Journal of Oral Implantology A novel technique for immediate provisionalization of single root form implants with an interim CAD/CAM milled screw-retained crown. --Manuscript Draft-Manuscript Number:
aaid-joi-D-15-00087R1
Full Title:
A novel technique for immediate provisionalization of single root form implants with an interim CAD/CAM milled screw-retained crown.
Short Title:
Immediate provisionalization CAD/CAM single dental implant
Article Type:
Clinical Research
Keywords:
Immediate loading, immediate provisionalization, CAD/CAM implant crown, milled interim implant crown, guided tissue healing, custom impression coping, milled impression coping
Corresponding Author:
Periklis Proussaefs, DDS, MS Loma Linda University Loma Linda, California UNITED STATES
Corresponding Author Secondary Information: Corresponding Author's Institution:
Loma Linda University
Corresponding Author's Secondary Institution: First Author:
Periklis Proussaefs, DDS, MS
First Author Secondary Information: Order of Authors:
Periklis Proussaefs, DDS, MS
Order of Authors Secondary Information: Abstract:
A technique is described where an interim abutment and crown are being fabricated in the laboratory by utilizing computer assisted design - computer assisted manufacturing (CAD/CAM) technology and placed the day of dental implant surgery. The design and contours of the interim crown are designed by the computer software to be identical to the contours of the tentatively designed definitive prosthesis. The interim crown satisfies esthetics immediately after dental implant surgery while it allows the tissue to heal and obtain contours similar to the contours of the definitive prosthesis. The interim crown can be either cement retained or screw retained. The presented technique describes fabrication of a screw-retentive interim crown. After osseointegration is confirmed, a definitive impression is made with a CAD/CAM impression coping. The definitive prosthesis is then fabricated.
Response to Reviewers:
Reviewers' comments: Recommendations if the manuscript is considered for resubmission: 1.Eliminate the portion on osseointegration in the "introduction section". The portion on osseointegration has been eliminated. 2.Focus on the importance of site development and techniques used to transfer information to the laboratory/technician. We have emphasized the importance of transferring the information. We have added a reference (Reference # 23, Joda T. Time-dependent supraimplant mucosa changes: short communication. Int J Oral Maxillofac Implants 2015;30:619-21) supporting the need to effectively transfer the anatomy of the developed site. 3. Discuss the advantages and possible disadvantages of the proposed technique. We have added in the discussion portion comments on the advantages and disadvantages of the technique. 4.Consider whether your situation is in fact "immediate loading" or "immediate
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provisionalization". If you are concerned with leaving the provisional out of occlusion (40 micron clearance) and the patient is advised not to function on that side then it should be termed immediate provisionalization. It is immediate provisionalization and we have utilized this term throughout the manuscript. 5.Discussion - (sentence 3) - there are a few sentences on cement vs screw retained restorations. This can be omitted since the article is describing the use of CAD/CAM to create interim, and definitive submergence profiles that are identical. The sentences pertaining to cement versus screw retention have been eliminated. We also eliminated the references that pertained to the cement versus screw portion of the discussion. 6. Conclusion/Summary - needs more attention other than restating the title of the manuscript. We have further extended the conclusion portion.
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Title of manuscript: A novel technique for immediate loading single root form implants with an interim CAD/CAM milled screw-retained crown. Principal Investigator: Periklis Proussaefs DDS, MS Assistant Professor, Advanced education Program in Implant Dentistry Loma Linda University, Loma Linda, CA, and private prosthodontic practice, Ventura, CA Corresponding author: Periklis Proussaefs DDS, MS Address: 3585 Telegraph Road, Suite C Ventura, CA 93003 e-mail: [email protected] Tel: (805)676-1611 Fax: (805)676-1521
ABSTRACT
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A technique is described where an interim abutment and crown are being fabricated in the laboratory by utilizing computer assisted design – computer assisted manufacturing (CAD/CAM) technology and placed the day of dental implant surgery. The design and contours of the interim crown are designed by the computer software to be identical to the contours of the tentatively designed definitive prosthesis. The interim crown satisfies esthetics immediately after dental implant surgery while it allows the tissue to heal and obtain contours similar to the contours of the definitive prosthesis. The interim crown can be either cement retained or screw retained. The presented technique describes fabrication of a screw-retentive interim crown. After osseointegration is confirmed, a definitive impression is made with a CAD/CAM impression coping. The definitive prosthesis is then fabricated.
INTRODUCTION Dental implants have been established as a predictable treatment modality for the completely1 or partially2,3 edentulous patient. For the partially edentulous patient, it is important to provide interim restorations because they help confirm the diagnostic design,4 esthetics and contours,4,5 which can be replicated in the definitive prosthesis.6,7 The healing response around the interim restoration can be evaluated,6,7 and the soft tissue around the fixtures can heal according the contours of the tentatively designed definitive prosthesis.5-9 The conventional protocol indicated that a healing period of 3 to 6 months is recommended to achieve osseointegration before loading the implants with a prosthesis.10 Immediate provisionalization is a technique for eliminating the 3 to 6 month healing period. The technique has been described in combination with mandibular bar-retained overdentures,11,12 complete arch implant supported screw retained prostheses,13-15 and in partial edentulism.16-20
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Regardless of the technique, various methods have been proposed and used21-23 to transfer soft tissue architecture to the laboratory so the definitive prosthesis can be fabricated in accordance to the acquired soft tissue morphology. Joda24 in a recent publication indicated that soft tissue has a tendency to collapse after removing the interim prosthesis, and exact duplication of the periimplant soft tissue can be challenging by utilizing conventional prefabricated impression copings. The purpose of the described technique is to introduce to the literature a method for immediately provisionalizing single root form implants with a computer-aided design and computer-aided manufacturing (CAD/CAM) interim restoration which is fabricated before performing dental implant surgery.
CLINICAL REPORT: A 56 year old Caucasian male patient presented at the primary author’ s private prosthodontic practice seeking treatment for his partial edentulism at the area of tooth #13. After evaluating different treatment options, the decision was made to place one root form implant along with an implant-retained single crown to treat his partial edentulism. The tissue around the edentulous area was evaluated and the determination was made that it was free of pathosis (Fig. 1). Complete arch preliminary impressions were made preoperatively from the patient’s maxillary and mandibular arches with polyvinyl siloxane impression material (Silgimix; Sultan Healthcare). An interocclusal record was also made with polyvinyl siloxane occlusal registration material (Exabite II NSD; GC America Inc) at the maximum intercuspation position. Radiographic evaluation included peri-apical radiographs and a cone-beam to confirm adequate bone volume for implant surgery. In addition, after providing local anesthesia, mapping of the
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alveolar ridge with an endodontic file with a rubber stop was performed (Fig. 2).25 With this technique, the thickness of the soft tissue was measured around the area of the prospective implant surgery. The stone models that were produced though the preliminary impressions were scanned (D700; 3Shape) and the definitive prosthesis was simulated with the provided software. The computer software, which is incorporated into the scanner allows the size and shape of each component to be designed digitally using precise measurements. The suggested implant placement was initially performed digitally through the software provided with the specific scanner. With the contours of the definitive prosthesis as reference, a custom interim abutment and crown were digitally designed (Fig. 3a). After completing the designing process, the interim abutment and crown were milled from a polymethyl methacrylate (PMME) block by utilizing a milling machine (TS150 Milling Solution; IOS Technologies) (Fig. 3b). The position the margins of the interim abutment was designed according to the thickness of the soft tissue measured during ridge mapping. The goal was to position the margins 0.5 mm subgingivally on the facial aspect of the restoration to satisfy esthetics, so that the interim abutment/crown transition line would not be visible. Therefore, the interim abutment and crown were fabricated in the laboratory before implant surgery was scheduled. In addition, a custom impression coping was digitally designed and milled (Fig. 4). The contours of the CAD/CAM impression coping were identical to the contours of the interim abutment and crown, and identical to the prospective definitive restoration as well. The custom impression coping was also milled from a PMME block through the same milling machine. A surgical stent was also fabricated based on the digitally planned implant position. The
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CAD/CAM interim crown was evaluated on the diagnostic stone cast to confirm ideal contours, contact areas, and esthetics. Implant surgery was performed with local anesthesia with the aid of the surgical stent and copious saline irrigation. A threaded root form resorbable blast media (RBM) surfaced dental implant was chosen (Inclusive; Glidwell Corp) and full thickness labial and lingual flaps were reflected. While the surgical stent was used for guided osteotomy, final implant positioning was performed free-hand. The implant was inserted with adequate torque 50 Ncm while the primary stability was confirmed through the Periotest device (Periotest; Siemens) by placing a 5mm long healing abutment before testing. For this patient this recorded -1 which was consistent with adequate implant stability.26 The interim crown was placed intraorally to confirm proper contours and contact points. After these parameters were evaluated, the interim abutment was placed intraorally (Fig. 5) and the interim crown was adjusted along the internal area to ensure proper fit on top of the abutment. The internal relief space between the interim abutment and crown provided by the designing software was 30 microns. After confirming proper fit, the occlusal aspect of the interim crown was opened with the use of a diamond bur and a high speed. Light-cured composite resin cement (RelyX Luting Plus; 3M ESPE Inc.) was applied along the internal aspect of the crown and along the external surface of the abutment as well. Applying the composite resin on both surfaces reduces the possibilities for air entrapment. After positioning the crown on top of the abutment, and extension screw was inserted to avoid composite resin cement flowing around the hex of the crown. The extension screw was secured on an implant analogue and was subsequently light-cured. After removing the excess composite resin cement, the screw-retained interim prosthesis was complete (Fig. 6).
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The interim prosthesis was then inserted intraorally (Fig. 7). The occlusal screw has hand-tightened and light-cured and a cotton pellet with composite resin cement was placed on top. Occlusal clearance was confirmed at approximately 40 μm with 4 layers of 10 μm shim stock (Occlusal registration strips; The Artus Corp). The proximal contacts were evaluated with a single layer of the shim stock before sealing the occlusal access hole. Four months postsurgery the soft tissue around the implant demonstrated no sign of pathosis (Fig. 8a). The implant stability was re-evaluated with the Periotest device. The Periotest measured -2 while radiographic evaluation revealed no pathosis confirming successful osseointegration. No probing greater than 4mm was detected around the implant, and no bleeding upon probing was recorded. The screw-retentive CAD/CAM interim crown was removed and the tissue was evaluated. (Fig. 8b). The tissue appeared to have obtained contours compatible with the contours of the prospective definitive prosthesis. The CAD/CAM custom impression coping was handtightened and a definitive impression with polyvinyl siloxane impression material (Exafast NDS; GC America Inc) was made. The definitive restoration was then fabricated. The original design of the definitive prosthesis was retained by the software and was duplicated after the soft tissue obtained contours similar to the contours of the definitive prosthesis (Fig. 9). A zirconia occlusal screw retentive crown with a bonded titanium insert27 was fabricated as the definitive prosthesis (Fig. 10a). After confirming proper contours, esthetics, occlusion, and contact points, the occlusal screw of the definitive prosthesis was torqued to 35 Ncm according to the manufacturer’s recommendations. Light viscosity polyvinyl siloxane impression material (Exafast; GC America Inc.) in the occlusal access hole with light-cured composite resin on top. Patient was re-evaluated 18 months
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after placing the definitive prosthesis (Fig. 10b). During the re-evaluation examination, no probing depth exceeding 3mm was detected around the implant, no bleeding on probing was observed while the soft tissue appeared to maintain its integrity. Radiographic examination revealed no pathosis or bone loss exceeding 1.5 mm.
DISCUSSION The significance of the presented technique is related to the ability of the operator to have a CAD/CAM interim crown fabricated before dental implant surgery from a milled PMME block. The presented technique offer the option to have a milled PMME interim abutment and crown fabricated instead of a chair-side acrylic resin crown that is typically connected to a prefabricated temporary abutment. According to the manufacturer’s recommendations, milled PMME has compressive strength in the range of 110-130 MPa. This is similar to the compressive strength of a definitive metal-ceramic restoration. Santing et al28 in a laboratory study reported that use of chairside fabricated PMME implant supported crowns do not have sufficient mechanical properties to withstand laboratory simulated occlusal wear. In the contrary, interim restorations made in the laboratory, had superior mechanical propertied and the ability to better withstand mechanical forces during simulated mastication circles. An advantage of the proposed technique is that it offers the clinician an option to contour the soft tissue in a way that will passively accommodate the definitive prosthesis since the contours of the CAD/CAM healing abutment are being saved by the designing software and they are identical to those of the definitive prosthesis. The assumption can be made that when the soft tissue acquires contours similar to the contours of the definitive restoration, the definitive restoration will be placed with minimal if any pressure on the tissue. This minimal or no pressure
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placement of the definitive prosthesis may lead to better long-term tissue stability; a clinical study is needed to confirm the validity of this hypothesis. In the described technique, a CAD/CAM impression coping was used to transfer soft tissue anatomy to the laboratory before fabricating the definitive prosthesis. The contours of the CAD-CAM milled PMME impression coping were identical to the contours of the interim and definitive crown as well. Other authors have suggested use of the interim prosthesis while making the impression,17,23 or fabricating a custom impression coping by placing autopolymerized acrylic resin around the impression coping.18,21,23 To the author’s best knowledge, there is no consensus in regards to which technique better transfers soft tissue architecture in the laboratory before fabricating a definitive prosthesis. The described technique might offer the advantage of having reduced chairtime by having the custom impression coping fabricated in advance before implant surgery. The CAD/CAM impression coping may have an advantage transferring soft tissue architecture since it is predesigned exactly as the interim prosthesis, so when secured on the implant with a retentive screw, it applies minimal or no pressure on the surrounding tissue. Joda24 reported 21.7% shrinkage of the periimplant soft tissue within ten minutes after removing the interim restoration. The described milled custom impression coping is designed preoperatively based on the contours of the tentatively designed definitive prosthesis and not based on the contours of the soft tissue when the final impression is being made. A clinical study is needed to validate a potential advantage of utilizing a CAD/CAM impression coping. A limitation of the described technique is that the CAD/CAM interim abutment and crown are digitally designed with the assumption that one of the flat surfaces of the implant hex is parallel to the tangent of the mid-buccal surface of the adjacent teeth. The final rotational
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position of the implant during surgery is critical to have reproducible fit of the pre-fabricated abutment and crown. The implant surgeon needs to have the implant placed so that one of the flat surfaces of the hex is parallel to the tangent of the mid-buccal surface of the adjacent teeth as well. The quest for this specific rotational implant positioning imposes an additional variable to the implant surgeon who needs to be well aware of the design methodology of the interim prosthesis. Another disadvantage of the presented technique may be associated with the increased cost of the milled abutment, crown, and impression coping. The reduced chairtime to place the interim restoration and the superior mechanical properties which may be associated with reduced incidences of failure may justify the additional expense.
SUMMARY The described technique offers an alternative method to fabricate interim restorations on dental implants the day of implant surgery. In addition, a digitally designed and milled custom impression coping may offer better accuracy in duplicating the periimplant soft tissue contours before fabricating the definitive prosthesis. The superior mechanical properties and reduced chairtime may justify the additional cost for having a milled interim abutment, interim crown, and custom impression coping. A prospective clinical study is needed to validate the use of the described technique.
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REFERENCES: 1. Adell R, Lekholm U, Rockler B, Branemark PI. A 15 year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416. 2. Jemt T, Lekholm U, Adell R. Osseointegrated implants in the treatment of partially edentulous patients: A preliminary study of 876 consecutively installed fixtures. Int J Oral Maxillofac Implants 1989;4:211-7. 3. Jemt T, Pettersson P. A 3-year follow-up study on single implant treatment. J Dent 1993;21:203-8. 4. Moscovitch MS, Saba S. The use of a provisional restoration in implant dentistry: A clinical report. Int J Oral Maxillofac Implants 1996;11:395-9. 5. Neale D, Chee WW. Development of implant soft tissue emergence profile: a technique. J Prosthet Dent 1994;71;364-8. 6. Proussaefs P. The use of healing abutments for an implant supported fixed partial denture. J Prosthet Dent 2002;87:333-5. 7. Biggs WF. Placement of a custom implant provisional restoration at the second-stage surgery for improved gingival management: A clinical report. J Prosthet Dent 1996;75:231-3. 8. Daftary F, Bahat O. Prosthetically formulated natural esthetics in implant prostheses. Pract Periodontics Aesthet Dent 1994;6:75-83. 9. Lewis S. Anterior single-tooth implant restorations. Int J Periodontics Restorative Dent 1995;15:31-41. 10. Branemark PI. Osseointegration and its experimental background. J Prosthet Dent 1983;50:399-410.
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11. Levkove M, Beals R. Immediate loading of cylinder Implants with overdentures in the mandibular symphisis: The titanium plasma-spray screw system. J Oral Implantol 1990;4:26570. 12. Chiapasco M, Gatti C, Rossi E, Haefliger W, Markwalder TH: Implant-retained mandibular overdentures with immediate loading. Clin Oral Implants Res 1997;8:48-57. 13. Schnitman P, Wohrle P, Rubenstein J, DaSilva J, Wang NH. Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants 1997;12:495-503. 14. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with To 5- year data. Int J Oral Maxillofac Implants 1997;3:319-24. 15. Ji TJ, Kan JY, Rungcharassaeng K, Roe P, Lozada JL. Immediate loading of maxillary and mandibular implant-supported fixed complete dentures: A 1- to 10-year retrospective study. J Oral Implantol 2012;38:469-76. 16. Oyama K, Kan JY, Rungcharassaeng K, Lozada J. Immediate provisionalization of a 3.0-mm-diameter implants replacing single missing maxillary and mandibular incisors: 1-year prospective study. Int J Oral Maxillofac Implants 2012;27:173-80. 17. Proussaefs P, Lozada J. Immediate loading of hydroxyapatite-coated implants at maxillary premolar area: three-year results of a pilot study. J Prosthet Dent 2004;91:228-33. 18. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and provisionalization of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxillofac Implants 2003;18:31-9. 19. Balshi TJ, Wolfinhger GJ, Wulc D, Balshi SF. A prospective analysis of immediate
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provisionalization of single implants. J Prosthodont 2011;20:10-5. 20. Abboud M, Koeck B, Stark H, Wahl G, Paillon R. Immediate loading of single-tooth implants in the posterior region. Int J Oral Maxillofac Implants 2005;20:61-8. 21. Noh K, Kwon KR, Kim HS, Kim DS, Pae A. Accurate transfer of soft tissue morphology with interim prosthesis to definitive cast. J Prosthet Dent 2014;111:159-62. 22. Lin WS, Harris BT, Morton D. Use of implant-supported interim restorations to transfer periimplant soft tissue profiles to a milled polyurethane definitive cast. J Prosthet Dent 2013;109:333-7. 23. Man Y, Qu Y, Dam HG, Gong P. An alternative technique for the accurate transfer of periimplant soft tissue contour. J Prosthet Dent 2013;109:135-7. 23. 24. Joda T. Time-dependent supraimplant mucosa changes: short communication. Int J Oral Maxillofac Implants 2015;30:619-21. 25. Koutouzis T, Neiva R, Nonhoff J, Lundgren T. Placement of implants with platformswitched Morse taper connections with the implant-abutment interface at different levels in relation to the alveolar crest: a short-term (1-year) randomized prospective controlled clinical trial. Int J Oral Maxillofac Implants 2013;28:1553-63. 26. Olive J, Aparicio C. Periotest method as a measure of osseointegrated oral implant stability. Int J Oral Maxillofac Implants 1990;5:390-400. 27. Kim JS, Raigrodski AJ, Flinn BD, Rubenstein JE, Chung KH, Mancl LA. In vitro assessment of three types of zirconia implant abutments under static load. J Prosthet Dent 2013;109:255-63. 28. Santing HJ, Kleverlaan CJ, Werner A, Feilzer AJ, Raghoebar GM, Meijer HJ. Occlusal wear of provisional implant-supported restorations. Clin Implant Dent Relat Res 2015;17:179-85.
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Illustrations: Fig 1. Pre-operative view. Fig 2. Bone sounding technique by utilizing an endodontic file. Fig 3a. Interim abutment and crown are designed. The design is stored by the software and the definitive crown will be designed with identical contours. Fig 3b. A CAD/CAM interim PMME abutment and crown are being milled. Fig 4a. Custom impression coping is designed to have identical contours with the interim abutment/crown and the definitive crown as well. Fig 4b. A CAD/CAM impression coping is being milled. Fig 5. Intraoral evaluation of the CAD/CAM interim abutment. Fig 6a. After curing and removing the excess composite resin cement, an occlusal screwretentive interim CAD/CAM prosthesis is completed. Fig 6b. Intaglio surface, notice the seal and lack of voids between the interim abutment and crown. The contours have been digitally designed to simulate the contours of the definitive prosthesis. Fig 7a. Interim screw-retained prosthesis insertion. Fig 7b. Interim screw-retained prosthesis after suturing. Fig 8a. Four months post-operative evaluation. Fig 8b. Intraoral view, 4 months after implant surgery. Notice the soft tissue contouring simulating the contours of the interim prosthesis. Fig 9. Digital design of the definitive crown. The contours of the definitive restoration are identical with the contours of the interim prosthesis.
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Fig 10a. A screw-retentive definitive prosthesis is being made. The contours of the prosthesis are identical to those of the interim restoration. Fig 10b. Intraoral view with the definitive prosthesis, 18 months after insertion.
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aaid-joi-D-15-00087R1
Full Title:
A novel technique for immediate provisionalization of single root form implants with an interim CAD/CAM milled screw-retained crown.
Short Title:
Immediate provisionalization CAD/CAM single dental implant
Article Type:
Clinical Research
Keywords:
Immediate loading, immediate provisionalization, CAD/CAM implant crown, milled interim implant crown, guided tissue healing, custom impression coping, milled impression coping
Corresponding Author:
Periklis Proussaefs, DDS, MS Loma Linda University Loma Linda, California UNITED STATES
Corresponding Author Secondary Information: Corresponding Author's Institution:
Loma Linda University
Corresponding Author's Secondary Institution: First Author:
Periklis Proussaefs, DDS, MS
First Author Secondary Information: Order of Authors:
Periklis Proussaefs, DDS, MS
Order of Authors Secondary Information: Abstract:
A technique is described where an interim abutment and crown are being fabricated in the laboratory by utilizing computer assisted design - computer assisted manufacturing (CAD/CAM) technology and placed the day of dental implant surgery. The design and contours of the interim crown are designed by the computer software to be identical to the contours of the tentatively designed definitive prosthesis. The interim crown satisfies esthetics immediately after dental implant surgery while it allows the tissue to heal and obtain contours similar to the contours of the definitive prosthesis. The interim crown can be either cement retained or screw retained. The presented technique describes fabrication of a screw-retentive interim crown. After osseointegration is confirmed, a definitive impression is made with a CAD/CAM impression coping. The definitive prosthesis is then fabricated.
Response to Reviewers:
Reviewers' comments: Recommendations if the manuscript is considered for resubmission: 1.Eliminate the portion on osseointegration in the "introduction section". The portion on osseointegration has been eliminated. 2.Focus on the importance of site development and techniques used to transfer information to the laboratory/technician. We have emphasized the importance of transferring the information. We have added a reference (Reference # 23, Joda T. Time-dependent supraimplant mucosa changes: short communication. Int J Oral Maxillofac Implants 2015;30:619-21) supporting the need to effectively transfer the anatomy of the developed site. 3. Discuss the advantages and possible disadvantages of the proposed technique. We have added in the discussion portion comments on the advantages and disadvantages of the technique. 4.Consider whether your situation is in fact "immediate loading" or "immediate
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provisionalization". If you are concerned with leaving the provisional out of occlusion (40 micron clearance) and the patient is advised not to function on that side then it should be termed immediate provisionalization. It is immediate provisionalization and we have utilized this term throughout the manuscript. 5.Discussion - (sentence 3) - there are a few sentences on cement vs screw retained restorations. This can be omitted since the article is describing the use of CAD/CAM to create interim, and definitive submergence profiles that are identical. The sentences pertaining to cement versus screw retention have been eliminated. We also eliminated the references that pertained to the cement versus screw portion of the discussion. 6. Conclusion/Summary - needs more attention other than restating the title of the manuscript. We have further extended the conclusion portion.
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Title of manuscript: A novel technique for immediate loading single root form implants with an interim CAD/CAM milled screw-retained crown. Principal Investigator: Periklis Proussaefs DDS, MS Assistant Professor, Advanced education Program in Implant Dentistry Loma Linda University, Loma Linda, CA, and private prosthodontic practice, Ventura, CA Corresponding author: Periklis Proussaefs DDS, MS Address: 3585 Telegraph Road, Suite C Ventura, CA 93003 e-mail: [email protected] Tel: (805)676-1611 Fax: (805)676-1521
ABSTRACT
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A technique is described where an interim abutment and crown are being fabricated in the laboratory by utilizing computer assisted design – computer assisted manufacturing (CAD/CAM) technology and placed the day of dental implant surgery. The design and contours of the interim crown are designed by the computer software to be identical to the contours of the tentatively designed definitive prosthesis. The interim crown satisfies esthetics immediately after dental implant surgery while it allows the tissue to heal and obtain contours similar to the contours of the definitive prosthesis. The interim crown can be either cement retained or screw retained. The presented technique describes fabrication of a screw-retentive interim crown. After osseointegration is confirmed, a definitive impression is made with a CAD/CAM impression coping. The definitive prosthesis is then fabricated.
INTRODUCTION Dental implants have been established as a predictable treatment modality for the completely1 or partially2,3 edentulous patient. For the partially edentulous patient, it is important to provide interim restorations because they help confirm the diagnostic design,4 esthetics and contours,4,5 which can be replicated in the definitive prosthesis.6,7 The healing response around the interim restoration can be evaluated,6,7 and the soft tissue around the fixtures can heal according the contours of the tentatively designed definitive prosthesis.5-9 The conventional protocol indicated that a healing period of 3 to 6 months is recommended to achieve osseointegration before loading the implants with a prosthesis.10 Immediate provisionalization is a technique for eliminating the 3 to 6 month healing period. The technique has been described in combination with mandibular bar-retained overdentures,11,12 complete arch implant supported screw retained prostheses,13-15 and in partial edentulism.16-20
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Regardless of the technique, various methods have been proposed and used21-23 to transfer soft tissue architecture to the laboratory so the definitive prosthesis can be fabricated in accordance to the acquired soft tissue morphology. Joda24 in a recent publication indicated that soft tissue has a tendency to collapse after removing the interim prosthesis, and exact duplication of the periimplant soft tissue can be challenging by utilizing conventional prefabricated impression copings. The purpose of the described technique is to introduce to the literature a method for immediately provisionalizing single root form implants with a computer-aided design and computer-aided manufacturing (CAD/CAM) interim restoration which is fabricated before performing dental implant surgery.
CLINICAL REPORT: A 56 year old Caucasian male patient presented at the primary author’ s private prosthodontic practice seeking treatment for his partial edentulism at the area of tooth #13. After evaluating different treatment options, the decision was made to place one root form implant along with an implant-retained single crown to treat his partial edentulism. The tissue around the edentulous area was evaluated and the determination was made that it was free of pathosis (Fig. 1). Complete arch preliminary impressions were made preoperatively from the patient’s maxillary and mandibular arches with polyvinyl siloxane impression material (Silgimix; Sultan Healthcare). An interocclusal record was also made with polyvinyl siloxane occlusal registration material (Exabite II NSD; GC America Inc) at the maximum intercuspation position. Radiographic evaluation included peri-apical radiographs and a cone-beam to confirm adequate bone volume for implant surgery. In addition, after providing local anesthesia, mapping of the
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alveolar ridge with an endodontic file with a rubber stop was performed (Fig. 2).25 With this technique, the thickness of the soft tissue was measured around the area of the prospective implant surgery. The stone models that were produced though the preliminary impressions were scanned (D700; 3Shape) and the definitive prosthesis was simulated with the provided software. The computer software, which is incorporated into the scanner allows the size and shape of each component to be designed digitally using precise measurements. The suggested implant placement was initially performed digitally through the software provided with the specific scanner. With the contours of the definitive prosthesis as reference, a custom interim abutment and crown were digitally designed (Fig. 3a). After completing the designing process, the interim abutment and crown were milled from a polymethyl methacrylate (PMME) block by utilizing a milling machine (TS150 Milling Solution; IOS Technologies) (Fig. 3b). The position the margins of the interim abutment was designed according to the thickness of the soft tissue measured during ridge mapping. The goal was to position the margins 0.5 mm subgingivally on the facial aspect of the restoration to satisfy esthetics, so that the interim abutment/crown transition line would not be visible. Therefore, the interim abutment and crown were fabricated in the laboratory before implant surgery was scheduled. In addition, a custom impression coping was digitally designed and milled (Fig. 4). The contours of the CAD/CAM impression coping were identical to the contours of the interim abutment and crown, and identical to the prospective definitive restoration as well. The custom impression coping was also milled from a PMME block through the same milling machine. A surgical stent was also fabricated based on the digitally planned implant position. The
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CAD/CAM interim crown was evaluated on the diagnostic stone cast to confirm ideal contours, contact areas, and esthetics. Implant surgery was performed with local anesthesia with the aid of the surgical stent and copious saline irrigation. A threaded root form resorbable blast media (RBM) surfaced dental implant was chosen (Inclusive; Glidwell Corp) and full thickness labial and lingual flaps were reflected. While the surgical stent was used for guided osteotomy, final implant positioning was performed free-hand. The implant was inserted with adequate torque 50 Ncm while the primary stability was confirmed through the Periotest device (Periotest; Siemens) by placing a 5mm long healing abutment before testing. For this patient this recorded -1 which was consistent with adequate implant stability.26 The interim crown was placed intraorally to confirm proper contours and contact points. After these parameters were evaluated, the interim abutment was placed intraorally (Fig. 5) and the interim crown was adjusted along the internal area to ensure proper fit on top of the abutment. The internal relief space between the interim abutment and crown provided by the designing software was 30 microns. After confirming proper fit, the occlusal aspect of the interim crown was opened with the use of a diamond bur and a high speed. Light-cured composite resin cement (RelyX Luting Plus; 3M ESPE Inc.) was applied along the internal aspect of the crown and along the external surface of the abutment as well. Applying the composite resin on both surfaces reduces the possibilities for air entrapment. After positioning the crown on top of the abutment, and extension screw was inserted to avoid composite resin cement flowing around the hex of the crown. The extension screw was secured on an implant analogue and was subsequently light-cured. After removing the excess composite resin cement, the screw-retained interim prosthesis was complete (Fig. 6).
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The interim prosthesis was then inserted intraorally (Fig. 7). The occlusal screw has hand-tightened and light-cured and a cotton pellet with composite resin cement was placed on top. Occlusal clearance was confirmed at approximately 40 μm with 4 layers of 10 μm shim stock (Occlusal registration strips; The Artus Corp). The proximal contacts were evaluated with a single layer of the shim stock before sealing the occlusal access hole. Four months postsurgery the soft tissue around the implant demonstrated no sign of pathosis (Fig. 8a). The implant stability was re-evaluated with the Periotest device. The Periotest measured -2 while radiographic evaluation revealed no pathosis confirming successful osseointegration. No probing greater than 4mm was detected around the implant, and no bleeding upon probing was recorded. The screw-retentive CAD/CAM interim crown was removed and the tissue was evaluated. (Fig. 8b). The tissue appeared to have obtained contours compatible with the contours of the prospective definitive prosthesis. The CAD/CAM custom impression coping was handtightened and a definitive impression with polyvinyl siloxane impression material (Exafast NDS; GC America Inc) was made. The definitive restoration was then fabricated. The original design of the definitive prosthesis was retained by the software and was duplicated after the soft tissue obtained contours similar to the contours of the definitive prosthesis (Fig. 9). A zirconia occlusal screw retentive crown with a bonded titanium insert27 was fabricated as the definitive prosthesis (Fig. 10a). After confirming proper contours, esthetics, occlusion, and contact points, the occlusal screw of the definitive prosthesis was torqued to 35 Ncm according to the manufacturer’s recommendations. Light viscosity polyvinyl siloxane impression material (Exafast; GC America Inc.) in the occlusal access hole with light-cured composite resin on top. Patient was re-evaluated 18 months
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after placing the definitive prosthesis (Fig. 10b). During the re-evaluation examination, no probing depth exceeding 3mm was detected around the implant, no bleeding on probing was observed while the soft tissue appeared to maintain its integrity. Radiographic examination revealed no pathosis or bone loss exceeding 1.5 mm.
DISCUSSION The significance of the presented technique is related to the ability of the operator to have a CAD/CAM interim crown fabricated before dental implant surgery from a milled PMME block. The presented technique offer the option to have a milled PMME interim abutment and crown fabricated instead of a chair-side acrylic resin crown that is typically connected to a prefabricated temporary abutment. According to the manufacturer’s recommendations, milled PMME has compressive strength in the range of 110-130 MPa. This is similar to the compressive strength of a definitive metal-ceramic restoration. Santing et al28 in a laboratory study reported that use of chairside fabricated PMME implant supported crowns do not have sufficient mechanical properties to withstand laboratory simulated occlusal wear. In the contrary, interim restorations made in the laboratory, had superior mechanical propertied and the ability to better withstand mechanical forces during simulated mastication circles. An advantage of the proposed technique is that it offers the clinician an option to contour the soft tissue in a way that will passively accommodate the definitive prosthesis since the contours of the CAD/CAM healing abutment are being saved by the designing software and they are identical to those of the definitive prosthesis. The assumption can be made that when the soft tissue acquires contours similar to the contours of the definitive restoration, the definitive restoration will be placed with minimal if any pressure on the tissue. This minimal or no pressure
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placement of the definitive prosthesis may lead to better long-term tissue stability; a clinical study is needed to confirm the validity of this hypothesis. In the described technique, a CAD/CAM impression coping was used to transfer soft tissue anatomy to the laboratory before fabricating the definitive prosthesis. The contours of the CAD-CAM milled PMME impression coping were identical to the contours of the interim and definitive crown as well. Other authors have suggested use of the interim prosthesis while making the impression,17,23 or fabricating a custom impression coping by placing autopolymerized acrylic resin around the impression coping.18,21,23 To the author’s best knowledge, there is no consensus in regards to which technique better transfers soft tissue architecture in the laboratory before fabricating a definitive prosthesis. The described technique might offer the advantage of having reduced chairtime by having the custom impression coping fabricated in advance before implant surgery. The CAD/CAM impression coping may have an advantage transferring soft tissue architecture since it is predesigned exactly as the interim prosthesis, so when secured on the implant with a retentive screw, it applies minimal or no pressure on the surrounding tissue. Joda24 reported 21.7% shrinkage of the periimplant soft tissue within ten minutes after removing the interim restoration. The described milled custom impression coping is designed preoperatively based on the contours of the tentatively designed definitive prosthesis and not based on the contours of the soft tissue when the final impression is being made. A clinical study is needed to validate a potential advantage of utilizing a CAD/CAM impression coping. A limitation of the described technique is that the CAD/CAM interim abutment and crown are digitally designed with the assumption that one of the flat surfaces of the implant hex is parallel to the tangent of the mid-buccal surface of the adjacent teeth. The final rotational
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position of the implant during surgery is critical to have reproducible fit of the pre-fabricated abutment and crown. The implant surgeon needs to have the implant placed so that one of the flat surfaces of the hex is parallel to the tangent of the mid-buccal surface of the adjacent teeth as well. The quest for this specific rotational implant positioning imposes an additional variable to the implant surgeon who needs to be well aware of the design methodology of the interim prosthesis. Another disadvantage of the presented technique may be associated with the increased cost of the milled abutment, crown, and impression coping. The reduced chairtime to place the interim restoration and the superior mechanical properties which may be associated with reduced incidences of failure may justify the additional expense.
SUMMARY The described technique offers an alternative method to fabricate interim restorations on dental implants the day of implant surgery. In addition, a digitally designed and milled custom impression coping may offer better accuracy in duplicating the periimplant soft tissue contours before fabricating the definitive prosthesis. The superior mechanical properties and reduced chairtime may justify the additional cost for having a milled interim abutment, interim crown, and custom impression coping. A prospective clinical study is needed to validate the use of the described technique.
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REFERENCES: 1. Adell R, Lekholm U, Rockler B, Branemark PI. A 15 year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416. 2. Jemt T, Lekholm U, Adell R. Osseointegrated implants in the treatment of partially edentulous patients: A preliminary study of 876 consecutively installed fixtures. Int J Oral Maxillofac Implants 1989;4:211-7. 3. Jemt T, Pettersson P. A 3-year follow-up study on single implant treatment. J Dent 1993;21:203-8. 4. Moscovitch MS, Saba S. The use of a provisional restoration in implant dentistry: A clinical report. Int J Oral Maxillofac Implants 1996;11:395-9. 5. Neale D, Chee WW. Development of implant soft tissue emergence profile: a technique. J Prosthet Dent 1994;71;364-8. 6. Proussaefs P. The use of healing abutments for an implant supported fixed partial denture. J Prosthet Dent 2002;87:333-5. 7. Biggs WF. Placement of a custom implant provisional restoration at the second-stage surgery for improved gingival management: A clinical report. J Prosthet Dent 1996;75:231-3. 8. Daftary F, Bahat O. Prosthetically formulated natural esthetics in implant prostheses. Pract Periodontics Aesthet Dent 1994;6:75-83. 9. Lewis S. Anterior single-tooth implant restorations. Int J Periodontics Restorative Dent 1995;15:31-41. 10. Branemark PI. Osseointegration and its experimental background. J Prosthet Dent 1983;50:399-410.
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11. Levkove M, Beals R. Immediate loading of cylinder Implants with overdentures in the mandibular symphisis: The titanium plasma-spray screw system. J Oral Implantol 1990;4:26570. 12. Chiapasco M, Gatti C, Rossi E, Haefliger W, Markwalder TH: Implant-retained mandibular overdentures with immediate loading. Clin Oral Implants Res 1997;8:48-57. 13. Schnitman P, Wohrle P, Rubenstein J, DaSilva J, Wang NH. Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants 1997;12:495-503. 14. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with To 5- year data. Int J Oral Maxillofac Implants 1997;3:319-24. 15. Ji TJ, Kan JY, Rungcharassaeng K, Roe P, Lozada JL. Immediate loading of maxillary and mandibular implant-supported fixed complete dentures: A 1- to 10-year retrospective study. J Oral Implantol 2012;38:469-76. 16. Oyama K, Kan JY, Rungcharassaeng K, Lozada J. Immediate provisionalization of a 3.0-mm-diameter implants replacing single missing maxillary and mandibular incisors: 1-year prospective study. Int J Oral Maxillofac Implants 2012;27:173-80. 17. Proussaefs P, Lozada J. Immediate loading of hydroxyapatite-coated implants at maxillary premolar area: three-year results of a pilot study. J Prosthet Dent 2004;91:228-33. 18. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and provisionalization of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxillofac Implants 2003;18:31-9. 19. Balshi TJ, Wolfinhger GJ, Wulc D, Balshi SF. A prospective analysis of immediate
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provisionalization of single implants. J Prosthodont 2011;20:10-5. 20. Abboud M, Koeck B, Stark H, Wahl G, Paillon R. Immediate loading of single-tooth implants in the posterior region. Int J Oral Maxillofac Implants 2005;20:61-8. 21. Noh K, Kwon KR, Kim HS, Kim DS, Pae A. Accurate transfer of soft tissue morphology with interim prosthesis to definitive cast. J Prosthet Dent 2014;111:159-62. 22. Lin WS, Harris BT, Morton D. Use of implant-supported interim restorations to transfer periimplant soft tissue profiles to a milled polyurethane definitive cast. J Prosthet Dent 2013;109:333-7. 23. Man Y, Qu Y, Dam HG, Gong P. An alternative technique for the accurate transfer of periimplant soft tissue contour. J Prosthet Dent 2013;109:135-7. 23. 24. Joda T. Time-dependent supraimplant mucosa changes: short communication. Int J Oral Maxillofac Implants 2015;30:619-21. 25. Koutouzis T, Neiva R, Nonhoff J, Lundgren T. Placement of implants with platformswitched Morse taper connections with the implant-abutment interface at different levels in relation to the alveolar crest: a short-term (1-year) randomized prospective controlled clinical trial. Int J Oral Maxillofac Implants 2013;28:1553-63. 26. Olive J, Aparicio C. Periotest method as a measure of osseointegrated oral implant stability. Int J Oral Maxillofac Implants 1990;5:390-400. 27. Kim JS, Raigrodski AJ, Flinn BD, Rubenstein JE, Chung KH, Mancl LA. In vitro assessment of three types of zirconia implant abutments under static load. J Prosthet Dent 2013;109:255-63. 28. Santing HJ, Kleverlaan CJ, Werner A, Feilzer AJ, Raghoebar GM, Meijer HJ. Occlusal wear of provisional implant-supported restorations. Clin Implant Dent Relat Res 2015;17:179-85.
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Illustrations: Fig 1. Pre-operative view. Fig 2. Bone sounding technique by utilizing an endodontic file. Fig 3a. Interim abutment and crown are designed. The design is stored by the software and the definitive crown will be designed with identical contours. Fig 3b. A CAD/CAM interim PMME abutment and crown are being milled. Fig 4a. Custom impression coping is designed to have identical contours with the interim abutment/crown and the definitive crown as well. Fig 4b. A CAD/CAM impression coping is being milled. Fig 5. Intraoral evaluation of the CAD/CAM interim abutment. Fig 6a. After curing and removing the excess composite resin cement, an occlusal screwretentive interim CAD/CAM prosthesis is completed. Fig 6b. Intaglio surface, notice the seal and lack of voids between the interim abutment and crown. The contours have been digitally designed to simulate the contours of the definitive prosthesis. Fig 7a. Interim screw-retained prosthesis insertion. Fig 7b. Interim screw-retained prosthesis after suturing. Fig 8a. Four months post-operative evaluation. Fig 8b. Intraoral view, 4 months after implant surgery. Notice the soft tissue contouring simulating the contours of the interim prosthesis. Fig 9. Digital design of the definitive crown. The contours of the definitive restoration are identical with the contours of the interim prosthesis.
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Fig 10a. A screw-retentive definitive prosthesis is being made. The contours of the prosthesis are identical to those of the interim restoration. Fig 10b. Intraoral view with the definitive prosthesis, 18 months after insertion.
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