DENTAL TECHNIQUE

Customized CAD-CAM healing abutment for delayed

loaded implants
Waled M. Alshhrani, BDS, MSa and Mohammad D. Al Amri, BDS, MS, FRCDCb

Dental implants are a con- ABSTRACT

temporary treatment strategy
When conventional prefabricated healing abutments are used, the surrounding soft tissue profile
for the oral rehabilitation of may be unfavorable at the time for restorative treatment, requiring additional time-consuming
individuals with partial or recontouring. This article presents a technique for fabricating a customized computer-aided
complete edentulism.1-3 In an design and computer-aided manufacturing (CAD-CAM) healing abutment for a delayed loaded
ideal clinical scenario, healing dental implant placed in the region of a missing maxillary right first premolar. A surgical guide was
abutments should conform to fabricated and a definitive cast was made from the surgical guide. The cast was digitized using a
the size of the tooth/teeth be- scanner, and a customized healing abutment was digitally designed using computer software. The
presented technique provides guided implant placement and predicts optimum soft tissue con-
ing replaced and guide the
tours that enhance the implant emergence profile. (J Prosthet Dent 2016;116:176-179)
healing of soft tissue around
4,5
the abutment. However, when conventional pre- healing of the tissue and obtains contours that are well-
fabricated healing abutments are used, the surrounding matched with the contours of the definitive prosthesis.4
soft tissue profile at the time of restorative treatment may A 53-year-old systemically healthy nonsmoking
be unfavorable, requiring additional time-consuming woman presented to the graduate prosthodontic clinic at
recontouring.6 Under such circumstances, the use of the School of Dentistry, University of Michigan, with a
prefabricated healing abutments may fail to support and missing maxillary right first premolar (Fig. 1). The patient
shape the supracrestal gingival contours.7 Thus, in the expressed the wish to have the missing tooth replaced
esthetic zone, interim abutments may be used to facilitate with a dental implant. Potential complications associated
the contouring of the periimplant soft tissues to develop with the implant surgery were explained to the patient
an optimal emergence profile.7-9 Restoration of the soft and written consent was obtained. CAD-CAM software
tissue profile may occur by reinstating a gingival form was used to place the implant and to design and fabricate
with the custom fabricated healing abutment and interim a customized healing abutment that provided optimum
restorations.7 soft tissue contours without the risk of early loading of
Computer-aided design and computer-aided the implant. This technique aimed to shorten the
manufacturing (CAD-CAM) systems have been chiefly restorative phase of dental implant rehabilitation while
used for the fabrication of prosthetic fixed restorations, enhancing the definitive esthetic outcome.
including crowns, inlays, onlays, and veneers.10-12
However, over the past decade, CAD-CAM technology TECHNIQUE
has increasingly been used to fabricate implant-
supported prostheses and abutments.13 CAD-CAM 1. Perform a computed tomography scan of the jaw
healing abutments are made from diagnostic casts before and digitally determine the optimal implant position
implant surgery, and contours of the healing abutment using virtual 3D implant planning (Fig. 2).
are based on the contours of a tentatively designed 2. Fabricate a surgical guide from clear acrylic
definitive prosthesis.1,5 The healing abutment facilitates resin (Ortho-Jet; Lang Dental Mfg Co) (Fig. 3).

a
Lecturer, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia.
b
Associate Professor, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia.

176 THE JOURNAL OF PROSTHETIC DENTISTRY

August 2016 177

Figure 1. Preoperative occlusal view of missing maxillary right first Figure 2. Computed tomography scan. Left: Digital 3D viewer of
premolar. maxillary arch. Right: Virtual 3D implant planning to determine optimal
implant position.

Figure 3. Surgical guide.

Figure 4. Fabrication of definitive cast from surgical guide.

3. Fabricate the definitive cast from the surgical guide

using a narrow platform 3.3-mm implant analog
with Type 5 die stone (Jade Stone; Whip Mix Corp)
(Fig. 4).
4. Use the definitive cast to fabricate a diagnostic
waxing that provides a guideline for the position
and dimensions of the definitive restoration.
5. Digitize the definitive cast with a scanner (Nobel-
Procera; Nobel Biocare), and design the customized
healing abutment using computer-based software
(NobelProcera v4.6.1; Nobel Biocare) (Fig. 5).
6. Place the endosseous implant (3.3×11.5 mm)
(NobelSpeedy Groovy; Nobel Biocare) using an
implant surgical guide system (NobelGuide; Nobel
Biocare). Figure 5. Designing customized healing abutment.
7. Use autopolymerizing acrylic resin (GC Pattern
Resin; GC America) to fabricate a resin index (Fig. 6)
to confirm the implant position. 9. Protect the interim abutment screw head with light-
8. After implant placement, screw the customized ti- body polyvinyl siloxane material (Virtual; Ivoclar
tanium healing abutment in place temporarily dur- Vivadent AG) and temporary filling material (Cavit;
ing the tissue healing (Fig. 7). 3M ESPE) (Fig. 8).

Alshhrani and Al Amri THE JOURNAL OF PROSTHETIC DENTISTRY

178 Volume 116 Issue 2

Figure 6. Resin index to confirm implant position. Figure 7. Occlusal view of customized titanium healing abutment
screwed in place.

Figure 8. Occlusal view of customized healing abutment after screw Figure 9. Buccal view of tissue healing around customized abutment
head protection. after 4 weeks.

DISCUSSION
This article describes a convenient technique for main-
taining soft tissue/gingival form using a custom CAD-
CAM healing abutment. This technique provides opti-
mum soft tissue contours and enhances timely tissue
healing (Figs. 9, 10).
Janakievski7 stated that prefabricated healing abut-
ments are unable to support the supracrestal soft tissues
because of their circular profile. Therefore, a custom
healing abutment is preferred because it provides a
replica of the definitive restoration to the patient’s
gingival architecture.10 One of the advantages of CAD
technology is that it allows the digital review and
adjustment of abutment designs before the fabrication Figure 10. Soft tissue contours after customized healing abutment
of a definitive abutment.11 In addition, CAD technolo- removal after 3 months.
gies also facilitate early detection of potential compli-
cations, such as inadequate abutment height for a ceramic abutment with strength and a precise fit in
cement-retained crown.12 Furthermore, CAM allows the addition to esthetic benefits.8
fabrication of high-quality implant abutments from solid The main disadvantage of this technique is the diffi-
blanks of titanium or zirconia.11 Bertolini Mde et al8 culty in surgical implant placement. The surgeon needs
used CAD-CAM technology to fabricate a custom to be familiar with the technique and must ensure that

THE JOURNAL OF PROSTHETIC DENTISTRY Alshhrani and Al Amri

August 2016
the surgical index provided is used, such that one of the
flat surfaces of the implant is parallel to the tangent
across the facial aspect of the adjacent teeth. In addition,
the proposed technique increases the cost of the proce-
dure as it includes milling a custom titanium abutment
and fabricating a surgical index. However, one of the
advantages of the technique is that it reduces the chair
time because the customized healing abutment is fabri-
cated before implant placement.9 Other benefits of this
technique include timely tissue healing, the elimination
of the need for second stage surgery, predictable esthetic
results, and the avoidance of immediate/early loading.3
Furthermore, providing customized interim restorations
helps confirm the diagnostic design, esthetics, and con-
tours, which can be replicated in the definitive pros-
thesis.5 The CAD-CAM technology of computer-assisted
implant impressions and computer-generated abutments
is a further advancement in prosthetic dentistry that may
replace traditional implant restorative protocols.11
SUMMARY
This article presents a technique for fabricating a
customized CAD-CAM healing abutment for delayed
loaded dental implants. The fabrication of a customized
CAD-CAM interim abutment promotes tissue healing
and provides optimum soft tissue contours that enhance
the implant emergence profile.
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Corresponding author:
Dr Mohammad D. Al Amri
Department of Prosthetic Dental Sciences
College of Dentistry, King Saud University
P.O. Box 60169, King Abdullah Rd
Riyadh 11545
SAUDI ARABIA
Email: dramri@yahoo.com
Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
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