Authors: Dr. Sergio H. Cacciacane (DDS), Dr. Maximiliano Cacciacane (DDS, MSc), Dr. Cristian Orlando (DDS, MSc), Dr. Frank Ernesto Perez Avila (DDS, MSc), Dr. Eng. Seyed Behnam Taghavi (PhD, MSc, BSc, DT). All: ESIRO Barcelona (Escuela Superior de Implantología y Rehabilitación Oral) (www.esiro.es)

Introduction

Immediate implants in fresh extraction sites were demonstrated to be predictable and successful. However, adherence to clinical protocols and the strict application of case selection criteria remain essential to ensure treatment success⁴.

With the new BLX implant, Straumann® has recently introduced an optimized implant design, addressing immediate stability - a key requirement for immediate placement in extraction sockets and temporization.^5,6 The implant is characterized by a protruding thread geometry, maximizing apical bone engagement and primary implant stability irrespective of bone quality⁷.

Digitally guided techniques have significant potential in rendering surgical workflows more accurate, predictable and less invasive8. The increasing digitalization and the introduction of novel techniques and materials, like, e.g. digital smile design, have recently also started to transform prosthetic workflows substantially^9,10. However, associated steps within the workflow remain platform, data format and site-dependent and may involve significant and laborious adaptation, validation and transfer steps to provide the desired outcomes.

With Smilecloud, a cloud- and AI-based platform has recently become available that significantly improves and facilitates the prosthetic workflows from planning to realization by removing interfaces between individual workflow steps, facilitating team cooperation across sites and optimizing patient communication. Specifically, the AI-assisted prosthetic design algorithm based on biometric libraries allows clinicians and technicians to seamlessly transition digital smile design concepts into prosthetic provisional and final wax-ups in one platform and with a few simple steps.

The presented case illustrates these exciting features of this novel tool for a patient undergoing immediate implantation and restoration in the aesthetic area using Straumann®BLX.

Initial situation

A 42-year-old female patient presented in our office with a chief complaint about a horizontal root fracture and complete crown loss of her upper left first premolar (tooth #14), compromising her aesthetics and masticatory function (Fig. 1). The patient reported to be a non-smoker, in good overall general health and displayed a history of periodontitis. Her periodontal status was assessed as stable after reinforcing hygiene routines and being included in a routine professional prophylaxis program. Oral examination revealed only a mild presence of plaque at free gingival margins and adjacent areas corresponding to a plaque index of 1, according to Silness and Löe¹¹.

The remaining tooth root of tooth #14 was considered hopeless and unrestorable. It did not allow for a reliable and predictable long-term treatment prognosis after assessment of all, i.e., the prosthodontic, periodontal and endodontic dimensions^_12,13. After consideration of all potential local, site-specific and more general patient-related factors, a recommendation for implant therapy was given and was consented to by the patient.

Treatment planning

The treatment plan was based on replacing tooth #14 with an immediate, i.e. immediately placed and provisionalized implant restoration using a fully digital workflow comprising Straumann® BLX implants. Novel artificial intelligence (AI) assisted design algorithms using Smilecloud were used for restorative planning and waxing. Prosthetically driven planning of the implant restoration was based on combined prosthetic anatomic virtual patient models. The surgical and prosthetic workflows were designed as a guided surgical approach combined with immediate restoration to ensure maximum placement precision and reliability as well as optimal hard tissue healing and soft tissue adaptation, respectively^3,14,15. A three-dimensional assessment of the patient's alveolar anatomy revealed adequate buccal wall thickness and confirmed ideal anatomic conditions for immediate implant placement¹⁶.

Digital smile design and digital waxing of the provisional wax-ups were obtained using the Smilecloud web-based platform. Figure 2 illustrates the real-time design of a provisional wax-up starting from frontal digital photographs and intraoral scans using Smilecloud's AI algorithms. The full process was intuitive and straightforward and comprised the following steps: First, the AI was instructed on the smile curve and available restorative space (yellow line), midline, and the patient's dento-gingival phenotype comprising tooth shape, proportions, contact points, gingival margins, papilla levels and embrasures (white dotted lines). Based on this input, the AI proposed an appropriate model from the system's biometric library, which was validated using real-time displayed overlays. Finally, the AI's algorithms directly converted the corresponding model into the provisional wax up. Morphed overlays of the patient's image and wax-up were used for patient communication and to illustrate and validate the planned final treatment outcomes.

Overlays of the delivered wax-up with intraoral scans indicated a perfect match between both STL data files. Figure 3 illustrates the alignment of the provisional wax-up from Smilecloud's biometric library (left) with the patient's intraoral scan (middle). Overlays indicated high consistency between proposed and existing dental and gingival structures. The design of the planned restorative crown and occlusal surfaces were considered ideal.

STL files of the digital wax-up were next combined with Digital Imaging and Communication in Medicine (DICOM) data from CBCT in coDiagnostix® to result in a virtual anatomic model. This model was used to plan the ideal position of the implant and, importantly, the bucco-palatal orientation and angulation of the implant (Fig. 4).

A tooth-born surgical guide was designed within coDiagnostix® and in-house 3D-printed (Cares® P30+) to transfer the virtual plan into the surgical field. The virtual model, the resulting fabricated guide and a printed mock-up model are illustrated in Figure 5. Verification windows were included in the design of the guide to ensure an adequate fit during the procedure.

Surgical procedure

Surgical procedures were performed under standard infiltration anaesthesia and started by atraumatically extracting the tooth root after sectioning the root in a mesiodistal direction, luxation of the segments using a periosteal elevator, and removal of the root segments using forceps. Visual assessment revealed that the buccal bone wall was entirely preserved after extraction and displayed no to minimal vertical bone loss. The socket morphology was classified as Elian Type I and, consequently, ideal for immediate placement and temporization^16,17.

The implant osteotomy was prepared following the manufacturer's instructions by guided drilling using a ∅2.2 mm pilot and ∅2.8 mm final drill (Figure 7). Next, a 3.75 mm x 12 mm BLX (SLActive®, Roxolid®) implant was placed guided using a motor handpiece. The surgical template served as a reference to define placement depth. The immediate primary stability, assessed by an insertion torque of >50 Nm and an ISQ value of 75, was high and adequate for immediate provisionalization.

Implant placement resulted in a gap between the implant and buccal bone of ca. 1.5 mm (Fig. 9). To limit buccal contour changes and potentially enhance the thickness of the peri-implant soft tissues coronal to the implant-abutment interface, the gap was filled with a particulate Xenograft (Straumann® Xenograft) that was combined with autologous bone. The latter was obtained by adopting a slow-speed drilling protocol without irrigation, as described by Anitua et al.^18,19. Straumann® Xenograft was chosen based on its ability to alter buccal bone healing and potentially improve peri-implant bone volume stability²⁰.

Prosthetic procedure

The implant was immediately restored to condition the peri-implant soft tissues to the new restoration and prevent soft tissue collapse until delivery of a CAD/CAM monomer-free PMMA provisional. The latter was prepared from final wax-ups combined from STL files of post-surgical intraoral scans using a CARES scan abutment and the Smilecloud-derived digital wax-up. Final wax-ups were prepared in Straumann® Cares® Visual (Fig. 9).

Figure 10 illustrates the delivery of the chairside prepared acrylic immediate provisional based on the final wax-up and a screw-retained temporary abutment. The emergence profile's critical and subcritical contours were adapted extraorally to support crestal soft tissue healing optimally.21 Occlusal aspects were modified to reduce initial loading.

Treatment outcomes and Conclusions

Figure 11 shows the resulting occlusal situation after immediate provisionalization and the lateral aesthetic appearance. Smilecloud's AI-enhanced digital workflow and biometric library models allowed for an efficient and straightforward design of a provisional wax-up feeding into subsequent surgical planning and prosthetic manufacturing steps. The patient expressed her complete satisfaction with the procedure, both in terms of aesthetics and functionality but also from a pre-treatment outcome visualization point of view.

Author's testimonial

Smilecloud was a valuable asset in the whole journey, as we used it to communicate with the patient about the potential outcome and benefits of an immediate restoration after an immediate implant, engage with the patient using Smilecloud and show in real-time how we could update her smile and also the designed provisional, all in the same platform was game-changer for the patient (and also the clinical team).