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    Compendium

    September 2013, Volume 34, Issue 8
    Published by AEGIS Communications


    CAD/CAM Implant Abutments Using Coded Healing Abutments: A Detailed Description of the Restorative Process

    Douglas H. Mahn, DDS; and Tony Prestipino, CDT

    Abstract:

    Computer-aided design/computer-aided manufacturing (CAD/CAM) represents a leap forward in the fabrication of implant restorations. Coded healing abutments can be digitally read, and they eliminate the steps needed to make implant impressions using traditional impression copings. This article provides a detailed description of the restorative process using CAD/CAM technology and coded healing abutments.

    Implant abutments must satisfy important biologic, functional, and esthetic demands.1 The materials they are made from, therefore, are critical to their success.2 Abutment emergence profiles with natural contours permit esthetic peri-implant soft-tissue remolding.3,4

    Traditionally, implant-level impressions have been made using an impression coping. This requires removal of the healing abutment. The impression is made, the impression coping is removed, and the healing abutment is replaced.5 Fabrication of a custom abutment typically has involved using a UCLA abutment.6 Quality custom abutments required skilled laboratory technicians and the use of precious metals.7 Prefabricated abutments reduce costs but do not predictably create natural emergence profiles.8

    Advances in impression systems and abutment fabrication have revolutionized implant dentistry. Computer-aided design and computer-aided manufacturing (CAD/CAM) technologies enable a sophisticated fabrication of customized implant abutments.9-13 Coded healing abutments can, furthermore, eliminate the need to remove healing abutments during impression making. The use of virtual imagery allows technicians to design abutments to meet certain specifications and conform to the surrounding dentition. The computer-designed abutments can then be milled from solid blocks of biocompatible material.

    This case report illustrates the steps involved in restoring implants using coded implant abutments and CAD/CAM technologies.

    Case Report

    The 67-year-old patient was seen for evaluation and treatment of her partial edentulism (sites Nos. 28 through 32). After thorough clinical and radiographic evaluation, a treatment plan was developed that called for placement of three implants to support individual porcelain-fused-to-metal (PFM) crowns in site Nos. 28 through 30.

    The patient agreed, and 4/3 mm x 11.5 mm Certain® PREVAIL® Implants (Biomet 3i, www.biomet3i.com) were placed as planned. BellaTek® Encode® Healing Abutments (Biomet 3i) were placed on the implants. The dimensions of each abutment were 3.4 mm (prosthetic diameter) x 5 mm (abutment profile) x 3 mm (abutment height). The gingival flaps were repositioned and secured using a continuous 4.0 chromic gut suture.

    Following 3 months of healing, all the implants were found to be healing well (Figure 1). At least 1 mm of the abutments were exposed above the gingiva circumferentially. The tightness of the BellaTek Encode Healing Abutments was verified using a 0.048 hex hand driver, and radiographs confirmed that the abutments were completely seated (Figure 2). Full-arch impressions of both arches were made, using trays filled with medium-body polyether impression material (Impregum™ F, 3M ESPE, www.3MESPE.com). Light-body polyether impression material (Permadyne™, 3M ESPE) was syringed around the healing abutments. The impressions were inspected for defects in the area of the healing abutments (Figure 3). A softened wax was used to make an occlusal registration. These records were sent to the dental laboratory with a completed lab prescription.

    The dental laboratory placed BellaTek Encode Healing Abutments that were the same dimension as those used in the impression on implant analogs. The abutments and analogs were placed in the impression, and silicone (Gi-Mask, COLTENE, www.coltene.com) was injected around them to aid in the fabrication of a soft-tissue model. The dental laboratory then removed the implant analogs and abutments and poured die stone to complete the master cast, void of any bubbles (Figure 4). The lab mounted the casts on a Stratos 100™ articulator using Adesso Split Plates (Ivoclar Vivadent, Inc., www.ivoclarvivadent.com ).The lab filled out a prescription and sent the models without the articulator to the BellaTek® Production Center in Florida.

    The casts were digitally scanned with a D700 3D scanner (3Shape Inc., www.3shape.com). Using the data derived from the BellaTek Encode Healing Abutments, virtual implant abutments were designed using the Abutment Designer™ CAD software (3Shape Inc.). These designs were sent to the dental laboratory, where the emergence profiles, crown-margin placement relative to the position of the gingival margin, space for definitive crown fabrication, and screw access-opening positions were all reviewed (Figure 5 through Figure 7). Once the designs were approved, Robocast™ Technology (Biomet 3i) was used to place implant analogs robotically in the master cast. Custom CAD/CAM abutments were then milled from a titanium alloy blank using a 5-axis industrial milling machine (Figure 8 through Figure 10).

    The custom abutments were sent to the dental laboratory on the Robocast for fabrication of the definitive PFM crowns. The crown wax-up was performed directly on the CAD/CAM abutments (Figure 11). The definitive crowns were placed on the Robocast to confirm proper seating, contours, and contacts (Figure 12 and Figure 13). The abutments and crowns were then sent to the restorative dentist.

    The CAD/CAM abutments were placed on the implants, and prosthetic screws were hand-tightened (Figure 14). Full seating was confirmed radiographically (Figure 15). After proper abutment seating was confirmed, Gold-Tite® Abutment Screws (Biomet 3i) were torqued to 20 Ncm using a torque driver. The PFM crowns were placed, and radiographs were taken to confirm their full seating (Figure 16). The crowns were cemented in place (RelyX™, 3M ESPE) (Figure 17), and all excess cement was meticulously removed.

    Discussion

    The use of traditional implant impression copings can be challenging.5 If healing abutment removal and placement of an impression coping is not done quickly, the soft tissue can slump and be pinched. Implant angulation can create situations where impression-coping placement is blocked by the adjacent teeth and/or impression copings. In posterior sites, access to the implant can be difficult. Once the copings are placed, patients cannot fully close their mouths. Finally, placing the impression tray over the coping(s) requires additional clinical skills. This is especially true when an open-tray pick-up impression coping must be positioned within the prepared hole in the tray. Elimination of the need for impression copings by using coded healing abutments that do not need to be removed during the impression process greatly simplifies the impression process and makes it less expensive and confusing.9-13 Only 1 mm of the abutment needs to extend beyond the surrounding gingiva. The ability of a 3-dimensional (3-D) scanner to digitize the master cast is integral to this process.

    Computer-aided design (CAD) of abutments allows for images of the abutment designs to be reviewed and adjusted prior to definitive abutment fabrication.9-13 Design elements such as the emergence profile and crown margin placement are critical to a properly contoured and natural-appearing restoration. Problems such as inadequate abutment height for a cement-retained crown can be recognized early. Visualizing the virtual abutment prior to its fabrication enables the dental laboratory to confirm that the abutment will be made according to the instructions given on the lab prescription.

    Computer-aided manufacturing (CAM) enables fabrication of high-quality implant abutments from solid blanks of biocompatible materials such as titanium or zirconia.9-13 After milling, the abutment is polished and cleaned. CAD/CAM titanium abutments do not have the risk of impurities or casting defects that cast abutments have. For esthetic purposes, a gold-nitride coating can be applied to titanium abutments, or alternatively, esthetic CAD/CAM zirconia abutments can be fabricated.

    Conclusion

    Combining CAD/CAM technologies with the use of coded healing abutments facilitates and simplifies the ability to deliver high-quality adjacent implant restorations.

    ACKNOWLEDGMENTS

    The authors would like to acknowledge Philip Wine, DDS, in the delivery of these restorations.

    REFERENCES

    1. Heydecke G, Sierraalta M, Razzoog ME. Evolution and use of aluminum oxide single-tooth implant abutments: a short review and presentation of two cases. Int J Prosthodont. 2002;15(5):488-493.

    2. Rasperini G, Maglione M, Cocconcelli P, Simion M. In vivo early plaque formation on pure titanium and ceramic abutments: A comparative microbiological and SEM analysis. Clin Oral Implants Res. 1998;9(6):357-364.

    3. Rompen E, Raepsaet N, Domken O, et al. Soft tissue stability at the facial aspect of gingivally converging abutments in the esthetic zone. a pilot clinical study. J Prosth Dent. 2007;97(6 suppl):S119-S125.

    4. Su H, González-Martin O, Weisgold A, Lee E. Considerations of implant abutment and crown contour: critical contour and subcritical contour. Int J Periodontics Restorative Dent. 2010;30(4):335-343.

    5. Wöstmann B, Rehmann P, Balkenhol M. Influence of impression technique and material on the accuracy of multiple implant impressions. Int J Prosthodont. 2008;21(4):299-301.

    6. Dario LJ. Implant angulation and position and screw or cement retention: clinical guidelines. Implant Dent. 1996;5(2):101-104.

    7. Binon PP. Implants and components: entering the new millennium. Int J Oral Maxillofac Implants. 2000;15(1):76-94.

    8. Daftary F. Dentoalveolar morphology: evaluation of natural root form versus cylindrical implant fixtures. Pract Periodontics Aesthet Dent. 1997;9(4):469-477.

    9. Priest G. Virtual-designed and computer-milled implant abutments. J Oral Maxillofac Surg. 2005;63(9 suppl 2):22-32.

    10. Grossman Y, Pasciuta M, Finger IM. A novel technique using a coded healing abutment for the fabrication of a CAD/CAM titanium abutment for an implant-supported restoration. J Prosthet Dent. 2006;95(3):258-261.

    11. Vafiadis DC. Computer-generated abutments using a coded healing abutment: a two-year preliminary report. Pract Proced Aesthet Dent. 2007;19(7):443-448.

    12. Kapos T, Ashy LM, Gallucci GO, et al. Computer-aided design and computer-assisted manufacturing in prosthetic implant dentistry. Int J Oral Maxillofac Implants. 2009;24(suppl):110-117.

    13. Drago C, O’Connor CG, Peterson T. Robotic analog placement and CAD/CAM abutments. J Dent Tech. 2009;26(7):22-28.

     

    Related Content:

    A CE article, Computer-Guided Implant Surgery: Indications and Guidelines for Use, is available at dentalaegis.com/go/cced457


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    Image Gallery

    Figure 1 Clinical view of coded healing abutments on implants placed in site Nos. 28 through 30.

    Figure 1

    Figure 2 Radiograph of implants verifying that the coded healing abutments were fully seated.

    Figure 2

    Figure 3 Polyvinyl siloxane (PVS) impression of the coded healing abutments.

    Figure 3

    Figure 4 Stone model showing the coded healing abutments.

    Figure 4

    Figure 5 Virtual image of the proposed abutment designs.

    Figure 5

    Figure 6 Virtual image of the proposed abutments with soft tissue and opposing dentition.

    Figure 6

    Figure 7 Virtual image of the screw-access openings within the abutment designs.

    Figure 7

    Figure 8 Master cast with soft tissue and analogs that were placed by the robot.

    Figure 8

    Figure 9 Robocast with soft tissue removed, exposing the robotically placed analogs.

    Figure 9

    Figure 10 CAD/CAM abutments in place on the Robocast.

    Figure 10

    Figure 11 The wax-up for the PFM crowns performed on the CAD/CAM abutments.

    Figure 11

    Figure 12 CAD/CAM abutments and PFM crowns seated on the Robocast.

    Figure 12

    Figure 13 CAD/CAM abutments and PFM crowns seated on the Robocast with soft tissue.

    Figure 13

    Figure 14 Clinical view of the CAD/CAM abutments inserted into the implants.

    Figure 14

    Figure 15 Radiograph confirming that the CAD/CAM abutments were fully seated.

    Figure 15

    Figure 16 Radiograph confirming that the PFM crowns were fully seated.

    Figure 16

    Figure 17 The final crowns in place.

    Figure 17