DENTAL TECHNIQUE

Digital verification and correction of digital intraoral scans for

fixed implant rehabilitation of edentulous arches: A dental
technique
William Matthew Negreiros, DDS, MSc,a Teresa Chanting Sun, DDS, MMSc,b,e
German O. Gallucci, DrMed Dent, PhD,c and Adam Hamilton, BDS, FRACDS, DCDd

The use of intraoral scanners ABSTRACT

in the rehabilitation of eden- A method is described for the verification and correction of a digital scan of a complete-arch
tulous patients has increased implant-supported prosthesis for a completely edentulous patient. The technique provides an
because of their efficiency, efficient way to integrate a highly accurate and precise scan of an implant index cast with a
versatility, favorable patient- digital intraoral implant scan by using a computer-aided design and computer-aided
centered outcomes, and manufacturing (CAD-CAM) software program. This method allows dental professionals to validate
improved workflow.1-4 The and, if necessary, correct the implant positions in the scan without the need for a conventional
impression. (J Prosthet Dent 2021;-:---)
accuracy of intraoral scans for
the fixed implant rehabilitation
of edentulous patients has been reported to be compa- The verification process is typically performed as a
rable with that of conventional implant impressions, but verification of the gypsum definitive cast and not a
this finding has mainly been based on in vitro studies.5 verification of the impression itself. Once the definitive
Although the accuracy has been reported to be compa- cast has been verified, it is digitized with a laboratory
rable, in the light of limited clinical evidence, verification scanner to fabricate the computer-aided design and
of the scan would be advisable before the fabrication of a computer-aided manufactured (CAD-CAM) implant-
definitive prosthesis. supported prosthesis. In such a sequential workflow,
The use of an implant verification index for the the verification process becomes an important fail-safe
definitive cast has been recommended because of the barrier that would identify any errors, with documented
potential inaccuracies derived from conventional implant techniques on how to correct the definitive cast if a
impressions and should be considered as a routine pro- discrepancy is noted; alternatively, the impression can be
cedure in a conventional workflow.6 It validates the ac- remade.7,8
curacy of the implant positions in the mouth to the In a fully digital workflow, the conventional verifica-
implant analogs in the definitive cast, allowing for the tion process performed on a printed or milled definitive
fabrication of a passively seating implant-supported cast would not be effective as it does not correct the
restoration, thereby reducing the risk of costly remakes. original digital scan from which the prosthesis will

Support provided by a grant (Grant no.:1293_2018) from the International Team for Implantology (ITI).
a
Research Associate of the Division of Regenerative and Implant Sciences, Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental
Medicine, Boston, Mass.
b
Research Fellow of the Division of Regenerative and Implant Sciences, Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine,
Boston, Mass.
c
Associate Professor and Chairman, Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine, Boston, Mass.
d
Assistant Professor and Director of the Division of Regenerative and Implant Sciences, Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of
Dental Medicine, Boston, Mass.
e
Attending Periodontics Specialist of the Department of Periodontology, Mackay Memorial Hospital, Taipei, Taiwan.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume - Issue -

eventually be manufactured. Furthermore, the incorpo-

ration of significant errors during the manufacturing of 3-
dimensional (3D)eprinted casts would limit any ability to
determine the accuracy of the original scan from which
they were manufactured.9
Therefore, the purpose of the present dental tech-
nique was to describe a predictable and straightforward
method of digitizing a verification index that can be
combined with intraoral scans to verify and correct any
accuracy in the recorded implant positions. In addition,
the technique aims to promote a streamlined process for
acquiring intraoral scans for complete-arch implant
prostheses. The verification index can also subsequently
be used to predictably lute titanium bases into a CAD-
CAM fabricated prosthesis.

TECHNIQUE

1. Make intraoral digital scans (TRIOS 3; 3Shape A/S)

of the arch containing the interim prostheses
tightened in position and the opposing arch, fol-
lowed by a buccal occlusion scan for the correct
articulation. Remove the interim prostheses and
insert scan bodies (CARES RC/NC Mono Scanbody;
Institut Straumann AG) into their respective im-
plants. Make a new digital scan of the arch with the
scan bodies and digitally cross articulate it the digital
scans of the provisional interim restoration and
opposing arch by using soft-tissue landmarks or fi-
duciary markers as references.10
2. Remove the scan bodies, attach nonengaging
interim titanium abutments (RC/NC Temporary
Abutment for bridges; Institut Straumann AG) into
the implants, and connect them with dental floss to
create a scaffold. Apply autopolymerizing acrylic
resin (Pattern Resin LS; GC) onto the dental floss
scaffold with a microbrush and allow for complete
polymerization.
3. Remove the assembly from the patient’s mouth,
section the segments with a fine diamond disk
(6.918B.11.220 HP Medium Flexible Coated Dou-
ble Sided Diamond Disc; Brasseler USA), and
Figure 1. Intraoral fabrication of implant-supported verification index. A,
reattach the nonengaging interim abutments into
Polymerized acrylic resin segments sectioned to mitigate polymerization
their respective implants. Reconnect the segments
shrinkage stresses. B, Segments reconnected with acrylic resin. C,
with new acrylic resin (Pattern Resin LS; GC). Completed verification index.
Upon complete polymerization, remove the veri-
fication index from the patient’s mouth (Fig. 1). 6. In a CAD-CAM software program (DentalCad
4. In the laboratory, attach implant analogs to the verifi- Matera 2.3; exocad GmbH), import the intraoral
cation index and fabricate an implant verification index digital scan of the implant scan bodies as “Jaw
cast with Type IV gypsum (New Fujirock IMP; GC). scan,” the opposing arch as “Antagonists,” and
5. Hand tighten the implant scan bodies into the verify the correct positioning. Import the digital scan
implant analogs and scan the implant verification of the implant verification index cast as “Scan
index cast with a precise laboratory scanner (D104i; abutments.” Digitally remove the base from the
Imetric4D) (Fig. 2).6 “Scan abutments” scan while preserving the scan

THE JOURNAL OF PROSTHETIC DENTISTRY Negreiros et al

- 2021 3

Figure 2. Digitization of implant index cast. A, Implant index cast with implant scan bodies attached to high-precision laboratory scanner. B, Digital
scan of implant index cast.

Figure 3. Registration of high precision benchtop scan (green) to intraoral digital scan (beige) by using dental CAD-CAM software. A, Intraoral digital
scan and digitally trimmed laboratory scan ready for alignment. B, Selection of matching landmarks between 2 sets to facilitate approximation. Note
that because bevels on scan bodies do not match rotation between sets, it is important to choose only flat top surface for correct superimposition. C,
Best fit algorithm calculation. D, Digital files aligned. CAD-CAM, computer-aided design and computer-aided manufacture.

bodies, which will maintain their relative positions.
Align the scan bodies from the laboratory scan
(“Scan abutments”) onto the scan bodies from the
intraoral digital scan (“Jaw Scan”) using an algo-
rithm of best fit for correct registration (Fig. 3). Color
mapping of the discrepancies between the positions
of the scan bodies in the digital implant scan and
the verification index can be used to verify the
original intraoral digital scan.
7. If significant discrepancies are noted, the scans
can be digitally altered to correct the implant po-
sitions. Select and crop the scan bodies (“Jaw

Negreiros et al THE JOURNAL OF PROSTHETIC DENTISTRY

4 Volume - Issue -

Figure 4. Digital file cleanup for better visualization of virtual patient data after integration of digital scans. A, Digital intraoral scan with originally
scanned scan bodies (Jaw Scan). B, Scan bodies cropped, and holes “filled” (Jaw Scan). C, Scan bodies from high accuracy scan overlaid onto digital
intraoral scan (Scan Abutments e green). D, Recognition of implant scan body using the “Scan Abutment” scan followed by detection of digital implant
position. E, Digital cast ready for fabrication of implant-supported CAD-CAM restoration. CAD-CAM, computer-aided design and computer-aided
manufacture.

Scan”) from the intraoral digital scan. Fill the holes
in the mesh and make the scan bodies from the
laboratory scan visible. Detect the new scan
bodies (“Scan Abutments”) in the CAD-CAM
software program to locate the position of the
implants (Fig. 4). This will allow for fabrication of
the prosthesis by using the soft tissue from the
intraoral digital scan and the implant positions
obtained from the scan of the implant verification
index cast.

THE JOURNAL OF PROSTHETIC DENTISTRY Negreiros et al

- 2021
DISCUSSION
A technique to digitally integrate a validated implant
verification jig for edentulous patients is described by
merging a digital scan of an implant index cast onto a
digital intraoral scan of an edentulous arch. This can be
an effective technique for a fully digital workflow and to
streamline implant-prosthodontic procedures.
This method can also be applied for 1-piece and
segmented implant-supported restorations at the
implant or abutment level. The verification index can be
easily fabricated chairside during the initial scanning
appointment or on a 3D-printed cast by a laboratory
technician and reluted intraorally in a subsequent
appointment in conjunction with the clinical evaluation
of a prosthesis prototype. Because a conventional pickup
impression was not required, the procedure time is
effectively reduced and along with possible increase in
patient satisfaction.1
Techniques for verifying 3D-printed or milled casts
made from intraoral digital scans have been described,
including those by Lin et al,11 who described a technique
for verifying and correcting a milled polyurethane
definitive cast. The technique had limitations as it
assumed that at least several of the analogs were in the
correct position and that the sites with misfit could be
manually identified for correction. Given that definitive
casts made with current 3D printing technology have
been shown to have to significant 3D deviations,9
avoiding compounding this error into the workflow
would be prudent. The technique described overcomes
these limitations as it serves to digitally verify and correct
the original scan without the addition of the known er-
rors present in 3D-printed and milled casts.
When fabricating the verification index, nonengaging
titanium interim abutments are generally recommended
to ensure a direct path of withdrawal while mitigating the
risks of inducing excessive stress to the acrylic resin
segments. This limits the technique to screw-retained
multiunit prostheses in which the definitive abutments
will also be of a nonengaging type. It also results in a
discrepancy in the rotational position of the bevel located
on top of the scan bodies from the digital implant index
cast with those of the scan bodies in the intraoral digital
scans. Thus, the flat top of the scan bodies should be
used as landmarks for the correct alignment and regis-
tration of the 2 data sets if nonengaging interim abut-
ments are used to fabricate the verification index.
Limitations of this technique include the need for
additional implant components and clinical time for the
fabrication and luting of the verification index. Clinical
and scientific validations of fully digital workflows in
fixed implant rehabilitation of the edentulous patient are
currently needed. The technique described provides a
workflow that can maintain a fully digital pathway, while
Negreiros et al
5
the verification index provides a failsafe barrier that has
been validated in conventional workflows. By sending an
implant index cast to the laboratory, it can also be used to
verify the relative passivity of the restoration fit before
being returning to the clinician and to allow for the more
accurate cementation of titanium base abutments, which
are often used in fully digital workflows.
SUMMARY
This article describes a straightforward technique for the
integration of a digitized implant index cast to an in-
traoral digital implant scan by using a high-precision
desktop scanner, intraoral scanner, and a CAD-CAM
software program. The integration can be achieved by
registering a laboratory scan of the verification implant
index cast to the intraoral digital scan. In this workflow,
the CAD-CAM software program can design and fabri-
cate a prosthesis based on the digitally verified and cor-
rected implant positions and the soft-tissue architecture
provided by the intraoral scan without the need for a
conventional impression.
REFERENCES
1. Joda T, Brägger U. Patient-centered outcomes comparing digital and con-
ventional implant impression procedures: A randomized crossover trial. Clin
Oral Implants Res 2016;27:e185-9.
2. Papaspyridakos P, Chen YW, Gonzalez-Gusmao I, Att W. Complete digital
workflow in prosthesis prototype fabrication for complete-arch implant
rehabilitation: A technique. J Prosthet Dent 2019;122:189-92.
3. Att W, Chen YW, Papaspyridakos P. Registration of patient-relevant refer-
ences in edentulous jaws using intraoral scanners: Simplification of the
clinical procedure. Int J Esthet Dent 2019;14:394-404.
4. Papaspyridakos P, Chochlidakis K, Kang K, Chen YW, Alghfeli A, Kudara Y,
et al. Digital workflow for implant rehabilitation with double full-arch
monolithic zirconia prostheses. J Prosthodont 2020;29:460-5.
5. Papaspyridakos P, Vazouras K, Chen YW, Kotina E, Natto Z, Kang K, et al.
Digital vs conventional implant impressions: A systematic review and meta-
analysis. J Prosthodont 2020;29:660-78.
6. Papaspyridakos P, Benic GI, Hogsett VL, White GS, Lal K, Gallucci GO.
Accuracy of implant casts generated with splinted and non-splinted
impression techniques for edentulous patients: An optical scanning study.
Clin Oral Implants Res 2012;23:676-81.
7. Knudson RC, Williams EO, Kemple KP. Implant transfer coping verification
jig. J Prosthet Dent 1989;61:601-2.
8. Ercoli C, Geminiani A, Feng C, Lee H. The influence of verification jig on
framework fit for nonsegmented fixed implant-supported complete denture.
Clin Implant Dent Relat Res 2012;14(Suppl 1):e188-95.
9. Papaspyridakos P, Chen YW, Alshawaf B, Kang K, Finkelman M,
Chronopoulos V, et al. Digital workflow: In vitro accuracy of 3D printed casts
generated from complete-arch digital implant scans. J Prosthet Dent
2020;124:589-93.
10. Negreiros WM, Hamilton A, Gallucci GO. A completely digital workflow for
the transition from a failed dentition to interim complete-arch fixed implant-
supported prostheses: A clinical report. J Prosthet Dent 2020.
11. Lin WS, Harris BT, Metz MJ, Morton D. A technique for verifying and cor-
recting a milled polyurethane definitive cast for nonsegmental implant
restoration in an edentulous jaw. J Prosthet Dent 2014;112:658-62.
Corresponding author:
Dr William Matthew Negreiros
Department of Restorative Dentistry and Biomaterials Sciences
Harvard School of Dental Medicine
188 Longwood Ave, REB Suite 216
Boston, MA 02115
Email: william_negreiros@hsdm.harvard.edu
Copyright © 2021 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2021.05.012
THE JOURNAL OF PROSTHETIC DENTISTRY