Virtual Custom Root-Form Healing Protocol
As a lover of technology and innovation, this is a great time to be practicing dentistry. The digital advances in both the clinical and laboratory world are growing at an exponential rate and really only limited by our imaginations. My unique computer systems engineering and electrical engineering degrees coupled with my clinical and laboratory experience has proved invaluable in maximizing the potentials of dental CAD/CAM softwares. I have been able to use the instruments in my “digital toolbox” to create clinical workflows that simplify the treatment process all while improving outcomes. One example of digitally streamlining traditional treatment is my “Virtual Custom Root-Form Healing Protocol”.
Traditional implant surgery often involves taking a CBCT scan of the patient (Figure 1). The resulting DICOM data set is used to render 3D images of the patient’s existing bone anatomy to help plan for implant placement (Figure 2). However, while pondering about digital treatment potentials I realized so much more useful information is captured within a CBCT data set. Specifically, the root form anatomy of the tooth (or teeth) that are to be removed and replaced with implants (Figure 3).
So this got me thinking, how can I maximize the data that’s been collected? One of the biggest challenges we face in our dental laboratory is that the tissues around an implant have not been properly restored prior to making the final impression. Unfortunately, more often than not, the restorative doctor has not taken the time to shape the surrounding gingival tissues with an implant provisional. The end result is that the final restoration design is limited to an unideal emergency profile (Figure 4). Even worse, if the technician in this case tries to design a restoration with an ideal trans-mucosal emergency profile, the restorative doctor often returns the case with the complaint of it not fitting, when in fact the only issue is the unsculpted gingival tissues holding the restoration up. The reluctance of clinicians to develop the soft tissue profile around an implant prior to it being restored is understandable given the chairtime associated with fabricating a custom healing abutment/ provisional crown and also the healing time needed for the tissues to mature to this ideal shape.
So back to the enormity of the CBCT scan data. Understanding that in the CBCT data I also had the root form anatomy of the tooth (or teeth) scheduled to be replaced with implants, I developed a technique using my CAD/CAM software (3Shape) to design restorations for my “Virtual Custom Root-Form Healing Protocol”. Specifically, this technique and then isolating the root form of the hopeless tooth (or teeth) (Figure 5) and bringing that data into my design software so I can copy the exact shape of the root(s) (Figure 6a, 6b, 6c). This design is then adapted to fit the implant system and diameter that has been planned for in the CBCT guided surgery. The end result is the fabrication of a custom root-form provisional restoration (Figure 7) that is milled and finished PRIOR to and delivered at the time of surgery (Figure 8,9) to support the surrounding gingival tissues in the exact same way as the tooth (or teeth) being replaced. This allows the gingival tissues to heal in an ideal shape from the time of surgery (Figure 10), such that they have matured to the shape needed for an ideal restorative emergency profile by the time the final impression is to be made.
My Virtual Custom Root-Form Healing Protocol opens the door to an easier, more seamless implant restorative workflow that yields better results. It also reduces chairtime at the final delivery appointment. This is because when it comes time to restore the healed implant I can use the saved custom root-form healing CAD file to design the final implant restoration. This ensures that the transmucosal profile that was developed during healing is maintained, so the final restoration has the same ideal emergence profile and seats effortlessly with no tissue resistance.
Understanding that not every surgery is as predictable as desired despite the best presurgical planning, my Virtual Custom Root-Form Healing Protocol can also provide a “plan B” solution if immediate provisionalization is not an option. Specifically, we can design a custom root-form healing abutment (Figure 11) that can be delivered along with an Essix-style provisional appliance at the time of surgery to maximize gingival healing (Figure 12).
My technique for the Virtual Custom Root-Form Healing Protocol demonstrates so beautifully how the potentials of digital dentistry are limited simply by our imagination. If you can dream it, engineers are ready to write software to make it happen. It’s up to us as clinicians to rethink our analog workflows and digitally convert them to streamline treatments and improve the overall experience and results for our patients. Questions, comments, ideas? I welcome your input and can be reached at firstname.lastname@example.org.
Figures for Virtual Custom Root Form Healing Protocol
Figure 1. Preoperative CBCT scan obtained for guided implant surgical planning.
Figure 2. Guided surgical implant planning was performed using 3Shape’s TRIOS intraoral scanner and Implant Studio lab design software.
Figure 3. Isolation of the root form anatomy captured within CBCT preoperative scan data.
Figure 4. An example of an unideal concave emergence profile due to lack of sculpting the soft tissues around an implant prior to its restoration.
Figure 5. Root form anatomy isolated from the preoperative CBCT.
Figure 6. Use of 3Shape CAD software to copy the root form(s) of a hopeless tooth (or teeth) to design a screw-retained provisional with the correct emergence profile for my Virtual Custom Root-Form Healing Protocol prior to the extraction of the corresponding hopeless tooth (or teeth).
Figure 7. Designed and milled PMMA screw-retained provisional crown that has same root form anatomy as the tooth to be extracted for the Virtual Custom Root-Form Healing Protocol.
Figure 8. Atraumatic extraction of #9 and guided surgical immediate placement of #9 implant.
Figure 9. Delivery of immediate provisional that was designed with an emergence profile to mimic the root-form anatomy of the extracted tooth to best contour the gingival tissues while healing.
Figure 10. Preoperative (left side) and 24-hour post-operative (right side) photographs demonstrating the improved cosmetic and gingival health results provided with my Virtual Custom Root-Form Healing Protocol.
Figure 11. Virtual design and milled custom root-form healing abutment to be used in the Virtual Custom Root-Form Healing Protocol.
Figure 12. For cases where immediate provisionalization is not an option, the Virtual Custom Root-Form Healing Protocol is adapted to include a custom root-form healing abutment and Essix-style appliance to ensure optimal gingival contouring during healing.