Advancements of specific implant components (implant replicas, and

Advancements in
computerized tomography scans (CT and CBCT technologies), coupled with
computer-assisted treatment planning and a double scan approach, allowed for
the virtual planning of placement of implants in 3D orientation relative to the
bone, soft tissue, and final planned prosthesis. In 2002, the concept of
software planning and surgically guided techniques combined with immediate
loading was clinically introduced in Leuven, Belgium, by prof. Daniel Van
Steenberghe. These early treatments were limited to the edentulous maxilla and
required a full-thickness flap. Later, the procedure was refined to allow
flapless implant placement through virtual planning, by producing a
stereolithographic surgical template incorporating metal sleeves to guide the
implant site preparation. Furthermore, 3D planning softwares allow the surgeon
to digitally plan on the computer, the position, length, and diameter of every implant
to be placed and, at the same time, helps to prevent damage to vital
structures. Then, the retrofitting of specific implant components (implant
replicas, and guided cylinders with pin) into the stereolithographic surgical
template, an implant-level model, could be produced and a temporary prosthesis
could be fabricated for immediate insertion at implant placement. Several
prospective studies and few RCTs have validated these concept.

          Currently computer-guided implant protocols are considered
safe procedures that may help clinicians to perform prosthetic drive implant
therapy often avoiding elevation of large flaps causing less pain and
discomfort to patients. However deviations in three-dimensional directions
between virtual planning and actual final position of the implant in the
patient’s jaws, and technique-related peri-operative
complications have to be taken into account. Although, favorable clinical
results of computer-assisted template-guided surgery have been shown in several
studies, only one randomized clinical trials (RCTs) has been published
comparing the use of computer-guided surgery with conventional treatment,
reporting no statistically significant differences in term of implant and
prosthetic survival and success rates between computer-guided and free-hand
rehabilitations, but less patient discomfort in the guided surgery group.

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          Described in 1998, the double-scanning workflow and
the 3D representation of the CT or CBCT images with a
layered prosthetic plan, represented a major breakthrough for digital implant
planning and preoperative patient assessment. Panoramic
radiography and intraoral radiography are still the basic imaging methods in
dentomaxillofacial radiology, a comparative study of Wolff et al. (2016) proved that
there is a better concordance in oral and maxillofacial surgery outcome when
planning with 3D images versus 2D images. The European Association for Osseointegration (EAO)
and The International Congress of Oral Implantologists (ICOI) have published
their recommendations quite recently.

          Double scan protocol is based on two separate sets of
DICOM files. It can be used for both partial and complete edentulous patients.
The first CBCT scan will be of the patient wearing the radiographic guide with
the radiopaque markers. The second scan will be of the patient’s radiographic
guide alone. Based on the spherical markers visible in both scans,
the scans are superimposed onto each other, resulting in a 3D bone model of the
patient together with a 3D model of the radiographic guide.

          The combination of a 3D bone model and 3D radiological
dataset lets dental professionals to evaluate bone quantity, underlying
anatomical structures such as nerves and blood vessels, as well as dental
roots, can be identified and marked with the help of several reslice views.
Special tools are available to highlight dental roots, nerves and other
anatomical structures or restrictions. Software allows to turn 3D images,
rotate these images, and to view the treatment plan from all angles simplifying
diagnostic procedures and placement of implants. 3D distances can easily be
measured, and a tool to measure the grey values is also available. These
anatomical annotations are visible in the 3D setting and in the reslice viewer. The combination
of a 3D bone model, including the 3D radiological dataset and the 3D
radiographic guide model, enables clinician to place implant locations
according to anatomical, functional and esthetics needs and demands based on the
prosthetic setup. In order to achieve this, the clinician virtually
positions the implants, with the optimal length and diameter. Any of the
modifications in 3D location and implant type, size or shape can be done in the
3D setting or in the reslice viewer. After finalizing the planning, the
corresponding surgical template is designed. The surgical template thus
fabricated contains all the necessary planning information-It is customized
according to location, type and size of the planned implants (Figures from case

          In the treatment of partially edentulous patient, it is
possible to save time by skipping the radiographic guide, also avoiding
additional patient visit. This is possible thought the introduction of a novel
digital integrated workflow that combines the DICOM data belonging to the CBCT
examination of the patient with the STL data derived from the optical digital
high-resolution scan of the preoperative patient master cast and tooth setup,
or by digital intraoral impression. The STL data are integrated with the craniofacial
model to create a more accurate 3D model of the teeth. It is thus possible to
visualize hard and soft tissue anatomy and to obtain a more precise
segmentation of the residual dentition. This process is named Smart Fusion, and it represents the ability of
NobelClinican to combine the CBCT patient scan with the NobelProcera scan of
the model & wax-up into a single surgical and esthetic view.  This
protocol greatly simplifies the overall treatment workflow by eliminating the
need for two CT scans while providing an enhanced fit of the Surgical Guide to
the patient (Figures from case 2).

          The prosthetic-driven planning workflow will start with
taking a cone beam computed topography scan of patient, by using a wax bite to
separate dental arches. The next step is to create a digital model, which can
be accomplished in two ways: the clinician can use an intraoral scanner to
create a digital models (fully digital workflow); or the clinician can take a
traditional impression and then scan the impression (reverse engineering) or
the poured master model, by using an extraoral scanner (conventional workflow).
It is highly recommend to take a definitive impression with the maximum
extension and details, by using vinyl polysiloxane or polyether materials, and
then poured the impression with a low expansion, class IV gypsum (usable with a
extraoral scanner). This is because the surgical template derives directly from
the master model. Afterwards, an occlusal registration can be made with hard
wax or resin.

          In the fully digital workflow, the digital STL data will be
imported in a 3D design software to realize a virtual wax-up according to the
esthetic and functional requirements. In the conventional workflow, a vinyl
polysiloxane or polyether impression will be taken with a customized tray. The
impression will be poured with Gypsum IV Class and then, the models will be
mounted in a fully adjustable articulator. Afterwards, a dental wax-up will be
made accordingly to the functional and esthetic requirements. Finally, master
cast and wax-up will be digitalized by using a lab scanner.

          Irrespective of the workflow used to digitalize the anatomy
information, the data from dental and gingival, acquired by intraoral or
extraoral scanning (STL data), and the bone informations, radiographically
acquired by a CBCT scan (DICOM, Digital Imaging and COmmunications in
Medicine), will be imported in a 3D software planning program. Then, the
reprocessed surface extrapolated from the DICOM data (by using a Hounsfield
scale filter) and the surface generated by the master cast scanning process or
by the intraoral scanning process, are merged based on the matching between
numerous points on the surface of patient’s dental casts
and the corresponding anatomical surface points in the CBCT data.

          Introduced in 2011, NobelClinician builds on its
predecessor, the NobelGuide treatment planning software, which was the first
virtual planning system based on the double-scan technique. In NobelClinician,
the clinician views the 3D data set derived from (CB)CT scan data that consist
of a series of transaxial images, orthogonally aligned to the patient’s
vertical axis and registered as one volume. By selecting slices in any plane,
data integrity is always fully preserved, as no recalculation is involved. Scan
data are stored and distributed in the standard DICOM (Digital Imaging and
Communications in Medicine) format and can be easily analyzed and shared. At this point,
prosthetic-driven implants/abutments size and location can be planned taking
into account the bone quality/quantity, soft tissue thickness, anatomical
landmarks, as well as, the type, volume and shape of the final restoration.

          Before surgery, the NobelClinician Communicator app(lication) helps dental
professionals (surgeons or surgical specialists as well as general
practitioners placing implants) to present chairside patient plans and images
exported from NobelClinician via NobelConnect, and to communicate
effectively all the diagnostic findings and discuss and explain the
proposed implant treatment plan to the patient. The application works with
NobelClinician Software, and it is designed for iPad®. The software also
allows to show clinical images, photographs, screenshots and
x-ray images, as well as, to select “educational
images” to explain different treatment options. Finally, drawing on images and
plannings to emphasize important topics is also allowed.

          In March 2017 Nobel Biocare will also launched a new
time-saving CAD/CAM-based protocol that enables clinicians to receive a screw-retained
TempShell provisional restoration from a dental laboratory in time for
placement on the day of implant surgery. The SmartSetup
software dramatically reduces the time it takes clinicians to
create a prosthetic-driven treatment plan. This plan can then be used by the
dental laboratory for the fully digital design of the cement-free TempShell
provisional restoration. Incorporating several of Nobel Biocare’s leading
digital technologies, the updated workflow has been developed not only to
shorten time-to-teeth, but to increase both treatment efficiency and acceptance
as well as further improve collaboration between dental professionals.

          The 2018 will not be less. The new DTX
Studio diagnostic software, will serve as a digital hub connecting the latest
Nobel Biocare and KaVo solutions for patient data digitization, diagnosis,
planning, surgery and restoration, from beginning to end. DTX Studio is
also set to offer easy access to industry-leading implants and restorative
options. By providing true, seamless links between every aspect of a dental
professional’s daily work, this smart solution aims to set a new standard in
treatment efficiency and patient care. The software easily connects any imaging
devices in dental practice, whether using 2D or 3D, introra or extraoral
technologies, allowing to view them directly in DTX studio software. The
software consists of different modules, with multiple work spaces, which can be
flexible selected according to the clinicians’ needs. The software can be simple
connected with other digital devices to easily produce surgical templates,
models and provisionals by using a 3D printing and in-lab milling, but also
production of prosthetic frameworks, full-contour restorations or surgical
template at one of our centralized production centers. In fact, users,
connecting to 3D printers, can be able to export STL files for local production
of surgical template, temporary eggshell provisionals (Tempshell) and models.
Connecting to in-lab production, users can be export files for local production
of tooth-based restorations, provisionals and models. Otherwise, Individualized
surgical templates and CAD/CAM prosthetics restorations (single- and
multiple-unit implant-based restorations, tooth—based restorations, and implant
bars for major implant platform, can be sent for industrial production with a
turnaround time of just a few days at external production facilities (milling
center) in USA or Japan.


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