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Digitale Abformungen als Grundlage innovativer Herstellungsverfahren in der Implantatprothetik: Ein klinischer Fallbericht
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Objectives
The aim of this in vitro study was to compare the accuracy of printed implant casts from digital impressions with two intra‐oral scanners (IOS) to stone casts from conventional impressions. The hypothesis was that printed casts would be more accurate than stone casts from conventional impressions.
Materials and methods
A mandibular stone cast with Kennedy class II edentulism was fabricated using two internal connection tissue‐level implants at 30 degrees to each other (Replace Select RP, Nobel Biocare) to serve as master. Digital impressions (n = 10) were made with the white light (WL) and Active Wavefront Sampling technology (AWST) IOS. The resultant standard tessellation language (STL) datasets were used to print implant casts through stereolithography (SLA) prototyping. The conventional casts (n = 10) were produced with splinted open tray impression technique and polyether material in type IV stone. The master cast and all groups were digitized with lab reference scanner. The test groups STL datasets were superimposed to master cast STL in inspection software (Geomagic control 2015) to calculate root‐mean‐square error.
Results
The conventional, WL IOS and AWST IOS groups had mean values of 53.49 μm (SD 9.47), 108.09 μm (SD 9.59) and 120.39 μm (SD 5.91), respectively. The Shapiro–Wilk test showed no evidence of nonnormality (p = 0.131) and Levene's test showed no evidence of heterogeneity of variance (p = 0.518). The one‐way ANOVA demonstrated a statistically significant difference (p < 0.001). Tukey's honest significant difference (HSD) showed statistically significant differences between all groups: for the comparison of AWST IOS and WL IOS, the p‐value was 0.009, and the p‐values of the other post hoc tests were <0.001.
Conclusion
Printed casts generated from digital impressions for partially edentulous posterior mandibular arches had inferior accuracy to conventional stone casts fabricated from splinted open tray impressions. The printed casts from WL IOS had better accuracy compared to AWST IOS.
Background
The continuous development in dental processing ensures new opportunities in the field of fixed prosthodontics in a complete virtual environment without any physical model situations. The aim was to compare fully digitalized workflows to conventional and/or mixed analog-digital workflows for the treatment with tooth-borne or implant-supported fixed reconstructions. MethodsA PICO strategy was executed using an electronic (MEDLINE, EMBASE, Google Scholar) plus manual search up to 2016–09-16 focusing on RCTs investigating complete digital workflows in fixed prosthodontics with regard to economics or esthetics or patient-centered outcomes with or without follow-up or survival/success rate analysis as well as complication assessment of at least 1 year under function. The search strategy was assembled from MeSH-Terms and unspecific free-text words: {((“Dental Prosthesis” [MeSH]) OR (“Crowns” [MeSH]) OR (“Dental Prosthesis, Implant-Supported” [MeSH])) OR ((crown) OR (fixed dental prosthesis) OR (fixed reconstruction) OR (dental bridge) OR (implant crown) OR (implant prosthesis) OR (implant restoration) OR (implant reconstruction))} AND {(“Computer-Aided Design” [MeSH]) OR ((digital workflow) OR (digital technology) OR (computerized dentistry) OR (intraoral scan) OR (digital impression) OR (scanbody) OR (virtual design) OR (digital design) OR (cad/cam) OR (rapid prototyping) OR (monolithic) OR (full-contour))} AND {(“Dental Technology” [MeSH) OR ((conventional workflow) OR (lost-wax-technique) OR (porcelain-fused-to-metal) OR (PFM) OR (implant impression) OR (hand-layering) OR (veneering) OR (framework))} AND {((“Study, Feasibility” [MeSH]) OR (“Survival” [MeSH]) OR (“Success” [MeSH]) OR (“Economics” [MeSH]) OR (“Costs, Cost Analysis” [MeSH]) OR (“Esthetics, Dental” [MeSH]) OR (“Patient Satisfaction” [MeSH])) OR ((feasibility) OR (efficiency) OR (patient-centered outcome))}.Assessment of risk of bias in selected studies was done at a ‘trial level’ including random sequence generation, allocation concealment, blinding, completeness of outcome data, selective reporting, and other bias using the Cochrane Collaboration tool. A judgment of risk of bias was assigned if one or more key domains had a high or unclear risk of bias. An official registration of the systematic review was not performed. ResultsThe systematic search identified 67 titles, 32 abstracts thereof were screened, and subsequently, three full-texts included for data extraction. Analysed RCTs were heterogeneous without follow-up. One study demonstrated that fully digitally produced dental crowns revealed the feasibility of the process itself; however, the marginal precision was lower for lithium disilicate (LS2) restorations (113.8 μm) compared to conventional metal-ceramic (92.4 μm) and zirconium dioxide (ZrO2) crowns (68.5 μm) (p < 0.05). Another study showed that leucite-reinforced glass ceramic crowns were esthetically favoured by the patients (8/2 crowns) and clinicians (7/3 crowns) (p < 0.05). The third study investigated implant crowns. The complete digital workflow was more than twofold faster (75.3 min) in comparison to the mixed analog-digital workflow (156.6 min) (p < 0.05). No RCTs could be found investigating multi-unit fixed dental prostheses (FDP). Conclusions
The number of RCTs testing complete digital workflows in fixed prosthodontics is low. Scientifically proven recommendations for clinical routine cannot be given at this time. Research with high-quality trials seems to be slower than the industrial progress of available digital applications. Future research with well-designed RCTs including follow-up observation is compellingly necessary in the field of complete digital processing.
Objectives:
This paper aims to observe peri-implant time-related vertical bone level and soft tissue changes with immediate, non-detached glass-ceramic (lithium-disilicate) individualized abutments and dis-/reconnections.
Materials and methods:
Sixteen split-mouth patients received provisionalized immediate definitive individualized abutments (test T) versus dis-/reconnected individualized abutments (control C). In group T, digital impressions were made by using titanium bases (Conelog, Camlog), and individualized abutments (E.maxCAD) and temporary crowns (TelioCAD) were designed and milled (CerecMCXL). Lithium-disilicate abutments were crystallized and luted (Multilink Hybrid Abutment) to titanium bases. Non-occluding temporary crowns were connected to abutments. After 16 weeks, definitive digital restorations were delivered. In group C, 8 weeks were allowed after healing cap mounting for conventional impressions. Lithium-disilicate individualized abutments were produced, try-ins were performed by dis-/reconnections. Crowns were luted. Cone beam computed tomography (CBCT) images were obtained at restoration delivery, 12 months and 24 months. Pink esthetic scoring was made, plaque-gingival index measurements were done and statistical analyses (Shapiro-Wilk, Mann-Whitney U, Wilcoxon's, Spearman's rank, α = 0.05) were completed.
Results:
No implant failures occurred. At 12 months, T (-0.1 ± 0.14 mm) exhibited significantly reduced vertical bone loss only on the labial side than C (-0.24 ± 0.13 mm) (p < 0.05). In T, all sides except distal presented reduced vertical bone loss at 24 months (p < 0.05). Vertical bone loss for all measurement sides in both C (-0.12 ± 0.09 mm; -0.18 ± 0.11 mm) and T (-0.17 ± 0.11; -0.26 ± 0.10 mm) was higher for 24 months than 12 months, respectively (p < 0.05).
Conclusions:
Reduced vertical bone loss was observed around implants with immediate definitive individualized abutments than abutments with repeated dis-/reconnections.
Clinical relevance:
Non-detached immediate definitive lithium-disilicate individualized abutments and provisionalization through digital technology resulted in successful clinical outcomes and can be routinely applied.
Purpose:
To compare the accuracy of digital and conventional impression techniques for partially and completely edentulous patients and to determine the effect of different variables on the accuracy outcomes.
Materials and methods:
An electronic and manual search was conducted to identify studies reporting on the accuracy of implant impressions. Pooled data were descriptively analyzed. Factors affecting the accuracy were identified, and their impact on accuracy outcomes was assessed.
Results:
The 76 studies that fulfilled the inclusion criteria featured 4 clinical studies and 72 in vitro studies. Studies were grouped according to edentulism; 41 reported on completely edentulous and 35 on partially edentulous patients. For completely edentulous patients, most in vitro studies and all three clinical studies demonstrated better accuracy with the splinted vs the nonsplinted technique (15 studies, splint; 1, nonsplint; 9, no difference). One clinical study and half of the in vitro studies reported better accuracy with the open-tray vs the closed-tray technique (10 studies, open-tray; 1, closed-tray; 10, no difference). For partially edentulous patients, one clinical study and most in vitro studies showed better accuracy with the splinted vs the nonsplinted technique (8 studies, splint; 2, nonsplint; 3, no difference). The majority of in vitro studies showed better accuracy with the open-tray vs the closed-tray technique (10 studies, open-tray; 1, closed-tray; 7, no difference), but the only clinical study reported no difference.
Conclusion:
The splinted impression technique is more accurate for both partially and completely edentulous patients. The open-tray technique is more accurate than the closed-tray for completely edentulous patients, but for partially edentulous patients there seems to be no difference. The impression material (polyether or polyvinylsiloxane) has no effect on the accuracy. The implant angulation affects the accuracy of implant impressions, while there are insufficient studies for the effect of implant connection type. Further accuracy studies are needed regarding digital implant impressions.
Purpose:
To evaluate the accuracy of a digital implant impression technique using a TRIOS 3Shape intraoral scanner (IOS) compared to conventional implant impression techniques (pick-up and transfer) in clinical situations.
Materials and methods:
Thirty-six patients who had two implants (Implantium, internal connection) ranging in diameter between 3.8 and 4.8 mm in posterior regions participated in this study after signing a consent form. Thirty-six reference models (RM) were fabricated by attaching two impression copings intraorally, splinted with autopolymerizing acrylic resin, verified by sectioning through the middle of the index, and rejoined again with freshly mixed autopolymerizing acrylic resin pattern (Pattern Resin) with the brush bead method. After that, the splinted assemblies were attached to implant analogs (DANSE) and impressed with type III dental stone (Gypsum Microstone) in standard plastic die lock trays. Thirty-six working casts were fabricated for each conventional impression technique (i.e., pick-up and transfer). Thirty-six digital impressions were made with a TRIOS 3Shape IOS. Eight of the digitally scanned files were damaged; 28 digital scan files were retrieved to STL format. A coordinate-measuring machine (CMM) was used to record linear displacement measurements (x, y, and z-coordinates), interimplant distances, and angular displacements for the RMs and conventionally fabricated working casts. CATIA 3D evaluation software was used to assess the digital STL files for the same variables as the CMM measurements. CMM measurements made on the RMs and conventionally fabricated working casts were compared with 3D software measurements made on the digitally scanned files. Data were statistically analyzed using the generalized estimating equation (GEE) with an exchangeable correlation matrix and linear method, followed by the Bonferroni method for pairwise comparisons (α = 0.05).
Results:
The results showed significant differences between the pick-up and digital groups in all of the measured variables (p < 0.001). Concerning the transfer and digital groups, the results were statistically significant in angular displacement (p < 0.001), distance measurements (p = 0.01), and linear displacement (p = 0.03); however, between the pick-up and transfer groups, there was no statistical significance in all of the measured variables (interimplant distance deviation, linear displacement, and angular displacement deviations).
Conclusions:
According to the results of this study, the digital implant impression technique had the least accuracy. Based on the study outcomes, distance and angulation errors associated with the intraoral digital implant impressions were too large to fabricate well-fitting restorations for partially edentulous patients. The pick-up implant impression technique was the most accurate, and the transfer technique revealed comparable accuracy to it.
Since Cerec (Chairside Economical Restoration of Esthetic Ceramics) was introduced as the first dental chairside computer-aided design/computer-aided manufacturing (CAD/CAM) system in the mid-1980s, this technology has enjoyed growing popularity, particularly in the recent past. There has been a considerable increase in the number of available chairside systems in only the last few years. One of the main reasons for this is that intraoral scanners have become increasingly better, smaller, and faster, while the design software has become more and more user-friendly. Many work steps are now automated, and a very large range of materials is now available for dental chairside applications. These advances have driven the rapid increase in the range of indications for chairside dentistry in the areas of prosthodontics, dental implantology, and orthodontics, and have paved the way for more novel treatment and treatment planning strategies. Another reason is that intraoral scanner-based digital impression techniques are already superior to conventional impression techniques in certain respects. Moreover, the quality of fit of digitally designed dental restorations is constantly improving because of advances in milling machine technology. Due to the sheer number of new possibilities, it is only a matter of time before chairside systems become a standard component of dental practice. This article reviews the actual advantages and limitations of the chairside workflow, and provides a summary of all the available chairside systems available today.
Purpose:
To assess the three-dimensional (3D) accuracy and clinical acceptability of implant definitive casts fabricated using a digital impression approach and to compare the results with those of a conventional impression method in a partially edentulous condition.
Materials and methods:
A mandibular reference model was fabricated with implants in the first premolar and molar positions to simulate a patient with bilateral posterior edentulism. Ten implant-level impressions per method were made using either an intraoral scanner with scanning abutments for the digital approach or an open-tray technique and polyvinylsiloxane material for the conventional approach. 3D analysis and comparison of implant location on resultant definitive casts were performed using laser scanner and quality control software. The inter-implant distances and interimplant angulations for each implant pair were measured for the reference model and for each definitive cast (n = 20 per group); these measurements were compared to calculate the magnitude of error in 3D for each definitive cast. The influence of implant angulation on definitive cast accuracy was evaluated for both digital and conventional approaches. Statistical analysis was performed using t test (α = .05) for implant position and angulation. Clinical qualitative assessment of accuracy was done via the assessment of the passivity of a master verification stent for each implant pair, and significance was analyzed using chi-square test (α = .05).
Results:
A 3D error of implant positioning was observed for the two impression techniques vs the reference model, with mean ± standard deviation (SD) error of 116 ± 94 μm and 56 ± 29 μm for the digital and conventional approaches, respectively (P = .01). In contrast, the inter-implant angulation errors were not significantly different between the two techniques (P = .83). Implant angulation did not have a significant influence on definitive cast accuracy within either technique (P = .64). The verification stent demonstrated acceptable passive fit for 11 out of 20 casts and 18 out of 20 casts for the digital and conventional methods, respectively (P = .01).
Conclusion:
Definitive casts fabricated using the digital impression approach were less accurate than those fabricated from the conventional impression approach for this simulated clinical scenario. A significant number of definitive casts generated by the digital technique did not meet clinically acceptable accuracy for the fabrication of a multiple implant-supported restoration.
In vielen Bereichen der Implantologie bieten digitale Technologien wesentliche Vorteile. Angefangen bei der digitalen Implantationsplanung und Verfahren der navigierten Chirurgie über die digitale Abformung von Einzelzahnimplantaten bis hin zum CAD/CAM-gefertigten Zahnersatz („computer-aided design/computer-aided manufacturing“) aus homogenen biokompatiblen Materialien ergeben sich viele Schnittstellen zur digitalen Zahnheilkunde. Die Verknüpfung dieser Einzeltechnologien zu einem durchgehenden digitalen Workflow ist aktuell im Gange und hilft, die zahnärztliche Vorgehensweise zu standardisieren, ohne die gebotene Individualität zu vernachlässigen. Im Gegenteil, digitale Technologien helfen dem Zahnarzt, den Behandlungsablauf und das Ergebnis auf jeden Patienten maßzuschneidern und vorhersagbar zu gestalten. Der vorliegende Artikel beschreibt den aktuellen Stand und bewertet die aktuellen Vor- und Nachteile kritisch.
Purpose:
To compare the three-dimensional (3D) accuracy of conventional direct implant impressions with digital implant impressions from three intraoral scanners, as well as different implant levels-bone level (BL) and tissue level (TL).
Materials and methods:
Two-implant master models were used to simulate a threeunit implant-supported fixed dental prosthesis. Conventional test models were made with direct impression copings and polyether impressions. Scan bodies were hand-tightened onto master models and scanned with the three scanners. This was done for the TL and BL test groups, for a total of eight test groups (n = 5 each). A coordinate measuring machine measured linear distortions (dx, dy, dz), global linear distortion (dR), angular distortions (dθy, dθx), and absolute angular distortions (Absdθy, Absdθx) between the master models, test models, and .stl files of the digital scans.
Results:
The mean dR ranged from 35 to 66 μm; mean dθy angular distortions ranged from -0.186 to 0.315 degrees; and mean dθx angular distortions ranged from -0.206 to 0.164 degrees. Two-way analysis of variance showed that the impression type had a significant effect on dx, dz, and Absdθy, and the implant level had a significant effect on dx and Absdθx (P < .05). Among the BL groups, the mean dR of the conventional group was lower than and significantly different from the digital test groups (P = .010), while among the TL groups, there was no statistically significant difference (P = .572).
Conclusion:
The 3D accuracy of implant impressions varied according to the impression technique and implant level. For BL test groups, the conventional impression group had significantly lower distortion than the digital impression groups. Among the digital test groups, the TR system had comparable mean linear and absolute angular distortions to the other two systems but exhibited the smallest standard deviations.
Purpose:
To conduct a systematic review to evaluate the evidence of possible benefits and accuracy of digital impression techniques vs. conventional impression techniques.
Materials and methods:
Reports of digital impression techniques versus conventional impression techniques were systematically searched for in the following databases: Cochrane Central Register of Controlled Trials, PubMed, and Web of Science. A combination of controlled vocabulary, free-text words, and well-defined inclusion and exclusion criteria guided the search.
Results:
Digital impression accuracy is at the same level as conventional impression methods in fabrication of crowns and short fixed dental prostheses (FDPs). For fabrication of implant-supported crowns and FDPs, digital impression accuracy is clinically acceptable. In full-arch impressions, conventional impression methods resulted in better accuracy compared to digital impressions.
Conclusions:
Digital impression techniques are a clinically acceptable alternative to conventional impression methods in fabrication of crowns and short FDPs. For fabrication of implant-supported crowns and FDPs, digital impression systems also result in clinically acceptable fit. Digital impression techniques are faster and can shorten the operation time. Based on this study, the conventional impression technique is still recommended for full-arch impressions.
Purpose:
The digitization of scanbodies on dental implants is required to use computer-aided design/computer-assisted manufacture processes for implant prosthetics. Little is known about the accuracy of scanbody digitization with intraoral scanners and dental lab scanners. This study aimed to examine the precision of different intraoral digital impression systems as well as a dental lab scanner using commercially available implant scanbodies.
Materials and methods:
Two study models with a different number and distribution of dental implant scanbodies were produced from conventional implant impressions. The study models were scanned using three different intraoral scanners (iTero, Cadent; Trios, 3Shape; and True Definition, 3M ESPE) and a dental lab scanner (D250, 3Shape). For each study model, 10 scans were performed per scanner to produce repeated measurements for the calculation of precision. The distance and angulation between the respective scanbodies were measured. The results of each scanning system were compared using analysis of variance, and post hoc Tukey test was conducted for a pairwise comparison of scanning devices.
Results:
The precision values of the scanbodies varied according to the distance between the scanbodies and the scanning device. A distance of a single tooth space and a jaw-traversing distance between scanbodies produced significantly different results for distance and angle measurements between the scanning systems (P < .05).
Conclusion:
The precision of intraoral scanners and the dental lab scanner was significantly different. The precision of intraoral scanners decreased with an increasing distance between the scanbodies, whereas the precision of the dental lab scanner was independent of the distance between the scanbodies.
Die Anforderungen an implantatgestützten Zahnersatz sind vielfältig. Entscheiden im Frontzahnbereich vor allem ästhetische Gesichtspunkte über klinischen Erfolg oder Misserfolg, sind im Seitenzahnbereich Stabilität und Sicherheit wichtige Gesichtspunkte. Seit der Möglichkeit, individuelle Abutments computergestützt aus Titan oder Zirkonoxid zu fertigen, kann das Emergenzprofil mit dem Abutment ausgeformt werden. Aus biologischen und wirtschaftlichen Gründen wäre es wünschenswert, wenn unmittelbar bei Eröffnung der Weichgewebe das individuelle Abutment eingesetzt werden könnte. Damit wäre nur einmal eine Weichteilheilung am definitiven Abutment nötig. Im vorliegenden Beitrag wird der Weg zur implantatgestützten Einzelzahnkrone in zwei Behandlungssitzungen aufgezeigt. Dabei wird in der Operation bereits die Implantatposition analog ohne konventionelle Abformung erfasst. Mithilfe des Übertragungsschlüssels kann dann das Modellanalog auf dem Planungsmodell eingesetzt werden. Während der gedeckten Einheilung des Implantats werden Abutment und Krone gefertigt. Bei Wiedereröffnung des Implantats kann dann direkt das definitive individuelle Abutment mit einer therapeutischen Krone aus gefrästem Polymethylmetacrylat (PMMA) eingegliedert werden; die Weichteile werden nun um die Krone vernäht. Neben der einfachen Ausformung eines naturidentischen Emergenzprofils werden vor allem Kosten und Behandlungssitzungen eingespart.
With the techniques of computer-aided design and computer-aided manufacturing (CAD/CAM) being applied in the field of prosthodontics, a concept of intraoral digital impressions was put forward in the early 1980s. It has drawn comprehensive attention from dentists and has been used for dental prosthesis fabrication in a number of cases. This new digital impression technique is expected to bring about absolute digitization to the mode of prosthodontics. A few published articles have indicated that dental prostheses fabricated from intraoral digital impressions have exhibited remarkable advantages over those from conventional impressions in several respects. The present review discusses intraoral digital impression techniques in terms of the following aspects: (1) categories and principles of intraoral digital impression devices currently available; (2) operating characteristics of the devices; and (3) comparison of the manipulation, accuracy, and repeatability between intraoral digital impression and conventional impression.
There is a scarce knowledge on the accuracy of intraoral digital impression systems for dental implants.
The purpose of this study is to evaluate the accuracy of a digital impression system considering clinical parameters.
A master model with six implants (27, 25, 22, 12, 15, 17) was fitted with polyether ether ketone scan bodies. Implant no. 25 was placed with 30° mesial angulation in relation to the vertical plane (y axis), and implant no. 15 was positioned with 30° distal angulation. Implant no. 22 was placed 2 mm and no. 12, 4 mm below the gingiva. Experienced (n = 2) and inexperienced operators (n = 2) performed scanning (Lava Chairside Oral Scanner; 3 M ESPE, St Paul, MN, USA) at standard and high accuracy mode. Measurements involved five distances (27-25, 27-22, 27-12, 27-15, 27-17). Measurements with high accuracy three-dimensional coordinated measuring machine (CMM) of the master model acted as the true values. The data obtained were subtracted from those of the CMM values.
Experience of the operator significantly influenced the results (p = .000). Angulation (p = .195) and depth of implant (p = .399) did not show significant deviation from the true values. The mean difference between standard and high accuracy mode was 90 μm.
With the active wavefront sampling, technology-based digital impression system training seems to be compulsory. Impressions of angulated implants may diminish the accuracy of the impression, yet the results were not significant.
In the present experiment, the effect on the marginal peri-implant tissues following repeated abutment removal and subsequent reconnection was studied. 5 beagle dogs were used. The mandibular premolars were extracted and 2 fixtures of the Brånemark System were installed, 1 in each mandibular quadrant. 3 months later, abutment connection was performed. A 6-month period of plaque control was initiated. Once a month during the plaque control period, the abutment of the right side (test) in each dog was disconnected, cleaned and reconnected to the failure. Thus, each test abutment was removed and reconnected altogether 5x during this period. The contralateral abutment remained undisturbed for 6 months and served as control. 1 month after the last reconnection, the animals were sacrificed and tissue samples, comprising the implant and the surrounding soft and hard peri-implant tissues, were obtained, decalcified, embedded in Epon and sectioned. The following landmarks were identified and used for linear measurements: PM (the marginal portion of the peri-implant mucosa), aJE (the level of the apical termination of the junctional epithelium), B (the marginal level of bone to implant contact), A/F (the abutment/fixture border). The findings indicate that the dis- and subsequent reconnections of the abutment component of the implant compromised the mucosal barrier and resulted in a more "apically" positioned zone of connective tissue. The additional marginal bone resorption observed at the test sites following abutment manipulation may be the result of tissue reactions initiated to establish a proper "biological width" of the mucosal-implant barrier.
Accuracy of digital implant impressions with intraoral scanners. A systematic review
- V Rutkūnas
- A Gečiauskaitė
- D Jegelevičius
Rutkūnas V, Gečiauskaitė A, Jegelevičius D et al. Accuracy of
digital implant impressions with intraoral scanners. A systematic review. Eur J Oral Implantol 2017; 10: 101-120
Das Münchener Implantatkonzept (MIC): Eine praxisreife Kombination von Intraoralscanner und digitaler Fertigung
- F Beuer
- J Schweiger
- J Hey
Beuer F, Schweiger J, Hey J et al. Das Münchener Implantatkonzept (MIC): Eine praxisreife Kombination von Intraoralscanner
und digitaler Fertigung. Z Zahnärztl Impl 2015; 31: 206-215