IFU

New tools for rehabilitation on implants, Arcsys and digital workflow

Author: Prof. Dr. Patricio Runnacles

Female patient, 48 years old.

CHIEF COMPLAINT

Get the definitive crown as soon as possible.

INTRODUCTION

A new era in the oral rehabilitation of patients with conventional fixed prostheses or unitary, partial, or full implants seems to be consolidating. For decades, there has been a pursuit for technological development. A new way to transfer the necessary information from the patient’s mouth to the laboratory bench.

In the context of oral rehabilitation, moldings play an essential role in the manufacture of any type of prosthesis, since without this step, a link in the restorative chain is broken. Although conventional molding is a common step in the dental clinic, it presents several problems, such as bubbles, tears, compression of tissues, distortion of the material itself, distortion of the plaster of the model, working time, pouring time, collection or shipping requirements, etc. Thus, mold selection, stock of molding materials, plaster, and other materials will be less and less used to mold and transfer, being replaced by digital workflow.

By means of an intraoral scan, the collection of images is compiled. With the help of a software, a digital copy of the region that has been scanned is reproduced. From that moment, the whole process of planning, waxing, and designing the future prosthetic part is done on the computer. Thus, the physical model is often no longer needed.

This new way of clinical practice–the digital workflow–is increasingly present in dental clinics, adding convenience, precision, and predictability to restorative procedures, and offers several advantages both for the clinician and for the patient as well as for the prosthesis laboratory. This was the means chosen to perform the steps of transferring the spatial position of the implant.

In this article we present a case report in which the patient sought treatment to recover her masticatory functions and comfort in the left posterior jaw region. We present these new technologies that have been used, such as the Arcsys implant and digital workflow.

CASE REPORT

The 48-year-old patient sought treatment in a private clinic in the city of Curitiba-PR, where she was rehabilitated with an implant in the region of element 37 and then received the installation of an abutment as a prosthetic component to receive a future unitary screw-retained crown. An immediate provisional in acrylic resin was made using the transfer on PEEK multifunctional abutment for screw-retained restoration as a provisional cylinder. Captured with the resin Bulk Fill Flow APS FGM.

After the necessary period of osseointegration with mature peri-implant tissues (Fig. 1), the patient underwent the definitive prosthetic rehabilitation processes.

Fig. 1a Vista oclusal do sextante inferior esquerdo com o provisório imediato meses após a cirurgia
Fig. 1a Occlusal view of the left inferior sextant with immediate provisional restoration months after surgery
Fig. 1b Vista oclusal do sextante inferior esquerdo sem o provisório mostrando o perfil de emergência alcançado e pilar Arcsys instalado
Fig. 1b Occlusal view of the left inferior sextant without the provisional restoration showing the emergence profile and installed Arcsys abutment for screw-retained restoration.
Fig. 1c Detalhe da relação do pilar com o perfil de emergência, alcançado com o provisório.
Fig. 1c Detail of the relation of the abutment for screw-retained restoration with the emergence profile achieved with the provisional restoration.

ORALINTRAORAL SCANNING

Intraoral scanning was performed in the upper arch and in the lower arch with the provisional restoration in position, the files generated with the images captured by a scanner. The temporary crown was then removed to start scanning and the emergency profile was created (Fig. 2), the Scan Body for the abutment was screwed in (Fig.3) with 10µm of torque, as indicated by the Arcsys FGM system and another scan was done on the implant region (Fig. 4). To complete the scan, new images were captured with the patient in occlusion. The images are then rendered, transformed into STL files with the help of software (Fig. 5).

Fig. 2 Imagem do perfil de emergência e pilar Arcsys capturada pelo escaner intraoral (transferência do perfil de emergência digital), após renderização.
Fig. 2 Arcsys emergence profile and abutment image captured by intraoral scanner (digital emergence profile transfer), after rendering.
Fig. 2a Imagem digital dos arcos superior e inferior em oclusão, após renderização.
Fig. 2a Digital image of the upper and lower arches in occlusion, after rendering.
Fig. 3 Imagem do Scan Body intra oral para pilar, instalado em boca, vista lateral.
Fig. 3 Image of intraoral Scan Body for abutment, installed in mouth, side view.
Fig. 3a Imagem do Scan Body intra oral para pilar, instalado em boca, vista anteroposterior e a relação com a mesa oclusal dos dentes adjacentes.
Fig. 3a Image of the intraoral Scan Body for abutment, installed in the mouth, anteroposterior view and the relationship with the occlusal table of the adjacent teeth.
Fig. 4 Imagem digital do arco inferior com o Scan Body intra oral para pilar, após a renderização das imagens capturadas pelo escaneamento intra oral (“moldagem digital”).
Fig. 4 Digital image of the lower arch with the intraoral body scan for abutment, after rendering the images captured by the intraoral scan (digital molding) Fig. 5 upper and lower arches in occlusion; STL files in exocad.
Fig. 5 Arcos superior e inferior em oclusão, arquivos STL no exocad.
Fig. 5 Lower arch; STL file in exocad; selected artificial gum and Arcsys abutment for screw-retained restoration in the Arcsys library.
Fig. 5a Arco inferior, arquivo STL no exocad, selecionados gengiva artificial e pilar Arcsys com parafuso na biblioteca Arcsys.
Fig. 5a Lower arch; STL file in exocad; selected artificial gum and Arcsys abutment for screw-retained restoration in the Arcsys library.

CAD/CAM

After the images are captured, the CAD process begins (Computer Aided Design). With the files properly selected and exported to another software the second step with CAD (Computer Aided Design) is carried out–the design for manufacturing the definitive crown. A metallic anti-rotational link was selected as the base of the activation in the Digital Library of the Arcsys FGM system (Fig.6). The crown of the second lower molar was digitally manufactured (Fig. 7). For this case, a monolithic zirconia infrastructure with a 1 mm cutback was defined to create room for makeup and layering of the final layer. With the design of this infrastructure finished, the TPD exports the files and starts the CAM (Computer Aided Manufacturing) process of milling the part and subsequent make-up and layering. Once the crown is finished, it is sent to the clinic for proof and installation.

Fig. 6 Arquivo STL do Scan Body em posição.
Fig. 6 STL file of Scan Body in position.
Fig. 6a Arquivo STL do arco inferior e link metálico selecionado na biblioteca Arcsys, sobre pilar.
Fig. 6a STL file of the lower arch and metallic link selected in the Arcsys library, over abutment.
Fig. 6b Arquivo STL do arco inferior e superior em oclusão e a relação do link metálico selecionado na biblioteca Arcsys, sobre pilar com o antagonista.
Fig. 6b STL file of the lower and upper arc in occlusion and the relationship of the metallic link over the abutment selected in the Arcsys library with the antagonist.
Fig. 7 Desenho da construção da coroa para o elemento 37.
Fig. 7 Crown construction design for Element 37.

CEMENTATION OF THE METAL LINK

To perform the cementation, blasting of the metal link with aluminum oxide was performed (Fig.8). The screw entry to the link was protected with teflon tape and the parts were cleaned with alcohol 70 [Fig. 9). A thin layer of Ambar APS FGM adhesive was applied to the inner part of the zirconia crown (Fig.10) and light-cured (Fig. 11). Almost instantly the cement FGM Allcem core in A1 color was dispensed with (Fig 12). It is important to remove all excesses before the initial polymerization, then photopolymerize the edges and wait for the chemical locking of the FGM Allcem Core dual cement. Finishing, polishing, and cleaning the part before installation [Fig.13).

Fig. 8 Imagem dos materiais utilizados para a cimentação extra oral da coroa sobre o link metálico.
Fig. 8 Image of the materials used for the extraoral cementation of the crown on the metal link.
Fig. 8a Imagem de dois links metálicos, o da direita após jateamento com óxido de alumínio.
Fig. 8a Image of two metal links, the one on the right after blasting with aluminum oxide.
Fig. 9 Imagem da proteção da entrada do parafuso do pilar com uma fita de teflon e limpeza das estruturas, interna da coroa e externa do link, com álcool 70.
Fig. 9 Image of the protection of the entrance of the abutment screw with teflon tape and cleaning of the structures, internal of the crown and external of the link, with alcohol 70.
Fig. 9a Imagem da proteção da entrada do parafuso do pilar com uma fita de teflon e a relação com a “chaminé” da coroa sobreposta.
Fig. 9a Image of the protection of the entrance of the pillar screw with teflon tape and the relationship with the “chimney” of the overlapping crown.

PROOF AND INSTALLATION

The temporary crown was removed and the new one installed (Fig. 14), performing the necessary assessments of contact, color, shape and adjusting the final torque of 10 N.cm. After protecting the screw inlet with a teflon “ball”, the “chimney” was closed with a composite resin restoration (Fig.15) via the Vittra APS Unique FGM. Static and dynamic occlusion contacts were checked, followed by adjustments, when necessary, and final polishing of the restoration (Fig.16).

Fig. 10 Aplicação de adesivo Ambar APS
Fig. 10 Application of Ambar APS adhesive.
Fig. 11 Imagem artística do processo de fotopolimerização
Fig. 11 Artistic image of the light curing process.
Fig. 12 Aplicação do cimento Allcem Core sobre o link metálico.
Fig. 12 Application of Allcem cement core on the metal link.
Fig. 13 Imagem da coroa cimentada sobre o link após acabamento e polimento, ao lado do análogo digital para modelos impressos.
Fig. 13 Picture of the cemented crown on the link after finishing and polishing, next to the digital analog for printed models.
Fig. 14 Vista lateral da coroa definitiva e sua relação com o dente adjacente e antagonista
Fig. 14 Lateral view of the definitive crown and its relationship to the adjacent and antagonistic tooth.
Fig. 15 Fotopolimerização da restauração de resina para fechar o acesso do parafuso na coroa sobre implante.
Fig. 15 Light-curing of the resin restoration to close the screw access in the crown over the implant.
Fig. 16 Vista oclusal da coroa após ajustes e polimento final.
Fig. 16 Occlusal view of the crown after adjustments and final polishing.

CONCLUSION

Comfort and predictability are some of the benefits of this modern option of molding and confection of prosthetic parts during oral rehabilitation.

The digital workflow, a new and timely tool, is increasingly being incorporated into orthodontic clinics. It is transforming our relationship with our patients, our colleagues, and above all, our dental prosthesis laboratory.

REFERENCES

  1. Joda, T., Zarone, F. & Ferrari, M. The complete digital workflow in fixed prosthodontics: a systematic review. BMC Oral Health 17, 124
    (2017). https://doi.org/10.1186/s12903-017-0415-0
  2. Azevedo JF, Catharino F, Zerbinat LP. O Fluxo Digital na Odontologia Contemporânea. J Dent Pub H. 2018;9(4):252-253
  3. Rafael Amorim Cavalcanti Siqueira, Renata Cimões, L. P. M. A. C. A. S. (2018). Impressão 3D na reabilitação com implantes dentários.
    ARCHIVES OF HEALTH INVESTIGATION, 7.
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