Management of a Complex Case during COVID-19 Time Using One-day Digital Dentistry: A Case Report

INTRODUCTION

During the pandemic outbreak of coronavirus disease-2019 (COVID-19), dental services have highly contributed to the national efforts to reduce the spread of COVID-19 and its impact on the population. More specifically, the COVID-19 has reshaped the working environment for health practitioners, especially dentists. Routine treatments have been suspended during the pandemic period and dentists had to reorganize urgent care and implement appropriate measures to avoid cross-infections. The priority was deemed to be protection for the patients and the doctors as well. With some minor differences between countries, minimizing the risks of transmission associated with dental procedures was mainly achieved by the following measures:^1–5

• Stopping all unnecessary patient contact with dentists, allowing only dental emergencies to be treated.
• Reducing gatherings in waiting rooms, by reorganizing and rescheduling appointments. Increasing the use of remote consulting.
• Implementing environmental/surface disinfection (ESD) protocols in dental settings, and personal protective equipment (PPE) for dentists and staff.
• Modifying treatments and, when possible, minimizing risks associated with aerosol-generating procedures (AGPs).

Coronavirus disease-2019 has strongly affected the dental business, not only in terms of potential risk of spreading the infection but also in terms of negative economic impact.

In nearly all countries, the lockdown measures reduced dental treatments to emergency procedures only, causing a dramatic reduction of earnings.

Finding the SARS-CoV-2 in the saliva of infected subjects (also asymptomatic ones) increased concern in the public opinion and in practitioners on its possible transmission in the dental setting due to the droplets spread by handpieces used during dental procedures. In a recent article, the New York Times listed the dentists and their staff as the workers who face the highest COVID-19 risk, since they can encounter COVID-19 infection daily and typically work in close proximity to one another and their patients.^3,6–10

Dentists are currently facing increased costs for more efficient PPEs, ESD protocols and huge reduction of patients due to limitations in the circulation of people, the reduction in household’s income due to closure of most of the working activities and/or employees’ dismiss. All these factors will unfortunately persist for many months ahead; even if limitations in the circulation of people and in the working activities will slowly go back to “normality,” nothing will be the same as before the pandemic. Consequently, reshaping of the activities in a dental setting will become paramount, with dentists trying both to reduce infection risk and to gain adequate incomes. This goal could be achieved mainly by reorganizing dental appointments in a different way and performing a wider number of procedures in the same visit, ideally to reduce management of clinical cases in a single visit. Such an approach would limit contacts not only between patients, practitioners, and staff but also between patients and patients in the waiting rooms, or between patients and other people, avoiding unnecessary use of public transportation related to multiple visits for dental treatments. Moreover, a lower number of visits will also decrease the overall costs and time needed for ESD (and PPEs).^11–20

Coronavirus disease-2019 could be also considered as a challenge to make innovative choices toward a more rationale and efficient approach to solve dental problems. In that direction, the use of digital technologies could simplify and optimize procedures, also to reduce the risk of cross-infections; it could allow the clinician to reduce the number of the scheduled appointments, and to perform complex implant prosthetic treatments with minimally invasive procedures more rapidly, and ideally in one single visit.^11–23

The aim of the present case report is to describe the digital management of an implant prosthetic rehabilitation of a patient who had lost a bridge in the upper arch and asked for an immediate rehabilitation by using different digital technologies, which allowed to successfully perform in 1 day both the surgical and the prosthetical stages with a minimally invasive approach and a high standard of care during the COVID-19 lockdown in Italy.

This case report will show how in many cases such a modern digital approach can be the best choice to perform complex treatments profitably in a single visit, while also minimizing the risk of contamination for practitioners, staff, and patients.

CASE DESCRIPTION

A 78-year-old male patient referred to the dental office, requiring an urgent appointment on March 2020, 2 weeks after the lockdown measures in Italy.

He referred that his anterior short span bridge was unstable, painful during chewing, and it bled during brushing. He requested an appointment to solve the problem.

A return call with the clinician was scheduled after 30 minutes by the secretary.

Before calling the patient, the dentist checked the patient’s health status at the time of the last visit to the dental office (May 13, 2019) and his last orthopanoramic (Fig. 1).

During the telephone call between the dentist and the patient, it was possible to establish that the lost bridge consisted of seven ceramic crowns on four pillars (one implant at 1.4 site and four natural pillars at 1.2, 1.1, 2.1, and 2.2 sites), by taking a picture by the patient’s smartphone.

The natural pillars supporting the bridge exhibited subgingival decays and they were unusable to support a new bridge.

The dentist explained to the patient that the quickest and safest solution during this period was the extraction of the residual teeth (1.2, 1.1, 2.1, and 2.2 sites) and the preparation of a removable provisional denture.

The patient was unwilling to accept this option due to an accentuated gag reflex, and asked for a fixed implant-supported prostheses, with a new definitive bridge to be placed at the end of the pandemic emergency.

After questioning to establish whether the health status of the patient had changed since his last appointment (no changes were noticed), the dentist explained that a preliminary cone-beam computed tomography (CBCT) scan would be necessary to determine if the desired plan was feasible. At this point, by referring to the previously acquired orthopanoramic, the dentist was able to confirm a provisional treatment plan to remove the residual roots, to retain the patient’s existing implant, to insert three new implants in the 1.3, 1.1, and 2.1 area, and to use these four implants to support a fixed screw-retained provisional prosthesis.

The relative risks of early and delayed implant placement were discussed with the patient, and it was explained that in this case a minimum torque of 35 N cm per implant placed would be desired if the implants were to be immediately loaded. A quote for the provisional and final prostheses was provided.

A specific COVID-19 precheck triage was also carried out to elicit his current health status and history of contact and travels.

The decision was made to carry out all of the treatment, including manufacture and delivery of the fixed screwed provisional, in 1 day in order to minimize interaction and possible risk of infection.

The patient’s availability for the following days was confirmed and after checking the availability of the lab technician, the secretary called the patient and gave him an appointment for 2 days later at 8.30 am.

At 7.30 am of the appointment day another phone triage was done, and good health status was again assessed.

At 8.15 am, the patient arrived in the office, bringing also routine diagnostic exams (including blood and coagulation tests) performed a few months before, showing no significant deviations from ordinary ranges. A record of his temperature was taken (36.5°C) and the patient was asked to wash his hands with a hand sanitizer.

A written informed consent was obtained from the patient after a detailed description of the proposed treatment was given.

The dental nurse provided him with medical protective equipment, asked the patient to gargle for 15 seconds followed by a rinse of 30 seconds with hydrogen peroxide, then a rinse of 60 seconds followed by a gargle of 15 seconds with chlorhexidine digluconate w/v 0.2%, prior to an examination of the oral cavity.

The lost bridge was disinfected and a temporary cement was used to maintain it in the correct position in the mouth for the time required to take the CBCT scan (this was important because the bridge was used as reference for prosthetically driven implant planning).

A CBCT scan was taken to evaluate the available bone and if there were any limitations to the proposed treatment.

The CBCT revealed that there was sufficient available bone to perform the treatment, and the patient received prophylactic antibiotic therapy with 2 g of augmentin (GlaxoSmithKline, London, UK).

An intraoral scanner (IOS) impression of both arches (upper arch with and without the failed bridge), with the occlusion, was carried out. The resulting stereolithographic (.stl) files were sent via mail to the lab technician with a prescription to prepare and print, using a 3D printer, a digital wax-up replicating the temporary bridge in terms of shape and occlusal contacts. The project was made by securing that the try-in was correspondent to the abutment of the remaining single implant, which was previously covered by the failed bridge. The digitally realized wax-up was screw retained above the implant by using a multiunit abutment (MUA) in order to move the implant-prosthetic junction well away from the soft tissues.

The DICOM images were uploaded into the Navident software (Claronav, Toronto, Ontario, Canada) to develop a prosthetic-driven implant plan, approximately 90 minutes after the patient’s arrival at the dental office.

Following careful extractions of the remaining roots (at 1.2, 1.1, 2.1, and 2.2 sites) and proper surgical toilette of the sites, the implant placement procedure was started using a dynamic computer-aided implantology system (Claronav, Toronto, Ontario, Canada).

DISCUSSION

In the present work, the management of an implant prosthetic rehabilitation of a patient who had lost a bridge in the upper arch and asked for an immediate rehabilitation was reported by using different digital technologies, which allowed to successfully perform in 1 day both the surgical and the prosthetical stages with a minimally invasive approach (no bone grafting) and a high standard of care during the COVID-19 lockdown in Italy.

Implant surgery and the following prosthetic treatment typically represent a case of delayed treatment that would, under normal circumstances, definitely require more than a single appointment.

The custom of using multiple appointments is mainly dictated by the time required by dental labs to receive and process the materials from the dental office, and then to manufacture and deliver the requested products. However, technological improvements, not only operative ones but also in communication between dental offices and labs, enables a significant saving of time (and consequently costs) in the whole process. In COVID-19 times, limiting the number of appointments has the added benefit of reducing contacts in confined environments like the dental office. In order to limit the potential for infection spread and to reduce fear in the general public, it is paramount we play our part in countering public movement, especially in crowded environments (like public transport) by minimizing the number of appointments.

In the presented case, the digital equipment enabled the multiple steps adopted in implant surgery and prosthetic restoration to be carried out in a single visit (1 full day), reducing the potential risk of cross-contamination.

Moreover, such a workflow could also be adopted in routine treatments, especially when patients do not have time for multiple appointments or live far from the dental office and wish to avoid unnecessary time traveling.^24–29

More precisely, the adopted workflow can be divided into the following steps:

1. First step: Analysis of the oral and general health status of the patient; consideration of his requests and evaluation of several options to solve the patient’s needs (new or recent orthopanoramic or periapical radiographs are needed); explanation of the possible options in terms of the clinical procedures, timing, and costs.
2. Second step: IOS impressions to prepare a digital wax-up and a related scan prosthesis (to be evaluated in consideration of the span width) and several pictures to get the intra- and extraoral esthetic requirements.
3. Third step: A check of the digital wax-up to evaluate aesthetics, phonetics, and occlusion; acquisition of a CBCT scan to evaluate the feasibility of the proposed surgery and to facilitate surgical planning.
4. Fourth step: Surgical procedure, MUA screwing; IOS impressions to prepare a fixed provisional prosthesis; a silicon bite-check index to convey the correct information regarding occlusal height.
5. Fifth step: Placement of the fixed provisional and carrying out an occlusal check.
6. Sixth step: Postsurgical appointments with periapical radiographs to monitor healing.

In this case, all of these steps were performed in 1 day, whereas traditionally for many reasons they are performed on different visits.

It should be clear that the spread of the coronavirus will change the workflow in terms of the number of appointments and these should be reduced where possible to limit the chances of becoming infected and/or spreading the infection.

The first step could be done by telephone consultation with the patient, evaluating photographs of his oral status, reviewing radiographs already present in the dental office, determining his health status, and discussing possible solutions to the problem.

In the second step, the clinician could develop the treatment plan and arrange an appointment in which he can check the digital wax-up, proceed to the surgical treatment, take the impression, accept delivery of the provisional prosthesis a few hours later, and give the patient the right information for the postoperative period (a memorandum should be prepared).

Reducing the number of the appointments from six to two will result in the additional advantage of a reduction in treatment costs for the dentist, taking in to consideration a lessening of the need for repeated use of single-use devices, air and surface decontamination, and chair time costs.

To perform case like that one presented in this study, a CBCT, an IOS, and a system able to perform a computer-aided implantology were used. Indeed, the most relevant issue is the combination of all these technologies and their integration in a well-organized treatment plan. Remote consulting also played a significant role in reducing time the patient had to spend in the office. Probably, remote consulting could not be sufficient to give all the clinical information that could be obtained by a face-to-face visit, but in this case, it resulted a very efficient tool to assess most patient’s postsurgical conditions. It served profitably in COVID-19 times, but its use will also significantly increase in the future, and more specific diagnostic tools will be developed for the purpose.

The CBCT allowed the clinician to immediately evaluate the residual bone volume where implants needed to be placed. At the same time, the availability of CBCT in the dental practice gave the opportunity not only to save time but also to reduce potential risks within the whole procedure.^4,13,29–31 Referring patients for CBCT scans, which has always been a common practice, is less recommended in COVID-19 times to limit human interactions, which has been reported as a major consideration in addressing the reduction of infection.

The IOS allowed the clinician to immediately take a preliminary digital impression of the arch to be treated. The resulting 3D files were sent by e-mail to the dental technician who provided a digital wax-up. The wax-up represented the ideal prosthetic outcome and it was uploaded to the planning software for the formulation of a prosthetically driven implant plan. Besides a considerable amount of time saved, the absence of any impression and/or plaster cast reduced the risk of cross-infections between the dental and laboratory teams. It also reduced the need for impression disinfection measures.^32,33

In COVID-19 times, these advantages were highly appreciated by all people working in dental offices and labs.

As long as 20 years ago, computer-aided implantology (CAI) was scientifically proposed to clinicians to guide the surgical approach in a prosthetic manner. Additional aims were to reduce the invasiveness of implant surgeries, limit bone augmentation procedures, and take advantage of the residual bone of the jaw.

The CAI field has been improved during the last two decades and has resulted in the emergence of two main approaches: a static-guided CAI and a dynamic-guided CAI. The first one is represented by a system joining a virtual project by the use of a physical object represented by a surgical guide, used to perform both osteotomies and implants seating.

The dynamic computer-aided implantology (DCAI) can make this procedure faster as it doesn’t require any radiographic device while taking the CBCT and it works without any surgical guide. In COVID-19 times, this is another advantage because making a conventional surgical guide takes more time since it must be delivered, checked, and precisely inserted. Moreover, the procedure of positioning a guide in multiple implant surgery is not easy and increases the risk of surface/aerosol contamination, which dentists should aim to limit and not increase in COVID-19 times.^24–29,34

As described above, a postoperative digital impression was taken with an IOS, and then sent to the lab via e-mail. The dental lab is able to start the manufacture of the prosthesis almost immediately, allowing it to be delivered on the same day of the surgery. The advantage is not only saving time but simplifying the procedure and minimizing cross-contamination.^35–37

With traditional techniques, a complex treatment such as one here described needs a lot of laboratory steps that make longer and more articulated all the technical procedures, to be completed in a single day.^38–46 This was only possible because all the digital devices present in the dental office allowed the clinician to reduce the necessary steps to complete the work. Moreover, the digital supplies helped to reduce material requirements and people movement.

A potential limitation of the presented workflow is the absence of the necessary technology in dental offices and/or labs. With the increasing use of digital technology in dentistry, the required devices to perform this “1-day digital dentistry” are becoming available and present in dental practices, being commercially available since years.

The minimally invasive approach allowed by CAI in order to limit bone augmentation procedures by using the residual bone of the jaw represents also a great advantage to minimize duration of the surgical procedure, number of appointments, costs, and patient morbidity. A more well-organized and profitable system of work will always be the key to a high-quality standard of care.

CONCLUSION

Digital technologies are promising innovative solutions to solve dental problems in pandemic times. In fact, they not only standardize treatments but also provide clinicians with the capability to reduce cross-infection risks. Moreover, digital technologies in general, and dynamic navigation specifically, empower clinicians to perform complex implant prosthetic treatments, not only in a minimally invasive way but also in one single visit.

The possibility of performing an effective treatment saving time by using efficient technology and minimally invasive procedure highlights the importance of digital planning in order to optimize every single step of the treatment.

The preservation of time involves the clinical side of the matter since the patient could receive an entire treatment without the need of several expositions to the potentially hazardous environment of the dental office.

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