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CAD/CAM implant provisional use reshapes gingival tissues while improving esthetics and hygiene.

How to use CAD/CAM technology for Improved restoration implants while reshaping gingival tissues, and improving both dental esthetics and oral hygiene.

After a high level of success with conventional crowns, inlays, onlays and veneers, chairside CAD/CAM dentistry has progressed to implant dentistry. Since the first ceramic inlay was milled in 1983 (1) many advances have occurred, and dentists and assistants continue to find new, innovative ways to use the technology. This article will provide a discussion of one of these new modalities.

CAD/CAM technology has been used to fabricate provisional restorations for immediate implants for a number of years (2,3). This article discusses the fabrication of a CAD/ CAM anterior implant provisional with an emergence profile designed to develop the soft tissue into a more esthetic and healthy contour.

The patient was referred to our clinic and presented with an implant provisional already in place. The patient was unhappy with the esthetics of the provisional, specifically with the contour and level of the gingiva. The following illustrates how using the E4D CAD/CAM system to fabricate a provisional restoration would facilitate easy removal and allow for modifications necessary to develop the desired soft tissue contours.

Figure 1 (right) shows the abutment and provisional as presented during the first appointment. The implant was placed approximately 5mm apical to the free gingival crest and the abutment was basically a cylinder shape.

The soft tissue (Figure 2, page 14) was thin and non-supported. Subsequent to the successful integration of a connective tissue graft, a new provisional was fabricated in the following manner:

1. A scan of a pre-waxed provisional restoration, representing the desired contours, was made using the E4D image acquisition wand.

2. An intra-oral bone level PVS impression was made.

3. A soft tissue cast capturing the existing architecture of the soft tissue was fabricated.

4. The soft tissue model was modified to improve the emergence profile of the restoration and provide more tissue support.

5. A screw-retained metal provisional abutment was placed into the soft tissue cast and flowable composite was injected around the abutment to the tissue height, capturing the remodeled contours of the soft tissue. (Figure 3, above left)

6. Composite was added to simulate an all-ceramic abutment preparation (Figure 4, above right) while maintaining the access hole for the screw.

7. Wax was placed into the screw hole and the abutment was scanned.

8. The design features of the E4D software were then used to create a digital model of the provisional restoration. Using the design tools, a "hole" was created into the provisional to allow communication with the existing screw access (Figure 5, above right). This access permits easy removal and re-seating of the provisional. The newly-designed provisional was then milled using a composite resin material (Figure 6 and Figure 7, page 16) and bonded to the abutment using flowable composite.

9. The patient returned at approximately two-week intervals to further expand and develop the tissue as desired. Flowable composite was added where necessary. Once the desired emergence profile (Figure 6 and Figure 7, above) was established, the provisional was left in place for approximately one month before the final impression was made.

This technique for using CAD/ CAM technology to mill a screw-retained provisional implant restoration has several advantages. The use of a CAD/CAM-generated provisional allows for efficiency, not only in fabrication, but also during adjustment, as the access hole for the screw-retained provisional allows for easy removal and replacement of the provisional for the addition of composite to the abutment.

The provisional is easily recontoured, by reduction or addition of composite, to further help develop the emergence profile. The restoration can be fabricated without ridge-lap and an appropriate emergence profile can be created. Because the provisional is milled from a monolithic block, the result is a much stronger and a very esthetic provisional restoration. The resulting abutment adds support for the tissue, giving the patient the esthetic results desired.

In addition, the majority of the steps outlined in this article can be accomplished by a dental assistant trained in the use of CAD/CAM technology. This can save the dentist considerable chair time; time which can be converted to increased clinical productivity.

Resources

1. Mormann W.H., The origin of the cerec method: a personal review of the first five years. Int J Comput Dent. 2004; 7(1): 11-24.

2. Tselios N., Parel, S.M., Jones J.D., Immediate placement and immediate provisional abutment modeling in anterior single-tooth implant restorations using a CAD/CAM application: A clinical report. J Pros Dent. 2006;95(3): 181-185

3. Gougaloff R, Stalley F.C., Immediate Placement and Provisionalization of a Dental Implant Utilizing the CEREC 3 CAD/CAM Protocol: A Clinical Case Report. CDA J. 2010; 38(3): 171-177.

Richard S. Callan, DMD

Associate Professor and Chair, Department of General Dentistry

Georgia Regents University

Jeril R. Cooper, III, DMD

Associate Professor, Department of General Dentistry

Georgia Regents University

Richard S. Callan, DMD directs the practice management curriculum for the College of Dental Medicine at Georgia Regents University and supervises the Comprehensive Care Clinic. His research interests involve educational pedagogy. He is a member of the American Dental Association, the American Dental Education Association, the International College of Dentists and the Pierre Fauchard Academy.

Jeril R. Cooper, III, DMD, Associate Professor of General Dentistry, joined Georgia Regents University (GRU) after 30 years of private practice. He maintains an active faculty practice. Memberships include the Pierre Fauchard Academy, and a Fellowship in the Academy of General Dentistry. In 2008, he received GRU's Judson C. Hickey Award.
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Author:Callan, Richard S.; Cooper, Jeril R., III
Publication:The Dental Assistant
Article Type:Report
Geographic Code:1USA
Date:May 1, 2014
Words:931
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