Dr Mike Kelliher walks you through how to streamline your dental implant procedure using Planscan and DDX software. You’ll also learn how to work with a custom-milled abutment for an ideal restoration.
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Hi, it’s Mike Kelliher. Let me show you a way to leverage the open-source nature of our Planscan Romexis system. As everyone, I’m sure knows, we’re able to freely export STL files from the Romexis software which allows us to do a lot of interesting things. One of those is an ability to export files to a laboratory for fabrication of a milled abutment for implants. We can utilize scan bodies which are essentially replacements for impression copings that you use in a physical impression to send that data to laboratory allow them to pull that into their software for fabrication of these abutments. That's my favorite way to do implant restorations. I’ve always used custom milled abutment. I like the ability to control emergence profile and cement margins so that we get an ideal implant restoration.
So I’ll show you a couple quick, easy steps that will allow you to use your PlanScan and Romexis software to do that very thing and then fabricate the restoration in the office. Hopefully, you’ll get some nice tips out of this and be able to start doing these restorations in office yourself.
So the first thing you’ll need to get started are the scan bodies themselves. What you’ll see when you order these is a scan body like this. It has a little angle on the top that helps locate that implant in space for the computer software. Of course, there’s a screw that comes with it to screw it down and what we're seeing here is a Nobel Replace Select scan body. All these are available from all the major manufacturers, from pretty much everybody.
The surface texture on this is kind of sand-blasted so it scans in very easily no need for accent or anything like that the PlanScan will pick it up without any trouble at all. You see how it's very nicely machined. They fit down to the parts very well. This is mounted onto a Nobel Biocare implant analog and you see that it fits very, very well with no gaps, no nothing. They fit very well machined very nicely and these are available from 5 Axis Dental Lab and give them a call and they can get these sent out to so you can start scanning.
So now we're going to start scanning. We will start with a preoperative scan of the case with the healing abutments still in place. You use a time-saver to erase that healing abutment. The reason you’ll start with a pre-op scan is that it makes it a little easier to get those proximal contacts. Then we're just going to simply scan that scan body into the model and you can see that scanned in pretty nicely.
The key area we want to look for here is that angled part of scan bodies. When you orient the scan body try to get that as buccal as possible so that makes it easy to pick that up. If you miss little proximal points in there that's not a real big deal you are going to have some spots you probably will miss. You want to just get the bulk of that thing scanned in and make sure you have all the data. We're going to be sending along an opposing and a buccal bite to the laboratory.
We're going to use the DDX export part of Romexis to send this off to the laboratory. You have a couple options and how to export model in Romexis. The one we’re going to use here is DDX. That’s what interfaces with the laboratory. So click on the case and on DDX export. We'll see we have a couple options as to the types of models: we can send STLs which were going to use in this case, or we can set ICE view models, or we can send the full CAD case out to the lab as well but for this one, we just need the STLs.
We click on “create new case” and that's going to bring us over to the DDX portal online ordering to select a laboratory, in this case, 5 Axis and then we can fill out the online laboratory prescription. Put in the typical things, when is the case due back, a patient named all that sort of thing. We’re also going to put in because it’s an implant abutment the type of implant it is, the platform, the size, what kind of tissue support we want and also very important for me is where do we want that margin to be. So on the right-hand side, you can see we can change, or let the laboratory know where we want that margin to be.
In my case, I tend to like these to be about a half a millimeter subgingival on the buccal and on the interproximals and on the lingual I may go a little equa-gingival or just a little bit super gingival. The idea here is to create an ideal emergence profile with this implant abutment and leave us in a situation where we can have a cemented crown that's very very easy to clean the cement up. We don't want to have deep sub-gingival margins that make that more difficult so that's how we kind of get around that issue. We can kind of control that margin by having a milled precisely to where we wanted to be. So we’re going to click “submit case” and it'll bring us back to the summary page. On the summary page, we’re can just double check that everything is what we had wanted to be if not we can go back and edit it but everything looks fine here.
So we're going to go back over into Romexis and we're going to now upload. What will happen is your patient's name will pop up in that list of patient names the top which I’ve got covered up with the little box for HIPAA reasons but we can click on that patient that we want to add the files to and then we'll go down to the bottom and you can see those four files. In this case, it's the opposing, the buccal bite, the pre-op, and the prep side. So we can ... click on those files and add those to the patient and they will start to upload and you'll see a little progress bar, that red progress bar, get started and that's going to indicate that those cases or those scans are heading up to the laboratory.
The nice thing with doing it this way is that we only have to worry about shipping cases one way. These will be to the laboratory in a few minutes. They can pull them into their software fairly quickly. No [waiting] for a couple of days for these things to go through the FedEx or UPS or whatever in order to get to the laboratory. So it speeds the process up with just the one-way shipping so a handy way to use our ride DDX export feature in Romexis.
So once the laboratory has the case in their software, they'll design that implant abutment for you and they’ll actually send you some screenshots of what they're proposing that abutment to look like and they'll share those with you via email and you can take a peek at it and decide if this is how you’d like that abutment shaped. Communicate with the technician if there are any changes you'd like to have made to it but it’s a really good way to get a preview of what's going to happen here.
Again this is going to be a milled titanium abutment. They can make zirconia as well. This is what we get back is a nice milled titanium abutment. You can see the screw and this is exactly how the design looked.
They're also going to send you back a printed model and I have aluminum analog built into this here. The aluminum analog makes it a little easier to scan the margins to make a really precise digital model of what's going on.
What I've done is I‘ve sandblasted that aluminum analog it makes it a little easier to scan. It’s a little shiny when we first get it back from the laboratory. So you just scan that in as if it was a regular model that you were doing case from. From there, really, it's no different than designing a regular crown case because that margin is pretty close to what you'd expect for an ideal crown preparation, we go ahead and we just design the case as if this was a regular crown.
The difference is here though I will change my margin gap on this .04 axially and I'm also going to change my margin ramp to .5. Those are very, very important to make sure you change those because this is such an ideal preparation essentially you want to make sure to tighten those two factors up so that you get a really really good fit .04 axially and a .5 margin ramp will give you a really nice fit with these guys. You don't need to worry about the occlusal die spacer setting because that's where the scroll axis is. You’re not going to affect anything.
So I’ve just gone through and I'm just doing my regular design. I've done the proposal. I’ve resized the proposal using alt and arrows and then drop them into place and basically, we're just going to use the rubber tooth here to kind of modify this out till I get a really nice proposal here. Very, very simple... again nothing any different than what you would do with a regular crown.
I’ve sped this up a little bit this is not at regular speed. It still is a fairly quick a process to go ahead make these. So not a very different thing than what you would do if you had a regular old to a tooth crown preparation here. Then we're going to go ahead and mill it. Again we’re going to use an LT block with this to mask out the titanium and we get a nice result. This is a typical LTE Max looking crown here. Nothing too fancy. Your typical case here.
You can see how beautifully the eMax is fitting down to that abutment and we have nice polished tissue surface on that abutment. And the tissue is going to be really happy there. Radiographically we look at this and again our emergence profile been created with that implant abutment. We're going to get a very, very nice tissue response there. We don't have any cement to clean up. [The] final result is we have a very typical eMax crown here.
The patient is very happy with this. We're going to end up with a good monolithic restoration here that should last a patient lot of years. So hopefully everybody finds this helpful and will be able to get up and start scanning some scan bodies for your own cases.
Dr. Michael Kelliher earned a Bachelor of Arts in Biology from the University of Massachusetts and went on to graduate from Boston’s Tufts University School of Dental Medicine in 1993 – where he received the Robert R. Andrews award for student research, and presented his original research at several national dental meetings.
Dr. Kelliher runs a general dental practice, Flagship Dental Group, in Longmeadow, MA, with a focus on restorative and CAD/CAM dentistry. He was a very early adopter of E4D, and incorporated the technology into his practice back in 2009.
He serves as an administrator and clinical mentor on LearnDigitalDentistry.com, acts as an administrator on Dental Town, and assists as a moderator for the E4D forums. Whether he’s online, at a study club, or at a lecture, Dr. Kelliher enjoys sharing his experiences in order to help everyone reach their potential with digital dentistry.
He is married with two children, and plays an active role in his community by serving on school committees and coaching youth sports.