This is a journal club presentation on the digital workflow of a full mouth rehabilitation using implants and as CBCT as a guide. The presentation and all the materials collected is available on request. Mail me at apurvathampi@gmail.com

1. Presented by :
Apurva Thampi

2. Introduction
•The first computed tomography (CT) scanner  Godfrey
Hounsfield the early 1970s.
•three-dimensional imaging  overcome the problems with
2D techniques
•Indications??  detection of periapical lesion, orthodontic
analysis, forensic facial reconstruction

5. Objective of the study
Provide a digital workflow and an
alternative treatment in the indicated clinical
scenario

6. Need for the study
•Implant supported fixed prosthesis  treatment option for edentulism
•Immediate loading + interim dentures  increased patient satisfaction
• Dierens M, Collaert B, Deschepper E, Browaeys H, Klinge B, De Bruyn H. Patient-centered outcome of immediately loaded implants
in he rehabilitation of fully edentulous jaws. Clin Oral Implants Res 2009;20:1070-7.
• Papaspyridakos P, Mokti M, Chen CJ, Benic GI, Gallucci GO, Chronopoulos V. Implant and prosthodontic survival rates with implant
fixed complete dental prostheses in the edentulous mandible after at least 5 years: a systematic review. Clin Implant Dent Relat Res
2014;16:705-17.

7. •Success reports of maxillary conventional CD and Mandibular implant-
supported FPD
Screw related complications are less
Davis DM, Packer ME, Watson RM. Maintenance requirements of implant-supported fixed prostheses opposed by
implant-supported fixed prostheses, natural teeth, or complete dentures: a 5-year retrospective study. Int J Prosthodont
2003;16:521-3

8. Wennerberg A, Carlsson GE, Jemt T. Influence of occlusal factors on treatment
outcome: a study of 109 consecutive patients with mandibular implantsupported
fixed prostheses opposing maxillary complete dentures. Int J
Prosthodont 2001;14:550-5.

9. •CAD/CAM fabricated conventional CD??
•Elastomeric impression materials still required  intraoral scanners not accurate
Lin WS, Chou JC, Metz MJ, Harris BT, Morton D. Use of intraoral digital
scanning for a CAD/CAM-fabricated milled bar and superstructure framework
for an implant-supported, removable complete dental prosthesis.
J Prosthet Dent 2015;113:509-15.

10. Clinical scenario
72 yr old caucasian man, with maxillary and mandibular partially edentulous dentition

11. • no relevant history
M/H
• gingival recession and cervical abrasions
• 22, 23, 35 – composite restorationO/E
• 13 – endodontically treated
• severe maxillary ridge atrophy in posterior regionR/E
• partial edentulism with generalised chronic severe
periodontitisDiagnosis
TREATMENT PLAN??
Maxillary – Conventional removable partial denture
Mandibular – Implant supported complete fixed dental prosthesis
(interim versions made – immediate placement and immediate loading)

12. Workflow
CBCT imaging done
Virtual diagnostic tooth arrangements in
CAD/CAM

13. Simulated virtual bone reduction Prosthetically driven implant surgical plan

14. Identification of soft tissue outline : coronal and sagittal views

15. Virtual diagnostic casts

16. CAD/CAM design of the maxillary and
mandibular interim prosthesis
CAD/CAM aided milling

17. Maxillary and mandibular interim prosthesis

18. CAD/CAM bone foundation devive with 3 reposition devises

19. Implant placement template assembled on the
bone foundation guide
Interim prosthesis for immediate
provisionalisation

20. Bone foundation guide with the jig was fitted
onto the alveolar ridge and stabilized with anchor
pins
Osseous recontouring completed

21. Interim abutments attachedImplant placement template assembled

22. Abutments fixed to resin with auto polymerising resin

23. Maxillary prosthesis relined with soft linerMaxillary teeth extracted, and sutures

25. Discussion
•Patient selection is important
•Minimum scatters were expected  CBCT used as primary diagnostic tool
•Segmentation of the earlier dentition  used to verify if the VD has been
maintained
•CBCT images were used to obtain soft tissue profiles

26. Lewis RC, Harris BT, Sarno R, Morton D, Llop DR, Lin WS. Maxillary and
mandibular immediately loaded implant-supported interim complete fixed
dental prostheses on immediately placed dental implants with a digital
approach: a clinical report. J Prosthet Dent 2015;114:315-22.

27. Pros and cons
◦ Pros
◦ No diagnostic impression
◦ No intra oral scan
◦ Performed in a single surgical
appointment
◦ Cons
◦ Minimal dental restorations
◦ Diagnostic tooth arrangements
only in centric positions
◦ Bone supported surgical templates
used

28. Sequence of events - Summary
CBCT
imaging done
Virtual diagnostic
tooth arrangements
in CAD/CAM
Simulated virtual
bone reduction
Prosthetically
driven implant
surgical plan
Identification of soft
tissue outline : coronal
and sagittal views
Virtual
diagnostic casts
CAD/CAM design of the
maxillary and mandibular
interim prosthesis
CAD/CAM aided
milling
Maxillary and
mandibular
interim prosthesis
CAD/CAM bone
foundation devive with 3
reposition devises
Implant placement template
assembled on the bone
foundation guide
Interim prosthesis for
immediate
provisionalisation
Bone foundation guide with the jig
was fitted onto the alveolar ridge and
stabilized with anchor pins
Osseous
recontouring
completed
Interim abutments attached

29. Conclusion
A well planned digital protocol for the rehabilitation of edentulousness with CBCT
as a primary diagnostic tool can prove to be very beneficial for the patient. Also,
with careful patient selection, the need for diagnostic impressions and casts can be
completely eliminated

30. References
• Dierens M, Collaert B, Deschepper E, Browaeys H, Klinge B, De Bruyn H. Patient-
centered outcome of immediately loaded implants in he rehabilitation of fully edentulous
jaws. Clin Oral Implants Res 2009;20:1070-7.
•Papaspyridakos P, Mokti M, Chen CJ, Benic GI, Gallucci GO, Chronopoulos V. Implant
and prosthodontic survival rates with implant fixed complete dental prostheses in the
edentulous mandible after at least 5 years: a systematic review. Clin Implant Dent Relat
Res 2014;16:705-17.
•Davis DM, Packer ME, Watson RM. Maintenance requirements of implant-supported
fixed prostheses opposed by implant-supported fixed prostheses, natural teeth, or
complete dentures: a 5-year retrospective study. Int J Prosthodont 2003;16:521-3.
• Wennerberg A, Carlsson GE, Jemt T. Influence of occlusal factors on treatment
outcome: a study of 109 consecutive patients with mandibular implantsupported fixed
prostheses opposing maxillary complete dentures. Int J Prosthodont 2001;14:550-5.

31. •Anderson PJ, Yong R, Surman TL, Rajion ZA, Ranjitkar S. Application of three-
dimensional computed tomography in craniofacial clinical practice and research. Aust
Dent J 2014;59 Suppl 1:174-85.
•Cevidanes LH, Oliveira AE, Grauer D, Styner M, Proffit WR. Clinical application of 3D
imaging for assessment of treatment outcomes. Semin Orthod 2011;17:72-80.
•Hwang HS, Choe SY, Hwang JS, Moon DN, Hou Y, Lee WJ, et al. Reproducibility of
facial soft tissue thickness measurements using cone-beam CT images according to the
measurement methods. J Forensic Sci 2015;60: 957-65.
•Lewis RC, Harris BT, Sarno R, Morton D, Llop DR, Lin WS. Maxillary and mandibular
immediately loaded implant-supported interim complete fixed dental prostheses on
immediately placed dental implants with a digital approach: a clinical report. J Prosthet
Dent 2015;114:315-22.

32. •Adibi S, Zhang W, Servos T, O’Neill PN. Cone beam computed tomography in dentistry:
what dental educators and learners should know. J Dent Educ 2012;76:1437-42
•Infante L, Yilmaz B, McGlumphy E, Finger I. Fabricating complete dentures with
CAD/CAM technology. J Prosthet Dent 2014;111:351-5.
•Andriessen FS, Rijkens DR, van der Meer WJ, Wismeijer DW. Applicability and accuracy
of an intraoral scanner for scanning multiple implants in edentulous mandibles: a pilot
study. J Prosthet Dent 2014;111: 186-94.
•Lin WS, Chou JC, Metz MJ, Harris BT, Morton D. Use of intraoral digital scanning for a
CAD/CAM-fabricated milled bar and superstructure framework for an implant-
supported, removable complete dental prosthesis. J Prosthet Dent 2015;113:509-15.

33. Thank you
and
Have a pleasant day!!!