Digital Workflow For Immediate Implant Placement A
Digital Workflow For Immediate Implant Placement A
Digital Workflow For Immediate Implant Placement A
Case Report
Digital Workflow for Immediate Implant Placement and
Chairside Provisionalization in the Esthetic Zone
Received 16 December 2021; Revised 6 March 2022; Accepted 8 March 2022; Published 1 April 2022
Copyright © 2022 Vincent J. J. Donker et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Introduction. Immediate implant placement and immediate chairside provisionalization in the esthetic zone require meticulous
treatment planning. A digital workflow that combines intraoral scans and a cone beam computed tomography scan can be
used to visualize the surgical and restorative aspects of the treatment and to plan a prosthetically driven implant position. A
digital workflow in implant dentistry enables the prefabrication of an individualized CAD/CAM temporary restoration, based
on the planned implant position. This could be a predictable method to deliver a screw-retained temporary restoration, directly
after static computer-assisted immediate implant surgery. Interventions. Three patients with a failing tooth in the maxillary
esthetic zone were treated with immediate implant placement and chairside provisionalization using this digital workflow.
After 3 months, a final restoration was placed. Clinical, radiographic, and patient-reported outcome measures were collected
prior to implant treatment, 6 weeks after placing the temporary restoration and then 1 month and 1 year after placing the final
restoration. Outcomes. At the 1-year follow-up, healthy soft tissues were observed, and peri-implant bone levels were stable.
Patient satisfaction after the treatment was high. Conclusion. The three reported cases demonstrate the potential for predictable
immediate implant placement and chairside provisionalization using a digital workflow.
Using static computer-assisted implant surgery with a surgi- 5. Diagnostic and Planning Procedures
cal template, the implant can then be placed in the correct
three-dimensional position and the individualized screw- Prior to the implant treatment, intraoral scans (TRIOS 3,
retained temporary restoration can be delivered. The whole 3Shape, Copenhagen, Denmark) of the upper jaw, lower
digital workflow could be a predictable method for immedi- jaw, and occlusion were made, as well as intraoral photo-
ate implant placement and chairside provisionalization. graphs (Figure 1) and a CBCT scan (ProMax 3D Max Pro-
The objective of this case report is to describe a treat- Face, Planmeca, Helsinki, Finland). The voxel size of the
ment with this digital workflow for immediate implant CBCT scan was 0.2 mm, and the field of view was 130 × 55
placement and chairside provisionalization in the esthetic mm. The intraoral scans and CBCT Digital Imaging and
zone and to report the clinical, radiographic, and patient- Communications in Medicine (DICOM) file were superim-
reported outcome measures of three cases with a 1-year posed with an implant planning software (DTX Studio
follow-up after placing the final restoration. Implant, Version 3.5, Medicim, Mechelen, Belgium) to cre-
ate an individualized digital set-up of the failing tooth
(Figure 2). The prosthetically driven implant position was
2. Study Design planned in a palatal position with ≥2 mm distance between
the implant and the buccal crest [10] and at a depth of 3-
Recruitment of patients, treatment, and follow-up took place 4 mm apical of the prospective restorative zenith point
in the Department of Oral and Maxillofacial Surgery at the [11]. The implant length was chosen based on the available
University Medical Center Groningen (UMCG), the Nether- bone height apicopalatal of the extraction socket (Figure 3).
lands, between August 2020 and December 2021. The A pilot-drill surgical template to facilitate static
research protocol was approved by the Medical Ethics computer-assisted implant surgery was designed with the
Review Board of the UMCG (METc 2020/014). This manu- implant planning software (Figure 4) and manufactured by
script was written following the CARE guidelines for case a dental laboratory (Dental LT Clear Resin, Formlabs, Som-
reports [9]. erville, MA, United States) (Figure 5). Furthermore, the den-
tal laboratory milled a multilayered polymethyl methacrylate
(PMMA) (Vipi Block Trilux, Vipi Odonto Products, Piras-
3. Patient Information and Clinical Findings sununga, Brazil) temporary shell restoration based on the
individualized digital set-up (Figure 6) using a dental
Patients were eligible for inclusion if they met the following computer-aided design (CAD) software (DTX Studio Lab,
criteria: at least 18 years of age when being treated, in need Version 1.10, Medicim).
of a single tooth implant-supported restoration in a postex-
traction site in the anterior region of the maxilla, the bone 6. Surgical Procedures
height of the planned implant site apicopalatal of the extrac-
tion socket was sufficient (≥4 mm, measured on a CBCT The patient was instructed to start oral disinfection with a
scan) to allow immediate implant placement, suitable ana- 0.12% chlorhexidine mouthwash twice daily on the day
tomical conditions (mesial-distal, buccal-palatal, and inter- before surgery and to continue for seven days. One hour
occlusal space) to place an anatomically designed screw- prior to surgery, the patient took a prophylactic antibiotic
retained restoration, and complies with good oral hygiene (amoxicillin 2 g or clindamycin 600 mg in case of penicillin
practices. Patients with medical and general contraindica- allergy). The surgical procedure was performed using local
tions for the surgical procedure, smoking habits exceeding anesthesia (Ultracain D-S forte, Sanofi-Aventis Deutschland
10 units a day, severe bruxism with dysfunctional tendencies, GmbH, Frankfurt am Main, Germany).
the presence of acute untreated periodontitis in the implant The periodontal ligament was detached by careful intra-
site or adjacent tissue, acute infections in the planned sulcular incision. A periotome and forceps (rotational move-
implant site or adjacent tissue, and a history of local radio- ment only) were used to remove the failing tooth as
therapy to the head and neck region were excluded. minimally traumatic as possible (Figure 7). Any periodontal
Three consecutively recruited patients agreed to partici- ligament remnants and granulation tissue were cleaned away
pate in the study (Table 1). An explanation of the costs, ben- with a bone curette and sterile gauze pads. The implant site
efits, and risks of an implant-supported restoration, and was prepared flapless using the surgical template. With the
possible alternative treatment options was given. Written last drill placed in the prepared implant site to prevent con-
informed consent was obtained from all the patients before gestion, the jumping gap between the buccal crest and the
being enrolled for implant treatment. implant site was grafted with a 1 : 1 mixture of bovine bone
(Geistlich Bio-Oss, Geistlich Pharma AG, Wolhusen, Swit-
zerland) and autogenous bone (Figure 8). After removing
4. Timeline the drill from the grafted alveolar socket, a tapered implant
with a conical connection (NobelActive TiUltra, Nobel Bio-
The patients underwent immediate implant placement and care AB, Gothenburg, Sweden) was inserted according to the
chairside provisionalization according to the treatment pro- manufacturer’s instructions (Figure 9). Primary implant sta-
cedures described in Table 2. One case is presented for illus- bility was attained with an insertion torque of ≥45 Ncm, ver-
trative purposes. ified with a manual torque controller (NobelActive Manual
Case Reports in Dentistry 3
Table 2: Timeline of the immediate implant placement, provisionalization, and final restoration treatment.
7. Restorative Procedures
The implant was restored chairside with a temporary resto-
ration, immediately after implant placement. A temporary
abutment (Temporary Snap Abutment Engaging CC, Nobel
Biocare AB) trimmed to the correct length was snapped onto
Figure 1: Clinical view of the patient with a root fracture of the the implant (Figure 10). The temporary shell restoration was
upper left central incisor. The root is still in situ. placed in position with the lateral wings seated on the adja-
cent teeth (Figure 11) and was connected to the temporary
abutment with a dentine shaded composite resin (Filtek
Supreme XTE, 3 M, Saint Paul, MN, United States). After
light curing, the temporary restoration was removed with
the abutment from the implant. The lateral wings were
trimmed, and a screw-access hole was prepared in the resto-
ration (Apical Drill, Nobel Biocare AB). The cervical part of
the restoration was contoured with composite resin to create
an emergence profile to support the adjacent papillae [12]
(Figure 12). The restoration was polished using polishing
rubbers (Diacomp Plus Twist, EVE Ernst Vetter GmbH,
Keltern, Germany) and tightened on the implant with a tor-
Figure 2: Digital set-up of the upper left central incisor, based on a que value of 35 Ncm using a manual torque controller (Man-
superimposed intraoral scan and CBCT scan. ual Torque Wrench Prosthetic, Nobel Biocare AB). The
screw access hole was sealed with polytetrafluoroethylene
(PTFE) tape and composite resin (Figure 13). The temporary
4 Case Reports in Dentistry
3.0 mm
Figure 3: Sagittal view of the CBCT scan showing the Figure 7: Minimally traumatic removal of the failing tooth using
prosthetically and biologically driven implant planning. forceps with rotational movement.
Figure 8: Buccal socket grafting with the last used drill placed in Figure 12: Emergence profile of the finished and polished
the implant site. temporary restoration.
9. Discussion
Figure 11: Temporary shell restoration with the lateral wings
seated on the adjacent teeth. This case report described a treatment with a digital work-
flow for immediate implant placement and chairside provi-
sionalization in three patients with a failing tooth in the
23.0, Adobe Inc. San Jose, CA, Unites States), and were maxillary esthetic zone. The clinical, radiographic, and
defined as a change in the vertical distance in mm mea- patient-reported outcome measures up to 1 year after plac-
sured from the zenith point to a reference line drawn ing the final restoration were favorable, which is similar to
between the incisal edges of the two adjacent teeth [7]. the 1-year results of immediate implant placement and
6 Case Reports in Dentistry
Table 3: Modified Plaque Index, modified Sulcus Bleeding Index, and Gingival Index (scores 0-3), keratinized mucosa width, Papilla Index
(scores 0-4), and pocket probing depth at T12. Midbuccal mucosal level changes from Tpre to T12. Modified Pink Esthetic Score and White
Esthetic Score (scores 0-10). Marginal bone level changes from T1 to T12. Buccal bone thickness at T12. Patient-reported satisfaction (scores
1-10).
implant planning and ensuing pilot-drill surgical template tion from the digital planning should be taken into consider-
fabrication was based on a stone cast with a conventional ation when using a pilot-drill surgical template [21, 22]. In
wax set-up. Possibly, the combined visualization of the hard the present case report, the temporary shell restorations
and soft tissues in the digital workflow used in this case were connected to the temporary abutment after immediate
report enabled to plan the implant in a more palatal posi- implant placement. This compensated for any deviations
tion, resulting in a thicker BBT. while still resulting in temporary restorations with screw-
In the surgical phase, static computer-assisted immediate access holes on the palatal side in all cases, indicating that
implant surgery with the pilot-drill surgical template this method for immediate single-implant provisionalization
resulted in correct three-dimensional implant placement. It can be used when a fully guided technique is not feasible.
must be acknowledged that a fully guided surgical technique In the restorative phase, the temporary restorations
can offer more accuracy and that a certain degree of devia- could be delivered in the same appointment as the implant
8 Case Reports in Dentistry
placement. Whereas in the studies with a conventional ject administration, and writing—original draft. G.M.
workflow mentioned earlier [6, 7], impression taking after Raghoebar contributed to the conceptualization, investiga-
the surgery was necessary to design and manufacture a cus- tion, methodology, supervision, project administration, and
tomized temporary restoration afterwards in the dental lab- writing—review and editing. A. Vissink contributed to the
oratory, as well as an extra appointment for the temporary conceptualization, methodology, supervision, project
restoration placement. Thus, chair time was reduced by administration, and writing—review and editing. H.J.A.
using the digital workflow. Other advantages of a digital Meijer contributed to the conceptualization, data curation,
workflow for implant restoration procedures are that investigation, methodology, supervision, project administra-
intraoral scanning lowers the procedure time and patient tion, and writing—review and editing.
discomfort compared to conventional impression taking
[23] and that CAD and computer-aided manufacturing
(CAM) can lower the production time and fabrication costs Acknowledgments
of the restorations [24]. These are all possible arguments for
Implant materials for the clinical study were provided by
choosing a digital workflow over a conventional workflow.
Nobel Biocare Services AG, Zürich, Switzerland (study code:
A downside of the temporary shell restorations used in
2019-1627).
these cases is the grayish discoloration of the metal tempo-
rary abutment through the composite and the PMMA. Due
to this discoloration, the mean WES for the temporary resto- References
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