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June 26, 2024

In recent years, dentistry has undergone a remarkable transformation, largely driven by the rapid advancement of digital technologies. 

From intraoral scanning and 3D imaging to computer-aided design and manufacturing (CAD/CAM), these innovations have revolutionized how dental professionals diagnose, plan, and execute treatments. 

Among these groundbreaking technologies, 3Shape has emerged as one of the most useful parts in our practice. 

Their scanners are excellent for implant cases, and the Unite software is a powerful tool for streamlining dental workflows, particularly in implantology.

This case study aims to showcase the huge impact digital dentistry can have on your workflows.

This article is not sponsored in any way by 3Shape.

I wanted to demonstrate how we use 3Shape Unite software to plan and complete dental implant treatment. 

About the Author

Dr Byron Park

Dr Byron Park is a general dentist combining 10 years of experience in general dentistry and a passion for digital dentistry. He works as a dentist and educator with the iDD team in Wellington, New Zealand. Byron has particular interests in the latest digital dentistry tools such as dynamic navigated dental implant surgery, jaw motion capture and artificial intelligence in diagnosis of dental radiographs. 

Patient Background

The patient, a male in his 60s, presented with multiple dental issues, including missing and cracked teeth and a bony defect in the area of a previously extracted tooth.

Over the years, the patient had experienced multiple cracked teeth, which had led to various complications and treatments. In 2021, the patient reported hearing a loud crack while eating, after which tooth 24 became tender to biting pressure. 

Upon examination by his previous dentist, a vertical root fracture was diagnosed, necessitating a surgical extraction. The procedure, which involved removing the buccal cortical bone, left the patient with a bony defect in the area of the extracted tooth.

His previous dentist retired, and the patient visited me for the first time as an emergency visit due to symptomatic irreversible pulpitis from a cracked tooth (46). Root canal treatment on tooth 46 was completed, and a crown placed.

Upon completing a comprehensive examination, it was revealed that teeth 25 and 26 were also cracked, and the patient expressed interest in replacing the missing tooth 24. 

To better understand the patient's overall dental health, a full mouth CBCT scan was taken, confirming the presence of a bony defect in the area where tooth 24 had been surgically extracted.

Treatment Planning

Following the patient's initial consultation and the discovery of additional dental issues, I conducted a thorough full mouth examination. The findings of this examination, combined with the CBCT scan results, provided a comprehensive picture of the patient's oral health status and allowed for the developing a personalized treatment plan.

The treatment plan consisted of crowning teeth 25 and 26, replacing missing tooth 24 with a dental implant, and placing a bone graft to replace lost bone tissue and provide a stable foundation for the implant.

The Digital Implant Workflow

3Shape Unite is a powerful digital platform that integrates a wide range of diagnostic and treatment planning tools, allowing dentists to create highly detailed, patient-specific virtual models of the oral cavity. 

By combining data from 3shape TRIOS intraoral scans, CBCT imaging, and other diagnostic sources, TRIOS enables practitioners to visualize and create treatment plans in a fully digital environment.

Intraoral scans were completed using the Trios 4 intraoral scanner and a H8 x D 15cm craniofacial field CBCT was taken.

Surgical Phase

The surgical phase of the implant treatment is a critical step in ensuring the success and longevity of the final restoration. 

I utilized 3Shape Implant Studio, a module within the 3shape Unite Platform, to plan and execute the surgical procedure.

Pre-surgical planning began with acquiring high-quality diagnostic data, including TRIOS intraoral scans and CBCT imaging. The data was imported into 3Shape Implant Studio, where I designed a virtual crown for tooth 24 and planned the precise positioning of the implant, considering critical factors such as sinus proximity, adjacent roots, bone density, and the location of the bony defect.

A custom surgical guide was designed and 3D printed, incorporating all the critical information from the virtual planning. The implant surgery was performed under local anesthesia, with the surgical guide firmly in place to ensure accurate implant placement. Bone grafting was performed to address the bony defect and promote optimal healing.

Create a New Case in Implant Studio and select the indication Implant Planning. The tooth-supported guide and virtual crown options are selected. TRIOS intraoral scans and CBCT imported.
Virtual crown design before implant planning is begun. Restorative-driven workflow ensures that the final crown will be both aesthetic and functional. The implant is planned to fit the restoration, not the other way around. The AI Design tool automated most of this virtual crown design. Transform and Morph tools were used to tweak the anatomy.
The CBCT is cropped down to reduce the load on the computer processor. The upper jaw intraoral scan is aligned with the CBCT. Initial alignment is automated. Alignment is checked using the proximity colour indicators above (Green colour across the teeth is good). Check the superimposition of the intraoral scan over the CBCT dicom (Yellow scan outline should closely match the teeth).
The implant is selected from libraries (downloaded freely in the Implant Studio settings). Brand, model, diameter, length. Position, angulation, and depth are adjustable. I aimed to place the implant within the native bone, planning to augment the ridge defect with a bone graft. Measurement tools used to plan implant platform depth at least 4mm from tissue level, in accordance with zero bone loss concepts. The sleeve is selected and can be visualised to ensure it does not intersect/collide with the jaw scan. In this case, I selected a Sleeveless design for simplicity of manufacture (no metal sleeve is required in the 3D-printed surgical guide).
Surgical guide design starts with selecting a practical path of insertion that minimises undercuts. The outline traced determines which tooth/gum surfaces the guide will be supported by.
A support bar (round or rectangular) can be placed to increase the stiffness and strength of the guide. Viewing windows can be cut out of the guide. These will help the clinician to visualise whether the guide is fully seated or not. ID tag with the patient’s name or code can be placed on the guide.
You must confirm the Approval of Planning and Approval of Surgical Guide before proceeding. This locks the case, and you can no longer alter the surgical planning or guide design. From here, you can download the surgical guide STL file and a PDF of the surgical report and drilling protocol.
These reports contain the implant information and the sleeve offset distance. The PDFs can be imported into the patient’s file in the dental clinic as a legal record.
Model 3D printed on NextDent 5100 and Surgical Guide printed on Formlabs Form 3B+ with Surgical Guide resin.
Implant surgery was done under local anaesthetic. Surgical guide fit check. Full thickness mucoperiosteal flap raise with no relieving incisions. The full extent of buccal defect in 24 site can be visualised.

The Osstem OneGuide kit is used with a fully guided osteotomy and implant placement.

Osstem TSIII D4 x H10mm implant on NoMount driver.

Implant inserted using a motorised driver. Finished placement with a torque wrench. Final torque > 40Ncm.
A 50:50 mix of xenograft/allograft particulate bone graft was used to augment the buccal defect. The collagen membrane was secured using a healing abutment with the ‘poncho’ technique. Simple interrupted sutures were used using resorbable Polyglactin 4-0.

Restorative Phase

Following the successful surgical placement of the implant, the focus shifted to the restorative phase of the treatment.

Three months after the implant surgery, a thorough post-operative assessment revealed excellent healing and implant stability.

Digital impressions were captured using the TRIOS 4 intraoral scanner, and the implant-supported crown was designed using 3Shape Design Studio. 

The crown was milled from a high-strength, multilayered zirconia and hand-finished to achieve a lifelike appearance. 

At the final appointment, the crown was securely attached to the implant, resulting in a beautiful, natural-looking restoration.

3 months after implant placement. An excellent volume of buccal contour was observed. 
Osstell Smartpeg hand tightened onto the implant. Hiossen IS3 ISQ Monitor with a reading of 87 indicated excellent implant stability and integration.
Osstem scan body is attached to the implant, and the Trios 4 Move wireless intraoral scanner is used for upper jaw, scan body, lower jaw, and bite scans.
Create a New Case in Trios Design Studio. Select a Single unit, Screw-retained crown. Import intraoral scans.

Implant detection matches the scan body in the intraoral scan with the digital library. A colour scale is given to show the accuracy of the matching (Green is good).

Anatomy design can be sped up with AI design. You can also copy the anatomy of another tooth present in the intraoral scan or select a tooth design from available libraries. Transform, Morph, and Wax knife tools adjust the anatomy. You can visualise and set adjacent and opposing contact distances.
Dynamic Virtual Articulator allows you to adjust articulator angles and movements. This helps to ensure canine guidance is respected and ensures no premature contacts and non-working side interferences.
Select Ti base from the library of options. In this case, I selected an engaging (hex) Ti base with a height of 6mm and a gingival height of 2mm. This is to ensure that the margin where the zirconia meets the Ti base will be subgingival, and there will be no visible metal. The crown is given a final sculpt to contour the transition from the emergence profile to the rest of the crown.
I did not alter the screw hole further, but an extra hole radius or cement gap can be added if needed. From there, an STL file is produced. This is saved and used to mill the designed crown out of multilayered zirconia.
Crown is milled, sintered, stained, glazed, and cemented to the Ti base. Dental technician Yang Heum Cho completed this at iDD Dental Lab. Armann Girrbach Zolid FX Multilayer zirconia used.
The healing abutment was removed, and excellent tissue health was observed.
The implant crown was inserted, and the abutment screw was tightened to 30Ncm with a torque wrench. PTFE tape, Clearfil ceramic primer, and Shofu Beautifil Injectable composite resin are used to fill the screw channel.
The buccal photo shows an excellent shade match of the crown and buccal contour of the soft tissue. A final PA radiograph was taken to check that the crown was fully seated and as a post-operative treatment record.

Treatment Outcomes

The successful completion of the implant treatment was evaluated based on aesthetics, function, and patient satisfaction. 

The implant-supported crown seamlessly integrated with the patient's natural dentition, and the patient reported excellent comfort and function. 

A radiographic assessment confirmed the proper integration and positioning of the implant.

The successful treatment outcome can be attributed to digital dentistry: planning, precise execution, and patient-centered approach facilitated by the digital workflow. 

By leveraging advanced technologies like 3Shape TRIOS, Implant Studio, and TRIOS Design Studio, I delivered a high-quality, customized implant-supported restoration that met the patient's functional, aesthetic, and emotional needs.

Discussion and Conclusion

The case study highlights the numerous advantages of the digital workflow in implant dentistry, particularly when compared to traditional analog methods.

Integrating advanced technologies, such as 3Shape TRIOS and TRIOS Design Studio, has revolutionized how dental professionals plan, execute, and deliver implant treatments, offering unparalleled accuracy, precision, and efficiency.

The digital workflow streamlines the entire implant treatment process, reducing the time and effort required for each stage.

 Digital technologies automate and standardize many processes, reducing the potential for human error and ensuring consistent, high-quality results. Moreover, the improved communication and collaboration enabled by digital files promote better coordination, faster decision-making, and a more cohesive treatment approach.

This case study demonstrates the remarkable potential of digital dentistry in revolutionizing implant treatment. By leveraging the power of 3Shape software and the digital workflow, I successfully planned and executed a complex implant case, achieving exceptional results in aesthetics, function, and patient satisfaction.

The successful outcome of this case underscores the future implications of digital dentistry in transforming the field of implant treatment. As digital technologies evolve and become more widely adopted, dental professionals will be empowered to deliver increasingly predictable, efficient, and patient-centered care.

As the dental profession continues to embrace the digital revolution, practitioners must stay informed about the latest advancements and best practices in digital dentistry. This case study serves as an invitation for readers to explore the world of digital implant dentistry and actively seek opportunities to integrate digital technologies into their own practices.

In summary, this case study demonstrates the transformative power of digital dentistry in implant treatment, highlighting the benefits of accuracy, precision, efficiency, and patient-centered care.

As the dental profession continues to evolve, the adoption of digital workflows will become increasingly critical for delivering optimal treatment outcomes and improving the lives of patients worldwide.

About the author 

iDD Collaborators

Here at iDD we love working with like-minded dentists, technicians and all auxiliary staff that make the dental office happen! These blogs are special guest posts where key opinion leaders worldwide have shared their content with us to be published on the iDD blog. If this sounds like you, reach out to us!

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