Chapter 5- Cases where special attention was paid to the prosthodontics- Application of CAD/CAM system
1. A case in which the all-ceramics crown fabricated with CAD/CAM system was fitted
Director of Tokyo Kagawa Dental Clinic
Toshiaki Miyazawa
The construction of dental prosthesis in the recent years, not exclusive to implant prosthesis fabrication,
have shifted from the casting from the mould that resulted from the bite registration techniques in thepast to the construction by implementing CAD/CAM systems. The materials utilized have also been
modified to metal-free materials such as zirconia that excels in estheticism, ceramics, and hybrid resins.
A case where the all-ceramics crown to be fitted onto a one-piece implant was constructed using the
CAD/CAM system (Advance Co., Ltd) is presented.
Patient: 74 year-old female
Main complaint: Requested implant prosthesis for the replacement of No. 13 tooth that was lost due
to root fracture.
Treatment plan: The all-ceramic crown fabricated by the CAD/CAM system was adopted as theprosthesis for the implant installation.
No. 13 tooth was extracted following its root fracture, to which one-piece implant (4SS) was installed inundergoing the standard protocol, after a year and nine months. Two months later, impression andocclusion registrations were conducted (Image-1,-2). Having constructed the model, all-ceramic crown
was fabricated using the CAD/CAM system, and the superstructure was mounted (Image-3,-4,-5,-6). With
regards to the dimensions of the crown, its occlusal plane was fabricated to be smaller than those of thenatural teeth, and as the opposing tooth was also implant prosthesis, the occlusal plane was designedwith the size to match its opponent. The occlusal relationship was designed to be 30 μm below that of
the anterior natural dentures, so that it would separate with the lateral movement. The dental
radiographs at the time of implant installation as well as the placement of the superstructure arefeatured in Imgaes-7, -8, -9,-10, where no inflammations in the surrounding structures can be observed.
Image-11 and 12 show the state, eight months after the installation, with no breakage of superstructure
or presence of any other abnormalities. There are no constrictions or inflammations in the gingiva
surrounding the implant prosthesis. The implant installations were conducted nine and a half years
previously to the opposing teeth No. 13 to 15, and had been mounted with a metal based hybrid to the No.
13 position, and the metal crown to No. 14 and 15. But there had been neither signs of bone resorption nor
gingival constriction, indicating a successful implantation case.
Observations
The field of dentistry is undergoing a significant renovation aided by the recent technological advances incomputational software and hardware. The effect that implementation of CAD/CAM system has had on
dentistry can be simplified to the change in the technique used in casting to cutting, but the most notableadvances with this modification is in the reproducibility of the data with regards to the implant sizes, andthe variety of different occlusal condition. The past techniques had been highly reliant on the level ofexperience of each technician therefore reproducibility in the superstructures was not easily come by. The
CAD/CAM system has enabled the information of occlusal relationships to be incorporated into
construction of the prosthetics.

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Image-1: Image of the oral cavity, two months after the installation
Image-2: Occlusal plane of the working model

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Image-3: Image of the oral cavity at the time of prosthetic placement.
Image-4: Prosthetics on the model.

56Image-5,-6: Before and after the prosthetic placement

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Image-7,-8: Radiograph directly after the implant installation

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Image-9,-10: Radiograph of prosthetic placement, two months after the implant installation.

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Image-11: Image of the oral cavity 8 months after the implant installation, and 6 months after theprosthetic placement. The implants of occluding teeth were installed 91/2 years previously.

2. The method to mount the superstructure fabricated with CAD/CAM system to the AQB
implant
Director of Nishimura Dental Clinic
Kouzo Nishimura
There are a variety of materials that are used as the superstructure with CAD/CAM including ceramics,
zirconia, hybrids, and metals. For AQB implant, Kaguya-block® (Advance Co., Ltd.), made of all-ceramics,
is used. As have been reported from clinical practices that the strength of the hybrid restoration material
is largely influenced by the adhesive strength with the adherends. The key to avoid superstructure fromits fracture is to increase the adhesive strength of the resin cement. If the adhesion between the titaniumof the abutment and hybrid resin or titanium and cement are weak, the superstructure and the resin
cement or the titanium do not become integrated therefore are more fragile.
Hence, explanation of a devised scheme is given to increase the adhesive strength in the placement ofceramics or hybrid superstructure to AQB implant.
Patient: 72 year-old male
Current condition: Root fracture of No. 29 tooth.
Treatment plan: Install 4LS type AQB Implant to No. 29 after its extraction. Place superstructure,
two months later.
The strength of the commercially supplied resin cement when compounded as instructed by the
manufacturer is relatively weak due to the absence of a bonding layer. To amplify the strength, a type ofbonding resin that can be made into a thin layer of less than a few micrometers, condensed withdry-blowing. By laying the thin bonding layer onto the titanium surface prior to the application of theresin cement, it is possible to amplify the adhesive strength. As long as the layer is within fewμm, it canbe fitted within the spacer at the time of superstructure fabrication, the increase in the height of thecrown can be ignored.
Additionally, the metal primer treatment to polished surface of the titanium AQB abutment isinsufficient to avoid the damage that occurs at the interface between the titanium surface and the resin
cement, leading to integration failure between the titanium and superstructure or with composite resin.
This is another possible causal factor to the damages of superstructure.
The sandblast treatment to the titanium surface acts to increase the surface area of adhesion and iseffective for strengthening the mechanical fit. However, it can become the surface for plaqueaccumulation if applied to the gingival margin. Therefore rubber dam should be adopted to protect themargin, the neighboring teeth as well as the gingiva. The blast treatment to the crown interior should be
avoided as it can create a point of fissure, and therefore the surface should be left untreated after cuttingwith diamond particles.
The aim of the treatment with phosphoric acid is not the etching of the internal structure but solely toclean the interior of the crown. After the silanization, under the clinical practice settings, the drying of
the titanium surface should be done with devices such as dryer that would limit the increase in thetemperature to reduce the difficulty in lowering the temperature since risks lie in the expansion of thecrown or shortening of the working time of cementing with heat.
While the dual-cure resin cement requires photo-irradiation, with Kaguya block® due to the opticaltransparency of the material used, it is thought that flowable resin can be used instead of the resin
cement, provided that sufficient amount of light can be output from the photo-irradiation device.

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Image-1: It is a single implantation case however, since the wearing of the incisal margin of No. 26 and 27
is significant, sufficient adhesive strength was necessary.
Image-2: The all-ceramics crown was fabricated with Kaguya block using the CAD/CAM system.
Image-3: The polished surface of the implant and the surrounding tissues in the margin were protectedby a rubber-dam. The surface was washed with water and then dried after the sandblast
treatment. Metal primer treatment was performed, and then dried. After the coating with thebond-force that had been condensed with air-blow, form a bonding resin polymerized layer withphoto-irradiation.

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Image-4: Rinse the superstructure interior with water, after a phosphoric acid treatment.
Image-5: After silane coupling treatment, undergone heat treatment with air-blow and dryer.
Image-6: Fill the internal surface with resin cement such as Clear-fill esthetic cement opaque color thatcan vary the color tone, and then set. Irradiate the crown interior one second at a time from thebuccolingual side. After the removal of excess resin, polymerize with an irradiation device withhigh irradiation strength. Adjust the occlusion, and polish after it has hardenedNote of caution for titanium surface maintenance
The resistance to microorganisms with implant prosthesis is considered to be much lower than that ofnatural teeth due to the absence of connective tissue attachment, and its exposure to the oral cavity. The
maintenance of oral hygiene with cleaning is essential for the long-term survival of the implant.
However the problem lies in the relative softness of JIS Class I pure titanium and therefore the low
resistance to frictional wear often are scratched with metal scalers (Fig. 1), polishing tools (Fig. 2,-3) orruined with phosphoric acid etching or acidic sodium fluoride solutions. The scratches on these polishedsurfaces become a great environment for the microorganisms to breed therefore great precaution has tobe taken when using phosphate etching when repairing the neighboring teeth; using concentrated acidic
sodium fluorides; during professional mechanical cleaning (PMC) with coarse polishing tools; or at thetime of air-powder polishing (Fig. 4). The uses of metal scalers should be avoided, and be replaced with aplastic scaler specific for implants.

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Fig. 1 Scratches made on the titanium surface with scalers (SEM image 1000×magnification
Fig. 2 Scratches made on the titanium surface with polishing tool (Medium)Fig. 3 Scratches made on the titanium surface with polishing tool (Fine)
Fig. 4 State of the titanium surface after air-powder polishing (for 30 seconds from 5 mm distance)3. A method to connect the superstructure at the time of multiple implantation of one-piece
implant
Director of Nishimura Dental Clinic
Kouzo Nishimura
The superstructure connection of the one-piece implant can be made difficult if the implant bodies are notinstalled in parallel to each other. However, there are numerous cases where this is not possible due tothe state of the bone, or due to the presence of nerves and blood vessels. In the case of multiple implantinstallations, overloading can be prevented by connecting the superstructures. In an attempt to solve thisissue, some clinical practitioners select the two-piece type implants so that suitable abutments can bechosen even though these require more complicated surgical interventions.
When using one-piece type, the superstructures have to be connected by constructing the abutments
within the oral cavity or by adopting key and keyway attachments.
Here, a case is presented where the superstructure attachment was formed within the oral cavity using
the one-piece type guaranteed with safety and ease in the surgical procedures, even if a sufficient tapper
on the abutment cannot be achieved.
Patient: 58 year-old female
Treatment: 4MS, 5MS, 5MS implants are planted to No. 13, 14 and 15.
The fixation with the bonding agent and composite resins to the natural teeth can result in fractures dueto the agitation of the periosteum from incompressibility, therefore are applied as transitional fixation
instead. The superstructure connections require extremely accurate craftsmanship and clinicaloperations as slight faults can have effects on the superstructure, abutment, implant body and thesurrounding bone structures in terms of internal pressure, resulting in damages and peri-implantits,
influencing the outcomes of the treatment.
The method of superstructure attachment in the oral cavity utilizes the fact that periosteum layer isabsent with implant, and the adhesion is a secure fixation technique. In other words, as the pressure to
the adhesive area is small in an undisturbed implant, the connection with adhesion can be a treatmentthat can be guaranteed for a long time. Furthermore, the advances in the recent composite resin haveenabled recovery with high stability of color tones and polish that also encompassed high tensile strength.
The ease in the superstructure fabrication as well as the clinical operations of intra-oral adhesion method
has advantages not only in reducing technical errors and mistakes, or in reducing patient expenditure,
but also with regards to the repair of the superstructure.

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Image-1: Implants were installed in parallel to No. 14 and 15, but No. 13 implants were inclined in the
distal direction therefore complicating the superstructure connection.
Image-2: The one-piece implants installed to positions No. 14 and 15 were planned to be mounted with

Esthenia veneer connected crown, but No. 13 implant with single Esthenia crown. A 300 μm
gap between No. 13 and 14 were left and were treated with sandblast treatment.
Image-3: First the connected crown was fitted onto No. 14 and 15.

45Image-4: Next the single crown to No. 13 implant.
Image-5: The gap between No. 13 and 14 were treated with phosphoric acid silanaization, and bonding
application, followed by polishing after the Estelite flow quick attachment (Tokuyama Dental
America Inc.).
<The treatment method for patients with strong lingual pressure and occlusal pressure>
For an osseointegration of an implant to be achieved, the micro-movement of the implant body must
be restricted to a space within 50 to 100μm. With one-piece implant however, even if a satisfactory
primary stabilization could be achieved at the time of installation, if subjected to great lingual or
occlusalpressureduring consolidation

periodcanresult indestabilization

andinhibitosseointegration from being achieved.
In particular, with cases in which the free-distal end region had been left unfilled for a long period oftime, habitual lateral protrusion of the tongue or the buccal mucosa though the missing space at thetime of swallowing or occlusion have been known to develop. Prompt control of the micro-movement
upon implant installation is required. To overcome this issue, the following measures were applied tillachieving osseointegration depending on the extent of the lingual and occlusal pressures.
1. Interdental wire fixation (Fig. 1)
Method:1) Apply sandblast treatment to the 0.9 mm stainless wire, and cut to the length that fits in
between the implants for preparation
2) Treat the implant surface and the ends of the wire with megabond primer. Blow-dry, apply
bonding, and photo-irradiate to finish.
3) Apply flowable resin, and fix the implant and wire.

Fig. 1
2. Form a large relief around the area of implant installation, and place a splint that covers up to thealveolar ridge region (Fig. 2 to 4) for 24 hours.
3. Concomitant application of 1. and 2.
Since neither screws nor hollow structures are present in AQB one-piece type implant, main

issues usually encountered with implants such as screw loosening and fractures are absent. Even
though the consolidation period of two months with AQB implant is much shorter than those
implants without HA coatings, there are instances where the micro-movements resulting fromhabitual lingual pressure at the time of swallowing, braxism, occlusal pressure have to becontrolled. In such cases, two-piece type would usually be the first line option but by applying thesplint as described above, the advantages of simple and less troublesome one-piece type implantcan be exploited (Fig. 4).

Fig. 2

Fig. 3Fig. 4