Introduction

Digital dentistry and the digital workflow concept have been described and established for over 30 years¹. The introduction of Computer-Aided Design/Computer-Aided Manufacturing (CAD/CAM)² and, subsequently the intraoral scanner³ sparked the interest and development of digital innovations in all parts of dental treatment practice, which has grown exponentially in the past decade and continues to do so⁴. In parallel, the rapid growth of Dental Service Organisations (DSOs) across the dental community is continuing; in the US 10.3% of dentists are affiliated with a DSO, with 30% of dental school seniors said they planned to join a DSO-affiliated practice, compared to 12% in 2015⁵. The combination of digital innovation and changes in practice ownership and management present both opportunity and challenge for DSOs and private practices alike; the wide variation in treatment methods, clinical specialties, years of experience, clinic setup, and other areas of day-to-day clinic activity reflect the complexity of ensuring the same quality of treatment offerings across clinics; identifying the optimal workflow for a given treatment is key. Digital dentistry is here to stay, and whilst it cannot replace all aspects of treatment delivery, it provides efficient and clinically acceptable patient outcomes. Standardizing treatments in the form of workflows encompassing digital methodologies is essential for achieving the gold standard of care, good clinical practice, and meeting growing governance requirements from dentist to DSO. Although digital workflows are not a new concept, structured implementation of a treatment solution in a single offering combining materials, training, clinical, and technical support is not currently provided by the dental industry. In addition, the complex nature of DSOs makes effectively identifying competencies and areas in need of improvement difficult.

Whilst digital dental innovations have proven clinically advantageous⁶, their practical use and application within the clinic is not. For example, intraoral scanners are shown in many studies that assess their efficiency in terms of scan time versus conventional impression taking, the outcome of which supports the transition from traditional to digital⁷. However, the practical application requires training, implementation, and support to incorporate into a clinic to meet the cost-effective and clinically excellent standards patients and clinicians expect. Collectively, this would be a workflow solution.

In this report, the focus is on a single-unit digital implant workflow solution called the Restorative Dentistry 360 (RD 360). One patient of a cohort underwent the same treatment type according to a defined digital-focused protocol according to a holistic end-to-end solution (Fig 1). The patient treatment described here is part of a larger study that aims to validate the clinical methodology and quantify the impact of the entire solution to both the clinic and the patient.

Initial situation

A healthy 62-year-old female patient presented with a root fracture with an associated periodontal pocket of the left upper lateral incisor. The fracture was too long in length to save the tooth, and an apicoectomy was not considered a viable option. She had no systemic diseases, was taking no regular medication, and had no smoking history. Her oral health status showed no history of periodontal disease and was considered periodontally stable. Radiographic evaluation with a Cone Beam Computed Tomography (CBCT) revealed the root fracture, as well as the feasibility of placing an implant (Fig. 3). The tooth was extracted several months before implant placement. During the post-extraction treatment consultation, an intraoral scan was taken (Fig. 4), and a discussion regarding treatment options was given. The patient was shown her IOS scan and a discussion around guided implant surgery using a guided implant planning and surgical guide production service (Straumann Smile in a Box^TM) using a demonstration case, which consisted of a demo model to aid in understanding and treatment proposal acceptance. After providing the treatment options, she consented to an implant with a temporary crown with a fixed crown with the expectation of complementary esthetics in the frontal area matching the opposing tooth. The treatment plan was confirmed via email following the discussion.

Treatment planning

Treatment planning and presentation to the patient involved communicating with the patient using IOS scans and a demo model representing a patient’s mouth with a surgical guide. Upon treatment consent, CBCT scans were taken, and an implant planning service was used. The steps in the treatment planning process were as outlined in Figure 5 and summarized below:

1. Firstly, CBCT and IOS scans were sent along with a prescription for desired implants/abutments/temporary crown among other options, requested to the implant planning service known as Smile in a Box (SiAB) (www.smileinabox.com).
2. Dental experts used the CBCT and IOS scans to plan implant placement using dedicated software (coDiagnostiX®)
3. The planning resulted in a digital treatment design and plan, which was presented to the clinician for final approval and to make any desired modifications to the plan.
4. Upon final approval by the clinician, the components (custom and stock) were produced, assembled, and sent to the clinic as a single delivery. The customized components included a surgical guide, a dedicated treatment plan (including drilling protocol), and a temporary prosthesis.
5. All ordered components, including the implant, closure cap, healing abutment, temporary crown, and model 3D printed guide, were sent to the clinic in a convenient singular order.

Surgical procedure

The patient was treated according to the RD 360 workflow. Virtual implant planning resulted in a finalized plan (Fig. 6) with a dedicated drilling protocol (Fig. 7). The treatment plan listed the ordered components and their article numbers for the patient notes (Fig. 8). The drilling protocol correlated to the dedicated surgical kit which was used according to the chosen implant system. The patient was given a 12mm Bone Level X (BLX) SLActive® implant; thus, the BLX surgical kit was used for the surgery (Fig. 9 & 10).

The rationale of the treatment plan relied on the following facts and/or expectations:

• The patient can be provided with a non-invasive surgical approach, allowing the presence of a fixed provisional crown throughout the therapy.
• The overall time of the treatment can be reduced.
• The use of a computer-guided approach enables the placed implant position to be assessed relative to the planned position (which is not available for freehand surgery). 
• The use of a BLX implant, thanks to its specific design and surface, provides optimal stability needed for immediate implant placement and provisional prosthesis.
• The presence of favorable site anatomy and a convenient amount of keratinized gingiva reduces the risk of esthetic complications.

On the day of surgery, the patient was given a local anesthetic (Lidocaine) in the area corresponding to the lateral incisor apex. The extraction of the tooth had been performed six months prior to the surgery. Following anesthesia, the surgical guide was placed in the patient’s mouth and the stability of the guide on the teeth was verified, and visual access through the guide windows was checked (Fig. 11). The patient received ae Straumann BLX ø3.5 mm SLActive® 12mm Roxolid® implant and an immediate prosthesis on position 22, using the computer-guided planning (coDiagnostiX®) and subsequent drill protocol sequence. The drill protocol used a series of drills (Figs. 12 & 13) to prepare the site for the implant (Figs. 14 & 15) insertion with a flap created as was deemed appropriate for this surgery, one of the first to be performed by this clinician. Following placement, an abutment was placed (Fig. 16), followed by the provisional crown (Fig. 17) on the day of the surgery. For this case, no biomaterials or post-op medication was necessary.

The surgery was timed from guide fit to final suture and took 18 minutes and 7 seconds.

Prosthetic procedure

At the 3-month follow-up visit, the patient presented with the final crown still in place (Fig. 18) with good healing of the soft tissues with no complications within the previous months (Figs. 19 & 20) as confirmed upon removal of the provisional crown and assessment of the implant site. Post-operative X-ray images were taken to assess placement visually (Fig. 21). An intraoral scan was taken with a scan body and used to order the final crown which was fitted at a later appointment (Figs. 22 & 23) using a Straumann Group-partnered lab. The crown fit time, from initial placement to final placement. The time needed, including any adjustments, was 5 minutes and 41 seconds.

Treatment outcomes

The patient and our team were extremely satisfied with the treatment outcome regarding health, aesthetics, and function. The patient’s needs and expectations were met, and the guided surgery component, which was the novel aspect in the RD 360 workflow to our clinic, demonstrated an enhanced approvement in comparison to the baseline situation in terms of time-saving and ensuring the best in patient treatment. Furthermore, the guided surgery achieved an outstanding level of accuracy (Fig. 24). Outside of digital assessment methods, the consensus for clinically acceptable implant placement is the implant 3 mm in the apical direction from the cervical contour and placed 2 mm in the palatal direction. Guided surgery enables detailed accuracy measurements by comparing the virtual implant plan with the scan body IOS scan, which is the same scan required for the final prosthesis design and manufacture. A recent review of numerous studies on implant placement accuracy reported a global deviation of 1.2 mm apical deviation at entry, 1.4 mm coronal deviation, and an angular deviation of 3.5°⁸. Studies assessing single implant accuracy confirm these parameters as the error limit⁹.

Dr Bryant’s recommendations

The RD 360 is a holistic workflow enabling an easier support interface to provide a better experience for clinic staff and patients. More time could be directed to other clinic activities by utilizing the treatment planning service central to the workflow. Furthermore, the ability to discuss the treatment plan at my convenience with expert planners helps me feel supported in my initial experience of guided surgery. This meets my expectation that the treatment meets the gold standard for clinical treatment delivery. The RD 360 is an excellent opportunity for increased adoption of digital technologies and a blueprint for transitioning from freehand to guided implant surgery.