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Digitising your implant practice

CBCT volume to aid in planning for mandibular implant placement. (Image: Dr Ross Cutts)

Dr Ross Cutts

Thu. 3. May 2018

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Undoubtedly, digital dentistry is the current topic. Over the last five years, the entire digital workflow has progressed in leaps and bounds. There are so many different digital applications that it is sometimes difficult to keep up with all the advances. Many dentists are excited about the advantages of new technologies, but there are an equal number who doubt that the improved clinical workflow justifies the expense.

I have many times heard the argument that there is no need to try to fix something that is not broken. It is so true that impressions have their place and there are certainly limitations to the digital workflow that anyone using the technology should be aware of. For me, however, the benefits of digital far outweigh the disadvantages. In fact, the disadvantages are the same as with conventional techniques.

Chairside CAD/CAM single-visit restorations have been possible for over 20 years, but it was only recently that we became able to mill chairside implant crown restorations after the release of Variobase (Straumann) and similar abutments. I made my first CEREC crown (Dentsply Sirona) back in 2003 with a powdered scanner, and the difference from what I remember then to how we can make IPS e.max stained and glazed restorations (Ivoclar Vivadent) now is amazing.

An investment not an expense

The results of a survey regarding the use of CAD/ CAM technology were published online in the British Dental Journal on 18 November 2016. Over a thousand dentists were approached online to take part in the survey and the 385 who replied gave very interesting responses. The majority did not use CAD/CAM technology, and the main barriers were initial cost and a lack of perceived advantage over conventional methods.

Thirty per cent of the respondents reported being concerned about the quality of the chairside CAD/CAM restorations. This is a valid point. We must not let ourselves lose focus that our aim should always be to provide the best level of dentistry possible. For me, digital dentistry is not about a quick fix; it is about raising our performance and improving predictability levels by reducing human error.

In the survey, 89 per cent also said they believed CAD/CAM technology had a major role to play in the future of dentistry. I really cannot imagine that once a dentist has begun using digital processes that he or she would revert to conventional techniques.

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What is digital implant dentistry?

Many implant clinicians have probably been using CAD/CAM workflows without even realising it, as many laboratories were early adopters, substituting the lost-wax technique and the expense of gold for fully customised cobalt–chromium milled abutments (Fig. 1).

One of my most important goals in seeking to be a successful implantologist is to provide a dental implant solution that is durable. We have seen a massive rise in the incident of peri-implantitis and have found that a large proportion of these cases can be attributed to cement inclusion from poorly designed cement-retained restorations (Fig. 2). Even well designed fully customised abutments and crowns can have cement inclusion if the restoration is not carefully fitted (Fig. 3). This has led to a massive rise in retrievability of implant restorations, with screw-retained crowns and bridges now being the goal. However, making screw-retained prostheses places even greater emphasis on treatment planning and correct implant angulation.

With laboratories as early adopters, we have been milling titanium or zirconia customised abutments for over ten years (Fig. 4). What has changed recently in the digital revolution is the rise of the intraoral scanner. We now have a workflow in which we can take a preoperative intraoral scan and combine this with a CT scan using coDiagnostiX (Dental Wings) in order to plan an implant placement accurately and safely. We can also create a surgical guide to aid in accurate implant placement, have a temporary crown prefabricated for the planned implant position and then take a final scan of the precise implant position for the final prosthesis.

Accuracy of intraoral scanners

Figures 4 to13 show the workflow for preoperative scanning, which includes the implant design, guide fabrication and surgical placement of two fixtures. Intraoral scanners have improved over the last few years, and their accuracy and speed provide a viable alternative to conventional impression taking. The digital scan image comes up in real time and you can evaluate your preparation and quality of the scan on the screen immediately. Seeing the preparation blown up in size no doubt improves the technical quality of your tooth preparations. The scan can then be sent directly to the laboratory for processing.

While we do not think of intraoral scanners as being any more accurate than good-quality conventional impressions, there are many benefits of scanning, such as no more postage to be paid for impressions, vastly reduced cost of impression materials, almost zero re-impression rates and absolute predictability.

Of course, there are steep learning curves with the techniques, but once a clinician has learnt the workflow, there really is no looking back.

We have three different scanners in the practice: the iTero (Align Technology), the CEREC Omnicam (Dentsply Sirona) and the Straumann CARES Intraoral Scanner (Dental Wings; Fig. 14). The CEREC Omnicam is fantastic for simple chairside CAD/CAM restorations, such as IPS e.max all-ceramic restorations on Variobase abutments. For truly aesthetic results, we, of course, still have a very close working relationship with our laboratory, but, undoubtedly, patients love the option of restoration in a day. Being able to scan an implant abutment and then an hour later (to allow for staining and glazing) fitting the definitive restoration is a game changer. Patients also love watching the production process as they see their tooth being milled from an IPS e.max block.

Figures 15–19 show the production process, including the exposure of the implant, the abutment seating, the scan flag on top of the abutment, the healing abutment during fabrication and the delivery of the final prosthesis. However, for more than single units or aesthetic single-unit cases, we use the iTero and Straumann scanners. The latter we have only had at our disposal since February. While it is a powdered system at the moment, this is due to change this month. Particularly with implant restorations, the need to apply a scanning powder is a limitation, owing to a lack of moisture control contaminating the powder. The technology, however, is superb, as is the openness of the system, which provides the advantage of being able to export files into planning software. A colleague of mine even uses it for his orthodontic cases now instead of wet impressions.

We invested in the iTero scanner five years ago and have used it for everything, from simple conventional crowns and bridges to scanning for full-mouth rehabilitations. When fabricating definitive bridgework, we use Createch Medical frameworks for screw-retained CAD/CAM-milled titanium and cobalt–chromium frameworks. Even though intraoral scanning appears extremely reproducible and accurate, I still use verification jigs where needed to ensure our frameworks are as accurate as possible. There are many intricacies that we consider and tips and techniques that we employ to make the scans more accurate that we have developed over time. The closer the scanbodies are together, the more accurate the scan is. Also, the more anatomical detail, such as palatal rugae or mucosal folds, the better the scans can be stitched together.

Figure 20 shows a CBCT volume to aid in planning for mandibular implant placement (Fig. 21) and realising the implant placement. We exposed the fixtures and placed Straumann Mono Scanbodies (Fig. 22). Then, we took an iTero scan of the fixtures in situ (Fig. 23) and made a verification jig from this (Fig. 24) to ensure passive implant positioning. The iTero models were made (Fig. 25) and a Createch titanium framework was used to support porcelain in a screw-retained design (Fig. 26). The last two figures show the excellent outcome and accurate framework seating (Figs. 27 & 28).

Choosing your workflow

There are many different systems on the market now, each offering a one-stop shop. If you are considering investing in a digital scanner, then take some advice from colleagues. One of the most important things is to ensure the system you opt for is an open one that allows you to extract the digital impression data into different software. We extract our files into CT planning software, model production software, chairside milling for stents, temporaries and definitive restorations, and now orthodontic planning software. I am convinced there will be yet more advances with time. The size of the camera is critical—some can be very cumbersome—and it is worth asking the salesperson what developments are underway.

Some companies are more on the cutting edge than others. My favourite at the moment is the Straumann scanner. Its design is light and user-friendly and it synchronises perfectly with implant planning software coDiagnostiX. Furthermore, while it offers a chairside milling unit, it also synchronises perfectly with my laboratory for larger cases.

To conclude, digital implant dentistry is the future and so why not take advantage of it and help improve your clinical outcomes?

Editorial note: A list of references is available from the publisher. This article was published in CAD/CAM - international magazine of digital dentistry No. 03/2017.

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Fig. 1a: Initial intra-oral photograph presenting the main features of ectodermal dysplasia. (All images: Dr Joëlle A. Dulla et al.)

Dr Gülce Çakmak

Dr Burak Yılmaz

Dr Eleni Trikoili

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3D printing has emerged as a disruptive innovation in restorative dentistry, offering a high degree of precision, efficiency and customisation.^1, 2 Recent advancements in printable resin composites, particularly those containing inorganic fillers, have broadened the clinical applicability of 3D-printed definitive restorations.³^–5 These materials support the fabrication of various-sized fixed prostheses, including veneers, inlays, onlays, partial crowns and complete crowns, with mechanical and aesthetic properties suitable for long-term intra-oral use.⁶

Among the latest innovations in chairside 3D printing is tilting stereolithography (TSLA; Dfab, DWS Systems), which utilises a proprietary cartridge-based delivery mechanism. This system offers significant advantages over traditional vat polymerisation methods, particularly in terms of contamination control, user convenience and environmental safety, because it eliminates the need for open resin vats and reduces operator exposure to volatile monomers.^7, 8 Additionally, the system allows for rapid fabrication of monolithic restorations with high precision and minimal post-processing.⁹ Recent in vitro and in vivo studies have demonstrated the dimensional accuracy, marginal adaptation and clinical feasibility of restorations produced with TSLA technology, especially for veneers and onlays.^1, 6, 9

The integration of 3D printing into paediatric dentistry is an area of growing interest, particularly in the management of complex craniofacial conditions such as ectodermal dysplasia (ED). ED encompasses a heterogeneous group of inherited disorders characterised by abnormalities in tissue derived from the ectoderm, including teeth, hair, nails and sweat glands.¹⁰ In the orofacial region, dental tissue alterations are often the earliest and most prominent clinical indicators, and features such as hypodontia, anodontia, conical teeth and reduced alveolar growth are commonly observed.^11, 12

This report presents the interdisciplinary management of a young child referred to a private dental practice in Lausanne in Switzerland in May 2023 with suspected ED. This case highlights the potential of 3D printing as a viable treatment modality in young paediatric patients with congenital dental anomalies.

Figs. 1b–e: Initial intra-oral and extra-oral photographs presenting the main features of ectodermal dysplasia.

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Case presentation and treatment

The 3.5-year-old male patient had complete eruption of the primary dentition (Figs. 1a–e), and a genetic evaluation owing to suspected ED was underway at the university hospital, prompted by his characteristic clinical features, including conical maxillary and mandibular primary incisors and hypotrichosis. His fingernails appeared clinically normal, and there was no documented family history of ED. Nonetheless, the dental findings evident even in the developing primary dentition were consistent with a diagnosis of ED. Clinical examination confirmed the presence of atypical conical morphology of the maxillary and mandibular primary anterior teeth, consistent with the phenotypic presentation of ED. Additionally, a deep overbite with mucosal impingement was noted, along with a pronounced mento-labial fold, suggestive of altered lower facial height and compromised soft-tissue support.

The treatment approach focused on addressing aesthetic, psychosocial and functional concerns related to the anterior dentition through appropriate dental care. Given the patient’s age and the need to restore both the vertical dimension of occlusion and facial aesthetics, a digital workflow incorporating the TSLA 3D-printing technology was employed to deliver a minimally invasive, aesthetically driven and age-appropriate prosthetic solution.

Figs. 2a–k: Initial digital design with increased vertical dimension of occlusion.

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Figs. 3a–c: Dfab printer, chairside (a) and desktop versions (b), and Dcure post- polymerisation unit (c)

The patient underwent an initial compliance and behavioural assessment. During this visit, intra-oral and extra-oral clinical photographs were obtained, and a digital impression was recorded using a TRIOS 4 intra-oral scanner (3Shape). The digital files were transferred to the dental clinics of the University of Bern in Switzerland for virtual design.

To establish anterior occlusal clearance, the vertical dimension of occlusion was increased by 2 mm, to achieve the required functional space. Minimally invasive partial-coverage veneers and crowns were designed for the maxillary arch (teeth #55–65) and mandibular anterior teeth (teeth #73–83; Figs. 2a–k).

To fabricate the restorations, the design’s STL files were uploaded to a Dfab printer (DWS Systems; Figs. 3a–c) and positioned so that the incisal edge or occlusal surface was perpendicular to the build platform, using the integrated nesting software (Photoshade, DWS Systems; Figs. 4a–d). Supporting structures were automatically created on the incisal edge or occlusal surface, and the restorations were printed at a 50 µm layer thickness using a hybrid resin composite (Irix Max, Shade A2; DWS Systems). The printing process took approximately 15 minutes and was completed without issue (Figs. 5a & b).

After fabrication, the restorations were cleaned in a shaker containing 96% ethanol for 45 seconds and then dried (Figs. 6a & b). The supporting structures were removed, and the manufacturer’s proprietary polymerisation unit (Dcure, DWS Systems) was used for a 9-minute post-polymerisation cycle. The restorations were then tried on 3D-printed models (Figs. 7a & b). The restorations were polished using a polishing kit (Kit 1439, Jota), cotton wheels and a polishing paste (Universal Polishing Paste, Ivoclar).

Figs. 4a–d: STL files of the restorations on the build platform as seen in the Photoshade orientation, nesting and colour gradient-setting software.

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Fig. 5a: Restorations produced with the Dfab printer and Irix Max hybrid resin composite.

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Fig. 6a: 3D-printed restorations after washing, ready for separation from the platform and post-polymerisation.

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Fig. 7a: 3D-printed restorations on the models.

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The restorations were then tried in the mouth to confirm fit and aesthetics, and the parents’ final consent was obtained. The restorations were sand-blasted (Renfert) internally using 50 µm aluminium oxide powder at a pressure of 200 kPa for a duration of 10 seconds from a distance of 10 mm and steam-cleaned for 10 seconds. The tooth surfaces were isolated using cotton rolls and lip, cheek and tongue retraction was achieved. The maxillary posterior crowns (on teeth #55, 54, 64 and 65) were cemented first, followed by the maxillary anterior crowns (on teeth #52, 51, 61 and 62) using a dual-polymerising resin cement (els cem, SAREMCO Dental) with its corresponding dual-polymerising, two-component self-etching bonding agent (els duobond, SAREMCO Dental) following the manufacturer’s recommendations. One drop of the els duobond base and one drop of the els duobond catalyst were mixed with a brush for around 5 seconds. This material was then applied to the tooth surfaces with a micro-brush and gently air-dried. The resin cement was applied directly into the restorations. Each restoration was seated individually, and excess cement was removed with a micro-brush, an explorer and dental floss. Light polymerisation was performed for 10 seconds on each surface.

At the second visit, adaptation to the altered occlusion without any problems and improvement of speech were confirmed. The protocol for treatment of the tooth surfaces and mandibular anterior restorations was identical to that of the first visit. After cementation, the crown margins were finished and polished using a diamond-coated file (Intensiv Proxoshape, 40 μm) and the same polishing kit (Figs. 8a–f).

Figs. 8a–f: Cementation of the restorations in the mouth.

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Outcomes

Enhancement of aesthetics and function without invasive preparation was successfully achieved. The patient adapted readily to the altered occlusion, modified anterior tooth morphology and changed facial profile (Fig. 9), and no discomfort or functional impairment was reported. According to his parents, improvements in speech articulation and masticatory function were observed, and their overall satisfaction with the outcome was high.

Fig. 9: Profile view after cementation.

Occlusal elevation was essential to address the deep overbite with mucosal impingement, and the restorations were delivered using a simplified cementation protocol optimised for paediatric patients. A dual-polymerising resin cement and corresponding adhesive system were selected for their ease of use, effectiveness and reduced procedural steps, critical factors in managing treatment within the behavioural limits of very young children. The result met clinical and parental expectations, although the cementation and excess cement removal presented a challenge owing to limited access and patient cooperation. Within these constraints, 3D-printed composite restorations demonstrated favourable clinical performance and represent a viable, minimally invasive treatment modality for managing functional and aesthetic needs in the primary dentition, particularly in cases involving dental anomalies such as ED.

Discussion

ED exhibits unique challenges in paediatric dental care owing to its early-onset impact on tooth development, facial aesthetics, oral function and psychosocial well-being. Previous studies have demonstrated that CAD/CAM-fabricated complete dentures, as well as overdentures, can be used as a solution for ED patients with a high aesthetic success rate.¹³ In the present case, a minimally invasive, aesthetically driven and functionally restorative approach was employed using chairside 3D-printed hybrid resin composite restorations in a 3.5-year-old child diagnosed with suspected ED. The treatment aimed to address pronounced dental anomalies, including conical anterior teeth, reduced vertical dimension of occlusion and deep overbite with mucosal impingement, all following a minimally invasive protocol owing to the patient’s age and simultaneously avoiding the use of local anaesthesia.

The application of the TSLA 3D-printing technology allowed for the rapid and precise fabrication of monolithic restorations tailored to the unique anatomy of a developing primary dentition. The closed-cartridge system offered significant clinical advantages, such as simplified material handling, reduced cross-contamination risk and improved workflow cleanliness, critical in paediatric settings, where treatment time and patient cooperation are limited. The use of partial restorations also facilitated relative isolation, optimised cementation conditions and enabled predictable removal of excess luting material in a paediatric setting. Previous studies have demonstrated the accuracy and clinical applicability of 3D-printed restorations using composite-based resins, supporting their use in definitive paediatric treatments.^1, 6

Overall, this patient treatment supports the clinical viability of 3D-printed composite restorations as a minimally invasive, patient-centred treatment option for children with developmental dental anomalies. However, longitudinal studies are warranted to assess the long-term durability, colour stability and retention of such restorations in the primary dentition.

Conclusion

This case demonstrates the clinical feasibility and effectiveness of using 3D-printed composite restorations for minimally invasive rehabilitation of a young patient with suspected ED. The treatment achieved improvements in aesthetics, speech and function without the need for tooth preparation or local anaesthesia, key considerations in paediatric dentistry. Despite challenges related to isolation, cement removal and polishing in a very young child, the digital workflow, combined with behaviourally adapted management, enabled a predictable and well-tolerated outcome. The 3D-printed composite restorations used represent a promising option for early, patient-centred intervention in cases involving developmental dental anomalies.

Editorial note:

This article was published in 3D printing–international magazine of dental printing technology vol. 5, issue 2/2025. The list of references can be found here.