All-on-6 Full Contour Zirconia upper dental implant bridge. 100% CAD/CAM. Part 1. PMMA try-in.

Haven't done it but want to get there
Which scanner software milling combination did you use
Really nicely managed!

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Anton. The smile line looks nice. Is this all on 5 or 6? It is hard to follow your sequence of treatment. Could you please elaborate more on the timing of treatment. Very interesting. I can't say I have seen Cad Cam used in this way. Thank you for sharing. Best regards. Chuck

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Charles,
its all-on-6 .
Sequence was very simple as the following:
1 stage surgery with extractions, bilateral sinus lifts(crestal), 6 implants + GBR where needed.
Complications: UL molar implant (7x9) failed due to " strangulation" by a wide (8mm) flared abutment. I'll post the case for that later.
So I had to redo that 6 th implant (8X11) with SL .
That's why , so far it is all-on-5 PMMA temp made after 5 implant have integrated.
Placing 6 vs 4 implants allowed to proceed with restorative phase without delays.
When the UL implant integrates I'll restore with final FCZ screw-retained All-on-6 bridge.
Thank you for comment

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Stephen,
I use TRIOS from 3Shape,
PMMA designed myself with Dental System (3Shape), outsourced to a milling center for milling,.
Finalized on-site at in-house lab.
Thank you

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Anton,
nice result. If you meant CAD-CAM using an intraoral scanner my answer is no. Is this the case?
Thanks for the original case presented.

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Yes Armando,
I meant to fabricate a case like that from intraoral scans, without models,impressions, face bow transfers, lab, technicians etc.
Besides , plan case just using a pano without CBCT, placing implants free-hand without any guides.
Thank you for compliments.

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Anton,
if you used Trios, just a comment: how did you manage to get the two arches in digital occlusion?
Scan abutment are easy enough to use and digital planning development too:)....
If you work that out digitally you did a great job.
(I'm a beginner on Trios I got on September).
Armando

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Great question Armando.
I hoped that someone could answer that question, when I started restoring my full arch implant cases digitally.
I developed few techniques for bite registration.
The easiest would be if pt has an old denture, I cut the 5 mm wide slots in it, so the scanner can capture ATTACHED gingiva during the bite scans.
But for this case, since the old denture was a mess, I used TENS and GNM work up .

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Anton , how does the scanner take the timing off the implants so it doesn't engage the hex. You said the whole case was scanned correct , so usually the scan can only create abutments from a scan body ... Am I correct?

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Mark,
There is a choice for certain size implants (3.5,4.5mm) between engaging and non-engaging abutments. For 5.7 mm platform there is only one choice - engaging. So for wide terminal implants I simply trim the hex slightly until it fits.

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Anton. Very cool! I am still trying to understand how (without using a prosthetic) you were able to digitally manage the lip line so well. Thank you for the update. Best regards. Chuck

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Charles,
another great question!
I do it according to principles of
Bio-mimetic Dentistry,
Facial Orthotropics by Dr. Mew
Gneuromuscular (GNM) Dentistry - thanks to Dr. Chan and others.
Also adding some of my own know-hows along the way.
99.9% of dentists probably have not heard above mentioned disciplines, not talking about dental techs.
Since I started using TRIOS scanner with CAD design streaming into CAM , I'd set myself free from lab techs lack of knowledge, ignorance, stupidity, bios and need to "communicate" with them. Of course, there are few lab techs in the world, who possess necessary skills and knowledge but I have no room in my fees to afford their services and no time explaining and coordinating cases.
thank you for the compliment!
I hope to meet you in Vegas.

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Anton,

Great use of technology. I find Zirconia to be too complicated and error prone. Have you considered skipping Zirconia all together and going with a PEEK material like Trinia. You can mill it 1:1 and thus achieve micron precision. No ovens, no shrinking errors.

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Peter,
Thank you for the idea,
For how long Have you used that material ? I am concerned about a wear of the finishing resin they put on the top of Trinia .
I will definitely ask my milling center if they can mill from that.
On bicon web site I've seen few cases but this material is very opaque and cannot be used in full contour like Zirconia. Thus it requires a lot of finishing by a specialized lab. My goal is to reduce to zero human factor of laboratory component in my cases.

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Great discussions....Dr. Salama

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Very well done! Gregory

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Thank you Gregory,
A compliment from a mentor cerec doctor is especially valuable !

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Thank you Anton! I am not a mentor anymore. Thank you for sharing your case! I like people like you who can demonstrate their knowledge into practice!

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Great case and I admire your use of technology.Have you not planned for any implants within the anterior area? Purely from biomechanical standpoint?
Thanks,
Simon Milbauer

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Simon, thank you for the compliment.
Regarding anterior sagital cantilever, from bio-mechanical standpoint its better than bilateral posterior cantilevers which is the standard for most if not all of AO4 cases.
On this particular case, even with an additional implant in the most anterior position of #8 or 9 we would end up with sagital cantilever anyway due to trapezoidal shape of atrophic premaxilla.
Looking back , there was an opportunity to place an implant directly into incisal canal with some GBR , I'll do it next time.

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Great case Dr. Andrews,

Just to make sure I follow your sequence.
You placed the implants after site preparation and then used an intra-oral scanner and articulated the arches digitally.
Then you designed the prosthesis on the software and had it milled at a different center.
Then, you proceeded with loading the implants.
A few questions. I apologize in advance if you have answered some of them:
1. Did you use ANY bite registration and facebow intraoraly?
2. What was the timing from the time of placement to delivery of the PMMA prosthesis?

thank you for your time,

Thanos Ntounis DDS,MS

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i have been using trinia for more than one year now no complications so far ,, its so light in compare to zirconia , even patients feel great , i have used it in full arch and 4 unites bridge , cemented and screw retained

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Anton, Great case and great discussions. While digital scan/plan of single & small bridges are becoming more routine, the work-flow, techniques, and occlusal complexities, including accuracy issues, of full arch cases continue to be an evolving protocol. Its communities and forums like this that will help it to evolve and become more routine. Thanks for the contribution. I'm really enjoying it and leaning from it.

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Henry,
thank you for the warm comment.
These type of cases are challenging in many ways: Planning, surgical, restorative, CAD/CAM, laboratory finishing.
It is really great to have an online resource like dentalxp were we can share, discuss, criticize and learn bringing our skills and knowledge to the new heights to better serve our patients.

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