CLINICAL REPORT

A completely digital workflow for an interim implant-supported

crown: A clinical report
Fernando Junqueira Leite, DDS, MSc,a Walter Martins, Jr, DDS, MSc, PhD,b Hugo Ricardo Rosin, DDS,c
Cassiano Ricardo Pires, DDS,d Fernando Lopes, DDS,e and Ricardo Faria Ribeiro, DDS, MSc, PhDf

Combining cone beam ABSTRACT

computed tomography (CBCT)
This article describes a completely digital workflow for the diagnostic phase, surgical and prosthetic
with computer-aided design planning, extraction, immediate single implant placement by guided surgery, and interim implant-
and computer-aided supported crown. From a virtual impression, zirconia abutments and a polymethylmethacrylate
manufacturing (CAD-CAM) (PMMA) interim crown was planned in a computer-aided design (CAD) software program. This
has become popular in implant workflow shortened the time required for chairside placement of an interim restoration with
dentistry.1 In addition to enhanced function and esthetics while restoring an anterior mandibular tooth lost after
diagnosis, it allows digital trauma. (J Prosthet Dent 2020;-:---)
reverse planning by clinicians
(surgical and restorative teams) to predict the different (Fig. 1). Five years later, he developed a fistula in the
stages of treatment.2 For guided implant placement,2 the area, associated with internal root resorption identified
virtual planning is transferred to the surgical stage with on a periapical radiograph (Fig. 2), confirmed with a
prototyped surgical guides that are software generated CBCT scan (Fig. 3). After the diagnosis, treatment alter-
and made by using 3D printers.3-6 The process takes natives were discussed, and extraction followed by im-
advantage of the receptor bone bed, with a path of mediate implant placement and an interim restoration
insertion that is prosthetically directed2 to prevent with a digital workflow was accepted.
damage to vital anatomic structures and optimize the A CBCT scan was made (PreXion3D; PreXion Inc),
outcome of the procedure.2-5 generating digital imaging and communications in
This clinical report presents the digital workflow of medicine (DICOM) files with slices of up to 0.1-mm
the diagnosis, planning, and fabrication of an interim thickness for evaluation of the alveolar bone in the
implant-supported crown by replacing a mandibular region. This procedure was followed by intraoral
right central incisor lost subsequent to trauma. scanning (TRIOS Colors3; 3Shape), producing stan-
dard tessellation language (STL) files. The DICOM and
STL files were merged in a software program (3Shape
CLINICAL REPORT
Dental System) (Fig. 4A).The shape and position of the
A 44-year-old man reported receiving dental trauma original teeth analyzed in the computer-aided design
some years previously which had resulted in the pulpal (CAD) software directed the selection of the diameter,
necrosis of the mandibular right central incisor and length, and 3D position of the implant by super-
which, when diagnosed, required endodontic treatment imposing CBCT data with digital trial restoration data

a
Doctoral student, Oral Rehabilitation Program, School of Dentistry of Ribeirao Preto, University of Sao Paulo (USP), Director DVI Radiology, Ribeirao Preto, Brazil.
b
Professor, School of Dentistry, University of Ribeirao Preto (UNAERP), Ribeirao Preto, Brazil.
c
Radiologist, Director DVI Rdiology, Ribeirao Preto, Brazil.
d
Radiologist, Director Digital Center Laboratory, Ribeirao Preto, Brazil.
e
Dental Technician, Diretor Digital Center Laboratory, Ribeirao Preto, Brazil.
f
Full Professor, School of Dentistry of Ribeirao Preto, University of Sao Paulo (USP), Ribeirao Preto, Brazil.

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Figure 1. Preoperative situation. A, Frontal view of traumatized
mandibular right central incisor. B, Periapical radiograph.
Figure 3. CBCT scan of mandibular right central incisor area. CBCT, cone
beam computed tomography.
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Figure 2. Periapical radiographs. A, Mandibular right central incisor
showing fistulae. B, Showing root resorption.
Figure 4. A, B, Merging CBCT scan and intraoral scan. CBCT, cone beam
computed tomography.
in the implant planning software (Fig. 4B).The plan-
ning included the virtual extraction of the mandibular
right central incisor and the determination of the ideal
position of the implant based on the prosthetic crown.
After the reverse planning was carried out and
approved, a surgical guide was made by using a 3D
printer (Form3; Formlabs) (Fig. 5).
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Figure 5. Three-dimesionally printed surgical guide. Figure 6. Atraumatic tooth extraction.

Figure 7. Mandibular right central incisor after extraction showing Figure 8. Implant placement.
radicular defect.

At the day of surgery, a single dose of antibiotic

(azithromycin, 500 mg) was administered prophy-
lactically, and a nonsteroidal anti-inflammatory drug
(Nimesulide; Aché, 100 mg) was administered 1 hour
before the surgery for pain control. Supraperiosteal
infiltrative anesthesia was induced, and minimal
traumatic tooth extraction was performed by using a
dental extractor (Neodent) (Fig. 6), followed by sur-
gical debridement. Figure 7 shows the extracted
tooth.
With the correct positioning of the surgical guide,
an implant (Alvim CM 3.5×11 mm; Neodent) was
inserted by using the guided surgical kit (Neodent)
and following the drill sequence recommended by the
Figure 9. Scan body in position for intraoral scan.
manufacturer (Fig. 8). After fixation of the implant
and removal of the guide, a new scan of the
mandibular arch was made. For this procedure, a scan software program (Ceramill Mind; Amann Girrbach
body device (Neodent) that allowed the capture of the AG) (Fig. 10). The merging of the first and second
implant position was used (Fig. 9). The digital file digital files ensured that the crown reproduced the
obtained was sent to the dental laboratory technician original tooth anatomy, improving patient acceptance
for abutment and crown design in a dental CAD and adaptation (Fig. 11).

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Figure 10. A, Intraoral scan with scan body. B, Digital design of mandibular right central incisor crown.

Figure 11. Digital design of abutment and crown for mandibular right central incisor.

By using a titanium base (Neodent), a zirconia abut- Amann Girrbach AG). Additionally, an interim poly-
ment (Ceramill Zi; Amann Girrbach AG) was designed methylmethacrylate (PMMA) crown (Ceramill temp;
and milled in a milling device (Ceramill motion 2; Amann Girrbach AG) was made with the milling device

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Figure 12. Abutment cemented over titanium base and interim crown.

Figure 13. A, Abutment screwed in position. B, Crown cemented and

occlusion adjusted.

Figure 14. Treatment outcome with interim crown.

Figure 15. Follow-up CBCT scan. CBCT, cone beam computed tomography.

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Figure 16. Follow-up radiograph.
(Ceramill motion 2; Amann Girrbach AG). The abutment
was cemented over the titanium base (Fig. 12) by using a
dual-polymerizing resin-based cement (RelyX U200; 3M
ESPE).
The titanium base with zirconia abutment was
screwed in place to 15 Ncm, the crown was cemented
with an interim cement (Temp Bond NE; Kerr Corp), and
the occlusion was adjusted (Fig. 13).
The functional and esthetic result was accepted by the
patient, and no complications were encountered during
or after treatment (Fig. 14).
During a recall appointment, a new CBCT scan (Fig. 15)
and radiograph (Fig. 16) was made, and although color
change of the interim crown was observed, peri-implant
health was maintained (Fig. 17), preserving ideal condi-
tions for the future definitive crown.
SUMMARY
This clinical report describes a complete digital workflow
to rapidly and successfully resolve the loss of an anterior
mandibular tooth caused by trauma.
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Figure 17. Follow-up appointment, showing healthy peri-implant
tissues but discolored interim crown. A, Buccal view. B, Occlusal
view.
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Corresponding author:
Dr Ricardo Faria Ribeiro
School of Dentistry of Ribeirao Preto, University of Sao Paulo
Dept. of Dental Materials and Prosthodontics
Av. do Café, sn e Monte Alegre
14040-904 Ribeirao Preto, SP
BRAZIL
Email: rribeiro@usp.br
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.01.022
Leite et al