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Special Issues
July/August 2024
Volume 45, Issue 1
Peer-Reviewed

Digital Workflow for Full-Arch Implant Restoration

Full-arch cases for terminal dentition have increased dramatically in recent years thanks to the innovative All-on-4® treatment concept (Nobel Biocare, nobelbiocare.com). This technique affords patients effective and functional chewing capabilities as well as esthetic confidence. In the past, this process was labor-intensive from both a surgical and restorative perspective; dentists would use multiple implants in conjunction with a fixed hybrid prosthesis to achieve both function and esthetics and to ensure the patient had a fixed set of teeth on the day of surgery. Today, the incorporation of digital workflows in everyday practice has changed how these cases are planned and executed for ideal outcomes. Tools such as photogrammetry coupled with CBCT, intraoral scanning, digital photography, and 3D printing allow for greater precision, predictability, and patient satisfaction. Additionally, the execution is streamlined, saving valuable chairtime. The case report presented showcases in step-by-step fashion how any dental practice can effectively incorporate a digital workflow to aid clinicians in confidently delivering the best possible results in the surgical and restorative domain. By embracing digital dentistry and utilizing the Nobel Biocare N1™ system, clinicians can provide patients optimal treatment with superior performance and results.

KEY TAKEAWAYS

A full arch of replacement teeth can be executed in a minimally invasive manner and provided in 1 day. The implant restoration provided in this case is natural looking and enhances a patient's ability to eat, speak, and smile.

Digital planning software allows clinicians to envision their goals for the patient's final prosthesis, helping predict incisal edges, arch form, smile design, implant placement, transition line, and the connection between the implants and multi-unit abutments to the temporary transitional fixed prosthesis.

Based on the protocol of the Nobel Biocare N1™ system used in this case the patient was ready for his final prosthesis 6 to 8 weeks after implant placement.

Navneet Arora, DDS, MPH
Private Practice, Roseville, California; Diplomate,
American Academy of Periodontology and Implant Dentistry

Fig 1. Preoperative patient smile. The patient had severe periodontitis, stage III, grade B. His primary concern was that despite recently having full-mouth periodontal surgery he was still experiencing discomfort eating and chewing food with teeth that had significant mobility. Based on the clinician’s examination and diagnosis, a full-arch fixed prosthesis was deemed the ideal treatment for the patient.

Figure 1

Fig 2. Preoperative retracted view.

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Fig 3. Preoperative CBCT. The digital workflow begins with recording accurate records at the time of the examination. These include full-mouth intraoral scans, CBCT imaging, correct occlusal bite, intraoral photographs, and detailed medical history.

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Fig 4. Upon completion of digital planning with DTX Studio™ suite, surgery was executed. All existing teeth in the maxillary arch were extracted and implant guides would be used to facilitate implant placement.

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Fig 5. Occlusal view of implant guide.

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Fig 6. Guided surgery aids in control of the placement of implants and multi-unit abutments (Nobel Biocare N1 system), ensuring accuracy

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Fig 7. Scans are taken on the day of surgery, including an intraoral scan of the soft tissue prior to the surgery, followed by a scan with the whitecaps exposed to acquire accurate relation between the whitecaps and soft tissue.

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Fig 8. A second scan on the day of surgery is taken using photogrammetry (iCam 4D, Imagine), which provides the XYZ coordinates of every implant placed.

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Fig 9. Based on the initial smile design, a temporary prosthesis is used to aid in acquiring an accurate bite registration. A third scan is of the intaglio and occlusal surface of this denture (as shown). STL files are then transferred to the laboratory technician to finalize the design of the temporary prosthesis using exocad software. The temporary prosthesis is then 3D-printed (SprintRay) and ready to be delivered in the patient’s mouth less than 90 minutes after surgery.

Figure 9

Fig 10. Final prosthesis. With the Nobel Biocare N1 system protocol, the patient was ready for his final prosthesis 6 to 8 weeks after implant placement. Because the temporary prosthesis was fabricated based on the ideal positioning of the implants, only slight change was expected in terms of hard-tissue remodeling and soft-tissue shrinkage and healing.

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Fig 11. After another intraoral scan (and in some cases repeated photogrammetry), final try-in is followed by final delivery of the full-arch prosthesis fabricated using NobelProcera®.

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Fig 12. Occlusal view of final prosthesis.

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Fig 13. Patient’s final smile.

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Fig 14. CBCT scan at 3-month postoperative follow-up showing radiographically the implant placement and temporization.

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