to the margin in advance. Embedding the stock abutment library in the implant planning software or CAD software itself would reduce the effort required to produce a library. Diffuse reflection due to the high gloss level of the abutment analog can sometimes interfere with the process of producing the library. In such situations, powder should be applied, as in this report, or the surface of the abutment analog can be airborne-particle abraded. The procedure described has limitations for a fixed prosthesis supported by 2 or more implants with different
Kim et al
installation paths in that the abutment shape should be modified in order to align the axes of the abutments. Additionally, the accuracy of the scan can be reduced when a fixed prosthesis with a long edentulous span is produced and there are insufficient landmarks within the edentulous area.10 An intraoral scanner that operates as a closed system and does not extract scanned data in an open format such as stereolithography (STL) files cannot be used to design an implant prosthesis in the manner presented in this article. However, because most intraoral scanner software programs support data extraction to STL files, the dental techniques presented in this article can be used with CAD software such as Exocad or a 3-shape dental system (3Shape A/S). SUMMARY A digital workflow can simplify the process of fabricating an implant prosthesis after connecting a stock
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Figure 4. Matching intraoral scan data to appropriate library file in computer-aided design (CAD) software. A, Intraoral scan data imported in Exocad CAD software. Distal margin portion of stock abutment not captured clearly. B, Superimpose intraoral scan data and library data of stock abutment using scan registration option. C, Scan data of stock abutment portion replaced by library data of same shape and size after registration process. D, Occlusal view showing margin portion of library data replaced.
Figure 5. A, Designing definitive prosthesis based on superimposed abutment data. B, Intaglio of designed prosthesis and margin.
abutment to the implant and scanning it with an intraoral scanner. In this technique, a superstructure is produced by superimposing a stock abutment with a library that was fabricated in advance. An accurate prosthesis can be fabricated rapidly because only the superstructure needs to be made and the margin in the library data that was scanned in advance can be used.
THE JOURNAL OF PROSTHETIC DENTISTRY
REFERENCES 1. Monaco C, Evangelisti E, Scotti R, Mignani G, Zucchelli G. A fully digital approach to replicate peri-implant soft tissue contours and emergence profile in the esthetic zone. Clin Oral Implants Res 2016;27: 1511-4. 2. Joda T, Ferrari M, Braegger U. A digital approach for one-step formation of the supra-implant emergence profile with an individualized CAD/CAM healing abutment. J Prosthodont Res 2016;60:220-3. 3. Vandeweghe S, Vervack V, Dierens M, De Bruyn H. Accuracy of digital impressions of multiple dental implants: an in vitro study. Clin Oral
Kim et al
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2016
4. 5.
6. 7. 8.
Implants Res 2016 May 6. http://dx.doi.org/10.1111/clr.12853. [Epub ahead of print]. Andriessen FS, Rijkens DR, van der Meer WJ, Wismeijer DW. Applicability and accuracy of an intraoral scanner for scanning multiple implants in edentulous mandibles: a pilot study. J Prosthet Dent 2014;111:186-94. Lin WS, Harris BT, Morton D. The use of a scannable impression coping and digital impression technique to fabricate a customized anatomic abutment and zirconia restoration in the esthetic zone. J Prosthet Dent 2013;109: 187-91. Telleman G, Raghoebar GM, Vissink A, Meijer HJ. The use of a coded healing abutment as an impression coping to design and mill an individualized anatomic abutment: a clinical report. J Prosthet Dent 2011;105:282-5. Brandt J, Lauer HC, Peter T, Brandt S. Digital process for an implantsupported fixed dental prosthesis: a clinical report. J Prosthet Dent 2015;114: 469-73. Ramsey CD, Ritter RG. Utilization of digital technologies for fabrication of definitive implant-supported restorations. J Esthet Restor Dent 2012;24: 299-308.
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9. Priest G. Virtual-designed and computer-milled implant abutments. J Oral Maxillofac Surg 2005;63:22-32. 10. Kim JE, Amelya A, Shin Y, Shim JS. Accuracy of intraoral digital impressions using an artificial landmark. J Prosthet Dent 2016. http://dx.doi.org/10.1016/ j.prosdent.2016.09.016.
Corresponding author: Dr June-Sung Shim Department of Prosthodontics College of Dentistry Yonsei University Seoul SOUTH KOREA Email: [email protected] Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY