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Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution by Tarun Agarwal, DDS, PA Go online for in-depth content The Inclusive Tooth Replacement Solution is touted as the industry s first all-in-one, restorative-driven treatment package, described in simplest terms as the complete set of components required to replace a missing tooth. But the true value of this full-service, patient-specific solution cannot be adequately measured with a mere list of parts and pieces, no matter how comprehensive that list may be. The ultimate benefit can instead be found in the freedom and flexibility inherent in the solution during all phases of treatment, which serve to maximize clinical efficiency and facilitate a predictable, esthetic outcome. Showcasing the most obvious example of this clinical flexibility is the Open Platform Inclusive Tooth Replacement Solution. While the original Inclusive Tooth Replacement Solution features an internal hex tapered implant of timetested design, the Open Platform treatment package is built around the clinician s implant of choice. A clinician accustomed to working with any of the major implant systems (Fig. 1) can therefore take full advantage of the Inclusive Tooth Replacement Solution prosthetic guide, custom temporary components, custom impression coping and final CAD/CAM restoration while placing an implant from his existing inventory. Whichever implant is used, the principal advantages to be found in utilizing the Inclusive Tooth Replacement Solution remain unchanged. With a stent to help direct implant placement from a prosthetic perspective, custom temporary components to provide contoured soft tissue management in the event of immediate provisionalization or conventional healing, and a custom impression coping to fully capture the resulting gingival contours, the patient is better prepared to receive the accompanying final restoration with minimal discomfort and fewer adjustments. By truly beginning with the end result in mind, the Inclusive Tooth Replacement Solution streamlines the treatment workflow and alleviates component and communication issues too often associated with traditional implant services. OsseoSpeed TX (DENTSPLY Implants) OSSEOTITE Certain Tapered Dental Implant (Biomet 3i) Brånemark System (Nobel Biocare) NobelActive (Nobel Biocare) NobelReplace Tapered Groovy (Nobel Biocare) Bone Level (Straumann USA, LLC) Tapered Screw-Vent (Zimmer Dental) Figure 1: The Open Platform Inclusive Tooth Replacement Solution supports the following implant systems: Astra Tech OsseoSpeed (now DENTSPLY Astra Tech Implant System ); Biomet 3i Certain ; Nobel Biocare Brånemark System, NobelActive and NobelReplace ; Straumann Bone Level; and Zimmer Screw-Vent. All associated third-party trademarks are the property of their respective owners. Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution 17

Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution Courtesy of Robert A. Horowitz, DDS Figure 2: Rx form for the Open Platform Inclusive Tooth Replacement Solution Figure 3: Radiograph of an MIS SEVEN implant (MIS Implant Technologies; Fair Lawn, N.J.) placed using the Open Platform Inclusive Tooth Replacement Solution Figure 4: A prosthetic guide featured with the Open Platform Inclusive Tooth Replacement Solution Figure 5: A custom healing abutment featured with the Open Platform Inclusive Tooth Replacement Solution Flexibility in All Phases To better examine the Open Platform Inclusive Tooth Replacement Solution and the options it affords clinicians during each stage of treatment, it is helpful to break the package down into four distinct phases. Phase 1: Treatment Planning When submitting an Open Platform Inclusive Tooth Replacement Solution case, clinicians may take either digital or conventional full-arch impressions, along with a bite registration, so that the laboratory may accurately produce articulated study models. The special Rx enables clinicians to denote the system, diameter and platform size of the implant to be used, along with the prescribed tooth shade and soft tissue depth noted in the edentulous site (Fig. 2). This information enables the laboratory to properly design custom components with patient-specific soft-tissue contours in an effort to provide a more natural emergence profile than that obtained with conventional stock components. Phase 2: Surgical Placement of the prescribed implant is performed according to clinician preference, using the system and instrumentation of choice (Fig. 3). Because implant placement within the edentulous space is critical to achieving an optimal restorative outcome, the Open Platform Inclusive Tooth Replacement Solution features a prosthetic guide (Fig. 4) with which to prepare the osteotomy in freehand cases. Anatomical landmarks should be properly accounted for during treatment planning, as the prosthetic guide does not take these into consideration. However, use of the guide will ensure swift, accurate seating of the custom healing 18 www.inclusivemagazine.com

Figure 6: A custom temporary abutment and BioTemps provisional crown featured with the Open Platform Inclusive Tooth Replacement Solution Figure 7: A custom impression coping featured with the Open Platform Inclusive Tooth Replacement Solution Figure 8: Anatomical sulcus following custom healing phase of the Open Platform Inclusive Tooth Replacement Solution Figure 9: Inclusive Custom Abutments are available in titanium, all-zirconia or zirconia with titanium base abutment or custom temporary abutment, and help to improve the final prosthetic outcome. Phase 3: Temporization/Healing Immediately upon implant placement, the clinician may elect to place the custom healing abutment (Fig. 5) or provisionalize the case with the custom temporary abutment and BioTemps provisional crown (Fig. 6). Temporization can also be performed after a period of healing, if indicated. The custom healing abutment and custom temporary abutment are each milled from a radiopaque, biocompatible polyether ether ketone (PEEK) material that is easy to adjust as needed, while the BioTemps crown milled from poly(methyl methacrylate) (PMMA) is designed with an internal relief space to allow for adjustable seating during cementation. The custom temporary abutment and BioTemps crown can even be modified and luted together extraorally to create a single-piece screw-retained provisional. Whatever the indication or preference, patient-specific soft tissue management can be initiated upon implant placement in a fraction of the time it would require to create a custom component chairside. Phase 4: Final Restoration When the time comes for the definitive restoration, a final impression is taken with the custom impression coping (Fig. 7). This CAD/CAM component is designed with the same gingival contours as the custom healing abutment and custom temporary abutment to precisely capture the final gingival architecture (Fig. 8) and convey that information to the laboratory, providing a greater understanding of the appropriate emergence profile. Along with final full-arch impressions, the clinician submits a final Rx for the desired Inclusive Custom Abutment (Fig. 9) and final BruxZir Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution 19

Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution Courtesy of Robert A. Horowitz, DDS Figure 10: Clinicians may prescribe a final crown made from BruxZir Solid Zirconia or IPS e.max Figure 11: A BruxZir Solid Zirconia screw-retained crown prescribed as the final restoration in a case utilizing the Open Platform Inclusive Tooth Replacement Solution Figure 12: Radiograph of tooth #19 after endodontic therapy to treat periapical abscess Figure 13: Periapical radiograph of site #19 post-extraction Solid Zirconia or IPS e.max (Ivoclar Vivadent; Amherst, N.Y.) monolithic crown (Fig. 10). A screw-retained final restoration may also be prescribed (Fig. 11). The precise nature of the manufacturing process used to produce both the temporary and final custom components helps to ensure efficient seating of the definitive restoration upon final delivery, without blanching and with little to no chairside adjustment. Clinical Example The following case report serves to showcase the advantages and flexibility of the Open Platform Inclusive Tooth Replacement Solution. This particular case features placement of a NobelActive implant from Nobel Biocare. Case Report Following endodontic therapy to treat a periapical abscess on tooth #19 (Fig. 12), the patient in this case suffered recurrent periapical infection requiring extraction of the compromised mandibular first molar. The patient was referred to an oral surgeon for drainage and extraction (Fig. 13), at which time immediate implant placement was contraindicated by the infection. 20 www.inclusivemagazine.com

Figure 14: Radiograph of NobelActive implant placed in edentulous site #19 Figure 15: Digital design of custom healing abutment Figure 16: Digital design of custom impression coping Figure 17: Milled custom impression coping (left) with custom healing abutment (right) A five-month healing period was observed, after which the patient returned for diagnostic evaluation for implant therapy. A 3-D cone beam computed tomography (CBCT) scan was obtained using a GALILEOS scanner (Sirona Dental Systems; Charlotte, N.C.). The treatment plan called for guided placement of an 11.5 mm NobelActive RP implant in the edentulous space, utilizing all-digital impressions and a two-stage surgical protocol. After guided placement of the NobelActive implant (Fig. 14), an Inclusive Scanning Abutment for NobelActive RP was attached to the implant fixture for the purpose of capturing the precise location, angulation and connection orientation of the implant during the intraoral scan. A digital impression was taken using the CEREC Omnicam (Sirona Dental Systems), and the information submitted to Glidewell Laboratories for the CAD/CAM production of the custom healing abutment and custom impression coping featured with the Open Platform Inclusive Tooth Replacement Solution (Figs. 15 17). Following a prescribed healing period, the patient returned for a second-stage procedure involving exposure of the implant platform (Figs. 18a, 18b). To account for the shifting of adjacent teeth during osseointegration, a second digital impression was taken during this visit, this time utilizing the custom impression coping (Fig. 19). Use of this custom impression coping facilitates capture of the patient-specific gingival Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution 21

Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution Figure 18a: Presentation of edentulous site post-implant placement, following prescribed healing period Figure 18b: Second-stage exposure of the NobelActive implant platform Figure 20: Digital impression with custom component in place Figure 19: Radiograph to confirm seating of custom impression coping Figure 21a: Seating of custom healing abutment Figure 21b: Radiograph to confirm seating of custom healing abutment contours. Once the digital impression was taken (Fig. 20), the custom healing abutment was placed (Figs. 21a 21c). Key advantages of the custom healing abutment include the preservation of keratinized soft tissue and preparation of that tissue into an ideal form for a more esthetic restoration, as well as simplified delivery of the definitive restoration. Having the abutment on hand eliminates tedious creation of a custom healing abutment chairside. For the definitive restoration, an IPS e.max screw-retained crown (Fig. 22) was prescribed and delivered. Due to proper preparation of the site utilizing the custom healing abutment (Figs. 23a, 23b), the accurate capture of that soft tissue architecture and the precise nature of the digital process, the crown seated easily into place. No adjustment was required. The use of a custom healing abutment and matching custom impression coping, combined with the use of digital impression technology, enabled this case to be completed in fewer visits, simplified delivery of the final prosthesis and resulted in a highly esthetic outcome. Both the patient 22 www.inclusivemagazine.com

Figure 21c: Soft tissue sutured into place around custom healing abutment Figure 22: IPS e.max screw-retained crown Figure 23a: Presentation of edentulous site #19 following prescribed healing period with custom healing abutment Figure 23b: Presentation of anatomically sculpted soft tissue at edentulous site #19 following removal of custom healing abutment and the practice saved time and money. Given the minimal cost differential between custom components and generic ones, an open, patient-specific solution warrants strong consideration in the planning of any implant treatment modality. Summary Advancements in the techniques and materials associated with dental implant therapy have served to widen the range of treatment protocols available to practicing clinicians. Successfully managing these protocols and the options that may arise during any individualized procedure can go a long way toward determining the efficiency and predictability with which a case is completed. Undue reliance on traditional components can restrict a clinician s choices during the course of treatment or require time-consuming chairside alternatives to avoid compromised results. The Open Platform Inclusive Tooth Replacement Solution is designed to meet this challenge by providing the flexibility needed to address any clinical situation, in whatever manner the clinician feels most comfortable or productive. Beginning with the implant of choice, those utilizing this solution may employ a single-stage or two-stage surgical protocol, provide patient-specific healing or custom provisionalization, take conventional or digital impressions, and select a definitive abutment and crown as indicated. Whatever the prescribed procedure, this adaptable, comprehensive solution aims to maximize clinical control during every phase of treatment, resulting in a simplified workflow that reduces chairtime while contributing to a more esthetic restoration. IM Maximizing Clinical Flexibility with the Open Platform Inclusive Tooth Replacement Solution 23