Periodontology 2000, Vol. 73, 2017, 178–192 © 2016 John Wiley & Sons A/S.

& Sons A/S. Published by John Wiley & Sons Ltd

Printed in Singapore. All rights reserved PERIODONTOLOGY 2000

Digital technology in fixed

implant prosthodontics
T I M J O D A , M A R C O F E R R A R I , G E R M A N O. G A L L U C C I , J U L I A -G A B R I E L A
€ GER
W I T T N E B E N & U R S B R AG

Continuous technological progress in both computer- for management of the supra-implant mucosa
based development and dental-fabrication processes architecture in esthetically demanding cases.
ensures new opportunities in clinical workflow (40). A
restoration-driven treatment concept is the key factor
for successful implant therapy in an interdisciplinary Digitization
team approach that coordinates the competences of
prosthodontics, periodontology, surgery, radiology
Bits and bytes
and dental technology (29). In the past, only one stan-
dard treatment approach was applicable, namely the In industrial processing, the benefits of computerized
classical impression technique and physical gypsum engineering technology are associated with high-pre-
casts for the manufacture of acrylic- and porcelain- cision, simplified, fabrication procedures and mini-
fused-to-metal reconstructions using the lost-wax mized manpower resources (5, 19). These may favor
technique. Currently, there are various treatment use of the digital workflow in dental medicine,
options, and the team of clinician and dental techni- through quality assurance, accurate production and
cian has to choose how and when to proceed digi- cost-effective implementation (25, 82). The prerequi-
tally: this starts with the selection and timing of site step for virtualization is to digitize, in a binary
digitizing the patient’s situation, and is followed by code created from the numerical digits 0 and 1, the
the choice of implant reconstructive design and situation in individual patients (72). In general, this
appropriate material components, the simulation digitization process of transforming bits and bytes
and virtual prereplication of the esthetic appearance can be used in two procedures: laboratory-side scan-
in difficult cases, and financial calculations (48). ning and chairside scanning (61). The scanning data
Various companies offer several devices, tools generated, whether in the laboratory or chairside, are
and software applications for digital reconstruc- stored as a Standard Tessellation Language file (1, 5).
tions, and consequently the different workflow Standard Tessellation Language files describe any
options may overwhelm clinicians and dental tech- surface geometry of three-dimensional objects by tri-
nicians (1, 57). In addition, only a few systems are angulation and can be used for computer-assisted
available with open workflows for stepwise selec- design/computer-assisted manufacturing of milled
tion of the data sets obtained (46, 84). Overall, the models, customized abutments and implant supras-
purchase, installment, facilities set-up, updates and tructures (33, 68, 69) (Fig. 1).
maintenance, as well as the implementation of
new technologies, are expensive, time-consuming
Laboratory scanning
and require the operator’s patience for an individ-
ual learning curve (30, 34, 81). Therefore, the aim The laboratory pathway starts clinically with the clas-
of this review was to highlight insights and antici- sical impression technique, using silicone or poly-
pate future visions of digital technologies in fixed- ether impression materials and implant-specific
implant prosthodontics in order to summarize the transfer posts, in combination with the production of
economic aspects, possibilities and limitations in a plaster master cast. The built-up gypsum model is
laboratory processing, and to develop a guideline then scanned by the dental technician using a

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 Digital implant prosthodontics

Fig. 1. Digital processing in implant

prosthetic dentistry. CAD, computer-
assisted design; CAM, computer-
assisted manufacturing.

laboratory scanning system. After this, the properties in systems using active wave front sam-
prosthodontic reconstruction can be designed and pling, confocal laser microscopy and stripe light pro-
fabricated further in a digital environment, with jection. Some of the intraoral optical scanner devices
higher precision and fewer production failures com- use a special powder enriched with titanium particles.
pared with purely analog techniques (22). It should The use of powder does interfere with the quality of
be considered that the initial capture of the three- the scan, in terms of precision and accuracy, and the
dimensional implant position, using conventional application is not convenient and patient friendly
implant impressions, can be qualitatively influenced (58).
by multiple factors, including the type of impression At the time of writing, the clinical indication for an
technique itself, tray selection, materials used, the intraoral optical scanner was mainly focused on
number and angulation of implants, the inherent fit tooth-retained and implant-supported single-unit or
of components and the operator’s skill (53, 60). How- short-span fixed restorations (16). Here, the digital
ever, although the clinician does not have to change protocol offers a streamlined and simplified workflow
their workflow in routine dental practice to use digital by means of a quadrant-like intraoral optical scan of
procedures, the dental technician has to invest in a the restorative site, as well as of the opposite arch,
new laboratory scanning device, including the pur- including occlusal registration, within one opera-
chase of computer software and its subsequent tional step. This protocol reduces the potential of
updates (16). Overall, this approach represents a pro- summation errors compared with the conventional
ven treatment concept, is applicable for all implant full-arch impression-taking procedures, which are
prosthodontic indications and therefore it is still the performed in a multistep approach (33). In vitro
gold standard in the manufacturing process of fixed investigations demonstrated a comparable level of
implant-supported reconstructions today (47, 48). accuracy, defined as precision + trueness, between
classical impressions and different intraoral optical
scanner systems, with or without the use of scanning
Digital impression
powder, for dentate full-arches (24, 73). Laboratory
The clinical situation can be recorded digitally by tests mainly addressed dentate situations, not
contact-free transfer using an intraoral optical scan- implant prosthodontic treatment. In addition, it
ner. In contrast to the laboratory pathway, use of an should be noted that these in vitro results also indi-
intraoral optical scanner can be used, chairside, for cate a strong dependency on the particular intraoral
immediate digitization of the patient’s oral cavity (17, optical scanner system and its characteristic proper-
27). Application of an intraoral optical scanner allows ties (63, 88), the fit of the implant-specific scan-body
real-time on-screen evaluation of the clinical situa- (75) and the operator’s skill (4, 80). An additional suc-
tion, the option to proceed with chairside milling, cess factor is the scanning strategy, which varies
and a convenient and patient-friendly treatment con- according to the intraoral optical scanner system
cept (35). In addition, chairside digitization is more used (23).
hygienic than the conventional impression-taking
technique because there is no potential infection
Patients’ expectations
from saliva and/or blood and no requirement for sec-
ondary transfer of the impression tray from the clinic New technologies may provide not only advanced
to the laboratory (17, 25). possibilities of functional rehabilitation but may also
Commercially available intraoral optical scanner change patients’ attitude as a result of a digitization
devices can be categorized by their technical trend in general (52). Patients are accustomed

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to using digital tools (such as smartphones and widespread overused phrase. Implant prosthodontic
tablet-computers) in their everyday life, and they are treatment seems to be, and has to be, entitled digital
well informed, from health-care-related online plat- because it is popular nowadays. However, the truth is
forms, about various technical advances. Therefore, that, in routine dental practice there is seldom a
patients’ mindset on dental implant therapy has purely conventional pathway or a fully digital work-
shown an ongoing change over the last years (65, 66). flow (37, 48). The individual work steps in the digital
Patients expect functional and esthetic treatment procedure are similar to those of the traditional pro-
results from implant-supported reconstructions. In cedure, comprising classical impression-taking proce-
fact, their expectations are higher for implant-sup- dures, fabrication of a dental master cast, use of the
ported reconstructions than for conventional lost-wax casting technique and completion of indivi-
prosthodontic rehabilitation concepts (13, 77). In dual restorations with hand-layered veneering ceram-
addition, the patients desire less intensive treatment ics (61). Changes are growing in the field of implant
protocols, including shorter appointments combined prosthodontic treatment such as use of an intraoral
with condensed overall therapy, as well as conve- optical scanner and computer-assisted design/com-
nience-oriented concepts without affecting their puter-assisted manufacturing production of frame-
social life (52, 59). With the use of an intraoral optical works. The result of this evolution is the mixed
scanner, patients do not experience the suffocation analog–digital workflow presently in use (82).
hazards, gagging and taste irritation encountered Most benefits of a digital dental workflow are
during conventional impression-taking procedures related to the technical production. In fixed-implant
(17, 61). However, studies on implants are mostly lim- prosthodontics, reconstructions are not limited to the
ited to dental implant survival and clinical/radio- lost-wax technique or milled frameworks with hand-
graphic surrogate parameters (20). layered veneering; rather, digitized veneering tech-
Recently published randomized controlled trials niques with bonding or over-pressing techniques of
compared patient-related outcomes for digital computer-assisted design/computer-assisted manu-
implant impressions with those for conventional facturing-milled occlusal surfaces to any kind of sub-
implant impressions (35, 85, 87). These clinical stud- structure, or even full-contour restorations, are
ies revealed consistent findings with an overall available (33, 37) (Fig. 2).
patients’ preference significantly in favor of the
intraoral optical scanner, rather than the conven-
Monolithic reconstructions
tional technique, for capturing the three-dimensional
implant position. Moreover, one pilot study evaluated Different ways of fabrication are applicable for treat-
the operators’ perceptions when comparing digital ment with implant-supported fixed dental prosthe-
and conventional impressions in a standardized set- ses: a conventional and a mixed conventional–digital
ting for single-implant crowns (54). Study participants approach, using a technical concept of framework
were inexperienced undergraduate dental students plus veneering, or, in contrast, full-contour, mono-
performing both techniques on a phantom model. In lithic restorations (5, 10, 28, 51, 57). For implant-sup-
this study, the digital protocol also resulted in higher ported single-unit restorations, the overall treatment,
operators’ acceptance than the conventional proce- starting clinically with an intraoral optical scanner,
dure. Overall, according to patients’ perception and and following on with a digital design without any
satisfaction with implant-impression procedures, the physical models, is simplified by having the option of
intraoral optical scanner is preferable to the conven- connecting fully anatomic restorations to prefabri-
tional technique’ (35, 85, 87). cated abutments (56). Then, this entire workflow can
really be named ‘digital’ within a complete setting of
bits and bytes (37). Demanding laboratory work steps
Prosthodontic design are streamlined, and the material-specific advantages
are ensured as a result of standardized fabrication
quality (44). Initial laboratory investigations have
Workflow
demonstrated promising results for monolithic
The ongoing development of information technology implant crowns (39, 43). The findings of these in vitro
systems and their acceptance in everyday life has pro- tests revealed constantly high values for stiffness and
vided the opportunity to implement computer-based strength under quasi-static loading for prefabricated
applications and fabrication techniques in dental titanium abutments in combination with the bonded
medicine (7, 30). In this context, ‘digital dentistry’ is a monolithic suprastructures. Monolithic implant

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 Digital implant prosthodontics

Fig. 2. Reconstructive design, and dental material solutions used in implant production.

crowns seem to represent a feasible and stable contour with proper space for the subsequent
prosthodontic construct under laboratory testing veneering (Fig. 4).
conditions, with higher strength than the average The advantages of computer-assisted design/com-
occlusal force of naturally dentate patients (39, 43). puter-assisted manufacturing technology for fabrica-
However, only a limited number of clinical trials tion of the framework have been proven in in vitro
are available at this time. The findings of a case series settings for different designs and material combina-
showed that fully anatomic implant-supported tions of implant-supported fixed dental prostheses
crowns, created using a complete digital workflow, (50). The findings have consistently shown signifi-
seem to be a feasible treatment concept. Partially cantly higher accuracy and precision of digitally pro-
quadrant-like intraoral optical scans and computer- duced frameworks compared with those made
assisted design/computer-assisted manufacturing according to the classical lost-wax technique. The lar-
technology, in combination with prefabricated ger the frameworks, including the number of involved
implant abutments, demonstrated a shortened treat- implants, the more obvious were the advantages of
ment approach in posterior sites (33). In addition, the computer-assisted design/computer-assisted manu-
need for chairside corrections, such as secondary facturing technology, especially for the production of
grinding and polishing, can be minimized, or may not full-arch multiunit reconstructions (49).
even be necessary, within a complete digitized proto- A complete digital approach for treatment with
col using monolithic restorations (44). This reduces implant-supported fixed dental prostheses seems to
work time but may also decrease the risk for cracks be technically feasible but has not yet been scientifi-
and chipping as a result of the absence of veneered cally investigated. Therefore, it should be considered
ceramics (34, 36) (Fig. 3). as experimental at this stage. The challenging aspect
A mixed conventional–digital approach is widely of full digital processing of implant-supported fixed
used for the treatment of multi-unit implant-sup- dental prostheses is the virtual definition of a func-
ported fixed dental prostheses (48). Only the appli- tionally correct occlusion and further fabrication
cation of prefabricated abutments free of rotational without any physical models. Dimensions predicting
limitations and the possibility of correcting axial incorrect antagonistic contacts impede registration of
divergences ensure a simplified workflow for predictable and reliable digital bite. Thus, the clinical
implant-supported fixed dental prostheses manu- fit and adjustments are the limiting factor in this pro-
factured from zirconium-dioxide, titanium or cess, which negate the advantages of the original digi-
cobalt-chrome using rapid prototyping techniques. tal protocol (44).
Finally, the dental technician can digitally design Besides the technical production restrictions, the
the framework in a virtual environment. It is type of restoration material suitable for monolithic
advantageous that a finalized occlusal relief can be implant restorations is controversial. On the one
simulated in order to create a uniformly reduced hand, these materials have to withstand high loading

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A B

C D

Fig. 3. Complete digital workflow

for treatment with a monolithic
implant-supported single-unit crown.
E (A) Intraoral scanning as a preopera-
tional step for creating a virtual
design. (B) Finalized implant recon-
struction of a prefabricated titanium
abutment plus a fully contoured
lithium-disilicate crown. (C, D) Clini-
cal situation with an inserted
lithium-disilicate reconstruction. (E)
Final radiograph.

forces, and, on the other hand, an increased risk for this bone level type implant concept may result in a
abrasion may occur at the antagonist over time, espe- change of terminology from peri-implant mucosa to
cially in the case of naturally existing tooth structures. supra-implant mucosa (Fig. 5). In general, dental
In addition, the visual appearance of monolithic implants and their prosthetic components differ from
restorations, regardless of the materials available, natural teeth in size and shape at the crestal bone
does not fulfill the expectations for the treatment in and at the level of the mucosa. When removing pre-
the esthetic zone. This still requires the artistic finish- fabricated healing abutments in the transition zone,
ing skill of the dental technician. the geometry of the mucosal profile is circular and
does not match that around teeth, which are natu-
rally triangular (15).
Emergence profile
Digital emergence profile
Esthetic considerations
Two classical approaches are available for creating
The imitation of the look of natural teeth by implant- the implant emergence profile, namely ‘immediate
supported reconstructions still remains one of the formation’ with the definitive implant restoration and
major challenges in fixed prosthodontics (18). The ‘sequential formation’ that involves step-wise modifi-
white and pink esthetics of the final restoration and cations of a fixed implant-supported provisional
mucosa has to mimic the previous tooth and match crown, combined with customized transfer of the
the adjacent dentition (8, 26). Bone-level implants are individually shaped soft-tissue architecture and sec-
commonly used in the esthetic zone. A subcrestal ondary insertion of the definitive restoration (14, 67).
implant position is advantageous in order to deal with The sequential formation approach with modulation
a higher amount of surrounding implant soft tissue of the profile before placement is very predictable
(3). However, the clinical management of the consec- (15, 71). However, it should be noted that additional,
utively prolonged trans-mucosal pathway becomes time-consuming, appointments for modification of
more challenging in terms of creating a harmonious the provisional implant crown are necessary (86), and
and pleasant emergence profile (41). Subsequently, possible biologic trauma of the fragile implant soft

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 Digital implant prosthodontics

A B

C D

E F

Fig. 4. Mixed conventional–digital

G H workflow for treatment with a three-
unit implant-supported fixed dental
prosthesis. (A) Intraoral scanning.
(B) Milled model situation with an
individualized mucosa mask. (C)
Prefabricated titanium abutments
with a special design for implant-
supported fixed dental prosthesis –
indication. (D, E) Virtual design of a
screw-retained implant-supported
I fixed dental prosthesis. (F) Com-
puter-assisted design/computer-
assisted manufacturing-produced
zirconium-dioxide framework. (G)
Finalized implant reconstruction
with manual ceramic veneering and
bonded titanium abutments. (H)
Clinical situation with the inserted
screw-retained implant-supported
fixed dental prosthesis. (I) Final
radiograph.

tissue may occur as a result of subsequent changes to The immediate delivery of a computer-assisted
the provisional implant (55). Because of the usually design/computer-assisted manufacturing-produced
long implant transmucosal pathway, it is still chal- healing abutment with an individualized shape, such
lenging to scan the final emergence profile intraorally. as a contour copy of the lost tooth, as a direct scan or
In addition to the possible limitation of the depth of mirrored image of the contralateral tooth, is an
focus of the intraoral optical scanner device, a time- approach with a predictable outcome in esthetically
dependent shrinkage of the supra-implant mucosa demanding cases (41). Beside the economic advan-
architecture complicates the optical impression tech- tages of this streamlined workflow, there is a biologic
nique (32, 45). benefit through avoiding repeated disruption of

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Joda et al.

Fig. 5. Use of bone-level-type

implants with subcrestal three-
dimensional positioning requires a
rethink of the implant prosthetic
concept in the esthetic zone because
of a prolonged transmucosal path-
way. Therefore, the term ‘peri-
implant’ mucosa should be changed
to ‘supra-implant’ mucosa.

epithelial attachment because the patient-specific combination with a high-quality outcome of the final
emergence profile can be defined even before prosthodontic rehabilitation (6, 21).
implant placement. Furthermore, it may no longer be Capturing cost parameters is crucial for decision-
necessary for multiple chairside adjustments of the making in any therapy and is assumed to be of com-
provisional implant, a side effect of which was poorly pelling interest to patients, health-care providers,
polished acrylic surfaces (86) (Fig. 6). third-party systems and society in general (83). Differ-
Digital applications should be viewed as addi- ences between service delivery systems, such as a uni-
tional tools in esthetically demanding cases. The versity environment or a private practice setting, and
architecture of the supra-implant mucosa can be the variability of treatment approaches combined
determined for individual teeth, created either with patient-centered factors, have to be taken into
according to the digitalization of the contour of the account. Moreover, international organizations with
extracted tooth or from the three-dimensional disparate health-care systems, and consequently dif-
radiographic shape of the mirrored contralateral for ferences in purchasing power and culture, and in atti-
single-step emergence profile formation. The clini- tudes toward patient age and gender, markedly
cian’s choice of which approach to use mainly impede the interpretation of outcomes (62, 70).
depends on considerations of patient-specific needs, Cost analysis of the economic efficiency of implant-
the quantity and quality of supra-implant mucosa, supported reconstructions is complex and accord-
as well as the availability and access to digital tech- ingly is rare in the dental literature. Nonetheless, it is
nologies and the collective knowledge and skills of important to consider economic calculations in the
the dental team (41) (Fig. 7). context of clinical state-of-the-art treatment and
when introducing new technologies (6, 30). A recently
published economic process investigation with a
Economics crossover design, which calculated direct costs, pro-
ductivity rates and cost-minimization, evaluated con-
ventional and digital workflows of single-implant
Cost analysis and time-efficiency
crowns (34). The findings demonstrated significant
Implant-supported crowns are the treatment of superiority of the digital workflow over the conven-
choice for the prosthodontic rehabilitation of short- tional pathway with classical impression-taking pro-
span edentulous spaces (1, 5). However, the implant- cedures and master plaster casts. In summary,
based treatment is a more cost- and time-intensive digitally fabricated implant-supported single-unit
solution compared with conventional tooth-sup- reconstructions were 18% less costly for the entire
ported fixed dental prostheses (11, 12). Therefore, it is clinical and laboratory treatment process than were
of great interest to offer the advantages of implant conventionally manufactured implant crowns (34).
dentistry to a wider population. This is only possible The purchase of long-lasting equipment is a sup-
if new technologies are affordable and can shorten plementary factor that should be considered in cost
the overall clinical treatment and technical produc- analysis. The clinical equipment needed for capturing
tion time to achieve a reasonable cost–benefit ratio in the three-dimensional implant position differs for

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 Digital implant prosthodontics

A B

Fig. 6. The mirrored-salami-techni-

que for one-step formation of the
C D supra-implant emergence profile.
(A) Maxilla Digital Imaging and
Communications in Medicine
(DICOM) data for segmented natural
tooth 11 (white) and a mirrored copy
for visualization of the prospective
emergence profile of the implant
reconstruction in position 21 (pink).
(B) Screenshot of the Standard Tes-
sellation Language (STL) file gath-
E F
ered from a digital impression with
screwed scanbody for detection of
the final implant location. (C) Three-
dimensional imaging of the individ-
ualized healing abutment on top of
the virtual implant in position 21.
(D) Prefabricated titanium bonding
base plus computer-assisted design/
computer-assisted manufacturing
G H abutment before luting (Vari-
obase + Polycon ae, CARES Digital
Solutions, Institut Straumann AG,
Basel, Switzerland). (E, F) Clinical
situation with individualized healing
abutment according to the mirrored
DICOM-based contour of the con-
tralateral tooth 11. (G, H) Modulated
final emergence profile, 4 days after
placement.

both workflows. The digital workflow requires pur- crowns of monolithic lithium disilicate vs. those of
chase of an intraoral optical scanner device and of porcelain fused to zirconium dioxide (37). Twenty
the subsequent software updates, and payment of the participants were included for single-tooth replace-
associated technical maintenance costs. The classical ment in posterior sites. The three-dimensional
procedure requires diverse trays of different sizes, implant position was captured using an intraoral
impression materials and the appropriate mixing optical scanner. After randomization, 10 patients
machines. Comparison of digital and conventional were restored with monolithic lithium disilicate
equipment costs is complex as both intraoral optical crowns bonded to prefabricated titanium abutments
scanner and classical impression procedures are without any physical models (complete digital work-
commonly used in daily dental routine for several flow), and 10 patients were restored with computer-
treatment procedures, such as tooth-retained restora- assisted design/computer-assisted manufacturing-
tions and implant-supported reconstructions in the fabricated zirconium dioxide suprastructures and
fields of fixed and removable prostheses. Therefore, hand-layered ceramic veneering with milled master
calculation of the cost for each separate procedure is models (conventional + digital workflow). The mean
difficult (83). total production time, namely the sum of clinical
Economic analyses also comprise time-efficiency. plus laboratory work steps, was significantly different
A recent randomized controlled trial aimed to ana- between implant types, being 75.3  2.1 min for the
lyze time-efficiency of a treatment with implant complete digital workflow and 156.6  4.6 min for

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Joda et al.

Fig. 7. Flow chart describing a decision tree for patient-selective pathways in supra-implant emergence profile formation
under consideration of esthetic demands, economic factors (such as time and budget), soft-tissue conditions and access to
digital media. CBCT, cone beam computed tomography; IOS, intraoral optical scan.

the mixed conventional-digital workflow (P = 0.0001; manufacturing technology. In addition, the digital
both results are expressed as mean  SD). Analysis workflow seems to be more profitable for the dentist
for clinical treatment sessions showed a significantly as a result of higher productivity rates and shorter
shorter mean chairtime for the complete digital prosthodontic treatments times necessary to achieve
workflow (P = 0.001). Even more obvious were the a reasonable cost–benefit ratio.
results for the mean laboratory work time, with a sig-
nificant reduction of 54.5  4.9 min vs. 132.5 
8.7 min, respectively (P = 0.0001; both results are Technology perspectives
expressed as mean  SD) (37).
The digital workflow seems to be more time-effi-
Processing
cient than the well-established conventional pathway
for treatment with single-unit implant restorations. Upcoming trends in reconstructive dentistry will
Regarding financial cost to the patient, cost-minimi- focus on developments in rapid production of proto-
zation analysis exhibited lower overall treatment types (2). Hence, the technological process is split
costs, including laboratory rates, for implant crowns into either subtractive methods, such as milling with
produced using an intraoral optical scanner plus multi-axis machines, or promising new approaches
computer-assisted design/computer-assisted (such as laser ablation) and additive processing (such

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 Digital implant prosthodontics

Fig. 8. Flow chart depicting the

process of rapid prototyping. CAD,
computer-assisted design; PEKK,
polyetherketoneketone; PMMA, poly
(methyl methacrylate).

as three-dimensional printing and selective laser At the time of writing this article, three-dimen-
melting) (78) (Fig. 8). sional printing is mostly used for provisional recon-
The standard in the field of computerized dental structions and surgical implant guides. However, the
fabrication is undeniably the milling technology. Even fabrication of definitive crowns or fixed dental pros-
though the quality of the devices has continuously theses is not feasible because of the limited properties
increased over time, the limitation of milling devices of the materials available in dental medicine (74).
is still the diameter of the drills used (79). In the Selective laser melting is widely used for cobalt-
future, this might be eliminated with use of the laser chrome and titanium frameworks, and the first
ablation technique. Despite that, the additive cre- studies published on this procedure demonstrated
ation of three-dimensional objects is more sustain- comparable results in fixed reconstructions made
able compared with the subtractive techniques, from from gold-alloy frameworks, and even superior
an ecological point of view. However, there are some results for reduced- and nongold-alloy frames pro-
early indications that three-dimensional printing may duced using the lost-wax technique (31).
be less accurate than milling because it reintroduces
the errors from polymerization contraction. Classical
Superimposition
computer-assisted design/computer-assisted manu-
facturing subtractive procedures, using commercial Digital technology approximates the interface of pros-
blanks for a single-unit crown, generate approxi- thetic and surgical implant treatment, from the vir-
mately 90% waste of fine particulates and only 10% tual planning (plotted on a guidance template), to the
are used for the reconstruction itself. In contrast, the computer-assisted design/computer-assisted manu-
additive procedure only makes use of the powder facturing-based design (including production of the
material really needed for the desired object. More- final prosthodontic rehabilitation). A prerequisite is
over, additive processing ensures achievement of the superimposition of cone beam computed tomog-
more complex geometries (9). raphy-generated Digital Imaging and

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Joda et al.

Communications in Medicine file data and Standard the analysis of anatomic structures and by simulating
Tessellation Language files gathered from intraoral prosthetic outcomes in advance. For example, a goal
optical scanner or laboratory scanning (40). The of future therapy planning should be the pretreat-
merging of different files is based on the concept of ment evaluation of whether adequate lip support
triangulation. At least three reference points, which could be achieved in demanding esthetic-functional
have to be clearly identified in both files, are used to rehabilitation protocols for fully or partly edentulous
build a plane triangle. The choice and visibility of the patients. Moreover, the amount of radiation to which
defined reference points are very important for the the patient is exposed’ or ‘the degree of radiation
act of merging. Therefore, the indication is mainly could be reduced because the field of interest for digi-
used for partially dentate situations. In addition, the talization would have been scaled down (38).
power of the software algorithm determines the over- At the present time, investigations present mainly
all precision of superimposition (Fig. 9). three-dimensional virtual simulations under static
Supplementary technologies for facial and dental conditions. It is a crucial step in the translational
imaging have to be considered for the creation of vir- aspect of the technical development to create a four-
tual patient simulation (82). The output of research dimensional virtual patient in motion – showing the
projects investigating virtual technologies has contin- dynamic actions of the jaws, lips and muscles – in
uously increased over recent times (81). order to build a complete four-dimensional replica-
However, the difficulty remains to superimpose tion of a human head. Even though it is feasible to
diverse tissue structures to a triad: facial skeleton extract a single frame of three-dimensional data from
(Digital Imaging and Communications in Medicine), a captured four-dimensional video sequence and
extraoral soft tissue (three-dimensional file) and den- export this for superimposition with cone beam com-
tition (including the surrounding intraoral soft tissue) puted tomography data, no commercially available
(42, 64). Not only are the anatomic structures unique system is (yet) able to fuse a four-dimensional
but the corresponding digital data, obtained from sequence of mimic facial movements onto Digital
radiology and scanning techniques, differ in their for- Imaging and Communications in Medicine, Standard
mal data structure (64). The replication of a four- Tessellation Language and/or any other three-dimen-
dimensional virtual patient requires the successful sional medical file format (38).
fusion of these specific data formats. The matching
process of the first method is based on corresponding
landmarks, while the other two use congruent sur- Conclusions and recommendations
faces or voxels of manually selected regions (76).
What progress has been made in virtual dentistry? Protocols for single-unit monolithic implant crowns
At present, none of the craniofacial imaging tech- connected to prefabricated titanium abutments start-
niques are able to capture the complete triad with ing with an intraoral optical scanner and combined
optimal quality in one single step (38). In advanced with virtual design and production without any physi-
implant prosthetic cases, a concentrated triad cal master casts have to be considered in place of
approach, limited to the anatomic regions of the conventional manufacturing. However, a complete
mandible and the maxilla, including the sinuses, digital approach for treatment with implant-sup-
could provide sufficient information for treatment ported fixed dental prostheses has not yet been scien-
planning. The patient would significantly benefit tifically investigated and therefore cannot be
from the four-dimensional model situation through recommended for routine use at this time.

Fig. 9. Superimposition technique

merging three-dimensional radio-
graphic Digital Imaging and Com-
munications in Medicine (DICOM)
data and an intraorally captured sur-
face scan [Standard Tessellation
Language (STL) file], by means of
defining at least three reference
points, to create a plane triangle.

188
 Digital implant prosthodontics

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