en y u i ntess n z CAD/CAM and Telescopic Technology: Design … · 2010. 8. 6. · BERGLER ET AL serve as a base for fabricating customized ceramic replacement teeth. Different ve-neering

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Alle Rechte vorbehalten

Michael Bergler, MDT

Department of Prosthodontics, Erlangen University Hospital, Erlangen, Germany

Stefan Holst, PD Dr med dent

Associate Professor, Department of Prosthodontics, Erlangen University Hospital

Erlangen, Germany

Markus B. Blatz, Prof Dr med dent

Professor of Restorative Dentistry, Chairman,

Department of Preventive and Restorative Sciences, Robert Schattner Center,

University of Pennsylvania, School of Dental Medicine, Philadelphia, Pennsylvania, USA

Stephan Eitner, PD Dr med dent

Associate Professor, Department of Prosthodontics

Erlangen University Hospital, Erlangen, Germany

Manfred Wichmann, Prof Dr med dent

Dean and Clinical Director, Department of Prosthodontics,

Erlangen University Hospital, Erlangen, Germany

CASE REPORT

THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

VOLUME 3 • NUMBER 1 • SPRING 2008

66

CAD/CAM and Telescopic Technology:

Design Options for Implant-Supported

Overdentures

Correspondence to: Mr Michael Bergler

Universitätsklinikum Erlangen, Zahnklinik 2 – Zahnärztliche Prothetik, Glückstraße 11, 91054 Erlangen, Germany;

e-mail: [email protected].

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BERGLER ET AL

serve as a base for fabricating customized

ceramic replacement teeth. Different ve-

neering techniques, such as pressed-on

ceramics for zirconia cores, ensure a fast

and economic work process. With the use

of electroforming it is possible to manufac-

ture highly precise secondary structures

that ensure passive seating of the prosthe-

sis in a stable position. This article demon-

strates a restorative treatment option using

current techniques with the aim of rehabil-

itation with an esthetic and functional im-

plant-supported removable denture.

(Eur J Esthet 2008;3:66–88.)

Abstract

There are many options with respect to

materials, construction methods, and de-

sign concepts for the technical implemen-

tation of implant-supported dental pros-

theses. Different methods of anchorage

can be used to attach removable super-

structures to implants. Telescopic crowns

make it possible to fabricate inexpensive

superstructures with precise and passive

fit. Computer-aided design/computer-as-

sisted manufacture (CAD/CAM) technolo-

gy allows copings to be fabricated from

materials such as zirconia or titanium.

Moreover, CAD/CAM crown copings can



67

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68

aided design/computer-assisted manufac-

ture (CAD/CAM) technology.13–20

CAD/CAM

was introduced into dentistry more than 30

years ago and is primarily being used today

in the processing of high-strength ceramics

such as zirconia or alumina. But the tech-

nology can also be used to process metals

such as titanium or cobalt-chromium alloys.

The intrinsic advantages of this technology

are the precise fit, customized design of the

core components, simple handling charac-

teristics, and time-saving production

process. In addition, CAD/CAM compo-

nents are extremely homogenous and bio-

compatible through their industrial produc-

tion. Yttria-stabilized zirconia is an oxide

ceramic material with a fracture strength

that permits its use in any region of the oral

cavity. The fine-grained material structure

(0.3 to 0.5 μm) and chemical composition

(partially stabilized with yttrium oxide) are

two reasons for its high flexural strength

(1,000 to 1,200 MPa) and fracture tough-

ness (10 MPam–1). It can therefore be used

for any type of core or framework.21–27

Be-

cause oxide ceramics have a high biocom-

patibility and low tendency for bacteria sur-

face accumulation, they are particularly well

suited for manufacturing implant-supported

superstructures that are in close contact

with soft tissues.

For the functional long-term success of

the removable secondary structure, a pre-

cise and passive fit of the secondary cop-

ings on the primary copings is crucial. The

required precision can be ensured through

the combination of suitable materials with

the appropriate manufacturing processes.

The secondary copings can either be man-

ufactured by traditional casting with the lost

wax process or with advanced procedures

such as electroforming. Electroforming

makes it possible to fabricate delicate sec-

There are different mechanisms to attach

removable implant-supported restorations

to endosteal implants; further, there are var-

ious construction methods and manufac-

turing techniques for these mechanisms.

While the exact and passive seating of

crown copings or prosthesis frameworks is

the all-important factor for the long-term

success of the implants, the precise fit of

the secondary structure on the copings or

framework is crucial for functional long-

term success of the removable superstruc-

ture.1–9

As an alternative to attaching the re-

movable restoration on a primary structure

or a coping with the help of passive retain-

ers such as bars or ball attachments, the

secondary structure can also be attached

with active retainers such as double

crowns.10–12

Telescopic anchors are not a recent in-

vention. Constructions known as double-

crown systems that had copings with more

or less parallel walls were available even on

the threshold of the 20th century. Double

crowns are characterized by the fact that

they consist of two parts: the coping, which

is attached firmly to the implant, and the

secondary or telescopic coping, which is in-

corporated into the removable restoration.

The connection that results from assem-

bling these parts can only be disengaged

by overcoming their frictional resistance in

reverse direction. Different manufacturing

techniques can be applied to fabricate

these framework components. In the past,

frameworks were cast, which posed some

challenges with respect to their exact fit (eg,

deformations due to the casting technique),

stability in the oral environment (eg, crevice

corrosion at the sprues, voids or bubbles),

and cost effectiveness (eg, large amounts

of precious metals required). Today, this

technique is often replaced with computer-

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69

plants in the maxilla and four implants in

the mandible. Because of the advanced

bone loss of the alveolar ridges, both the

missing teeth and a larger amount of hard

and soft tissues had to replaced. After im-

plant insertion, an implant-supported fixed

provisional prosthesis was inserted in the

mandible following an immediate loading

protocol, and a provisional removable

overdenture was placed in the maxilla.

When healing of the implants was com-

plete, ball attachments were placed on the

implants to increase stability of the denture.

Treatment planning

Bilateral sinus floor elevation was carried

out 6 months prior to implant insertion, be-

cause the available bone in the posterior

maxilla was insufficient. Subsequently, the

insertion of four implants in the mandible

and six implants in the maxilla was

planned with the help of computerized to-

mography (CT). While immediate tempo-

rization was planned for the mandible, a

fixed immediate provisional restoration

was contraindicated in the maxilla due to

the unfavorable anatomic situation. Thus, a

removable complete denture was planned

ondary copings that are electroformed di-

rectly onto the primary structures. This

achieves an exactness of fit that is hard to

obtain with conventional methods.28–32

If

pure gold is used exclusively, the friction

characteristics are favorable, which is es-

pecially important for the double-crown

technique. In addition to precise fit, the

good sliding characteristics of electro-

formed gold layers play an important role.

These properties are taken advantage of in

many industrial and aerospace applica-

tions.

The patient case described below

shows the fabrication and construction of

an implant-supported removable super-

structure using current techniques. The

permanent restoration was created using

the double-crown technique with CAD/

CAM-engineered primary copings.

Case report

Initial situation

A 64-year-old female patient presented in

the outpatient Department for Restorative

Dentistry of the Department of Dentistry,

Oral and Maxillofacial Surgery of Erlangen

University Hospital with the wish to have

her maxillary and mandibular dentures re-

placed. On presentation, the patient had a

telescopic overdenture with a coping at the

right first molar in the maxilla and an entire-

ly mucosa-borne complete denture in the

mandible. Both dentures were rated as es-

thetically and functionally insufficient. The

alveolar ridges of the maxilla and mandible

were severely atrophic (Fig 1).

Treatment goal

The treatment goal was to fabricate remov-

able superstructures supported by six im-

Fig 1 Initial situation with complete dentures in place.

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Implant insertion

and immediate temporization

To support and fixate the CT template, sur-

gical template, and transfer frame in a sta-

ble position, temporary positioning screws

(FRP) were inserted 2 weeks prior to im-

plant placement (Fig 2). These served as

a dental “GPS system.” Three factors—the

available bone, important anatomic fea-

tures, and planned implant positions—were

as a temporary solution. Two weeks prior to

implant insertion, three positioning screws

each (Fixed Reference Points [FRP], Bre-

dent) were inserted in the mandible and

maxilla as navigation aids for implant inser-

tion, impression taking, and immediate

restoration.

Fig 2a Intraoral situation with a residual tooth (max-

illary right first molar) and the positioning screws al-

ready in place.

Fig 2b Positioning screw in the maxilla.

Fig 3 Maxillary (a) and mandibular (b) casts with transferred screw positions.

a b

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which, in addition, was used as a basis to

fabricate the CT template, surgical tem-

plate, and provisional restoration. For the

CT template, the waxup was reproduced in

clear acrylic (ProBase Cold, Ivoclar) in the

laboratory. The template was subsequent-

ly remade into a surgical template, which

was also supported on the FRP screws.

The ideal implant positions were deter-

mined with the help of the CT data in a stat-

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71

considered when positioning the screws.

After the impressions were taken (Im-

pregum, 3M ESPE), master casts were fab-

ricated (Fuji Rock EP, GC) to which the po-

sition of the FRP screws was transferred

(Fig 3). The master casts were then

mounted in a semi-adjustable articulator

with the correct vertical dimension of occlu-

sion. A functional and esthetic assessment

was carried out with the help of a waxup,

Fig 4c CT templates in the patient’s mouth ready for

the CT scan. The templates rest on the positioning

screws, and are indexed with silicone.

Fig 4d Ideal implant positions can be determined

with the computer model.

Figs 4a and 4b Acrylic CT template with incorporated Lego block for the Med 3D system.

a b

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72

first premolar (Fig 4). The impression

frame (FRP Frame, Bredent) used to trans-

fer the implant positions to the casts was al-

so supported on the positioning screws

(Fig 5). Finally, the provisional restoration

for immediate temporization was prepared

with the help of the tooth setup. The stabil-

ity of the denture in the mandible was max-

ic navigation system (Med 3D, Med 3D)

and were transferred to the surgical tem-

plate. In cooperation with colleagues from

the Department for Dental Surgery, the im-

plant positions were planned for the follow-

ing regions: maxillary left and right canine

and first and second premolar and

mandibular left and right lateral incisor and

Fig 5 Impression frame resting on the positioning screws.

Fig 4e CT templates were altered into surgical tem-

plates in the laboratory.

Fig 4f Implant positions determined with the Med 3D

system were transferred to the surgical templates.

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73

in the region of the left and right lateral in-

cisors and first premolars using the labora-

tory-made surgical template (Fig 7). To

transfer the implant positions in the

mandible, impression copings were

screwed into the implants during surgery.

A light-curing splinting material (FRP

Resin, Bredent) was used to splint the im-

imized by incorporating a metal reinforce-

ment, while the maxillary restoration was

fabricated following the traditional proce-

dures for complete dentures (Fig 6).

The surgical procedure comprised ex-

tracting the maxillary right first molar and

placing four implants in the mandible

(Mark IV, Regular Platform, Nobel Biocare)

Fig 6a The provisional mandibular restoration was

reinforced with cobalt-chromium to provide enhanced

stability.

Fig 6b Finished provisional mandibular restoration.

Figs 6c and 6d Provisional maxillary restoration with customized acrylic denture teeth. For structural reasons,

the restoration extends only to the second premolar.

c d

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74

pression copings with the transfer frame

that was stabilized by the positioning

screws. This procedure allows for transfer-

ring of the precise three-dimensional im-

plant positions onto the existing cast, on

which the provisional restoration has al-

ready been prepared (Fig 8).

In the maxilla, six implants (Mark IV, Reg-

ular Platform, Nobel Biocare) were placed

in the region of the left and right canine and

first and second premolar. A complete

Fig 7 Implant insertion. The surgical template is also

supported by the positioning screws.

Fig 8a The impression copings are splinted with the

transfer frame.

Fig 8b Transfer frame with lab analogs screwed in

to transfer the situation to the cast.

Fig 8c Transfer frame positioned on the positioning

screws.

Fig 8d Lab analogs embedded into the master cast.

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75

denture with a soft lining served as the pro-

visional restoration. Simultaneously with

the placement of the implants in the max-

illa, the temporary cylinders were incorpo-

rated into the pre-prepared superstructure

of the mandibular restoration, which was

immediately inserted (Fig 9).

The patient wore the provisional restora-

tion for a period of 6 months and was

symptom-free. The implants osseointe-

grated during this time, and the restoration

in the maxilla was additionally stabilized

through the integration of ball anchors.

Since the interarch distance was very

short, probably as a result of the previous

dentures, the provisional phase was also

used to incrementally raise the vertical

dimension of occlusion by approximately

4 mm.

Final restoration

After the healing stage, impressions were

taken of the maxilla and mandible with an

open custom tray and polyether material

(Impregum, 3M ESPE). The master casts

were fabricated using a firm, removable

polyurethane-based gingival mask (Al-

paPur, Alpina) (Fig 10). Registration with

an arbitrary facebow system and the inte-

rocclusal record were taken in a separate

appointment. Because the restoration was

to be made without further intermediate

steps (ie, framework try-in), an implant reg-

istration splint was fabricated and its exact

fit was tested intraorally at the second ap-

pointment (Fig 11). A screw-retained es-

thetic setup was made to verify the com-

mon treatment goal with respect to the

esthetic appearance of the permanent

restoration with the patient. The visual ap-

pearance of the setup had the highest pri-

ority for the patient. This included the ide-

al contouring and support for her upper lip.

Fig 9a Temporary cylinders were incorporated into

the provisional mandibular restoration.

Fig 9b Provisional mandibular restoration with

placeholders for the temporary cylinders.

Fig 9c Provisional restorations in place.

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76

Fig 10 Maxillary (a) and mandibular (b) casts with inserted lab analogs. Removable gingival masks (c) were

fabricated for both master casts.

a cb

Figs 11a and 11b Prepared implant registration splint on the maxillary (a) and mandibular (b) cast.

Figs 11c and 11d Implant registration splint in place to check the implant position in the maxilla (c) and

mandible (d).

a b

c d

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77

given time. A tertiary cobalt-chromium

structure, luted to the secondary copings

tension-free, maximizes the stability of the

entire restoration. With the help of the es-

thetic setup, 24 custom-made ceramic re-

placement teeth were fired and luted onto

the CAD/CAM-designed zirconia cores.

The individual all-ceramic crowns have cer-

tain advantages over prefabricated, subse-

quently customized ceramic teeth. The

bond strength between the ceramic mate-

rials of prefabricated, customized ceramic

teeth is limited and—in the authors’ experi-

ence—leads to an increased fracture rate.

Alternatively, prefabricated acrylic denture

teeth can be used; however, while they

have a more favorable price, they lose a

considerable amount of their resistance to

plaque and discoloration after customiza-

tion with composite materials.

The CAD/CAM copings were fabricated

with the help of a waxup. The primary cop-

ings were formed with pattern resin (Pattern

Resin, GC) and subsequently scanned with

a mechano-optical scanner (Procera, No-

All functional parameters (static and dy-

namic occlusion, tooth positions, phonet-

ics) were checked prior to the technical im-

plementation of the implant-supported

permanent restoration. Intraoral try-in of the

esthetic tooth setup is indispensable for a

predictable esthetic outcome (Fig 12).

Technical implementation

For both the maxilla and mandible, remov-

able superstructures were fabricated that

were attached with CAD/CAM telescopic

copings on the osseointegrated implants.

Removable designs offer far more options

for adequate upper lip and buccal support

than fixed restorations. Large segments of

alveolar mucosa can be covered as need-

ed without compromising the patient’s abil-

ity to keep the entire restoration clean. The

secondary copings were electroformed di-

rectly onto the copings. Because the friction

of electroformed frameworks decreases

over time, additional passive retainers were

incorporated into the design. This allows for

a later “activation” of the restoration at any

Fig 12 Intraoral view of the

esthetic tooth setup.

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Fig 13 Pattern Resin casts of the maxillary (a) and mandibular (b) primary copings.

a b

Fig 14 CAD/CAM-fabricated titanium primary copings for the maxilla (a) and mandible (b).

a b

Fig 15 (a) Finished and polished maxillary primary copings. (b) The mandibular zirconia primary copings were

finished with water-cooling.

a b

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79

Technologies) were used as additional re-

tainers (Fig 16). To fabricate the electro-

formed secondary copings, the Mini-Pres-

so-Matics were luted to the appropriate

parallel surfaces of the primary copings

with cyanoacrylic adhesive and were thus

incorporated in the electroformed second-

ary copings (Fig17). When applying the

conductive silver lacquer, it is important not

to apply the lacquer to the outer surface of

the Mini-Presso-Matic. The insulating effect

bel Biocare) (Fig 13). The data were trans-

mitted to the milling center for fabrication of

the zirconia and titanium abutments. Be-

cause of the very limited space in the max-

illa and the fact that additional friction ele-

ments would be incorporated into the

restoration, titanium abutments were se-

lected in this case. In the mandible, zirco-

nia was used (Fig 14). All abutments were

subsequently finished and polished with a

bur (Fig 15). Mini-Presso-Matics (Metalor

Fig 16 Individual components of the Mini-Presso-

Matic.

Fig 17 Mini-Presso-Matic’s housing in place on the

primary coping. The lumen was closed with Pattern

Resin.

Fig 18a Electroformed secondary copings for the

maxilla.

Fig 18b The housing of the Mini-Presso-Matic was

included into the electroformed coping.

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80

Fig 18c Secondary copings removed from their

counterparts.

Figs 18d and 18e Secondary copings on the cast.

Fig 19 Cobalt-chromium tertiary structure for the maxilla (a) and mandible (b).

d e

a b

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81

ter cast as they will have in the patient’s

mouth (Fig 20). This ensures the passive fit

of the entire restoration. Two frameworks or

splints were fabricated, each connecting

the primary copings of the maxilla and

mandible, thus securing and maintaining

the exact position of the individual compo-

nents (Fig 21). The secondary structure

was then bonded to the tertiary structure

with autopolymerized compomer cement

(AGC Cem, Wieland). To fabricate the cus-

tomized ceramic teeth, separate special

casts with removable individual dies were

prepared (Fig 22). CAD/CAM-milled zir-

of the lacquer would prevent a sufficient

bond with the electroformed gold layer. The

secondary copings were electroformed in

a gold-plating bath (Galva TK 210, Gold-

quadrat). Through its higher strength, the

stability of the secondary copings is maxi-

mized directly after the electroplating pro-

cedure (Fig 18). Next, the tertiary structures

were made from cobalt-chromium alloy

(Wironit, Bego) (Fig 19). Before the second-

ary copings can be luted into the tertiary

structure, a metal splint must be created to

ensure that the individual primary copings

have the exact same position on the mas-

Fig 20 All functional parts for the maxillary (a) and mandibular (b) dentures.

Fig 21 Metal splint used as a positioning aid for the maxilla (a) and mandible (b). The splints keep the indi-

vidual components in the exact same position in relation to each other.

a b

a b

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82

Fig 22 Casts prepared with individual dies for fabri-

cating the ceramic teeth.

Fig 23 Maxillary (a) and mandibular (b) crown frameworks made from wax were used for the double-scan-

ning procedure.

Fig 24 Zirconia cores for the maxilla (a) and mandible (b) ready for veneering.

a b

a b

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83

1980s, customized crowns can be fabricat-

ed in a predictable and controlled manner.

Subsequently, the anatomic shape of the

tooth was completed with different translu-

cent ceramic powders (luster shades) (Fig

27). The posterior cores were veneered

with pressable ceramics (Cerabien ZR

Press, Noritake). With pressed-on ceramics,

ceramic crowns can be fabricated in a fast

and cost-effective manner. There are two

techniques to choose from: a staining tech-

nique and a layering technique. With the

layering technique, only the dentin core is

conia cores (Procera AllZirkon, Nobel Bio-

care) were used as crown copings for the

ceramic teeth. They were fabricated using

a double-scanning procedure. This proce-

dure is used to design framework struc-

tures that are optimally adapted to the indi-

vidual patient situation and ideally support

the veneering ceramics. Crown copings

that were slightly smaller than the actual

anatomy were built up with wax (Fig 23).

First, the individual dies were scanned, and

a second scan was then taken with the

waxups in place. The two scans were then

superimposed (Fig 24). The ceramic ve-

neers for the anterior teeth were built up us-

ing a ceramic-layering technique with syn-

thetic feldspathic porcelain (Cerabien ZR,

Noritake). With this ceramic system, the lay-

ers are built up in three steps. The first step

comprises building the internal tooth struc-

ture with a dentin material, edge material,

and transparent materials (Fig 25). In the

second step, characteristic features are

painted onto the dentin core with specially

developed stains and fixed on the surface

with a stains-fixation firing cycle (Fig 26).

With this internal-staining technique

(known as the internal live stain technique),

developed by Hitoshi Aoshima in the

Fig 25a Dentin and enamel layering for the anterior

teeth.

Fig 26 Internal structures of the teeth were painted

on (internal live stain technique).

Fig 25b Dentin and enamel shades supplemented

with effect shades.

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84

pressed and subsequently completed with

suitable enamel materials. In the present

case, the staining technique was used (Fig

28). When the ceramic teeth were complet-

ed in the same way as the frameworks, ad-

ditional friction elements were added in the

maxilla. These pins were planned as addi-

tional attachments that could be activated

as needed, since the friction surfaces of the

copings were rather small due to the limit-

ed amount of space. With the help of a sil-

icone index, the ceramic teeth were pre-

bonded with self-curing compomer

Fig 27 Finished ceramic teeth for the maxilla (a) and mandible (b).

Fig 28a Posterior teeth were fabricated using press-

able ceramics for zirconia cores.

Fig 28b Pressed-on ceramic material.

Fig 28c Finished posterior crowns after staining and

glazing.

a b

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85

base portion of the gingival structure was

made from a methyl methacrylate material

(Aesthetic Color Set, Candulor). The facial

aspect of the gingiva was built up with resin

composite (Gradia Gum, GC). The esthet-

ic properties of this composite make it pos-

sible to create a natural-looking gingival

structure. Moreover, due to their excellent

handling characteristics, the different gingi-

val materials can be placed far more pre-

cisely than methyl methacrylates. After-

wards, the recesses required for the

integrated Mini-Presso-Matics were cut in-

cement (AGC Cem). To achieve a secure

bond between the adhesive and the zirco-

nia core, the zirconia surface must be con-

ditioned.33,34

The intaglio surfaces of the

crowns were cleaned and activated with

air-particle abrasion (50 μm aluminum ox-

ide at a pressure of 2.0 to 2.5 bar). Next,

special bonding agents (Clearfil SE Bond

Primer and Porcelain Bond Activator, Ku-

raray) were mixed in a 1:1 ratio and applied

to the surface.34

When all denture teeth

were bonded into place, the gingival por-

tion of the restorations was added. The

Fig 29a Maxillary denture with incorporated friction

elements.

Fig 29b Mandibular denture with methyl methacry-

late base.

Figs 29c and 29d Ceramic teeth for the maxilla (c) and mandible (d).

c d

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86

tions, the patient could easily place and re-

move the removable superstructures her-

self. Since the primary structures are indi-

vidual unsplinted copings, they can be

easily cleaned with a regular toothbrush,

and no interdental brushes are required.

Figure 31 shows the final outcome.

Conclusion

This article demonstrates a restorative

treatment option using current techniques

with the aim of rehabilitation with an esthet-

ic and functional implant-supported re-

to the appropriate places of the primary

copings. The openings of these friction el-

ements were closed with the screw-in caps

and covered with composite (Fig 29).

At the try-in of the tooth setup, the tooth

shades and desired features had already

been agreed upon with the patient; there-

fore, the entire reconstruction could be fin-

ished without further appointments. The

primary copings were screwed into the im-

plants with a defined torque with the help

of the two metal splints. Subsequently, both

the palateless maxillary denture and the

mandibular denture were placed (Fig 30).

Having received the appropriate instruc-

Figs 30a and 30b Metal splint positioned in the maxilla (a) and mandible (b) as a positioning aid to perma-

nently screw in the primary copings.

Figs 30c and 30d Intraoral situation in the maxilla (c) and mandible (d) with the primary copings screwed in.

a b

c d

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87

movable denture. Telescopic crowns

make it possible to fabricate inexpensive

superstructures with precise and passive

fit. CAD/CAM technology allows copings

to be fabricated from materials such as zir-

conia or titanium. Moreover, CAD/CAM

crown copings can serve as a base for

fabricating customized ceramic teeth. Dif-

ferent veneering techniques, such as

pressed-on ceramics for zirconia cores,

ensure a fast and economic work process.

With the use of electroforming it is possi-

ble to manufacture highly precise second-

ary structures that ensure passive seating

of the prosthesis in a stable position.

Fig 31 (a to e) Final result.

a b

c d

e

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