DENTAL TECHNIQUE

Digital workflow for the design and additively manufacture of

a splinted framework and custom tray for the impression of
multiple implants: A dental technique
Wenceslao Piedra Cascón, DDSa and Marta Revilla-León, DDS, MSDb

In a complete-arch prosthesis ABSTRACT

supported by multiple implants,
This article describes a step-by-step digital protocol for the design and fabrication, through additive
the impression technique must manufacturing, of a splinted framework and a custom tray for the impression of a complete-arch
accurately reproduce the prosthesis supported by multiple implants. The protocol presented uses open source software to
3-dimensional (3D) implant control the thicknesses of the custom tray, splinting material, and impression material during the
position and orientation and procedure, reducing laboratory and chairside time and costs. (J Prosthet Dent 2018;120:805-11)
transfer this to the definitive
cast.1 An accurate definitive cast is essential for achieving with elastomeric impression materials are still the gold
the passive fit of the implant-supported fixed dental pros- standard.25 Nevertheless, a digital workflow can simplify
2-5
thesis, avoiding biological and mechanical complica- the design and manufacturing processes for the fabrication
tions.6,7 In the conventional technique, factors which affect of a metal splinting framework and a custom tray to make
the accuracy of the impression for multiple implants include an impression of multiple implants.26
2 8,9
the impression technique, impression material, implant Additive manufacturing (AM) technology, also known
connection type,10-12 impression coping design, whether as 3D printing, is defined as a process of joining material
the impression copings are splinted,2 implant angula- to make objects from 3D data, layer upon layer.27,28
13-15
tion, number of implants, polymerization shrinkage of ASTM International committee F42 in AM technologies
the resin assembly material,16 expansion of the dental has defined 7 categories: stereolithography, material
stone, and design of the custom tray.17-19 Of these factors, jetting, material extrusion, binder jetting, powder bed
whether the impression copings are splinted or not seems fusion, sheet lamination, and direct energy deposition.29
to be the most relevant to the accuracy of the definitive Among these categories, binder jetting is an AM tech-
impression.2 nology in which a liquid binding agent is selectively
In the early 1980s, computer-aided design and deposited onto thin layers of metal powder as raw ma-
computer-assisted manufacturing (CAD-CAM) technol- terial, producing, layer by layer, a 3D metal object.30,31
20-22
ogies were introduced into dentistry, allowing im- Stereolithography technology is a resin-based AM tech-
provements in laboratory and clinical procedures. The nology that turns the polymer into a solid object by
CAD-CAM workflow involves 3 fundamental steps: data repeatedly solidifying the liquid resin with an ultraviolet
acquisition, data processing, and the manufacturing pro- laser. The laser polymerizes a cross section of the object
cess.22-24 Intraoral scanners avoid the errors encountered to build up the first layer; the process is then repeated
with conventional impressions. However, intraoral scan- until the complete object is fabricated.32-34
ner accuracy for complete-arch intraoral impressions for The present article describes a step-by-step digital
multiple implants is limited, and conventional procedures protocol to digitally design and manufacture a splinted

a
Resident, Aesthetic Dentistry, Complutense University of Madrid, Madrid, Spain; and Researcher, Revilla Research Center, Madrid, Spain.
b
Assistant Program Director AEGD Program, College of Dentistry, Texas A&M University, Dallas, Texas; Researcher at the Revilla Research Center, Madrid, Spain; and
Affiliate Faculty, Graduate Prosthodontics, University of Washington, Seattle, Wash.

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806
Figure 1. A, Impression coping abutments attached to implant fixtures.
B, Preliminary impression poured with Type IV stone. C, Preliminary cast
digitized with optical laboratory scanner.
framework for a complete-arch impression with multiple
implants and a custom tray by using open source CAD
software and AM technology to reduce laboratory pro-
cedures, time, and cost.
TECHNIQUE
A patient with an edentulous maxilla but with 6 im-
plants (MIS V3SP; MIS Implants Technologies Ltd)
supporting a complete-arch implantesupported fixed
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Volume 120 Issue 6
Figure 2. A, Cylinder placed in center of impression coping in maxillary
right second molar position. B, Each cylinder placed with a corresponding
implant impression coping. C, x-, y-, and z-axis location for each
cylinder prepared to be exported as standard tessellation language
(STL) file.
dental prosthesis is used to illustrate this technique. The
implants were located in the maxillary right second
molar, right first premolar, right lateral incisor, left
lateral incisor, left first premolar, and left first molar
positions. The following technique was used to design
and manufacture a splinted framework for the impres-
sion of multiple implants.
Piedra Cascón and Revilla-León
December 2018 807

Figure 3. A, Cylinders imported in Meshmixer software (Autodesk). B,

Cylinders connected to each other through cubes. C, Creation of gingival
support structures for splinting framework.

1. Remove the healing abutments and place 6 open

tray impression copings (MIS Implants Technolo-
gies Ltd) at a preload of 15 Ncm with a torque
wrench (Fig. 1A).
2. Make a preliminary impression with an irreversible
hydrocolloid impression material (Hydrogum 5;
Zhermack, SpA) in a conventional metal impression
Figure 4. A, Raw splinted framework imported into Blender software
tray. Pour it with dental stone Type IV (Fujirock EP;
(The Blender Foundation). B, Boolean operation between splinted
GC Corp) according to the manufacturer’s in- framework and cast. C, Result of Boolean operation. D, Final splinted
structions (Fig. 1B) and digitize the cast with a framework placed in position.

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808
Figure 5. A, 2-mm offset as spacer. B, 2.5-mm offset cast superimposed
with 4.5-mm offset cast. C, Tray of 2.5 mm in thickness after Boolean
operation difference.
laboratory scanner (R1000; 3Shape) to obtain a stan-
dard tessellation language (STL) file of the cast
(Fig. 1C).
3. Alternatively, make an intraoral digital scan
(TRIOS; 3Shape) of the impression copings,
obtaining the STL file directly.
4. Replace the healing abutments on each implant.
5. Import the STL file into open source CAD software
(Blender, version 2.77a; The Blender Foundation)
(Fig. 2A). Go to “create” on the menu and use the
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Volume 120 Issue 6
Figure 6. A, Cylinders placed in impression copings of digitized cast. B,
Tray and cylinders. C, Boolean operation difference between cylinders
and tray.
“cylinder” tool of the software to design cylinders
around each impression coping in the optimal 3D
position. The cylinders should have a thickness of
2.5 mm and a height of 4 mm, and a uniform space
of 1.5 mm should be left around each impression
coping (Fig. 2B, Supplemental Video 1).
6. Export the cylinders as an STL file (Fig. 2C).
7. Import this STL file of the cylinders into another
open source CAD software (Meshmixer, v11.0.544;
Piedra Cascón and Revilla-León
December 2018 809

Figure 8. A, Splinting framework manufactured through metal binder

jetting additive manufacturing technology in stainless steel. B, Custom
tray produced through stereolithography-laserebased additive
manufacturing technology. C, Splinting framework positioned in custom
tray.

Autodesk) (Fig. 3A). Connect each cylinder to

Figure 7. A, Tray imported into Meshmixer software (Autodesk). B,
Cutting custom tray. C, Smoothing custom tray. D, Design of handle.
another using the “primitives preforms” tools of
the software (Fig. 3B) and select “cube.” Then,
create 3 structures, 2 posterior and 1 anterior, in
the splinting framework by using the “primitive
preform” of the software called “cylinder” (Fig. 3C)
to serve as support structures in the patient’s

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810 Volume 120 Issue 6

Figure 9. A, Impression copings embedded in 3-dimensional printed metal splinting framework with Type I dental stone. B, Definitive impression with
polyether impression material.

gingiva. Finally, export this design as an STL file DISCUSSION

(Supplemental Video 2).
Revilla-León et al26 showed how to integrate analog and
8. Import the 2 STL files obtained into the CAD soft-
digital procedures using CAD software and additive
ware (Blender, v2.77a; The Blender Foundation)
manufacturing to be applied for a conventional impres-
(Fig. 4). Select both STL files and subtract one from
sion technique with multiple implants. However, they
the other to obtain the intaglio reproduction of the
did not describe a step-by-step protocol for obtaining the
gingiva in the framework support structure (Fig. 4B-
splinted structure and the custom tray. The present
D, Supplemental Video 3).
article describes an in-office workflow for digitally
9. To fabricate the custom tray, import this STL file
designing a splinted framework and its custom tray for a
twice. In one STL file, create a 2.5-mm offset (Fig. 5),
complete-arch implant impression (Fig. 9); the technique
and in the other create a 4.5-mm offset. Once done,
uses open source software available to any dentist at a
use the software tools to subtract one from the other
low cost. An important consideration is the time taken
(Fig. 5B) to obtain the custom tray with a thickness
for the CAD design phase. Once the learning curve has
of 2 mm (Fig. 5C, Supplemental Video 4).
been overcome, the whole 3D design process of the
10. Create cylinders with the diameter of the impres-
splinting framework and the custom tray should take no
sion copings to obtain a single path of insertion for
more than 10 to 15 minutes, depending on the expertise
the impression tray with sufficient clearance for the
of the clinician or dental technician.
impression copings. Align them on the same x-, y-,
The digital workflow provides advantages over con-
and z-axes as the implant impression copings po-
ventional procedures as follows: manual laboratory pro-
sition (Fig. 6A). Subtract each cylinder from the
cedures are eliminated, holes for unscrewing the implant
custom tray, obtaining the holes for unscrewing
abutments are calculated by the CAD software, a
the impression copings (Fig. 6B, C; Supplemental
consistent space is achieved for impression material be-
Video 5).
tween the splinting structure and the custom tray, and
11. Use the tools of the software to make a handle for
the volume of material between the splinted structure
the custom tray using the “primitive preform” of
and the implant abutments is controlled. These devices
the software called “cube.” Once done, cut and
allow an affordable and predictable implant impression
smooth the custom tray to be 3D printed (Fig. 7,
technique that reduces the time taken to splint the
Supplemental Video 6). Export the STL file.
implant impression copings; also, the tray is guided by
12. Send the STL files of the splinted framework and
the design, for which there is only one possible position
the custom tray to a laboratory for fabrication. The
in the mouth with no error, reducing time and further
framework will be manufactured through binder
repetitions. Last but not least, once the definitive cast is
jetting (Fig. 8A), and the custom tray will be
obtained, the splinted structure with the implant
manufactured through 3D printing with
impression copings embedded in the impression material
stereolithographyelaser beam technology (Form 2;
can be removed from the custom tray to be used for the
Formlabs) with clear resin (Formlabs) at a layer
intraoral passive fit test.
thickness of 100 mm. (Fig. 8B).

THE JOURNAL OF PROSTHETIC DENTISTRY Piedra Cascón and Revilla-León

December 2018
SUMMARY
The protocol described used open source software and
AM technology to design in office and fabricate a splinted
structure and a custom tray for a complete-arch
impression for multiple implants.
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Corresponding author:
Dr Wenceslao Piedra Cascón
Pza. Ramón y Cajal
s/n Bajo. 28040. Madrid
SPAIN
Email: wpiedra@ucm.es
Copyright © 2018 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2018.02.003
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