3D virtual patient-Magnetically retained printed stackable system for implant guided placement: Case report.

OBJECTIVE: The aim of this report is to present the complete workflow of 3D virtual patient for planning and performing implant surgery with magnetically retained 3D-printed stackable guides. CLINICAL CONSIDERATIONS: A 3D-printed stackable system was proposed based on bone, dental, and facial references. Initially, a 66-year-old male patient was digitalized through photographs, cone beam computed tomography, and intraoral scans (Virtuo Vivo, Straumann). All files were merged to create a 3D virtual patient in the planning software (coDiagnostiX, Straumann). Sequential stackable guides were designed, printed, and cured. Magnets were inserted into connectors, and the interim protheses received color characterization. Four mounted guides were produced for the specific purposes of pin fixation, bone reduction, implant placement, and immediate provisionalization. After surgery and healing period, patient digital data were updated. Final implant positions were compared to planned values and inconsistencies were clinically acceptable. The mean angular deviation was 5.4° (3.2-7.3) and mean 3D discrepancies were of 0.90 mm (0.46-1.12) at the entry point and 1.68 mm (1.00-2.20) at implant apex. Case follow-up revealed stability, patient's comfort, and no intercurrences. CONCLUSION: Magnetically retained stackable guides provide treatment accuracy and reduce surgical and prosthetic complications. The projected virtual patient enhances decision-making and communication between the multidisciplinary team and the patient, while decreases time and costs. CLINICAL SIGNIFICANCE: Bidimensional diagnosis and freehand implant placement have limitations and outcomes often rely on professionals' expertise. Performing facially driven virtual planning improves treatment predictability. This approach promotes function, esthetic harmony, and patient satisfaction. Implant guided surgery and 3D printed prostheses constitute a reproducible digital workflow that can be implemented into clinical practice to optimize dental care.

Modified Surgical Guide for Root Sectioning in the Socket Shield Technique-In Vitro Study.

OBJECTIVE: This in vitro study aimed to evaluate the effectiveness of a printed surgical guide for root sectioning in the socket-shield technique. MATERIALS AND METHODS: A typodont model of the maxilla with augmented filler was used for the upper right central incisor, and CBCT images were obtained. Two types of vertical root sectioning guides were tested: one with a buccal sleeve (Group A, n = 10) and another with a buccal orientation slit (Group B, n = 10). Control group (n = 10) performed freehand cuts on printed models. After crown cutting with diamond burs, root sectioning was conducted using an ultrasonic tip with the guides. Mean and standard deviation were calculated for the remaining root length, width, and volume. Data were analyzed using the Kruskal-Wallis test and Dunn's post hoc test. RESULTS: Statistical analysis showed significant differences in root width between the control group (2.0 mm) and both Groups A (2.655 mm; p < 0.0001) and B (2.460 mm; p < 0.0001). Group B (5.585 mm) also showed a significant difference in root remnant compared with the control (13.880 mm; p < 0.0043). Groups A and B did not differ significantly from each other. CONCLUSIONS: The socket shield technique is safe and effective, this study aimed to add improvements through the introduction of surgical guides, facilitating the root section, which is the critical phase so that the parameters that are requisite for success are achieved in terms of width, length, and volume of the root remnant. Both guided techniques effectively facilitated root sectioning, maintaining satisfactory root thickness and length. CLINICAL SIGNIFICANCE: Sectioning the root is challenging for the correct angulation to remove the palatal portion in the socket shield technique. Therefore, modifying this technique with the use of the presented guides, it is possible to prevent damage to the soft tissues and to plan the surgery with the help of cone beam computed tomography (CBCT) scans to remove the root apex and maintain the root remnant with a thickness greater than 1.5 mm, making the socket-shield technique more predictable.

CAD-CAM natural restorations-Reproducing nature using a digital workflow.

OBJECTIVES: Natural restorations combine digital workflow and shell technique to create CAD/CAM restorations with the form and texture of natural teeth. This case report describes an interdisciplinary digital workflow combined with CAD/CAM natural restorations to achieve the naturalness of an anterior rehabilitation. CLINICAL CONSIDERATIONS: A 38-year-old patient attended to the office with esthetic issues. An interdisciplinary treatment plan was conducted, which included periodontal surgery to recreate the gingival contour, associated with bleaching and manufacturing CAD/CAM ceramic veneers to return an optimal teeth surface texture and shape. CONCLUSIONS: The design and manufacturing of CAD/CAM natural restorations using a digital workflow allowed a predictable result and overcame the limitations of conventional shell technique. CLINICAL SIGNIFICANCE: Conventional shell technique is used to create restorations with the form and texture of natural teeth. This article presents a combination of the conventional shell technique with a digital workflow, facilitating the design and manufacturing of CAD/CAM natural restorations.

Artifacts in magnetic resonance imaging of the head and neck: Unwanted effects caused by implant-supported restorations fabricated with different alloys.

STATEMENT OF PROBLEM: Implant-supported restorations may cause artifacts in magnetic resonance imaging (MRI) of the head and neck area. However, the effect of different alloys remains unclear. PURPOSE: The purpose of this in vitro study was to assess artifacts in head and neck MRI caused by implant-supported restorations with different alloys. MATERIAL AND METHODS: Three dry mandibles were prepared to receive bilateral dental implants at the second premolar and second molar sites. Different alloy combinations were evaluated: titanium implants+cobalt chromium restorations; titanium-zirconium implants+cobalt chromium restorations; and zirconia implants+ceramic restorations. Specimens were imaged by using a 3-Tesla magnetic resonance scanner system (Achieva 3.0T TX; Philips GmbH) with a turbo-spin-echo sequence. Scan protocols were adjusted to optimize metal artifact reduction and shorten scan time. Artifact volumes were assessed and statistically analyzed by using the Kruskal-Wallis and Spearman tests (α=.05). RESULTS: A statistically significant difference was found among artifact volume caused by different materials (P=.002). The presence of titanium alloy was correlated with the artifact volume (r=-.87). Artifacts were greater for titanium and fewer for titanium-zirconium alloys, whereas zirconia implants found only minimal artifacts. CONCLUSIONS: The dimension of artifacts produced by implant-supported restorations varied according to the material.

A digital technique for cloning the emergence profile of the interim to the definitive implant-supported restoration.

The subgingival contour of implant-supported restorations is key to ensuring the long-term health of the peri-implant bone and soft tissues. This report describes a step-by-step technique used to accurately clone the emergence profile of the interim crown for the definitive implant-supported restoration.

Clinical outcomes of digital scans versus conventional impressions for implant-supported fixed complete arch prostheses: A systematic review and meta-analysis.

STATEMENT OF PROBLEM: With the growing use of digital scanning, an evaluation of the clinical impact of digital scans versus conventional impressions in complete arch implant-supported prostheses is needed. However, systematic reviews on this subject are lacking. PURPOSE: The purpose of this systematic review was to evaluate the scanning and impression times and the radiographic marginal bone loss over time associated with digital scans and conventional impressions for complete arch implant-supported fixed prostheses. MATERIAL AND METHODS: The search was performed in MEDLINE/PubMed, SCOPUS, EMBASE, and Web of Science. Only randomized clinical trials (RCTs) comparing digital scans and conventional impressions for complete arch prostheses were included in the review. The scan and impression times and marginal bone loss were analyzed through random effects meta-analysis. RESULTS: Six RCTs were included. The meta-analysis was conducted by using a standardized mean difference (MD) and indicated a statistically significant reduction in time for the digital scan group compared with the conventional group (MD 10.01 [7.46, 12.55], P<.001, I²=80%). The fact that digital scans were used did not lead to significant differences in radiographic marginal bone loss compared with conventional impressions after 6 months (MD -0.03 [-0.14, 0.08], P=.58, I²=0%), after 12 months (MD -0.06 [-0.24, 0.12], P=.12, I²=45%), and after 24 months (MD -0.12 [-0.32, 0.09], P=.28, I²=58%). CONCLUSIONS: Digital scans significantly reduced the time required compared with conventional impressions for complete arch implant-supported prostheses. Nevertheless, additional studies with more consistent methodologies are needed for confirmation. No significant differences were found in radiographic marginal bone loss between treatments performed with digital scans and conventional impressions.

Evaluation of the 3D error of 2 face-scanning systems: An in vitro analysis.

STATEMENT OF PROBLEM: Facial scanning systems have been developed as auxiliary tools for diagnosis and planning in dentistry. However, little is known about the trueness of these free software programs and apps for facial scanning. PURPOSE: The purpose of this in vitro study was to evaluate the trueness of 3D facial scanning by using Bellus3D and +ID ReCap Photo. MATERIAL AND METHODS: A mannequin head was used as the master model. The control group was created by scanning the mannequin head with a noncontact structured blue light 3D scanner (ATOS Core). Two facial scanning methods were used for the experimental groups: a facial scanning app (FaceApp) and the Plus identity photogrammetry methodology (ReCap Photo). In both methods, image capturing was performed under the same natural lighting conditions with a smartphone (iPhone X) calibrated with an app. Trueness was assessed from the 3D measurement error, which was calculated with a 3D mesh analysis software program (GOM Inspect). Two comparison groups were created: ATOS versus Bellus3D (B3D) and ATOS versus +ID with ReCap Photo (+IDRP). The results were statistically evaluated by using the Shapiro-Wilk and paired t tests (α=.05). RESULTS: B3D had a greater error than +IDRP in measuring the regions of the upper and lower lips, nose, and mentum (P<.01). This error was statistically higher for +IDRP (P<.01) in the right face area, but the left face area showed no statistically significant difference between the evaluated scanning methods (P=.93). The 3D global trueness of B3D was 0.34 ±0.14 mm, and that of +IDRP was 0.28 ±0.06 mm. CONCLUSIONS: Both methods evaluated in this study provided a 3D model of the face with clinically acceptable trueness and should be reliable tools for planning esthetic restorations.

Digital approaches to facially guided orthodontic and periodontal rehabilitation in the anterior esthetic zone: A case report.

OBJECTIVE: The present case report describes digital approaches to plan an orthodontic and periodontal rehabilitation at the anterior esthetic zone. CLINICAL CONSIDERATIONS: A young patient attended to the dental practice with esthetic concerns. The facially driven digital planning showed the need of an interdisciplinary treatment to improve smile harmony. Orthodontic treatment was conducted with aligners, followed by periodontal and restorative approaches. Tooth alignment was performed with 31 aligners, whereas eight aligners were used for refinement. Harmony between pink and white esthetics was improved with crown lengthening, followed by bleaching. CONCLUSION: By using a conservative approach, a successful esthetic result was achieved respecting functional and biological principles. CLINICAL SIGNIFICANCE: Digital resources can be used to the interdisciplinary esthetic planning taking into consideration the harmony between smile and face. This approach allows a predictable outcome of the treatment.

Interdisciplinary rehabilitation of a patient with ectodermal dysplasia utilizing digital tools: A clinical report.

The present clinical report describes the rehabilitation of a patient diagnosed with ectodermal dysplasia performed by an interdisciplinary team in a comprehensive approach aided by digital technology. The complexity of the treatment was related to predictability regarding timing and the type of approach. The patient was referred for treatment because of congenitally missing and abnormally shaped permanent teeth. The need for an interdisciplinary team involving orthodontic, periodontic, and prosthodontic specialists was identified. A virtual treatment plan was developed to guide tooth movement, placement of dental implants, and tooth preparation for indirect restorations. Therefore, each treatment phase could be communicated to the patient and treatment team in a predictable way.

Jaw tracking integration to the virtual patient: A 4D dynamic approach.

This dental technique describes a novel cost-effective workflow for integrating mandible kinematics into a static virtual patient. Computed tomography data are segmented and merged with intraoral surface scans and a target tracking video reproducing the mandible movements. A 4-dimensional dynamic virtual patient is created by using an open-source software program, and all patient-specific parameters can be exported for individualization of a virtual or analog articulator.

Esthetic treatment planning with digital animation of the smile dynamics: A technique to create a 4-dimensional virtual patient.

A method is presented for obtaining a virtual 4-dimensional patient that replicates the intended esthetic treatment. The process involves facial and intraoral scanning to acquire records and software manipulation to enable a virtual waxing of the smile. Once the digital design is complete, patient information can be merged to generate an animated video of the projected rehabilitation, displaying movement and smile dynamics. This strategy provides a noninvasive and reliable diagnostic tool for predicting clinical outcomes.

Digital versus conventional workflow for the fabrication of physical casts for fixed prosthodontics: A systematic review of accuracy.

STATEMENT OF PROBLEM: A consensus on the accuracy of additively manufactured casts in comparison with those fabricated by using conventional techniques for fixed dental prostheses is lacking. PURPOSE: The purpose of this systematic review was to determine the accuracy of additively manufactured casts for tooth- or implant-supported fixed dental prostheses in comparison with that of gypsum casts. MATERIAL AND METHODS: This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (CDR42020161006). Eight databases were searched in December 2019 and updated in September 2020. Studies evaluating the dimensional accuracy of additively manufactured casts for fixed dental prostheses in comparison with that of gypsum casts were included. An adapted checklist for reporting in vitro studies (Checklist for Reporting In vitro Studies guidelines) was used to assess the risk of bias. RESULTS: Eight studies evaluating tooth-supported fixed dental prosthesis casts and 7 studies evaluating implant-supported fixed dental prosthesis casts were eligible for this review. Gypsum casts showed greater accuracy (trueness and precision) in most studies, although additively manufactured casts also yielded highly precise data. One study was associated with a low risk of bias, 9 with a moderate risk of bias, and 5 with a high risk of bias. CONCLUSIONS: In vitro studies showed that additively manufactured casts and gypsum casts share similar accuracy within the acceptable range for the fabrication of casts. The quality of scanned data, additive manufacture technology, printing settings, and postprocessing procedures plays an essential role in the accuracy of additively manufactured casts. Clinical studies are required to confirm these findings.

Three-Dimensional (3D) Facially Driven Workflow for Anterior Ridge Defect Evaluation: A Treatment Concept.

The esthetic rehabilitation of anterior ridge defects and achieving patient satisfaction have become major clinical challenges for dentists and technicians. Poor diagnosis and treatment planning are frequently associated with multiple surgical procedures that fail to meet patient expectations. The loss of hard and soft tissues in anterior ridges results in an esthetically compromised zone that affects the rehabilitation prognosis. The presence of interdental papilla and papillary configuration play a decisive role in patient satisfaction. A treatment plan considering esthetic parameters, prosthetic needs, and morphological defects must be used to improve treatment outcomes. Therefore, this study aims to propose a treatment concept for anterior ridge defects that focuses on digital evaluation systems and is guided by an ideal facially driven smile design project. In addition, the relevance of the papilla for esthetic outcomes and treatment alternatives for anterior ridge defects are also addressed.

Dental software classification and dento-facial interdisciplinary planning platform.

OBJECTIVE: Despite all advantages provided by the digital workflow, its application in clinical practice is still more focused on device manufacturing and clinical execution than on treatment planning and communication. The most challenging phases of treatment, comprehensive planning, diagnosis, risk assessment, and decision-making, are still performed without significant assistance from digital technologies. This article proposes a new dental software classification based on the digital workflow timeline, considering the moment of patient's case acceptance as key in this classification, and presents the ideal software tools for each phase. CLINICAL CONSIDERATIONS: The proposed classification will help clinicians and dental laboratories to choose the most appropriate software during the treatment planning phase and integrate virtual plans with other software platforms for digitally guided execution. A dento-facial interdisciplinary planning platform virtually simulates interdisciplinary clinical procedures and assists in the decision-making process. CONCLUSIONS: The suggested classification assists professionals in different phases of the digital workflow and provides guidelines for improvement and development of digital technologies before treatment plan acceptance by the patient. CLINICAL SIGNIFICANCE: Three-dimensional interdisciplinary simulations allow clinicians to visualize how each dental procedure influences further treatments. With this treatment planning approach, predictability of different procedures in restorative dentistry, orthodontics, implant dentistry, periodontal, and oral maxillofacial surgery is improved.

Interdisciplinary guided dentistry, digital quality control, and the "copy-paste" concepts.

OBJECTIVE: The aim of this report is to present an interdisciplinary approach with novel concepts to virtually plan and achieve esthetics and function. CLINICAL CONSIDERATIONS: Despite the advancements in the digital workflow applied to restorative dentistry, the final outcomes are commonly not similar to initial planning. To overcome this major limitation, three concepts are proposed: guided dentistry, digital quality control and "copy-paste" dentistry. Guided dentistry consists of simulations in 3D software and also includes the manufacture of guides/appliances to assist dentists in all clinical steps. Digital quality control involves the use of intraoral scanners and 3D software to compare the real outcomes with the pre-operative simulations after every procedure. "Copy-paste" dentistry is a consequence of the previous two concepts. Using the capacity of the software to overlap files, the original project can be maintained and adapted to achieve results more comparable with the initial design. The proposed method associates facially driven treatment planning and periodontal and restorative procedures to perform the patient's dental rehabilitation. CONCLUSION: Through a guided workflow and digital control of clinical steps, the final outcomes obtained were equivalent and closer to the initial design. CLINICAL SIGNIFICANCE: In interdisciplinary cases, the treatment plan needs to address individual requirements and to coordinate sequential clinical stages. It is challenging to meet these demands in a conventional process. The proposed concepts engage technological resources to orientate the procedures and to provide assessment in each step. This approach enables the development of a complete and accurate functional-esthetic rehabilitation. Ultimately, the technique presented is reproducible and the results reflect the established plan.

Clinical efficiency and patient preference of digital and conventional workflow for single implant crowns using immediate and regular digital impression: A meta-analysis.

OBJECTIVE: To assess whether digital workflow gives better results than the conventional one in the single implant crowns, when analyzing the impression time, patient preference, time efficiency, and adjustment time. MATERIAL AND METHODS: MEDLINE, Embase, and Cochrane were searched and supplemented via hand search up to June 19, 2019. Only clinical trials assessing conventional versus digital workflows for single implant crowns were included. Impression time was evaluated using random effects meta-analysis, while patient preference, adjustment time, and time efficiency were reported descriptively. RESULTS: Among 1,334 publications identified, ten studies were included. The random effects models revealed statistically significant reduction in time in the digital impression group when compared to the conventional group by the mean meta-analysis (MD: 8.22 [95% CI: 5.48, 10.96]). Analysis from immediate digital impression versus conventional (MD: 3.84 [95% CI: 3.30, 4.39]) and regular digital impression versus conventional (MD:10.67 [95% CI: 5.70, 15.65]) showed statistically significant reduction in time on using the digital impression. Impression time in the digital process ranged between 6 min 39 s and 20 min, whereas for conventional, it was between 11.7 and 28.47 min. Patients showed greater preference for digital impression. Adjustment time in the digital process ranged between 1.96 and 14 min, whereas for conventional, it was between 3.02 and 12 min. Time efficiency in the digital process ranged between 36.8 and 185.4 min, whereas for conventional, it was between 55.6 and 332 min. CONCLUSION: The digital workflow has demonstrated better clinical efficiency considering impression time, patient preference, and time efficiency. According to the adjustment time, different results were presented.

Chairside 3D digital design and trial restoration workflow.

Different digital tools have been used in clinical practice to assist in the planning and rehabilitation of patients. Some applications (apps) and software programs used in esthetic planning allow simulation of the smile design, improving communication between patients and professionals. Nonetheless, they are usually difficult to use, time-consuming, unattractive to present to the patient, and complicated to link with the 3D workflow. This article presents a new 3D digital smile design app for esthetic planning, smile simulation, chairside 3D virtual wax pattern, and trial restoration performed with portable devices. In this technique description, a facial frontal photograph, a facial scan standard tessellation language (STL) file, and a maxillary intraoral scan STL file were uploaded to the app. The files were calibrated to each other to allow a 3D facially driven smile design project. The definitive maxillary 3D digital waxing of facial templates was exported to a 3D printer as an STL file. The printed resin templates were directly placed in the mouth with flowable composite resin for an immediate trial restoration without the need for casts, silicone guides, or autopolymerizing resin. The workflow presented in this article linked the 3Dapp project to a printer and allowed straightforward chairside trial restorations.

Integrating a Facially Driven Treatment Planning to the Digital Workflow for Rehabilitation of Edentulous Arches: A Case Report.

AIM AND OBJECTIVE: This case report presents the integration of a digital facially driven prosthetic plan to the computer-assisted implant planning for rehabilitation of edentulous arches. BACKGROUND: Diagnosis of edentulous arches is hampered by the lack of intraoral references. However, a digital facial profile analysis facilitates the treatment plan, taking into consideration the harmony among teeth, lips, and face to restore a pleasant smile. CASE DESCRIPTION: The first appointment consisted of digital documentation including intraoral scans, facial scans, and photographs. Based on these data, a smile frame was created to guide the digital wax-up. Cone-beam computed tomography (CBCT) scans were merged to facial and intraoral scans to perform the virtual surgical planning. Integration between facial, intraoral, and bone tissues were used as a reference to define implant position and prosthetic planning. The digital planning was integrated into the surgical procedure using stackable templates, and an immediate loading was performed. The interim prosthesis was manufactured based on the digital wax-up. With digital data, quality control could be performed to evaluate the esthetic outcome of the treatment. CONCLUSION: An esthetic and functional rehabilitation was possible using the respective digital workflow to define harmony between a smile and facial tissues. CLINICAL SIGNIFICANCE: A digital treatment implant planning can be conducted considering patient's individual needs to improve the esthetic outcome.

Accuracy of digital technologies for the scanning of facial, skeletal, and intraoral tissues: A systematic review.

STATEMENT OF PROBLEM: The accuracy of the virtual images used in digital dentistry is essential to the success of oral rehabilitation. PURPOSE: The purpose of this systematic review was to estimate the mean accuracy of digital technologies used to scan facial, skeletal, and intraoral tissues. MATERIAL AND METHODS: A search strategy was applied in 4 databases and in the non-peer-reviewed literature from April through June 2017 and was updated in July 2017. Studies evaluating the dimensional accuracy of 3-dimensional images acquired by the scanning of hard and soft tissues were included. RESULTS: A total of 2093 studies were identified by the search strategy, of which 183 were initially screened for full-text reading and 34 were considered eligible for this review. The scanning of facial tissues showed deviation values ranging between 140 and 1330 µm, whereas the 3D reconstruction of the jaw bone ranged between 106 and 760 µm. The scanning of a dentate arch by intraoral and laboratorial scanners varied from 17 µm to 378 µm. For edentulous arches, the scanners showed a trueness ranging between 44.1 and 591 µm and between 19.32 and 112 µm for dental implant digital scanning. CONCLUSIONS: The current digital technologies are reported to be accurate for specific applications. However, the scanning of edentulous arches still represents a challenge.

Accuracy of Casts Fabricated by Digital and Conventional Implant Impressions.

The purpose of this study was to compare the accuracy of stereolithographic casts (SCs) with those obtained using conventional implant impressions. An epoxy resin model containing dental implants was used as master model. Dental casts (n = 10) were fabricated through both conventional and digital implant impressions. The conventional casts (CCs), SCs, and the master model were digitized, and the accuracy was determined through a deviation analysis and linear measurements. Data were analyzed using paired Student t test with P < .05. The SCs showed higher deviation at the vestibular area (CC: 41 ± 28.87 µm; SC: 117 ± 36.83 µm) and lingual cusps (CC: 40.70 ± 19.79 µm; SC: 80 ± 42.95 µm) in comparison with CCs. No statistically significant difference was found for linear measurements of conventional and digital casts. The entire-arch accuracy was comparable between casts. However, SCs were less accurate at the cusp level in comparison with CCs.