Complete Digital Workflow for Mandibular Full-Arch Implant

Rehabilitation in 3 Appointments
Panos Papaspyridakos, DDS, MS, PhD ,1,2 Andre De Souza, DDS, MS,1 Anshu Bathija, BDS, MS,1
Kiho Kang, DMD, MS, FACP,1 & Konstantinos Chochlidakis, DDS, MS, FACP 2
1
Department of Prosthodontics, Tufts University School of Dental Medicine, Boston, MA
2
Department of Prosthodontics, Eastman Institute for Oral Health, University of Rochester, Rochester, NY

Keywords
CAD/CAM; complete-arch implant
rehabilitation; dental implants; digital
dentistry; digital workflow; monolithic
zirconia; zirconia prosthesis.
Correspondence
Panos Papaspyridakos, Associate Professor,
Department of Prosthodontics, Tufts
University School of Dental Medicine, One
Kneeland Street, Boston, MA 02111.
E-mail: panpapaspyridakos@gmail.com
The authors do not have any financial interest
in the companies whose materials are
included in this article.
Abstract
The aim of this clinical report is to describe a complete digital workflow protocol for
mandibular full-arch implant rehabilitation from guided surgery to definitive pros-
thesis in only 3 appointments. This expedited protocol allows for guided implant
placement with a system of stackable surgical templates and CAD/CAM prosthodon-
tic rehabilitation using a digital workflow. At the first appointment, a guided implant
placement protocol with the stackable template concept was done followed by imme-
diate loading with a prefabricated interim prosthesis. At the same appointment, the
Double Digital Scanning (DDS) technique was used for scanning, maxillomandibular
relationship registration and virtual articulation. The anchor pins from guided surgery
were used as fiducial markers for DDS data superimposition. At the second appoint-
ment, the prosthesis prototype was tried-in and adjustments were made. At the third
appointment, the definitive monolithic zirconia full-arch prosthesis was delivered.

Accepted March 21, 2021

doi: 10.1111/jopr.13356

Digital dental technology innovation and implementation is
rapidly growing, and its clinical applications in implant
dentistry translate into the so-called digital workflow.1–5
This workflow includes digital 3-dimensional (3D) imag-
ing, computer-guided implant placement, digital impressions
with intraoral scanner (IOS) systems, and computer-aided
design/computer-aided manufacturing (CAD/CAM).1–5
For full-arch implant rehabilitation using a complete digi-
tal workflow has been challenging.5,6 The reason lies within
the data acquisition procedures with IOSs and the absence of
anatomic landmarks such as teeth that represents a challenge
for the registration and data superimposition.6 Recent reports
illustrated approaches to overcome the challenge of registering
the maxillomandibular relationship and superimposition of dif-
ferent Standard Tesselation Language (STL) files.6–9 Fiducial
markers attached in the soft tissues can be used to facilitate
the superimposition of the generated STL files. A recent pa-
per demonstrated how to perform a complete digital workflow
in the maxillary arch using fiducial markers attached to kera-
tinized mucosa on the hard palate.6 However, in the mandibular
arch the presence of keratinized mucosa is often limited, and
the attachment of fiducial markers in keratinized mucosa may
be problematic or not feasible.
It has been shown that patients have a tendency to prefer min-
imally invasive approaches to treatment.10 There is a current
trend in implant prosthodontics to develop techniques and pro-
tocols that reduce the treatment time and simplify treatment
procedures in order to increase patient acceptance and satis-
faction while maintaining long-term predictability of treatment
outcomes.11 Besides the shortening of treatment time, miti-
gation of the prevalence of prosthetic complications encoun-
tered with metal-resin and metal-ceramic implant fixed com-
plete dental prostheses (IFCDPs) has risen to attention.12–15
The use of monolithic zirconia has been proposed to miti-
gate the prevalence of prosthetic complications.14,15 This clin-
ical report describes the step-by-step complete digital work-
flow protocol from guided implant placement to the delivery
of the definitive monolithic zirconia IFCDP for the edentulous
mandible in only 3 appointments.
Clinical report
A 61-year-old completely edentulous male presented for im-
plant consultation at the Postgraduate Prosthodontic clinic at
Tufts University School of Dental Medicine. Comprehensive
diagnostic work-up revealed complete edentulism, Angle Class

Journal of Prosthodontics 00 (2021) 1–5 © 2021 by the American College of Prosthodontists 1

Complete Digital Workflow for Full-Arch Implant Rehabilitation
Figure 1 Smile view of initial situation.
III skeletal relationship and mandibular gingival display upon
smiling (Fig 1). After presentation and discussion of vari-
ous treatment options, the patient elected to proceed with full
mouth implant rehabilitation.
A new set of interim complete dentures was fabricated and
inserted after satisfactory assessment of esthetics, phonetics,
occlusal vertical dimension, and lip support. Fiducial markers
(CT spots; Beekley Medical) were attached to the complete
dentures which served as radiographic templates for cone-
beam computed tomography (CBCT) scanning using the dual-
scan technique.5 The resultant DICOM files were imported
into commercially available software (co-Diagnostix®, Dental
Wings GmbH, Dusseldorf, Germany) and digital implant plan-
ning was performed.5 In the edentulous maxilla, and due to ad-
equate keratinized mucosa and bone quantity, 6 implants with
a flapless approach were planned. In the mandible, 6 implants
were placed with simultaneous alveoloplasty due to limited
prosthetic space and excessive mandibular gingival display.
The digital surgical plan was exported, and CAM software
was used to 3-D print (P30+ printer, Institute Straumann AG,
Basel, Switzerland) the surgical templates. A surgical template
for flapless surgery was printed for the maxillary jaw, while a
surgical template system (Smile in a box, Institute Straumann
AG, Basel, Switzerland) with a series of stackable templates
was printed for the mandibular jaw. In the maxillary jaw, 6 im-
plants (Bone Level Tapered, Institute Straumann AG, Basel,
Switzerland) were placed with the use of a surgical template
and a flapless approach. Due to lack of desirable primary stabil-
ity, a conventional loading protocol was followed in the max-
illa. In the mandible, the first surgical template was secured
with 5 anchor pins, and then removed and replaced by the sec-
ond template which was secured in place on the same 5 anchor
pins. The second template was used for bone reduction and
would be secured with the same anchor pins as the first tem-
plate. Once alveoloplasty was completed, a third surgical tem-
plate was positioned on top of the second template for guided
implant placement. After implant placement, the third template
was removed, and a prefabricated 3D printed interim prosthe-
sis was positioned on top of the second template with opening
clearance in the areas of the placed implants in order to accom-
modate temporary abutments for the conversion of the prosthe-
2 Journal of Prosthodontics 00 (2021) 1–5 © 2021 by the American College of Prosthodontists
Papaspyridakos et al
Figure 2 Prefabricated interim prosthesis on top of alveoplasty tem-
plate, prior to pick up of the temporary abutments with acrylic resin.
Figure 3 First digital scan of interim conversion prosthesis with the an-
chor pins at the same location for the DDS technique.
sis (Fig 2). Temporary implant abutments were connected to
the multi-unit abutments (SRA, Institute Straumann AG, Basel,
Switzerland) and rubber dam was used to isolate the under-
lying soft tissue. Poly(methylmethacrylate) (PMMA) acrylic
resin was injected to pick-up the temporary abutments (den-
ture conversion technique) and convert the denture into screw-
retained fixed interim prosthesis. Minor occlusal adjustments
were performed and then the interim prosthesis was polished.
During the same clinical appointment, intraoral digital full-
arch abutment-level impressions were made with an intraoral
scanner (IOS) system (TRIOS® 3, 3Shape A/S, Copenhagen,
Denmark) for the edentulous mandible following the Double
Digital Scanning (DDS) technique as described previously.2
Prior to DDS technique, titanium powder was sprayed on the
soft tissues to facilitate the intraoral scanning and reduce re-
flection due to the presence of blood. A first digital impression
(STL file 1) with the fixed interim prosthesis was made after
placing the 3 anchor pins in place to serve as fiducial landmarks
(Fig 3). Subsequently, the interim prosthesis was removed, and
a second digital impression (STL file 2) was made after scan
bodies (CARES Mono scan bodies, Institute Straumann AG,
Basel, Switzerland) were hand tightened onto the multi-unit
Papaspyridakos et al
Figure 4 Second digital scan of the scan bodies with the anchor pins
used during guided surgery, serving as fiducial markers attached to the
bone for the DDS technique.
Figure 5 Master STL file after the superimposition of the two STL files,
with the aid of the anchor pins serving as fiducial markers.
abutments with the same anchor pins in place as well (Fig 4).
The generated STL files from the 2 intraoral scans (STL files
1 and 2) of the implants and the interim prosthesis were saved.
Finally, the immediately loaded interim prosthesis was used
to generate an index cast after connecting analogs and pouring
the index cast with low expansion stone (Resin Rock, Whipmix
Corp., Louisville, KY). The index cast would be used for the
cementation of the titanium inserts (Variobase SRA abutment,
Institute Straumann AG, Basel, Switzerland) to the definitive
zirconia IFCDP and ensure the accuracy of fit for quality con-
trol. Subsequently, the immediately loaded interim prosthesis
was delivered to the patient with postoperative instructions on
how to clean it and maintain a soft diet for the next 8 weeks.
The same prosthodontic procedures were performed for the
edentulous maxilla 2 months after successful implant osseoin-
tegration and fixed provisionalization.
In the laboratory, the saved STL files were imported into
CAD software (Exocad DentalCAD, exocad GmbH, Darm-
stadt, Germany) and superimposed into one master STL file
for the design of the prototype prosthesis (Fig 5). The pro-
totype prosthesis was milled out of PMMA blanks, and tita-
Journal of Prosthodontics 00 (2021) 1–5 © 2021 by the American College of Prosthodontists
Complete Digital Workflow for Full-Arch Implant Rehabilitation
Figure 6 Intraoral view of PMMA prosthesis prototypes, after applica-
tion of pink composite and minor occlusal and esthetic adjustments.
nium inserts (Variobase SRA abutment, Institute Straumann
AG, Basel, Switzerland) were cemented inside the prototype
prosthesis.
At the second clinical appointment, which occurred after
8 weeks of uneventful healing, the patient presented for try-
in of the prototype prosthesis (Fig 6). The accuracy of fit
was confirmed clinically and radiographically.5 Minor occlusal
adjustments were made and shade selection for the gingiva
was done. At the laboratory, the PMMA prototype prosthe-
sis was digitally scanned with the extraoral scanner (Dental
Wings, Institute Straumann AG, Basel, Switzerland), and the
STL file was imported into the CAD software (Exocad Den-
talCAD, exocad GmbH, Darmstadt, Germany). With the aid
of the CAD software, the definitive mandibular prosthesis was
copy milled on a CAM milling unit (Tizian Cut Eco plus,
Schuetz Dental GmnH, Rosbach, Germany) from a zirconia
monoblock (Katana HT zirconia block, Kuraray Noritake Den-
tal Inc, Tokyo, Japan) with a high flexural strength of 1,100
MPa followed by sintering and staining. After sandblasting the
internal surfaces of both monolithic zirconia prostheses, they
were subsequently thoroughly rinsed and air-dried. The zir-
conia surfaces and the titanium inserts (Variobase SRA abut-
ment, Institute Straumann AG, Basel, Switzerland) were ad-
ditionally treated with a 10-methacryloyloxydecyl dihydrogen
phosphate (MDP)-containing bonding/silane coupling agent
mixture (Clearfil Ceramic Primer; Kuraray Europe GmbH,
Hattersheim am Main, Germany) for 60 seconds.5 The cemen-
tation was done with a self-adhesive resin cement (Clearfil Ce-
ramic Primer; Kuraray Europe GmbH, Hattersheim am Main,
Germany) at the verification index cast for quality control.2
At the third clinical appointment, the monolithic zirconia
prostheses were inserted. Clinical and radiographic accuracy
of fit was confirmed with the screw resistance test and with
periapical radiographs, respectively.5,6 Articulating paper (Ac-
cuFilm II; Parkell Inc, Edgewood, NY) and shimstock (GMH;
Hanel Medizinal, Warrendale, PA) were used to identify oc-
clusal contacts, and fine red diamond burs were used for oc-
clusal adjustments under copious water. The zirconia prosthe-
ses were delivered and the prosthetic screws were torqued to
15Ncm. Teflon tape and composite resin (Z250, 3M ESPE, St
3
Complete Digital Workflow for Full-Arch Implant Rehabilitation
Figure 7 Frontal view of definitive monolithic zirconia prostheses.
Figure 8 Post treatment panoramic after 6 months.
Paul, MN) were used to seal the screw access channels. The
6-month clinical and radiographic follow-up showed a stable
outcome (Figs 7, 8).
Discussion
In the present case report, a complete digital workflow for the
edentulous mandible was performed. A 3-appointment treat-
ment protocol was applied from digitally planned guided im-
plant placement to the delivery of the definitive prosthesis. The
present case report shows how complete digital workflow can
be used to efficiently streamline and expedite implant treat-
ment for the edentulous mandible. With the presented proto-
col, chairside time is reduced, the cost of implant treatment
may be decreased, and treatment acceptance may potentially
be increased.
The primary advantage of this expedited protocol is that all
the necessary information for the fabrication of the definitive
prosthesis is acquired from the immediately loaded interim
prosthesis with the DDS technique. The DDS technique and
the anchor pins allow for superimposition of the STL files from
the 2 digital scans irrespective of the presence of keratinized
mucosa in the edentulous mandible. The anchor pins serve
as fiducial markers and facilitate the superimposition of the 2
4 Journal of Prosthodontics 00 (2021) 1–5 © 2021 by the American College of Prosthodontists
Papaspyridakos et al
STL files. This leads to one master STL file that is used for
the CAD/CAM fabrication of the PMMA prototype prosthesis
in a complete digital workflow.2 The DDS technique also
allows for making maxillomandibular records simultaneously
with the impression since all the diagnostic information is
embedded in the interim prosthesis. This shortens treatment
time by 1 appointment making the maxillomandibular in-
terocclusal records unnecessary and going from impression
directly to prosthesis prototype try-in. This fusion of impres-
sion and maxillomandibular records into 1 visit can also be
done with the conventional prosthodontic workflow as shown
by Ercoli et al who showed how to manage the impression,
maxillo-mandibular relationship, and cast articulation in a
single appointment through a conventional workflow.11 How-
ever, the complete digital workflow seems significantly faster
and less cumbersome when compared with the conventional
workflow.
Additionally, the use of a digital workflow allows for reduc-
tion of chairside time, reduction of cost, optimization of clini-
cal prosthodontic procedures and improvement of patient satis-
faction with reduction of treatment time. Especially after a long
day of surgery, the DDS technique is significantly faster than
the conventional impression workflow. An additional advan-
tage of the DDS technique included the fact that even if a mis-
fit of the PMMA prosthesis prototype is detected, the prototype
can be sectioned and reconnected intraorally and the adjusted
prototype can be rescanned in the laboratory and copy milled
into the definitive zirconia prosthesis. Alternatively, the imme-
diately loaded interim prosthesis can be used to generate an
index cast after connecting analogs and pouring the index cast
with low expansion stone, as was done in the present report for
quality control. As always, the accuracy of fit of the generated
prosthesis prototype, is directly dependent on the accuracy of
the full-arch digital implant impression and the complete digi-
tal workflow as presented in this technical note may solve the
problems encountered with 3D printing full-arch physical casts
and incorporating additional errors in the cascade of the fabri-
cation of the prosthesis prototype.2,5,6
Limitations of the present technique include positioning of
the anchor pins which should be planned in a position that they
do not interfere with seating of the interim prosthesis. This can
be easily achieved during the digital planning. Additionally,
scanning of the anchor pins may be challenging due to the
reflective metallic nature so the use of powder may be recom-
mended to facilitate the scanning of the anchor pins. Limited
mouth opening may also be a limitation with guided implant
placement and this has to be assessed during the diagnostic
work-up in order to confirm the feasibility of intraoral fit of
the guided surgical instrumentation. Finally, a potential misfit
of the prosthesis prototype with subsequent sectioning and
reconnecting of the prototype, can be prevented by creating
the aforementioned verification index cast from the conversion
prosthesis for quality control and cementation of the titanium
inserts.
Summary
The presented protocol overcomes the limitation of attach-
ing fiducial markers on non-keratinized mucosa, and utilizes
Papaspyridakos et al
anchor pins during guided implant placement to enable an ac-
curate complete digital workflow for the edentulous mandible.
A mandibular full-arch implant rehabilitation from guided 7.
surgery to definitive prosthesis can be carried out in only 3 ap-
pointments.
8.
Acknowledgments
The authors would like to thank Mr. Yukio Kudara, Division of 9.
Postgraduate Prosthodontics, Tufts University School of Den-
tal Medicine, for his expertise in the CAD/CAM fabrication of
the definitive prostheses, and Dr Hoon Ko, Division of Post- 10.
graduate Prosthodontics, Tufts University School of Dental
Medicine, for his assistance in clinical care.
11.
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