Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic by Dr. Grant Olson

Categories: Prosthodontics;
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic 

Integrating technologies leads to innovative solutions


by Dr. Grant Olson


Digital technologies have transformed the practice of dentistry to offer clinicians a more efficient and accurate means to diagnose and plan how to treat their patients. Innovative production technologies, high-performance restorative materials and pioneering clinical technologies, tools and techniques are converging in the digital workflow space to expand patient treatment options and offer clinicians new solutions for restorative treatment from single-tooth to full-arch implant-supported cases.1,2

The ability to combine digital technologies with tools and materials for restorative care opens up a host of new possibilities for surgical and prosthetic treatments that offer solutions for both patients and clinicians. Reduced chair time, lower patient cost and fewer treatment phases are all possible while improving the quality, fit and aesthetics of the final outcome. This is particularly true in the arena of full-arch, implant-supported prosthetics. Although past advancements in technology and techniques have resulted in 3D guided surgery protocols that can deliver a full-arch short-term temporary in a single visit, one of the biggest barriers to treatment acceptance is the high cost of the permanent high-quality full-arch prosthetic.3

It is estimated that 40 million Americans are missing all of their teeth.4 Although most patients understand the benefits of immediate-load implant-retained prosthetics, the challenge today is to develop simplified restorative protocols that are immediate, aesthetic and cost effective.5

The case presented here demonstrates how integrating three patented technologies can result in a same-day full-arch, implant-retained prosthetic solution that not only is cost-effective but also offers the patient a strong, longer-term, highly aesthetic fixed hybrid that is not screw retained.

Case report

A patient in her 70s presented to the practice with the chief complaint that her existing maxillary denture had changed over time and was now slipping, which triggered a gag reflex when swallowing. In addition, she was dissatisfied with the aesthetics of the denture and wanted her smile back (Fig. 1).

 Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 1

She and the clinician discussed several restorative options, from a new conventional denture to an immediate-load, implant-retained prosthesis that would eliminate the palatal aspect of a conventional denture. Although she was pleased with a solution that would eliminate the palatal aspect she found unbearable, the final implant-retained solution was out of financial reach for her.

The clinician then proposed a lower cost immediate-load, implant-borne approach that included a long-term solution—one that could be replaced after many years or taken to a final zirconia solution if or when finances allowed. In addition, the surgery and placement of the prosthesis could be completed in a single two- to three-hour visit with only one follow-up visit to finalize the prosthesis.

The patient accepted this solution and was scheduled for a record-taking appointment.

Treatment planning and record taking

To execute any digitally and prosthetically driven full-arch case, the initial record-taking appointment is critical to provide the dental team with the information needed to treatment-plan the case and for the laboratory to fabricate the surgical guidance system components (Chrome GuidedSmile, Roe Dental Laboratory) and the immediate-load, long-term, full-arch prosthesis for delivery the day of surgery.6

X-rays and a CBCT scan (Axeos, Dentsply Sirona) were taken to assess the patient’s bone quality and density for 3D presurgical team planning (BlueSkyPlan, BlueSkyBio) of optimal placement of six implants in correct position in relation to the final prosthesis. Digital photos with the patient wearing her existing maxillary denture smiling, with an exaggerated smile, and a full-face profile were taken, as well as retracted views full center, left and right in occlusion (Figs. 2 and 3). The CBCT scan and digital photos were sent to the dental laboratory and integrated for a review of the comprehensive digital and clinical information for the design and creation of an immediate-load, long-term, full-arch prosthetic that would meet the form, fit, function and aesthetics the patient expected.
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 2
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 3

To provide the patient with a strong, long-term, more affordable full-arch solution, the team decided to use a CAD/CAM-milled long-term monolithic provisional material (Ivotion, Ivoclar) that would rely on a unique retention mechanism (Smileloc Abutment System, Rodo) to provide the patient with a fully functional and aesthetic solution and eliminate the need for the more conventional method of drilling holes through a solid prosthesis for screw retention, which can weaken the structure and lead to potential fracture.7

Surgery and implant placement

With the virtual plan confirmed, all components for the guided surgical approach were delivered to the practice. On the day of surgery, the patient was administered local oral anesthesia and the labial tissue flap was reflected and sutured (Fig. 4).

 Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 4

Because administering anesthesia may cause the palate to swell, a 15-minute waiting period was instituted before placing the palatal tissue-supported see-through pin guide. The patient ensured correct indexing of the pin guide to the palate by biting into the pin guide during the pinning process. The pin guide fits intimately over existing dentition or mucosa and guides the precise anchoring of the surgical fixation base on the presurgical anatomy (Figs. 5 and 6).
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 5
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 6

The upper edge of the patient-specific fixation base for this case indicated that a bone reduction level of 15 millimeters would be necessary to accommodate the full-arch restoration and implant components (Figs. 7 and 8). Once bone leveling was accomplished and confirmed by the system’s carrier guide (Fig. 9), the osteotomy drill guide was secured to the fixation base to guide placement of six implants (Ultimate, Ditron Medical) to the proper angulation, trajectory and depth (Figs. 10 and 11). The osteotomy guide also ensured precise implant timing so the internal hex was optimally positioned for receiving angled multiunit abutments. With this no-hole, screwless protocol, implant placement can be planned for the central portion of the prosthesis or even along the incisal edge, which not only provides added strength to the prosthetic but also allows fabrication of a thinner, less bulky solution.
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 7
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 8

 Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 9
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 10
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 11

With the implants placed, the osteotomy guide was removed and a carrier guide secured to the fixation base (Figs. 12 and 13). The carrier guide provides an interface to secure the placement and rotational position of the multiunit abutments and to index it precisely to the Rapid Appliance (Fig. 14). The appliance, a 3D-printed replica of the final long-term prosthesis, is critical to the conversion process.
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 12
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 13

 Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 14

The appliance was placed on the indexed carrier guide, which is attached to the fixation base to verify the bite, and impression cylinders were fitted onto the implants and locked in place (Figs. 15 and 16) with a dual-cure resin (Stellar, Taub Products). The resin was light-cured, the impression cylinders unscrewed and the appliance removed. Healing caps were placed on the implants and the tissue sutured (Fig. 17).
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 15
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 16

 Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 17

Final prosthetic conversion

The extraoral conversion of the Rapid Appliance to the provisional prosthetic was completed by a dental assistant while the clinician grafted and sutured the tissue. The extraoral conversion process began by attaching multiunit abutment analogs (Smileloc) to each of the temp cylinders in the appliance (Fig. 18). The appliance was then mounted onto the patient-specific 3D-printed model articulator base (Smileloc Patient Model, Roe Dental Laboratory) and locked into position (Fig. 19) with acrylic (Stellar). After the material set, the appliance was removed and fixed attachments and copings (Smileloc) were placed on the multiunit abutment analogs. The long-term prosthesis was then seated on the Smileloc articulator to verify passivity over the copings (Fig. 20). Once confirmed, acrylic (Stellar) was applied, half-filling the predesigned wells in the prosthetic. The Smileloc model was then connected back to the prosthesis to connect the prosthesis to the temp cylinders (Fig. 21). After the resin cured, the prosthetic was removed from the model using a unique activation device (Smilekey, Rodo) for four seconds near each of the abutment locations, unlocking the nickel titanium alloy of the copings and allowing the prosthesis to release (Fig. 22). The acrylic housing areas in the long-term prosthesis were finished, filling any voids and adjusting any flash. Then, the nickel titanium Smilelocs were placed on the abutments in the mouth, following the seating instructions, and the final prosthetic was seated, placing downward pressure to engage the copings (Figs. 23–25).
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 18
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 19
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 20
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 21
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 22
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 23
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 24
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Fig. 25


The case was minimally equilibrated, and the patient was dismissed, thrilled with her new smile (seen below).
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic
Creating an Affordable, Aesthetic Same-Day Full-Arch Prosthetic

Conclusion

The evolution of same-day, full-arch implant reconstruction continues to improve as new and existing technologies, materials and innovative techniques are integrated to provide clinicians with a digital workflow that is more efficient and accurate and, for patients, more affordable. This case demonstrates how the use of three different technologies provides a solution that offers a stronger, narrower final prosthesis and a prosthetically driven 3D treatment plan that can be equilibrated throughout the process both in and outside the mouth. For patients, it offers a more affordable, long-term, same-day, full-arch solution, which can be easily maintained and cleaned in the dental practice more efficiently than screw-retained prosthetic alternatives.



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References
1. Spagnuolo G, Sorrentino R. “The Role of Digital Devices in Dentistry: Clinical Trends and Scientifi c Evidences.” J Clin Med. 2020 Jun 2;9(6):1692.
2. Culp, L. “Digital Dentistry: a New Era of Patient Care.” Compendium 2013 Nov/Dec; 34(10).
3. Russel, A. “How Much Do Implants Cost?” Forbes Health. https://www.forbes. com/health/body/how-much-dental-implants-cost/ June 24, 2022. Accessed July 20, 2022.
4. Talking Points. Missing Teeth. American College of Prosthodontists. https:// www.prosthodontics.org/assets/1/7/ACP_Talking_points_for_Missing_ Teeth_1-12-15.pdf. Accessed July 20, 2022
5. Soto-Penaloza D, Zaragozí-Alonso R, Penarrocha-Diago M, Penarrocha-Diago M. “The All-on-Four Treatment Concept: Systematic Review.” J Clin Exp Dent. 2017 Mar 1;9(3):474–e488.
6. D’ haese J, Ackhurst J, Wismeijer D, De Bruyn H, Tahmaseb A. “Current State of the Art of Computer-Guided Implant Surgery.” Periodontology 2000. 2017 Feb;73(1):121–133.
7. Suarez-Feito JM, Sicilia A, Angulo J, Banerji S, Cuesta I, Millar B. “Clinical Performance of Provisional Screw-Retained Metal-Free Acrylic Restorations in an Immediate Loading Implant Protocol: A 242 Consecutive Patients’ Report.” Clin Oral Implants Res. 2010 Dec;21(12):1360–1369.


Author Bio
Author Dr. Grant Olson is the owner of Innovative Dental and Rheostat App & Consulting in Springfield, Missouri. As a dentist and clinical director of Innovative Dental, he uses his experience in cosmetic and implant dentistry to transform smiles for patients traveling from all over the United States. As a Cerec doctor mentor, he uses his knowledge and experience in digital dentistry to train and deliver the latest in same-day smile transformations. Most recently, he has been developing advancements in Chrome GuidedSmiles utilizing Rodo Smile.
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