Fully integrated digital implant dentistry with Sirona’s CEREC-GALILEOS integration workflow

Dr. Farhad E. Boltchi provides a step-by-step overview of his digital workflow

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Introduction
Sirona’s CEREC-GALILEOS integration workflow provides a completely integrated digital implant dentistry workflow incorporating all aspects of surgical and restorative implant dentistry. This article will provide a step-by-step overview of this digital workflow.

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Case example

Figure 1: Preoperative occlusal view of edentulous site No. 19; Figure 2: Preoperative periapical radiograph of site No. 19
Figure 1: Preoperative occlusal view of edentulous site No. 19; Figure 2: Preoperative periapical radiograph of site No. 19

This patient is a 38-year-old male patient with a noncontributory medical history, who presented for implant therapy to replace missing tooth No. 19. The initial clinical and periapical radiographic evaluation revealed an edentulous site with clinically adequate ridge width and with adequate bone and soft tissue volume for dental implant therapy (Figures 1-2).

A cone beam CT radiographic evaluation was performed with the Sirona Orthophos XG 3D CBCT machine, and a digital impression of the patient’s maxillary and mandibular arches was obtained via scanning with the CEREC Omnicam. A virtual restoration was then designed in the CEREC Chairside software, and the corresponding CAD/CAM data was exported into the GALILEOS Implant treatment planning software, where it was merged with the CBCT scan. The GALILEOS Implant treatment planning software was utilized to plan a BioHorizons®
Tapered Internal Plus 5.8 mm x 12 mm implant in site No. 19 (Figure 3). The treatment planning data was then exported from the GALILEOS Implant treatment planning software and sent to SiCat in Bonn, Germany for the design and fabrication of a SICAT OPTIGUIDE surgical guide (Figure 4).

Figure 3: GALILEOS Implant CBCT implant treatment plan for site No. 19
Figure 3: GALILEOS Implant CBCT implant treatment plan for site No. 19

The surgical procedure was performed under local anesthesia, and implant placement in site No. 19 was accomplished via a flapless guided approach. The SICAT OPTIGUIDE and the BioHorizons guided surgery system were then utilized to prepare the guided implant osteotomy according to the virtual treatment plan in the GALILEOS Implant software, and a BioHorizons Tapered Internal Plus 5.8 mm x 12 mm implant was placed through the SICAT OPTIGUIDE in a fully guided fashion in the restoratively correct and preplanned position (Figures 5-12). The implant achieved excellent primary stability and was placed in a flapless approach within the confines of the osseous alveolar housing (Figure 13). A Sirona ScanPost and the corresponding Scanbody were then inserted onto the implant, and a CEREC Omnicam digital impression/scan of the Scanbody was obtained to allow for the fabrication of a screw-retained provisional restoration while the implant was undergoing the osseointegration healing phase (Figure 14). In order to start developing the implant tissue transition zone, a wide healing abutment was then placed on the implant (Figures 15-16).

Figure 4: Close-up view of the completed SICAT OPTIGUIDE
Figure 4: Close-up view of the completed SICAT OPTIGUIDE
Figure 5: Close-up view of the intraorally seated SICAT OPTIGUIDE; Figure 6: Precise guided tissue-punch preparation
Figure 5: Close-up view of the intraorally seated SICAT OPTIGUIDE; Figure 6: Precise guided tissue-punch preparation
Figure 7: Guided implant osteotomy preparation; Figure 8: BioHorizons Tapered Internal Plus implant with guided mount
Figure 7: Guided implant osteotomy preparation; Figure 8: BioHorizons Tapered Internal Plus implant with guided mount
Figure 9: Fully guided implant placement with handpiece driver; Figure 10: Fully guided implant placement with ratchet driver
Figure 9: Fully guided implant placement with handpiece driver; Figure 10: Fully guided implant placement with ratchet driver

Based on the CEREC Omnicam digital impression/scan of the Scanbody, a full-contour screw-retained crown was designed in the CEREC chairside software (Figures 17-21). The corresponding custom screw-retained provisional restoration was then milled out of an Ivoclar Vivadent® Implant Solutions Telio® CAD A16 block, adjusted and polished, and then bonded to a Sirona TiBase with Ivoclar Vivadent’s Multilink® Hybrid Abutment cement (Figure 22). After an uneventful healing period of 8 weeks, this custom screw-retained provisional restoration was screwed onto the implant to develop the ideal peri-implant soft tissue profile (Figures 23-25).

Figure 11: Precise fully guided implant placement; Figure 12: Implant placement in the preplanned and restorative ideal position
Figure 11: Precise fully guided implant placement; Figure 12: Implant placement in the preplanned and restorative ideal position
Figure 13: Flapless guided implant placement; Figure 14: Sirona ScanPost and Scanbody in place
Figure 13: Flapless guided implant placement; Figure 14: Sirona ScanPost and Scanbody in place
Figure 15: Wide healing abutment in place; Figure 16: Immediate postoperative periapical radiograph
Figure 15: Wide healing abutment in place; Figure 16: Immediate postoperative periapical radiograph
Figure 17: CEREC Omnicam scan of ScanPost/Scanbody; Figure 18: Buccal view of restorative emergence profile design in CEREC Chairside software
Figure 17: CEREC Omnicam scan of ScanPost/Scanbody; Figure 18: Buccal view of restorative emergence profile design in CEREC Chairside software
Figure 19: Occlusal view of the digital restorative design in the CEREC Chairside software; Figure 20: Buccal view of the digital restorative design in the CEREC Chairside software
Figure 19: Occlusal view of the digital restorative design in the CEREC Chairside software; Figure 20: Buccal view of the digital restorative design in the CEREC Chairside software
Figure 21: Inferior view of the digital restorative design to assess gingival tissue pressure
Figure 21: Inferior view of the digital restorative design to assess gingival tissue pressure

After an additional 3 weeks, the previous digital full-contour design in the CEREC software was used to fabricate the final implant restoration as a split custom abutment with a cemented final implant crown. The final clinical, periapical radiographic, and CBCT radiographic evaluation revealed an optimal hard and soft tissue integration of the final implant-supported restoration (Figures 26-27).

Figure 22: Chairside milled screw-retained provisional restoration; Figure 23: Peri-implant tissue contours after removal of healing abutment
Figure 22: Chairside milled screw-retained provisional restoration; Figure 23: Peri-implant tissue contours after removal of healing abutment
Figure 24: Occlusal view of screw-retained provisional restoration; Figure 25: Buccal view of screw-retained provisional restoration
Figure 24: Occlusal view of screw-retained provisional restoration; Figure 25: Buccal view of screw-retained provisional restoration

Discussion
This case report demonstrates the high degree of precision and efficiency that can be achieved with the CEREC-GALILEOS integration digital implant dentistry workflow. In an ideal scenario such as the case described previously, the entire implant treatment can be accomplished in two-to-three appointments. The first appointment would consist of a preoperative digital impression, virtual implant planning, guided implant placement, digital impression of the implant, and the digital fabrication of a custom provisional implant restoration as needed. The second appointment would be optional and would consist of the insertion of the custom provisional restoration for the development of the peri-implant tissue transition zone as needed. The third appointment would then consist of the in-house digital fabrication of the final implant restoration without the need for an additional digital impression, removal of the provisional restoration, and the insertion of the final implant restoration.

 

Figure 26: Buccal view of final restoration; Figure 27: Final postoperative CBCT scan
Figure 26: Buccal view of final restoration; Figure 27: Final postoperative CBCT scan

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Boltchi_HeadshotFarhad E. Boltchi, DMD, MS, is in private practice limited to periodontics and dental implants in Arlington, Texas, and is Clinical Assistant Professor, Graduate Periodontics Program, at the Texas A&M University College of Dentistry in Dallas, Texas. He is a Diplomate of the American Board of Periodontology and a Fellow of the International Team for Implantology (ITI).

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