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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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Broken file management is one of the most challenging parts of endodontic treatment. Regardless of whether the clinician is faced with a retreatment involving retrieval of the broken file or with a file breaking during the primary root canal preparation, the situation usually affects the success rate of treatment.

As is well known, one of the most important factors in root canal treatment is the eradication of the biofilm. The broken file is not a problem per se, but it is an obstacle to proper disinfection. In some cases, removing the broken file requires sacrificing a large amount of very precious peri-cervical dentine. Therefore, in every case, the clinician has to consider all the benefits and disadvantages of the retrieval and decide whether is it worth removing the broken file, leaving it in place or trying to bypass it.¹

The advantages of SWEEPS technology

As mentioned, one of the most important factors of endodontic treatment is root canal disinfection. Usually around the broken file, there is a great deal of accumulated hard-tissue debris, and if the broken file is located in the middle part of the root, the disinfection of the apical part of the canal may be insufficient.

The novel SWEEPS (shock wave-enhanced emission photoacoustic streaming) irrigation technique offers the clinician an easier and more predictable means of managing broken files. The basic principle of the technology is the delivery of synchronised pairs of ultra-short pulses, which create primary cavitation in the vicinity of the fibre tip, followed by secondary cavitation in the remote, difficult-to-reach apical areas. This phenomenon creates shock waves that spread in all directions at a speed of up to 10 m/s—so the impulse reaches 10 mm in depth in just 0.001 seconds.²Moreover, the available data shows that the removal of accumulated hard-tissue debris with the Er:YAG laser is very efficient³and three times more efficient than passive ultrasonic irrigation.⁴

Fig. 1: Pre-op radiograph. Periapical lesion and broken file visible.

Fig. 2: Pre-op CBCT scan. Broken file far beyond the canal curvature.

Fig. 3: Pre-op CBCT scan. Tip of the broken file located below the junction of the mesiobuccal and mesiolingual canals.

Case 1

The patient was referred to the office after failure to retrieve a broken file. After enlarging the canal and attempting to remove the file, the previous operator gave up the treatment. The tooth was symptomatic, so the patient wanted to proceed with the file retrieval and root canal treatment.

The periapical radiograph and the CBCT scan revealed that the file had broken far beyond the curvature in the mesiobuccal canal and below the junction with the mesiolingual canal. Also, a periapical lesion was visible around the apices of the mesial and distal roots (Figs. 1–3). The length of the file was approximately 5 mm. Bypassing the file through the mesiolingual canal would have been a risky procedure because it may have caused the fracture of the second instrument and the obturation may also have been very challenging. Thanks to SWEEPS technology and a bioceramic sealer, an alternative approach could be taken. After administering anaesthesia and placing a dental dam, the temporary restoration was removed (Figs. 4 & 5). The pulp chamber was rinsed with 5.25% sodium hypochlorite and the irrigant activated with ultrasonics. After cleaning the chamber of the tooth, the dental dam and clamp were rinsed with water and dried and flowable dental dam was placed to seal the tooth and enlarge the space in the pulp chamber for the laser-activated irrigation (Fig. 6). Activation was performed with the SkyPulse laser (Fotona). The AutoSWEEPS mode was chosen. The power of activation was set to 1 W. The flat SWEEPS 300/20 fibre tip was used (Fig. 7). The tip was placed slightly below the orifice of the mesiobuccal canal for the majority of the irrigation with sodium hypochlorite. After 120 seconds of activation with sodium hypochlorite, the tip was placed in the pulp chamber to activate the sodium hypochlorite in all the canals simultaneously for 30 seconds. This procedure was continued for 30 minutes. Only the distal canal was shaped with rotary files, up to size 40/.04. Both mesial canals remained the same size as they were before the file broke during the primary treatment. Finally, the canals were flushed with EDTA activated with AutoSWEEPS at a power of 0.4 W, and sodium hypochlorite was activated for three cycles with AutoSWEEPS at a power of 0.6 W and with a 30-second break for the resting phase. The irrigant flow between the mesiobuccal and mesiolingual canals was rapid, indicating that obturation could be performed.

The canals and chamber were dried with micro-suction and paper points (Fig. 8). A bioceramic sealer (CeraSeal, META BIOMED) was used in the piston technique. The sealer was injected in all canals and covered with flowable gutta-percha in the orifices (Fig. 9). Periapical radiographs were performed, and they revealed that the root canals had been filled correctly, showing puffs of sealer in the periapical area (Figs. 10 & 11).

Fig. 4: Treated tooth after dental dam isolation. Damaged temporary restoration.

Fig. 5: Tooth after removal of the temporary restoration.

Fig. 6: Tooth after removal of the caries and sealing of the chamber with flowable composite and dental dam.

Fig. 7: Fotona 300/20 laser tip.

Fig. 8: Pulp chamber after the irrigation protocol.

Fig. 9: Pulp chamber after obturation with the piston technique.

Fig. 10: Post-op radiograph. Puffs of the sealer visible.

Fig. 11: Mesially shifted post-op radiograph.

Case 2

The patient came to the office because of moderate pain connected with the mandibular right first molar. A periapical radiograph and CBCT scan were performed. The images revealed radiolucency around the mesial root of the molar. Also, two pieces of a broken instrument were visible, one in the middle part of the root, before the curvature, and the other slightly below the curvature (Figs. 12 & 13).

Fig. 12: Pre-op CBCT scan. Periapical lesion visible.

Fig. 13: Pre-op radiograph. Two pieces of the broken file visible.

After administering anaesthesia and placing a dental dam, the composite restoration was removed, and a temporary restoration with flowable composite and flowable dental dam for the root canal treatment was performed (Figs. 14–17). After removing the filling material from the mesiolingual and distal canals, access to the broken file was performed. The first piece of the instrument was removed with the ultrasonic tip (Fig. 18), and the tip of the second piece of the file then became visible. Unfortunately, the removed file piece broke in the middle and only the coronal part could be retrieved (Fig. 19). Because the apical part of the broken file was invisible and did not emerge from the canal during the irrigation and activation, an attempt at bypassing it was made. Analysis of the CBCT scan did not reveal a clear answer as to whether there was one apical foramen, so during the bypass procedure through the mesiolingual canal, a periapical radiograph was performed. The radiograph indicated that either there was a ledge in the apical area or there were two separate apical foramina (Fig. 20). For the irrigation protocol, the AutoSWEEPS mode was used at 1.2 W power with the flat SWEEPS 300/20 fibre tip. The tips of both mesial canals were placed below the orifice. The Less-Prep Endo protocol was performed twice in the manner described elsewhere.⁵ After the irrigation, irrigant flow between both canals was rapid.

The canals were dried with paper points and micro-suction (Fig. 21). After the irrigation protocol, there was still a lack of patency and tugback was achieved only in the mesiolingual canal. The mesiobuccal and distal canals were filled with an epoxy resin sealer and warm gutta-percha (squirting technique), and the mesiolingual canal was filled with a 30/.04 gutta-percha cone with the continuous wave of condensation technique (Fig. 22). A distally shifted periapical radiograph was performed (Fig. 23). The radiograph revealed a puff of sealer in the periapical area of the mesial root and the isthmus filled with the sealing material. A composite material was placed into the access cavity, and the patient was scheduled for the control appointment. At six months and 12 months, CBCT scans were performed (Figs. 24 & 25). The images found no signs of inflammation in the periapical area, and the tooth was asymptomatic.

Fig. 14: Treated tooth after dental dam isolation.

Fig. 15: Tooth after removal of the composite restoration.

Fig. 16: Tooth after removal of the restoration.

Fig. 17: Tooth after removal of the caries and sealing of the chamber with flowable composite and dental dam.

Fig. 18: First removed piece of the broken file.

Fig. 19: Second removed piece of the broken file.

Fig. 20: Intra-op radiograph confirming lack of bypass and of patency.

Fig. 21: Pulp chamber after the irrigation protocol.

Fig. 22: Pulp chamber after obturation.

Fig. 23: Post-op radiograph. Puff of the sealer visible.

Fig. 24: CBCT scan at the six-month follow-up.

Fig. 25: CBCT scan at the 12-month follow-up.

Case 3

The patient was referred to the office for root canal retreatment of three teeth before prosthodontic treatment. One of these teeth was the mandibular left first molar. The CBCT scan revealed two radiolucent spaces around both roots (Fig. 26). Moreover, the periapical radiograph showed a broken file in the mesiobuccal canal (Fig. 27). After administering anaesthesia and placing a dental dam, the old restorations were removed, a temporary composite build-up was performed, and the tooth was sealed with flowable dental dam (Figs. 28 & 29). The old gutta-percha cones were removed from all the canals (Fig. 30).

Fig. 24: CBCT scan at the six-month follow-up.

Fig. 25: CBCT scan at the 12-month follow-up.

Fig. 26: Pre-op CBCT scan. Two apical lesions visible.

Fig. 27: Pre-op radiograph. Broken files visible.

Fig. 28: Treated tooth after dental dam isolation.

Fig. 29: Tooth after removal of the caries and sealing of the chamber with flowable composite and dental dam.

Fig. 30: Removal of the gutta-percha.

Fig. 31: Apparent over-instrumentation of the root canal orifice, probably performed with ultrasonics during a previous attempt at broken file removal.

Fig. 32: Root canal orifice sealed with flowable composite.

Fig. 33: View of the two broken files together in the mesiobuccal canal.

Fig. 34: One of the retrieved file pieces in the lasso tool.

After the removal of the gutta-percha and cleaning of the root canals, it was apparent that a large amount of the dentine had been removed from the orifice of the mesiobuccal canal (Fig. 31). Most probably, this had occurred during an attempt at removing the broken file in the previous treatment. Fortunately, there were no visible signs of perforation in the orifice. The damaged wall was sealed with composite resin (Fig. 32). Irrigation of the mesiobuccal canal with the AutoSWEEPS mode and sodium hypochlorite and inspection under 16× magnification revealed two pieces of the broken instruments (Fig. 33), complicating treatment. The tips of both files were visible, but both were also jammed. An attempt at removal with an ultrasonic file was ineffective, so the flat SWEEPS 300/20 fibre tip was used with the AutoSWEEPS mode at a power of 1.2 W. After a few minutes of irrigation with sodium hypochlorite and EDTA, both file pieces started to move a little, indicating that both were removable. Both pieces were retrieved with a lasso loop tool (BTR Pen, CERKAMED; Fig. 34). A periapical radiograph was performed to confirm that there were no more broken file pieces (Fig. 35).

After the file retrieval, all the canals were shaped with rotary files, and the final irrigation protocol was performed with the SSP (super-short pulse) mode. After the irrigation protocol, irrigant flow between the mesiobuccal and mesiolingual canals was rapid. The canals were dried. We could clearly see that the orifices of the mesial canals were of very similar ISO size, indicating that the file retrieval had been very conservative (Fig. 36). The canals were filled with an epoxy resin sealer and gutta-percha with the continuous wave technique (Fig. 37). A distally shifted periapical radiograph was performed, and on it, we could see in the mesial root that two parts of the isthmus had been filled with the sealer (Fig. 38). The tooth was restored with a fibre post and referred to the prosthodontist for indirect restoration.

After 12 months, a CBCT scan was performed (Fig. 39). The image found no signs of inflammation in the periapical area, and the tooth was asymptomatic.

Fig. 35: Intra-op radiograph. All pieces of the broken files had been removed.

Fig. 36: Pulp chamber after the irrigation protocol.

Fig. 37: Pulp chamber after obturation.

Fig. 38: Post-op radiograph.

Figs. 39a & b: CBCT scan at the 12-month follow-up.

Fig. 39b

Conclusion

Incorporating the Er:YAG laser into challenging endodontic treatments gives clinicians new possibilities, allowing them to achieve more effective, predictable and conservative treatment in many cases. In some cases, we can loosen the file without using ultrasonic tips, allowing us to be more conservative. Moreover, thanks to the much more effective reduction of accumulated hard-tissue debris, we can clean the space around the broken file to avoid removing the file (for example, if the file broke behind the curvature) and still have successful treatments with less risk of creating perforations in the classic approach to file retrieval.

Editorial note:

This article was published in roots—international magazine of endodontics vol. 19, issue 2/2023. A complete list of references can be found here.