Casereport Evo plus Sven Rinke (NL)

Fabrication of a screw-retained implant-supported
maxillary restoration in a completely digital
workflow with the EvoPlus system
Dentist: Dr. Sven Rinke

INTRODUCTION
The fabrication of implant-supported full-arch bridge restorations requires
maximum precision, whether for analog or digital impressions,
to achieve perfect and passive fit. In this context, the application of
intraoral scanners has been controversially discussed [1, 2]. Through
the development of new scanner systems (e.g., i700, Medit Corp. Seoul,
Korea) and specially adapted scan gauges for these indications (Nexus
IOS, Osteon Medical, Melbourne, Australia) as well as the application of
appropriate scanning techniques, these systems allow for improved
precision [3]. The EVO+ system, developed by Modern Dental Europe
(Elysee, Labocast, Permadental, Southern Cross, CDI), incorporates
these optimization strategies into a purely digital workflow for the fabrication
of removable and fixed implant-supported restorations in
edentulous patients.
The present case report describes the fabrication of an implant-supported
screw-retained FDP restoration with the EVO+ system. The
restoration provides a high level of fitting accuracy and could be fabricated
in three appointments only. The patient was highly satisfied
with the esthetic and functional outcome. The main advantage of this
technique is a reduced number of treatment steps compared to conventional
procedures.
The following case report describes the clinical and technical procedures
required for the fabrication of a screw-retained implant-supported
FDP restoration with the Evo+ system.
Dr. Sven Rinke
Dr. Rinke specializes in implant
dentistry and periodontology
and holds an MSc in oral
implantology and an MSc in
periodontology. From 1997 to 1998,
he was a visiting assistant professor
at the Harvard School of Dental
Medicine in Boston, USA.
In September 2021, he was
appointed as an associate professor
at the University of Göttingen. He
has been in joint practice since
2002.
CASE REPORT
A 65-year-old female patient came to our dental clinic and asked for
the renewal of an implant-supported maxillary FDP that was inserted
6 years ago. The resin-veneered construction was cemented on 5 implants
and showed pronounced fractures of the veneering resin, as
well as limited accessibility for oral hygiene (Fig. 1). In addition to the
esthetic limitations, the patient mentioned a limited chewing ability.
The patient was offered two options for prosthetic reconstruction:
screw-retained FDP restoration or bar-retained palate-free coverdenture.
The patient opted for the screw-retained full-arch FDP.
The restoration was fabricated with the Evo+ system in 3 appointments,
using an intraoral scanner (i700, Medit Corp, Seoul, Korea) and
system-specific scan gauges (Nexus IOS, Osteon Medical, Melbourne,
Australia).
Fig. 1: Initial clinical situation with inadequate
implant-supported maxillary restoration.

1. APPOINTMENT
Full-arch maxillary and mandibular scans were taken with existing restorations. In addition, two lateral scans were
required for a fixation of the current bite (Fig. 2). When using the i700 Medit scanner, a patient case is first opened and
the setting “orthodontic option” is chosen for the full-arch scans. These data are stored and dispatched separately.
Fig. 2: Basic scans of existing maxillary and mandibular restorations, lateral scans for bite registration.
At this point, it is also meaningful to determine the correct
tooth-shade and the shade of the gums that have to
be replaced. The simplest way to transfer this information
to the production center is a digital photo (Fig. 3).
In a second step, the existing suprastructure was removed.
The fixed restoration with the Evo+ system is always
fabricated on multi-unit abutments, as the special scan
gauges (Nexus IOS, Osteon Medical, Melboune, Australia)
only fit on this type of abutments. In the present case,
multi-unit abutments (Astra EV Multi-Base Abutment
3.6 mm, Dentsply Sirona, Bensheim, Germany) were fixed
to 5 implants with cone connection (Astra EV, Dentsply
Sirona, Bensheim, Germany). The height of the abutments
was chosen to allow a slightly subgingival location
of the abutment shoulder, that is, the transition between
the abutment and the suprastructure. Now, the scan
gauges were inserted, which are available in various
lengths and heights. When choosing the scan gauge, it
is important to avoid pressure on the subjacent soft tis-
Fig. 3: A digital photo with a shade tab is used to transfer the
correct tooth-shade for the restoration. Using a gum shade
guide, this information can be transferred for the gums to be
replaced as well.

sues; ideally, there is a small gap between the basal surface
of the scan gauge and the soft tissues. The scan
gauges should be chosen accordingly and aligned along
the ridge, resulting in the largest achievable overlap of
the reference surface (Fig. 4). This is one of the most important
steps to achieve a perfect passive fit of the final
restoration.
After the scan gauges have been fixed in the appropriate
position, the next step of the scanning process is performed
by selecting a new case with the “orthodontic option”
in the scan mode “HD mode”. Data collection of the
scan gauges is performed in a unidirectional scanning
path from left to right. It is essential to move the camera
in one direction only and to cover all reference surfaces
of the scan gauges with a slight panning of the camera.
After this step has been completed, a new scanning
Fig. 4: Alignment of the scan gauges for the two HD scans
window is opened (for a Medit scanner, this is by default
the window for the mandibular scan), and a new HD
scan is performed in the opposite direction. Now, the
scan gauges should be completely recorded in two separate
scans. These data are also stored and sent separately
(Fig. 5). Each scan gauge is marked with a unique
identifier code that encodes its exact dimension. To reach
a maximum level of precision, it is important to note
these identifier codes and the implant position where
the respective scan gauge was for.
The third and last scanning process again required a
new case with the “orthodontic option”, the scan bodies
were removed. This clinical situation (implants with screwed
multi-unit abutments) was captured in a full-arch
scan (Figs. 6), stored separately, and dispatched. This
scan can be performed in regular mode; it records the
soft tissue of the jaw to be restored.
Fig. 5: HD-scan of the correct aligned scan gauges is performed in
two separate unidirectional scans from left to right and right to left.

Fig. 6a-b: Clinical situation and full-arch scan of the soft tissue and the multi-unit-abutments in place.
To determine the relevant esthetic reference lines and
structures (bipupillar line, center line, lip profile, and smile
line), a face scan was performed. In this face scan, the
scans of the existing prosthetic situation were matched
(Fig. 7).
Alternatively, digital portraits can be sent together with
the scan data.
For the fabrication of this fixed restoration with the Evo+
system, a total of 4 sets of data were sent to the production
facility (Permadental GmbH, Emmerich/Rhein, Germany,
Modern Dental Europe).
• Scans of the existing situation: maxilla and mandibula
with existing restorations, lateral scans for bite registration,
information on the tooth and gum shades (digital
photos)
• 2 complete HD scans of the correctly aligned scan gauges
including the identifier codes and the position of
the gauges used
• Full-arch scan of the edentulous jaw (with MUA) to be
restored for soft tissue documentation
• Additional facial scan, matched with the scans of the
existing prosthetic restorations (alternative: digital portraits)
Fig. 7: Face scan with separate scan to match the basic scans. Face scan allows for a transfer of the relevant esthetic reference lines (bipupillar
line, center line, laugh line).

Fig. 8: Data set for the design of the screw-retained try-in restoration.
ALTERNATIVELY, DIGITAL PORTRAITS CAN BE
SENT TOGETHER WITH THE SCAN DATA.
For the fabrication of this fixed restoration with the Evo+
system, a total of 4 sets of data were sent to the production
facility (Permadental GmbH, Emmerich/Rhein, Germany,
Modern Dental Europe).
• Scans of the existing situation: maxilla and mandibula
with existing restorations, lateral scans for bite registration,
information on the tooth and gum shades
(digital photos)
• 2 complete HD scans of the correctly aligned scan
gauges including the identifier codes and the position
of the gauges used
• Full-arch scan of the edentulous jaw (with MUA) to be
restored for soft tissue documentation
• Additional facial scan, matched with the scans of the
existing prosthetic restorations (alternative: digital
portraits)
FABRICATION OF THE TRY-IN RESTORATION.
Based on the data collected during the first appointment,
a digital design was prepared, and after approval, a
try-in restoration was fabricated in the centralized production
facility (MD3D in Germany). In the present case,
no modification of the position or alignment of the tooth
was necessary compared to the existing restoration, so
the try-in could be fabricated accordingly. The scan of the
existing restoration was used as a „shell“ to design the
try-in. The screw channels were positioned at the same
time. At this point, it is possible to design screw channels
with an angle of up to 30° to the implant axis (Fig. 8).
2. APPOINTMENT
During the second appointment, the esthetic and functional
aspects of the digitally fabricated try-in restoration
are evaluated. First, the static and dynamic occlusion of
the screw-fixed temporary restoration is checked. In the
present case, only minor adjustments were required in
the distal region (Fig. 9).
Fig. 9: Fixed try-in with marked occlusal contacts. Minor adjustments
are only required in the distal region.

If no alterations of the try-in, or as in the present case only
minor ones, are required, the final restoration can be
fabricated.
Fig. 10: Extraoral photos with the inserted try-in allow an improved
communication regarding necessary changes (e.g., with regard to
tooth position or length, mid- and lipline).
The shape and position of the teeth were in good accordance
with the previous restoration and could be adapted
to the final restoration.
It is always helpful to send extraoral photos with the inserted
try-in to the fabrication center, as this enhances the
communication regarding necessary changes (Fig. 10).
If modifications are required, they can be performed by
grinding the try-in or by application of a composite material.
If the try-in is scanned again, all modifications can be
transferred digitally to the production facility; however, in
this case, two lateral scans are required for bite registration.
In this phase of the fabrication process, full-face photographs
of the patient (with and without smile) and
detailed color information should be transferred. Of
course, the modified situation of the try-in can be matched
with the existing face scan – this procedure was chosen
for the present case, as it allows a good digital transfer
of the esthetically relevant parameters (interpupillary line,
lip line, shape of the face).
Fabrication of the final restoration
A screw-retained FDP fabricated with the Evo+ system
consists of two components: First, a stabilizing substructure
is milled from pure titanium. It forms the basal surface
of the FDP construction, holds the connections with
the implant abutments, and splints the implants on the
primary level. This titanium structure is typically anodized
and has a golden yellowish color. The metallic substructure
allows high precision of fit of the implant-abutment
connection and stabilizes the entire structure. The surface
of the metallic construction is designed with conical and
plane fitting areas without undercuts, so that an overlay
construction made of different materials can be cemented
to the construction.
The overlay construction mimics the missing hard and
soft tissues and the full dental arch with polymer-based
or zirconia materials. In the present case, the overlay construction
was fabricated from a multi-layer composite
material. In in vitro studies, this combination of a metallic
substructure with a monolithic composite overlay construction
has shown a significantly increased fracture
strength compared to conventionally manufactured
implant-supported metal-composite FDPs [4]. The data
required for the fabrication of the metallic substructure
and the overlay construction are produced by a separation
resp. reduction of the data used for the fabrication of
the try-in (Fig. 11).
Fig. 11: Design data for the fabrication of the final prosthetic constructions: metallic substructure, tooth-colored overlay construction, based
on the data of the try-in fabrication. .

Abb. 12a: Occlusal view of the final Evo+ FDP. Angulated screw channels allow access to the palatal screw channel in the anterior region. The
overlay constructions were fabricated from a multi-layer composite material. The gingival parts were colored with appropriate staining materials.
. Abb. 12b: Basal view with anodized titanium structure and milled metal implant-abutment connections.
3. APPOINTMENT
During the third appointment, the final restoration is
inserted. After removal of the existing resp. the try-in restoration,
the FDP structure was screw-fixed to the multibase
abutments. Here, an additional check of the passive
fit according to the Sheffield test is recommended, with
only one fixation screw inserted at a distal abutment. For
this test, the entire construction must not be removed
from the other abutments when one screw is tightened
by hand. If this precondition is met, all fixation screws can
be manually tightened (Fig. 13).
Fig. 13: Occlusal view of the screw-retained maxillary FDP construction.
The access screw channels are sealed after a trial period of 7 to
10 days after insertion.
The patient was highly satisfied with the esthetic results
of the restoration. It is recommended that the patient
now gets a 5- to 7-day “trial period”. During this time, she
can check the chewing ability and get a deeper impression
of the esthetic result. Above all, during this trial
period, the patient can test the accessibility of the restoration
for oral hygiene. Therefore, it is recommended to
refresh the oral hygiene instructions and provide the patient
with a choice of suitable instruments (interdental
brushes). At the following check-up appointment (7 days
after insertion), the patient did not report any discomfort.
The restoration was removed and cleaned once again, a
good opportunity to check accessibility to domestic oral
hygiene, which revealed no problems at all. Therefore, the
restoration was reinserted and the fixation screws were
now tightened to the required torque (Astra EV Multi-
Base abutment: 15 Ncm). The access cavities were then
closed with a 1 to 2mm thick layer of Teflon tape on top of
the fixation screw. Finally, the access cavities were adhesively
sealed with a filling composite material in a matching
color.

SUMMARY
The Evo+ system allows the fabrication of implant-supported
screw-retained FDP restorations in a fully digital
workflow. The core of this system is the application of indication-specific
scan gauges with significantly enlarged
reference surfaces and the use of a modified high-resolution
scan strategy (i700 Medit Corp, Seoul, Korea). In the
present case, this technology led to a good fit of the fullarch
restoration. Using the Evo+ system, an implant-supported
FDP construction can generally be fabricated in 3
appointments. This means a significant reduction in the
number of appointments compared to the conventional
fabrication of this type of restoration. However, it should
be considered that necessary modifications of the try-in
restoration may lead to additional appointments.
The FDP construction is fabricated as a combination of a
metallic substructure and a custom monolithic toothcolored
overlay construction. This leads to a significantly
increased fatigue strength and a lower risk of material
fractures compared to conventional FDP restorations [4].
PMMA, composite, or zirconia materials are suitable for
milling the monolithic overlay construction that is adhesively
connected to the substructure. The choice of material
should be based on indication, considering the respective
advantages/disadvantages [5, 6].
In summary, the Evo+ system is an interesting expansion
of possible applications in a digital workflow. However, the
collection of sufficient data on long-term clinical success
is important.
REFERENCES
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in edentulous patients? Evid Based Dent 20:97–98. https://doi.org/10.1038/s41432-019-0052-3
3. Giachetti L, Sarti C, Cinelli F et al. (2020) Accuracy of Digital Impressions in Fixed Prosthodontics: A Systematic
Review of Clinical Studies. Int J Prosthodont 33:192–201. https://doi.org/10.11607/ijp.6468
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jomi.7545
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Clin Med 10. https://doi.org/10.3390/jcm10040816
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