CLINICAL REPORT

Facially generated and cephalometric guided 3D digital

design for complete mouth implant rehabilitation:
A clinical report
Christian Coachman, DDS, CDT,a Marcelo Alexandre Calamita, DDS, MSD, PhD,b Francis Gray Coachman, DDS,c
Robert Gray Coachman, DDS,d and Newton Sesma, DDS, MSD, PhDe

The use of digital resources ABSTRACT

in implant dentistry has impro-
Harmony among the teeth, lips, and facial components is the goal of prosthodontic treatment,
ved diagnosis and allowed the whether performed by conventional or digital workflow methods. This clinical report describes a
establishment of more predict- facial approach to planning computer-guided surgery and immediate computer-aided designed
able treatment plans.1 The stan- and computer-aided manufactured (CAD-CAM) interim complete-arch fixed dental prostheses on
dardization and quality of these immediately placed dental implants with a digital workflow. A single clinical appointment for data
processes have also increased, collection included dentofacial documentation with photographs and videos. On these photo-
thereby reducing the number graphs, facial reference lines were drawn to create a smile frame. This digital smile design and
sagittal cephalometric analysis were merged with 3-dimensional scanned casts and a cone beam
of appointments. Moreover, the
computed tomographic file in virtual planning software, thus guiding virtual waxing and implant
digital workflow has been positioning. Computer-guided implant surgery and CAD-CAM interim dental prostheses allowed
shown to be more efficient than esthetic and functional rehabilitation in a predictable manner and integrated with the patient’s
the conventional workflow in face. (J Prosthet Dent 2016;-:---)
terms of cost and time2 and has
shown better acceptance by patients.3,4 In anterior situations and extensive rehabilitations of
Virtual planning and performing treatments with complete arches, treatment plans must be guided by the
computer-aided designed and computer-aided manu- face to obtain esthetic and functional results.20-23 A great
factured (CAD-CAM) digital methods have been re- challenge in rehabilitating patients with complete or
ported.5-19 Digital photographs have been used to design anterior partial edentulism has always been to relate the
the smile from facial references and improved commu- face to a definitive cast and fabricate wax patterns in
nication between the interdisciplinary team and patient.5 harmony with the face. In the digital workflow, the
Planning software programs, digitally milled casts,6,7 and challenge remains the same, only now these facial ref-
virtual articulators8 complement the resources for an erences need to be transferred to the virtual cast in the
evaluation and interpretation of clinical data to help planning software program.
predict patient outcomes and moderate expectations. A digital workflow in implant dentistry starts with a
New technologies such as intraoral scanners,9-11 digitally session of clinical data collection, intraoral scanning, and
produced surgical guides,12-14 and CAD-CAM methods cone-beam computed tomographic (CBCT) scans.24 Vir-
15-19
and materials enable rehabilitative therapies to be tual diagnostic waxing was performed over the stereo-
performed with greater safety and predictability. lithography (STL) files of the virtual casts. They were

Presented at the American Academy of Restorative Dentistry’s 87th Annual Meeting, Chicago, Ill, February 2017.
a
Private practice, São Paulo, Brazil.
b
Private practice, São Paulo, Brazil.
c
Private practice, Madrid, Spain.
d
Private practice, São Paulo, Brazil.
e
Professor, Department of Prosthodontics, School of Dentistry, University of São Paulo, São Paulo, Brazil; and private practice, São Paulo, Brazil.

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Figure 1. Data acquisition in first clinical appointment. A, Facial frontal view. B, Frontal view with lips retracted. C, Facial profile at rest. D, Facial profile
in smile.

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Figure 1. (continued). Data acquisition in first clinical appointment. E, Bird’s-eye view. F, Occlusal view. G, Smartphone video. H, Panoramic radiograph.
I, Digital smile design.

then superimposed on the CBCT Digital Imaging and extraoral scans and CBCT data, created the virtual
Communications in Medicine (DICOM) files and guided patient; however, the static scans did not express the
the virtual planning of implant surgery. The superimpo- facial movements.33 Moreover, they reported that up to
sition of various digital files has been proved to be a now, no systems and software allow 4-dimensional
reliable procedure.25-29 Some authors have reported videos to be fused with DICOM and STL files.
limitations to this pathway, especially related to esthetic In view of this, photographs of the smile may be
outcomes.30,31 To overcome this limitation, intraoral superimposed on digital casts and could guide virtual
photographs overlapped with digital diagnostic impres- waxing in the digital workflow. This clinical report
sions for complementary information in virtual tooth describes a facially generated and cephalometrically
arrangements31,32 have been used, but without a facial guided 3-dimensional (3D) digital design for planning
approach that could guide virtual waxing. guided implant surgery and immediate CAD-CAM
The use of extraoral scanners allows visualization of interim complete fixed dental prostheses with a digital
the facial soft tissues, which, superimposed on the workflow.

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Digital photographs/videos
Intraoral or cast scan CBCT scan
with DSD facially guided

JPEG files STL files DICOM files

1st superimposition: photographs+DSD+virtual cast

Virtual waxing guided by DSD

(Optional) Clinical trial restoration

2nd superimposition: virtual cast+approved virtual waxing+CBCT data

Surgical planning prosthetically guided by virtual waxing

3D-printed surgical guides and CAD-CAM interim restorations

Computer-guided implant surgery and immediate provisionalization

Figure 2. Digital workflow guided by face (adapted from Arunyanak et al24). Clinical appointments are highlighted.

Figure 3. A, Two-dimensional (2D)/3-dimensional (3D) calibration: overlapping 2D photograph with smile frame to 3D scanned cast, bringing
facial references to intraoral situation. B, 3D digital waxing of maxillary arch guided by 2D facially generated smile frame. C, Overlapping
cephalometric analysis to 3D model and digital waxing to position central incisor according to face. D, Evaluating facial esthetics and lip dynamics digitally.

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Figure 3. (continued). E, Evaluating intermaxillary relationship digitally. F, Evaluating vertical dimension digitally. G, Evaluating occlusion digitally. H, 3D
digital waxing of mandibular against maxillary arch to create ideal intercuspation and guidance.

CLINICAL REPORT vertical dimension, anterior guidance, and occlusal plane.

A 73-year-old man sought care at a private dental office Impressions of the arches, interocclusal registration,
for esthetic and functional problems. Anamnesis and panoramic radiographs, photographs, videos, and CBCT
clinical examination revealed the absence and structural scan were made to provide data for treatment planning
compromise of various teeth, moderate periodontal (Fig. 1A-H). The photographs were used for the digital
problems, and particularly occlusal disorders in the smile design (DSD), guided by the face (Fig. 1I). After

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Figure 4. A, Printed cast and vacuum-formed tray. B, Clinical trial restorations. C, Trial restorations in harmony with face.

Figure 5. Superimposition of cone-beam computed tomography data and virtual cast and approved virtual waxing. Prosthetically driven implant
surgical plan for maxilla and mandible.

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The starting point for the proposed digital workflow

was the DSD (Fig. 2), which brought facial references for
guiding virtual waxing. Superimposition of the scanned
casts with the smile design allowed virtual waxing to be
performed, correcting the occlusal imbalances and
harmonizing the position of the teeth with face and smile
(Fig. 3A, B). A sagittal analysis was also used to generate
a cephalometrically guided waxing using the same
planning principles as for orthognathic surgery to find
the best position and angle of the maxillary central incisor
in harmony with the lips and face.
Instead of moving the maxilla surgically, the correc-
tion of the esthetic position of teeth and soft tissue was
done with a denture in a procedure termed the “pros-
thetic orthognathic” (Fig. 3C). Facial esthetics, lip dy-
namics, intermaxillary relationship, vertical dimension,
and occlusion were evaluated digitally (Fig. 3D-H). The
maxillary digital waxing was exported as an STL file to be
printed. A vacuum tray was fabricated for the fabrication
of trial restorations (Fig. 4A-C). This clinical step was
useful for esthetic evaluation; however, this is not always
possible, especially in patients with excessive over-
eruption or abnormal tooth angulations.
After approval of the trial restorations, the surgical
steps were planned. In the same software (NemoDSD), a
second superimposition of the files was performed:
superimposing the cast with virtual waxing and the CBCT
data allowing prosthetically driven planning of the position
of implants (Fig. 5). From this planning, 2 surgical guides
for each arch were fabricated in a 3D printer (Digital Wax;
DWS Systems), and CAD-CAM complete dentures were
milled for the maxilla and mandible, all with the sleeves
for anchor guide pins in the predetermined position.
The patient received local anesthesia, and the first
tooth-supported guide (Fig. 6A) was used only to
determine the position of the anchor guide pins so that
the second guide for implant placement, already without
support of the teeth, and the dental prostheses would
have the same positional references given by these pins
Figure 6. A, Tooth-supported guide and anchor pins. B, Maxillary surgical
(Fig. 6B). Six implants (Ar Torq; Conexão) were inserted
template. C, Partially guided maxillary and mandibular surgery with in-
termediate multiunit abutments and interim cylinders in place.
with 40 Ncm torque (Fig. 6C) immediately after the ex-
tractions in the maxilla and mandible.
The interim dental prostheses fabricated from poly-
consultation with specialists in other disciplines, treat- methyl methacrylate by the CAD-CAM method were
ment options were presented. positioned in the mouth by using the anchor guide pins
Despite the acceptable prognosis for some teeth, the (Fig. 7A, B). Definitive abutments were tightened to the
patient elected to have his remaining teeth in both arches implants with 20 Ncm torque, and interim titanium cyl-
extracted, followed by the immediate placement of im- inders were connected to the prostheses with autopoly-
plants and interim dental prostheses with immediate merizing acrylic resin (Fig. 7C, D). The tissues were
loading. After this decision, all the digital clinical items of repositioned and sutured, and, after the interim cylinders
information were uploaded to a software program had been fixed, the anchor guide pins were removed from
(NemoDSD; Nemotec). These included Joint Photo- the bone and their sleeves removed from the dentures. The
graphic Experts Group (JPEG) files of photographs and occlusion was evaluated (Fig. 7E) and clinically adjusted,
screenshots of smartphone videos, STL files of scanned and a layer of pink composite resin (Gradia; GC America
casts, and DICOM files of the CBCT scan. Inc) was added to simulate the color of gingival tissues

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Figure 7. CAD-CAM interim prostheses. A, CAD. B, CAM. C, Interim prosthesis positioned in mouth. D, Interim titanium copings connected to prosthesis
with autopolymerizing acrylic resin. E, Occlusion trial. F, Pink composite resin to simulate tissue color. CAD, computer-aided design; CAM, computer-
aided manufacturing.

(Fig. 7F). The immediate dentures were finished, polished, represent unreliable references and require correction.
and screw retained with 10 Ncm torque (Fig. 8A, B). The Among these situations are those patients with partial
screw access holes were sealed with Teflon tape and edentulism, who may present with indications for
composite resin. The patient received postoperative in- extraction of all the teeth. This is a challenging situation
structions, and weekly evaluations were made for 4 because the clinical evaluation of teeth for the new
months until the definitive prostheses were fabricated. dental prostheses may be difficult, even impossible. The
use of digital resources may be the only way to
DISCUSSION visualize the future dental arrangement before the
Complex rehabilitative situations commonly present extractions are performed. This virtual waxing must be
unbalanced esthetic and occlusal clinical conditions that guided by facial references and has to be in harmony

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Figure 8. Facially driven functional smile design and postoperative situation. A, Intraoral view. B, Facial frontal view.

with the smile, making a facial approach to planning Multiple digital data were combined in a single software
essential. program that allowed virtual planning, guided dental
The use of photographs and videos combined with implant surgery, and permitted immediate CAD-CAM
scanned casts or intraoral scans and CBCT improves interim complete-arch fixed dental prostheses from a
diagnosis and allows the visualization of patient out- facial perspective.
comes. They allow the surgical position of implants to be
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Corresponding author:
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planning computer-guided surgery and immediate provisionalization in a Dr Newton Sesma
partially edentulous patient. J Prosthet Dent 2016;116:8-14. School of Dentistry
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Integration of digital dental casts in 3-dimensional facial photographs. Am J 2227 Professor Lineu Prestes Ave
Orthod Dentofacial Orthop 2008;134:820-6. São Paulo, 05508-000
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accuracy of matching three-dimensional photographs with skin surfaces Email: sesma@usp.br
derived from cone-beam computed tomography. Int J Oral Maxillofac Surg
2008;37:641-6. Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

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