The Inclusive® Tooth Replacement System is touted as the industry’s first all-in-one, restorative-driven treatment package, described in simplest terms as the complete set of components required to replace a missing tooth. But the true value of this full-service, patient-specific solution cannot be adequately measured with a mere list of parts and pieces, no matter how comprehensive that list may be. The ultimate benefit can instead be found in the freedom and flexibility inherent in the solution during all phases of treatment, which serve to maximize clinical efficiency and facilitate a predictable, esthetic outcome.Showcasing the most obvious example of this clinical flexibility is the Open Platform Inclusive Tooth Replacement System. While the original Inclusive Tooth Replacement System features an internal hex tapered implant of time-tested design, the Open Platform treatment package is built around the clinician’s implant of choice. A clinician accustomed to working with any of the major implant systems (Fig. 1) can therefore take full advantage of the Inclusive Tooth Replacement System prosthetic guide, custom temporary components, custom impression coping and final CAD/CAM restoration while placing an implant from his existing inventory.Whichever implant is used, the principal advantages to be found in utilizing the Inclusive Tooth Replacement System remain unchanged. With a stent to help direct implant placement from a prosthetic perspective, custom temporary components to provide contoured soft tissue management in the event of immediate provisionalization or conventional healing and a custom impression coping to fully capture the resulting gingival contours, the patient is better prepared to receive the accompanying final restoration with minimal discomfort and fewer adjustments. By truly beginning with the end result in mind, the Inclusive Tooth Replacement System streamlines the treatment workflow and alleviates component and communication issues too often associated with traditional implant services.
To better examine the Open Platform Inclusive Tooth Replacement System and the options it affords clinicians during each stage of treatment, it is helpful to break the package down into four distinct phases.
Phase 1: Treatment Planning
When submitting an Open Platform Inclusive Tooth Replacement System case, clinicians may take either digital or conventional full-arch impressions, along with a bite registration, so that the laboratory may accurately produce articulated study models. The special Rx enables clinicians to denote the system, diameter and platform size of the implant to be used, along with the prescribed tooth shade and soft tissue depth noted in the edentulous site shade and soft tissue depth noted in the edentulous site (Fig. 2). This information enables the laboratory to properly design custom components with patient-specific soft-tissue contours in an effort to provide a more natural emergence profile than that obtained with conventional stock components.
Phase 2: Surgical
Placement of the prescribed implant is performed according to clinician preference, using the system and instrumentation of choice (Fig. 3). Because implant placement within the edentulous space is critical to achieving an optimal restorative outcome, the Open Platform Inclusive Tooth Replacement System features a prosthetic guide (Fig. 4) with which to prepare the osteotomy in freehand cases. Anatomical landmarks should be properly accounted for during treatment planning, as the prosthetic guide does not take these into consideration. However, use of the guide will ensure swift, accurate seating of the custom healing abutment or custom temporary abutment, and help to improve the final prosthetic outcome.
Phase 3: Temporization/Healing
Immediately upon implant placement, the clinician may elect to place the custom healing abutment (Fig. 5) or provisionalize the case with the custom temporary abutment and BioTemps® provisional crown (Fig. 6). Temporization can also be performed after a period of healing, if indicated. The custom healing abutment and custom temporary abutment are each milled from a radiopaque, biocompatible polyether ether ketone (PEEK) material that is easy to adjust as needed, while the BioTemps crown milled from poly(methyl methacrylate) (PMMA) is designed with an internal relief space to allow for adjustable seating during cementation. The custom temporary abutment and BioTemps crown can even be modified and luted together extraorally to create a single-piece screw-retained provisional. Whatever the indication or preference, patient-specific soft tissue management can be initiated upon implant placement — in a fraction of the time it would require to create a custom component chairside.
Phase 4: Final Restoration
When the time comes for the definitive restoration, a final impression is taken with the custom impression coping (Fig. 7). This CAD/CAM component is designed with the same gingival contours as the custom healing abutment and custom temporary abutment to precisely capture the final gingival architecture (Fig. 8) and convey that information to the laboratory, providing a greater understanding of the appropriate emergence profile. Along with final full-arch impressions, the clinician submits a final Rx for the desired Inclusive® Custom Abutment (Fig. 9) and final BruxZir® Solid Zirconia or IPS e.max® (Ivoclar Vivadent; Amherst, N.Y.) monolithic crown (Fig. 10). A screw-retained final restoration may also be prescribed (Fig. 11). The precise nature of the manufacturing process used to produce both the temporary and final custom components helps to ensure efficient seating of the definitive restoration upon final delivery, without blanching and with little to no chairside adjustment.
Clinical Example
The following case report serves to showcase the advantages and flexibility of the Open Platform Inclusive Tooth Replacement System. This particular case features placement of a NobelActive™ implant from Nobel Biocare.
Case Report: Following endodontic therapy to treat a periapical abscess on tooth #19 (Fig. 12), the patient in this case suffered recurrent periapical infection requiring extraction of the compromised mandibular first molar. The patient was referred to an oral surgeon for drainage and extraction (Fig. 13), at which time immediate implant placement was contraindicated by the infection.A five-month healing period was observed, after which the patient returned for diagnostic evaluation for implant therapy. A 3-D cone beam computed tomography (CBCT) scan was obtained using a GALILEOS scanner (Sirona Dental Systems; Charlotte, N.C.). The treatment plan called for guided placement of an 11.5 mm NobelActive RP implant in the edentulous space, utilizing all-digital impressions and a two-stage surgical protocol.After guided placement of the NobelActive implant (Fig. 14), an Inclusive® Scanning Abutment for NobelActive RP was attached to the implant fixture for the purpose of capturing the precise location, angulation and connection orientation of the implant during the intraoral scan. A digital impression was taken using the CEREC® Omnicam (Sirona Dental Systems), and the information submitted to Glidewell Laboratories for the CAD/CAM production of the custom healing abutment and custom impression coping featured with the Open Platform Inclusive Tooth Replacement System (Figs. 15, 16, 17).Following a prescribed healing period, the patient returned for a second-stage procedure involving exposure of the implant platform (Figs. 18a, 18b). To account for the shifting of adjacent teeth during osseointegration, a second digital impression was taken during this visit, this time utilizing the custom impression coping (Fig. 19). Use of this custom impression coping facilitates capture of the patient-specific gingival contours. Once the digital impression was taken (Fig. 20), the custom healing abutment was placed (Figs. 21a, 21b, 21c). Key advantages of the custom healing abutment include the preservation of keratinized soft tissue and preparation of that tissue into an ideal form for a more esthetic restoration, as well as simplified delivery of the definitive restoration. Having the abutment on hand eliminates tedious creation of a custom healing abutment chairside.For the definitive restoration, an IPS e.max screw-retained crown (Fig. 22) was prescribed and delivered. Due to proper preparation of the site utilizing the custom healing abutment (Figs. 23a, 23b), the accurate capture of that soft tissue architecture and the precise nature of the digital process, the crown seated easily into place. No adjustment was required.The use of a custom healing abutment and matching custom impression coping, combined with the use of digital impression technology, enabled this case to be completed in fewer visits, simplified delivery of the final prosthesis and resulted in a highly esthetic outcome. Both the patient and the and the practice saved time and money. Given the minimal cost differential between custom components and generic ones, an open, patient-specific solution warrants strong consideration in the planning of any implant treatment modality.
Advancements in the techniques and materials associated with dental implant therapy have served to widen the range of treatment protocols available to practicing clinicians. Successfully managing these protocols and the options that may arise during any individualized procedure can go a long way toward determining the efficiency and predictability with which a case is completed. Undue reliance on traditional components can restrict a clinician’s choices during the course of treatment or require time-consuming chairside alternatives to avoid compromised results. The Open Platform Inclusive Tooth Replacement System is designed to meet this challenge by providing the flexibility needed to address any clinical situation, in whatever manner the clinician feels most comfortable or productive. Beginning with the implant of choice, those utilizing this solution may employ a single-stage or two-stage surgical protocol, provide patient-specific healing or custom provisionalization, take conventional or digital impressions, and select a definitive abutment and crown as indicated. Whatever the prescribed procedure, this adaptable, comprehensive solution aims to maximize clinical control during every phase of treatment, resulting in a simplified workflow that reduces chairtime while contributing to a more esthetic restoration.
