Digital Workflow in Implant Treatment Planning For Terminal

Dentition Patients
Panos Papaspyridakos, DDS, MS, PhD ,1,2 Armand Bedrossian, DDS, MSD, FACP ,3 Andre De
Souza, DDS, MS ,1 Abdullah Bokhary, BDS, MSc,4 Luiz Gonzaga, DDS, MS,5 &
Konstantinos Chochlidakis, DDS, MS, FACP 2
1
Department of Prosthodontics, Tufts University School of Dental Medicine, Boston, Massachusetts, USA
2
Department of Prosthodontics, University of Rochester Eastman Institute for Oral Health, Rochester, New York, USA
3
Department of Prosthodontics, University of Washington, Seattle, Washington, USA
4
Department of Dental Public Health, King Abdulaziz University Faculty of Dentistry, Jeddah, Saudi Arabia
5
Center for Implant Dentistry, University of Florida, Gainsville, Florida, USA

Keywords
Digital implant planning; implant
rehabilitation; digital workflow; digital
dentistry; digital smile design; 3D printing;
mock-up; failing dentition; terminal dentition;
guided surgery; alveoloplasty.
Correspondence
Associate Professor Panos Papaspyridakos,
Department of Prosthodontics, Tufts
University School of Dental Medicine, One
Kneeland Street, Boston, MA 02111, USA.
Email: panpapaspyridakos@gmail.com
Received: November 1, 2021
Accepted March 21, 2022
Abstract
Treatment planning for the transition of patients from terminal dentition to full-arch
implant rehabilitation poses challenges. Such challenges pertain to achieving the new
orientation of the occlusal and esthetic plane as well as the change of vertical dimen-
sion of occlusion (VDO), while the fixed provisionalization using a digital workflow
still tends to be considered complex and hard to perform. This article illustrates step-
by-step the utilization of a digital workflow protocol in the treatment planning for
rehabilitation of terminal dentition patients, simplifying the smile design and ensur-
ing that fixed provisionalization serves both functional and esthetic requirements.
This protocol includes facially driven, three-dimensional (3D) digital smile design
and chairside mock-up restoration workflows that enable prosthetically driven as-
sessment prior to implant treatment planning and 3D printing of surgical templates
and prefabricated interim prostheses, which can predictably reduce chairside time and
adjustments at the surgical and fixed provisionalization appointment.

doi: 10.1111/jopr.13510

Treatment planning for implant rehabilitation of terminal den-
tition patients is complex and there are significant challenges
for both the surgical and prosthodontic aspects. Systematic pre-
treatment evaluation algorithms have provided guidelines for
proper diagnoses, prosthetic options, smile evaluation, and sur-
gical planning.1 In terms of provisionalization, after extraction
of the hopeless teeth, different approaches can be employed:
(1) immediate placement and loading with a fixed interim pros-
thesis, (2) immediate placement and removable provisionaliza-
tion with a complete denture followed by conventional implant
loading after osseointegration, (3) early placement and remov-
able provisionalization followed by conventional implant load-
ing, and (4) staged approach with fixed provisionalization by
strategically maintaining some hopeless teeth during the im-
plant osseointegration period.2–7
What makes treatment planning for terminal dentition most
challenging is the inability for a preoperative evaluation of the
proposed esthetic plane orientation, incisal edge position, and
maxillomandibular relationship.6,8,9 Digital technology offers
tools to assist in the smile design and rehabilitation of ter-
minal dentition patients.9–12 Commercially available software
programs can be used to allow simulation of the digital smile
design, enabling communication between patients, clinicians,
and the interdisciplinary team.9–12 Data acquisition involving
a combination of photographs, facial scans, radiographs, and
intraoral digital scans have been employed to generate facially
driven smile design and simulation of future tooth position.9–12
Techniques have been recently reported to register the vertical
dimension of occlusion (VDO) and the maxillomandibular re-
lationship and integrate data with a virtual articulator for the
creation of the so-called “virtual patient.”13–15 Nevertheless,
these software may be difficult to use, time-consuming, and
challenging to bridge the three-dimensional (3D) digital work-
flow to the intraoral confirmation of the future tooth position.
Complete digital workflow from planning to prosthesis
insertion with various approaches has been described for
completely edentulous patients and patients with terminal
dentition.9,10,11,13,14,16–19 Previously reported protocols include
digital workflow combined with cephalometric data for digi-
tal assessment of VDO and maxillomandibular relationship.9

Journal of Prosthodontics 31 (2022) 543–548 © 2022 by the American College of Prosthodontists. 543

Digital Implant Treatment Planning For Terminal Dentition
Figure 1 Initial situation of a patient with terminal dentition. Advanced
periodontal disease, recurrent caries, multiple failing restorations, erup-
tion of the right side maxillary teeth, splaying of lower right mandibular
teeth, and uneven occlusal plane, in combination with partial edentulism
were found upon comprehensive diagnostic work-up.
Additionally, virtual simulation of the proposed smile has been
reported for patient approval without intraoral mock-up prior to
treatment.9–11 The purpose of the present techniwue report is to
illustrate, step-by-step, a digital protocol in the treatment plan-
ning phase of terminal dentition patients requiring fixed, full-
arch implant rehabilitation. Digital data acquisition is coupled
with clinical assessment of incisal edge position, VDO, and
maxillomandibular relationship, thus fusing digital technology
with fundamental prosthodontic principles. The present proto-
col allows for esthetic planning, digital smile design, chairside
smile simulation with a mock-up, followed by digital implant
planning for implant placement with a stackable surgical tem-
plate system. The advantages of this protocol include simplify-
ing the digital smile design, bridging the gap between analog
and digital workflows and ensuring that fixed provisionaliza-
tion serves both the functional and esthetic requirements. This
protocol can predictably reduce chairside time and adjustments
at the surgical and fixed provisionalization appointment at time
of loading.
Technique
1. During consultation with a patient for treatment of
terminal dentition, assess the midline and the incisal
edge position for esthetics, phonetics, and adequate
function, based on established prosthodontic guidelines
(Fig 1).8–12 If additive changes are necessary, perform a
direct mock-up for the incisors with composite resin to
facilitate the determination of incisal edge position, mid-
line, and occlusal plane inclination. Once deemed suffi-
cient, the next step can be carried out.
2. Assess VDO and centric relation (CR) position and
record the interocclusal distance. If VDO is collapsed,
then record the available interocclusal distance and how
many millimeters will be necessary to restore the VDO
based on established prosthodontic guidelines.8–12 The
VDO can be recorded using occlusal rims, leaf gauge,
or anterior deprogrammer. An anterior deprogrammer is
544 Journal of Prosthodontics 31 (2022) 543–548 © 2022 by the American College of Prosthodontists.
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Papaspyridakos et al
Figure 2 Digital set-up with CAD software.
fabricated out of autopolymerizing resin (Pattern Resin
LC, GC America, Alsip, IL) and used to manipulate into
CR position. Once CR and VDO are determined, the
next step can be carried out.
3. Use an intraoral scanner (TRIOS® 3, 3Shape A/S,
Copenhagen, Denmark) to scan the partially edentulous
arches with and without the direct mock-up, as well
as the maxillomandibular relationship. The maxillo-
mandibular relationship at the CR position will be digi-
tally registered with the same intraoral scanner (TRIOS®
3, 3Shape A/S, Copenhagen, Denmark) with the aid of
the anterior deprogrammer. Save all the STL files. Take
two facial frontal photographs (same angle and distance)
with the patient in retraction and with smile and save the
generated JPEG files.
4. Obtain a cone beam computed tomography (CBCT) scan
with the two jaws separated via cotton rolls to separate
the volume of interest. Save the generated Digital Imag-
ing and Communication in Medicine (DICOM) files.
5. Import the saved STL into computer-aided design
(CAD) software (Exocad DentalCAD 3.0; Exocad
Gmbh, Darmstadt, Germany) and superimpose these
files to the DICOM files and the JPEG photograph files.
Perform facially driven digital diagnostic trial arrange-
ment (set-up) based on the facial and intraoral measure-
ments done in steps 1 and 2 (Fig 2). Use the virtual
articulator (Exocad DentalCAD 3.0; Exocad Gmbh,
Darmstadt, Germany) to virtually articulate the digital
casts based on average condylar settings. Complete the
digital set-up on the virtual articulator. Export the STL
file from the digital set-up to a 3D printer (Form 3b+,
Form labs, Somerville, MA) and generate a 3D-printed
cast of the new digital set-up. Fabricate a silicone ma-
trix (Splash lab putty, Denmat, Lompoc, CA) on the 3D-
printed cast to serve as index for the chairside mock-up
(Fig 3).
6. Perform a chairside mock-up with the silicone matrix
and bis-GMA acrylic resin. Assess esthetics, phonet-
ics, function, VDO, and treatment position with estab-
lished guidelines (Figs 4 and 5). Assess smile line, tran-
sition line, and the potential need of bone reduction
(alveoloplasty). Changes on the mock-up can be made
 1532849x, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jopr.13510 by Universidad Nacional Autonoma De Mexico, Wiley Online Library on [15/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Papaspyridakos et al Digital Implant Treatment Planning For Terminal Dentition

if necessary, and use an intraoral scanner (TRIOS® 3,

3Shape A/S, Copenhagen, Denmark) to scan the par-
tially edentulous arch. Save the STL file. If no changes
are made on the mock-up, the need to re-scan the mock-
up is eliminated.
7. Import the saved STL of the digital set-up/mock-up and
DICOM files into commercially available digital plan-
ning software (co-Diagnostix® , Dental Wings GmbH,
Dusseldorf, Germany) and superimpose them with the
aid of the solid landmarks such as the remaining teeth
(minimum 3). This introduces the intraorally verified
tooth position so that prosthetically driven implant plan-
ning can be achieved (Fig 6). Use a 3D printer to print
the series of stackable surgical templates (Smile-in-a-
Box concept, Institute Straumann AG, Basel, Switzer-
land) to be used for guided surgery.
8. Perform extractions, alveoloplasty (if necessary), and
guided implant placement with the stackable surgical
templates; insertion of a prefabricated interim prosthesis
is carried out if primary stability of more than 30 Ncm
is achieved after implant placement (Figs 7 and 8).
Figure 3 3D-printed casts from digital set-up and silicones indices.
Discussion
As digital workflow protocols continue to evolve, further
clinical research is necessary to evaluate the accuracy and
validate each protocol’s ability to demonstrate predictable sur-
gical and prosthetic outcomes. Patients who present with termi-
nal dentition are challenging to treat, as they are often anxious
about losing their teeth and concerned about how the definitive
prostheses will function and appear. Fundamental analog tech-
niques, such as a direct mock-up appointment, can serve as an
efficient communication tool with the patient and secure case
acceptance. For scenarios in which an analog direct mock-up
cannot be utilized, a digital technique with CAD smile design
software can simulate the proposed tooth shape, smile arc, and
design. In the present case, a combination of analog and digital
techniques was used by way of two standardized facial frontal
photographs (retracted view and smile), intraoral STL files, and
Figure 4 Facially driven digitally designed intraoral mock-up.
CBCT DICOM files. The superimposition and calibrated align-
ment of the initial data acquired, allowed for a facially driven
smile design, which was then 3D printed to fabricate silicone
indices. The silicone indices are superior to the 3D-printed in-
dices since they are flexible, and this is preferable for full-arch
situations. The direct mock-up seen in the present case helped
the patient envision the proposed treatment, while allowing the
clinician to evaluate the fundamental esthetic principles prior
to any definitive surgical intervention. It should be highlighted
though that there may be differences between the diagnostic
set-up for the mock-up and the final set-up for digital implant
planning and fabrication of the interim prosthesis. In some sce-
narios, the presence of teeth may necessitate the fabrication of
two diagnostic set-ups. One additive set-up to enable chairside
mock-up (additive approach), for patient approval. Once pa-
tient approval is confirmed, a second set-up may be required
which may be less additive for ideal prosthetically driven tooth
positioning prior to digital implant planning.
Figure 5 Frontal facial view of facial-driven mock-up.

Journal of Prosthodontics 31 (2022) 543–548 © 2022 by the American College of Prosthodontists. 545

Digital Implant Treatment Planning For Terminal Dentition
Figure 6 Digital implant planning with the stackable guide concept.
Figure 7 Double-arch implant rehabilitation with the stackable guide
concept, after digital implant planning.
These diagnostic steps also allow for thorough communica-
tion with the interdisciplinary team, identifying landmarks for
incisal edge position and measurements for digital planning
and surgical treatment. The use of CAD implant planning soft-
ware enabled surgical planning with prosthetic landmarks to
aid in ideal positioning and distribution of implants for favor-
able surgical and prosthetic prognoses (Fig 9).
The presented guided implant system can be designed
and manufactured in a sequential or stackable system.
The sequential system allows each guide (tooth-borne/bone-
reduction/implant/prosthetic conversion) to be sequentially fix-
ated utilizing the same fixation pin locations. In contrast, the
stackable system allows for the tooth-borne guide to be sta-
bilized onto the teeth for osteotomy preparations of the fixa-
546 Journal of Prosthodontics 31 (2022) 543–548 © 2022 by the American College of Prosthodontists.
1532849x, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jopr.13510 by Universidad Nacional Autonoma De Mexico, Wiley Online Library on [15/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Papaspyridakos et al
Figure 8 Postoperative smile view.
tion pins, followed by placing the bone reduction guide into the
same fixation holes and maintaining it in place. The subsequent
implant placement guide is “stacked” onto the bone-reduction
guide throughout the entire subsequent surgical steps. Addi-
tionally, the prefabricated interim prosthesis is stacked on top
of the bone-reduction guide for simplification of the conver-
sion process. In this presented technique, the stackable system
was employed since it can reduce the number of possible errors
upon placement or removal of the various guides. The stack-
able guide concept allows for predictable surgical placement
by way of guided surgery, and also significantly reduces chair-
side time and complications with the conversion of the prefab-
ricated interim prosthesis.
Advantages of the present protocol include bridging the
gap between analog and digital workflows and ensuring that

Papaspyridakos et al
Figure 9 Diagram of the digital workflow.
fixed provisionalization serves both the functional and esthetic
requirements. The use of analog principles by way of the direct
mock-up provides immediate evaluation by the clinician and
interdisciplinary team, and most importantly, communication
with the patient for the proposed esthetic outcome. The nov-
elty of the present protocol lies in the enhancement of dentist-
patient communication, helping the patient visualize the pro-
posed treatment plan and desired endpoint. More importantly,
it does not rely on 2D smile design photos which can be mis-
leading for the patient, but instead ensures the intraoral try-in
of the 3D design in these complex double full-arch rehabili-
tations. Additionally, this protocol can reduce chairside time
and adjustments at the surgical and fixed provisionalization ap-
pointments at time of loading.
Limitations of the present digital protocol include the opera-
tor’s experience with treatment planning and guided surgery.
An essential step in any digital workflow is the “superim-
position” step (step 5 described in this technique). If the
clinician or operator misaligns the CBCT and STL file, the
subsequent treatment planning and surgical steps will be neg-
atively affected. Furthermore, the use of the illustrated guided
surgery protocol requires a keen eye to ensure accurate seat-
ing and fixation of all guides, and to make certain that what
was 3D-planned in the software is represented in the clinical
setting. When the remaining teeth are splayed in a far labial
position, then the intraoral mock-up may be impossible. In this
context, the feasibility of the digital smile design can aid in
addressing this limitation when trying to predict intraoral and
extraoral facial support changes. Extractions of some teeth and
fabricating a tooth-supported interim prosthesis before the fi-
nal implant planning (staged approach) can be an alternative in
such situations, or when extreme skeletal Class II & III mal-
occlusions are present. An additional limitation of the present
technique is the lack of virtual facebow, which can register
the hinge axis and antero-posterior inclination of the occlusal
plane in the virtual articulator prior to completing the digital
set-up. Nevertheless, the 3D rendering of the digital set-up into
Journal of Prosthodontics 31 (2022) 543–548 © 2022 by the American College of Prosthodontists.
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Digital Implant Treatment Planning For Terminal Dentition
an intraoral mock-up can compensate with intraoral occlusal
adjustments. Further clinical studies are necessary to assess the
efficacy of the presented protocol.
Summary
This article illustrates step-by-step the utilization of a digital
workflow protocol in the treatment planning for rehabilitation
of patients with terminal dentition, simplifying the smile de-
sign, and ensuring that the fixed provisionalization serves both
functional and esthetic requirements. This protocol includes
a 3D digital smile design and chairside mock-up restoration
workflow that enables prosthetically driven assessment prior
to implant treatment planning and 3D printing of surgical tem-
plates, which can predictably reduce chairside time and adjust-
ments at the surgical and fixed provisionalization appointment.
Acknowledgments
The authors would like to express their gratitude to Dr. Daniel
Sabra, for clinical surgical care, and Mrs. Chelsey Morin, for
assistance in clinical surgical care.
Conflict of interest
The authors declare no conflict of interest.
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