CAD/CAM international No. 4, 2018
Cover
/ Editorial by Dr Scott D. Ganz
/ Content
/ The battle between digital and analogue
/ The fully digital Pro Arch protocol
/ Fixed or removable? That is the question.
/ Computer-assisted implant rehabilitation of tumour patients
/ X-Guide empowered by DTX Studio suite
/ Azento brings the clinician financial and time-saving benefits
/ Bringing a turnkey restoration solution to dentists
/ Manufacturer news
/ Meetings
/ Submission guide
/ International imprint
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[1] =>
issn 1616-7390 • Vol. 9 • Issue 4/2018
4/18
CAD/CAM
international magazine of digital dentistry
special
The battle between
digital and analogue
case report
Fixed or removable?
That is the question.
cone beam supplement
Computer-assisted implant
rehabilitation of tumour patients
[2] =>
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Patient can visualize the therapeutical recommandation.
Control the dose of the x-ray emmission.
X-MIND trium is a class 3R laser product per IEC 60825-1:2007. Avoid direct eye exposure to laser radiation. Viewing the laser output with magnifying optical instruments (for example, surgical
microscope and binocular glasses) may pose an eye hazard and thus the user should not direct the beam into an area where such instruments are likely to be used.
SOPRO l a company of ACTEON Group
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Tel. +33 (0) 442 980 101 l Fax. +33 (0) 442 717 690
E-mail: info@sopro.acteongroup.com l www.acteongroup.com
[3] =>
editorial
|
Dr Scott D. Ganz
Editor-in-Chief
What is next?
As 2018 comes to a close, we should take a moment
to appreciate all of the incredible advances in technology
and new products that have been introduced during the
year. Regardless of which area of dentistry is considered
the industry continues to innovate, clinicians continue to
push the envelope, and hopefully these advances will
translate to improved care for our patients. 2019 will bring
us many additional surprises at the upcoming International
Dental Show (IDS) in Cologne, Germany, always the focus
for new product introductions and the world’s premier
venue to showcase products related to all phases of dentistry. What is there to look forward to? Plenty.
It has become crystal clear that dentistry has been
slowly moving from the analogue to the digital universe.
Intraoral radiographs are no longer processed film with
chemicals in a darkroom as digital sensors and computer
software have provided an interactive medium for quicker
access to images with enhanced diagnostic tools. Images
that exist on the computer screen can be enlarged,
adjusted for clarity, archived easily, printed or e-mailed
with a few keystrokes. Each year the sensor technology
continues to evolve to become the industry standard, yet
digital radiography has not reached 100 % saturation with
dental offices around the world. What’s next?
Digital radiography has further expanded to include
cone beam computed tomography which has become
an essential diagnostic tool for dental implants, oral
surgery, orthodontics, endodontics, and airway analysis.
Computers continue to gain faster and faster hardware
processors with more powerful graphics cards pushing
shrinking pixels on higher-resolution monitors, therefore,
providing clinicians with increased ability to visualise
individual patient anatomical presentations.
Additionally, interactive software applications are constantly undergoing upgrades with advanced tools for
both clinicians and dental laboratory technicians. However, as we all know the ultimate goal for our patients is
to maintain good oral health, function, and aesthetic restorations. To that end, one of the major catalysts for the
growth of digital dentistry has been the intraoral scanner.
The ability to move from the analogue impression to a
digital impression for a tooth preparation or to capture
the position of an implant has transformed the restorative
protocols and workflows for the present and the future.
Virtual teeth can be designed on a tablet computer or a
smart phone. Perhaps it is the merging of these technologies that has truly provided new levels of accuracy for the
diagnostic, surgical, and restorative phases of dentistry.
A second major catalyst that has caught our industry by
storm is the availability of low cost, accurate, 3-D printers
that can take our ideas, our virtual designs, our virtual
treatment plans, and bring them to a physical model that
we can hold in our hands. Our world is changing rapidly...
dentistry is forever evolving—and the ultimate beneficiary are the patients we serve. Let’s all look forward to
“what’s next” in the coming year!
Happy Holidays to all!
Dr Scott D. Ganz
Editor-in-Chief
CAD/CAM
4 2018
03
[4] =>
| content
editorial
What is next?
03
Dr Scott D. Ganz
special
The battle between digital and analogue
06
Interview with Dr Galip Gurel, Dr Stefan Koubi & Hilal Kuday
page 06
case report
The fully digital Pro Arch protocol
14
Drs Luis Cuadrado de Vicente, Andrea Sánchez Becerra
& Cristina Cuadrado Canals
Fixed or removable? That is the question.
18
Dr Alessio Casucci & Alessandro Ielasi
cone beam supplement
page 14
Computer-assisted implant rehabilitation of tumour patients
30
Ioannis Papadimitriou, Dr Petros Almagout,
Dr Erich Theo Merholz & Dr Stefan Helka
industry news
X-Guide empowered by DTX Studio suite
38
interview
page 38
Azento brings the clinician financial and time-saving benefits
40
Bringing a turnkey restoration solution to dentists
42
manufacturer news
44
meetings
Sometimes faster, sometimes safer, sometimes both—
The digital practice at IDS 2019
46
International events
48
about the publisher
Cover image courtesy of Nobel Biocare
(www.nobelbiocare.com).
issn 1616-7390 • Vol. 9 • Issue 4/2018
4/18
CAD/CAM
international magazine of digital dentistry
special
The battle between
digital and analogue
case report
Fixed or removable?
That is the question.
cone beam supplement
Computer-assisted implant
rehabilitation of tumour patients
04 CAD/CAM
4 2018
submission guidelines
49
international imprint
50
[5] =>
© MIS Implants Technologies Ltd. All rights reserved.
Open Frame Design
Access for Irrigation
and Anesthesia
Single Handed Procedure
MAKE IT SIMPLE. WE KNOW HOW!
The innovative design of the MIS MGUIDE and its surgical kits
simplifies digital dentistry. The use of CAD/CAM, allows for a
prosthetically driven, safe and accurate procedure. To learn more
about the MIS MGUIDE, go to www.mis-implants.com
®
P A R T
O F
T H E
M C E N T E R
G R O U P
[6] =>
| special
The battle between digital
and analogue
Interview with Dr Galip Gurel, Dr Stefan Koubi & Hilal Kuday
The use of digital technologies in dentistry is on the rise,
a fact that clinicians Dr Galip Gurel, Dr Stefan Koubi and
dental technician Hilal Kuday are well aware of. They are
convinced that the use of modern technologies is a growing trend in all areas and to believe that this will not come to
the dental clinic would be a big mistake. Ulyana Vincheva,
Managing Director of Dental Tribune Bulgaria and publisher
of Dental Tribune Bulgarian Edition, had the opportunity to
talk with them about their lecture during the 2018 Competence in Esthetics meeting held in Belgrade in Serbia on
10 November and organised by Ivoclar Vivadent. They told
her of their fascination for digital dentistry and their vision
of the near future, in which they believe virtual reality and
artificial intelligence will feature.
You are three of the world’s top experts in dentistry
and you work together as a team, but you are also
good friends, right?
Koubi: Of course! Nicely done teamwork is only possible among people who like each other.
During your lecture you spoke about “the most personalised smile design”. What is the point? Do you
believe in the individualised approach for every case,
and how does it fit in with a fully digitalised workflow?
Gurel: As I explained in our lecture, we have been working
like this for years. It provides a personal touch. It depends on
your intuition how you approach and evaluate the patient
06 CAD/CAM
4 2018
and his or her smile. Even with this protocol, you should
have some trials. Maybe sometimes the result will be
superb; sometimes the patient won’t like it. Our workflow
was already a personalised smile design, but we didn’t
know it until we started our research. When we started
sharing cases with each other, at first, we selected only
the best cases, trying to evaluate which part of the smile
design goes with which part of the patient. Does it depend
on physical appearance, which we can’t change, or on
personality, how the patient wants to be perceived?
We fragmented all these smiles and tried to analyse, for
example, on what the tooth axis depends, on what the
tooth shape depends. After that, we cross-matched these
cases and came out with some results, which we put into a
software programme. This software is based on hundreds
of algorithms, and most recently, we developed software
that is driven by artificial intelligence and suggests smile
designs that are appropriate for the patient because they
go well with his or her facial appearance and his or her
personality. That is how we started using this programme.
The first stop was the VisagiSmile, which gives us the 2-D
design. This programme was amazing for someone who is
into aesthetics. If I show the programme to Hilal or to Stefan,
they will understand it and transfer it to the patient either
as a mock-up or a wax-up, but for majority of the dentists
it wasn’t an easy task. The main problem was that many
dentists couldn’t translate it to the patient’s mouth. We
realised that many of our colleagues don’t use mock-ups.
[7] =>
special
They take an impression, send it to the lab and the lab technician prepares a wax-up. Back then, the lab technicians
didn’t have much supporting material. They had only a few
photographs and a stone model, and they tried to build up
the entire case based on that. Nothing was personalised.
Everything changed the moment we realised that our
IT team could transform 2-D into 3-D. That is how Rebel
was born. Thanks to Rebel, we can transform all of this
knowledge into a 3-D digital wax-up, which can be sent
to the dentist for 3-D printing, then for impressions and
back to the patient’s mouth. This is the chronology of how
personalised smile design became a reality.
As I mentioned in our lecture, when you go into Rebel,
there are some mandatory fields you need to fill in, like the
facial photographs, the intraoral scanning, the questionnaire, and your or your patient’s preferences. For example,
if you would like to have a mild surface texture or a strong
or smooth one, you need to enter this information into the
software. Ninety per cent of the information needed can be
entered only by clicking, nothing further. Some of the data
needs to be entered as a text, but this is very limited, so definitely I can state that Rebel is extremely user-friendly. From
a technical perspective, if you send a case without writing
anything, only with the information that has been registered
by clicking and selecting one of the given options, you will
still have a 100 % digital wax-up. Maybe only 5 % needs to
be entered manually by the clinician in order to complete
|
the smile design. As far as I know, to date, this is the only
software that instantly gives you a 100 % digital 3-D wax-up.
A few years ago, you emphasised the importance of
proper communication with lab technicians. Does
Rebel help in this matter?
Gurel: I think Rebel is an amazing tool for ceramists—
and I am not talking only for ceramists like Hilal, who is a
superstar and a great professional. For the majority of lab
technicians, Rebel represents an amazing tool and opportunity to immediately create a 3-D wax-up that not only is
aesthetic in their opinion, but also perfectly suits the patient’s facial appearance and personality. At the beginning
when starting beta testing of this project and giving lectures to dentists and lab technicians, the lab technicians
were the first to embrace the idea because it makes their
lives much easier. Instead of spending hours carving and
sculpting the wax-up without having all the information and
parameters needed, with Rebel they can have an accurate
wax-up ready in a split second. Of course, they can make
some small changes if they like. In my lecture, you saw how
amazingly one can translate all details, like surface texture
and tooth shape, into 3-D printing or CAD/CAM milling in
order to be tested in the patient’s mouth even before one
starts prepping the teeth.
Dr Koubi, what are the benefits of digital technology
for dentists?
Gurel: Thanks to digital solutions, even more dentists who were previously afraid to work in the aesthetic area will go into aesthetic dentistry. Imagine that
every patient who needs an aesthetic smile rehabilitation is like an empty canvas, and it is up to us to create a masterpiece. Digital technology will support us
in our artwork, enable us to be even more precise.
CAD/CAM
4 2018
07
[8] =>
| special
Koubi: I would like to briefly address the previous two
questions. Generally speaking, you have two realities. One
is the patient’s expectations. Patients would always prefer a
customised smile, not a standardised one. And the second
one is the technician’s abilities. Most lab technicians have
a specific signature, their own style, and they pretty much
repeat it with every case. I am talking about the majority of
technicians, not the top professionals. The beauty of the
software is that you have a digital library and you can include as many tooth shapes and forms as you like. And after
that, you can play with the software and make some modifications. The problem is that most dentists are not able to
experiment with the software because we don’t have the
knowledge and ability to do it. That’s the main problem with
smile design: the dentists are not able to experiment with
the software and the lab technicians have one and the same
signature. Rebel provides a solution, giving you the advantage of outsourcing the headache of smile design. We have
to be realistic: most dentists are not able to use the software
or Keynote properly; we are dentists, not fancy speakers,
or we just don’t have enough time to spend hours in front
of the computer. The ceramists don’t have the knowledge
or ability to create all the different tooth morphologies because there are more than 12,000 different tooth shapes.
That is where Rebel comes in; its algorithm supports you
in this task. Returning to the question, the benefit for dentists is that it is so user-friendly—you just plug and play!
Rebel saves a great deal of time and gives you a quality
product, so it meets every dentist’s needs!
Mr Kuday, would you like to add something to this
topic?
Kuday: As a dental technician, I would like to say that
digital workflow is a tool you can always rely on. If you
integrate digital technology into your everyday practice,
it definitely raises the quality of your work. We dental technicians study anatomy, biology and morphology and are
a part of the team, so if dentists don’t respect our work
as lab technicians and don’t send us all information needed
to create beautiful, nicely fitting prosthetic restorations,
then our hands are tied. Fortunately, I am lucky to work
with dental experts like Drs Gurel and Koubi, who appreciate my work in the lab. All of the precious information that
they register from the patient’s mouth, the questionnaire in
Rebel, give us an idea of how to follow nature. At the end
of the day, we are a team; we sit down and work together
in order to create a beautiful job as partners.
Koubi: With Rebel, we are not talking about replacing
the lab technician; we are talking about supporting and
assisting him or her. It is very important to keep that in
mind. Rebel is a very useful tool to improve the quality
of the technician’s work in order to create even more
beautiful restorations.
Gurel: One other thing: thanks to Rebel, even more
dentists who were previously afraid to work in the aesthetic
08 CAD/CAM
4 2018
zone will go into aesthetic dentistry. Imagine that every
patient who needs an aesthetic treatment is like an empty
canvas. You need to create an artwork there and not every
dentist is capable of doing that. Rebel gives you the opportunity to create a masterpiece without worrying about
how to use Rebel. All other programmes, as Stefan and Hilal
have already said, require detailed computer knowledge
in order to create proper smile designs or a great deal of
time to work with digital libraries, to position the teeth and
to establish a really aesthetic smile. For the dentist to be
able to achieve a perfect smile with a single mock-up is
a completely different story. That’s the beauty and ease
of using Rebel. The effect of integrating Rebel into the
dental world will not be erasing and replacing all dental technicians. Instead, it will create a huge community
of dentists doing aesthetic cases, which will increase the
number of veneers, crowns and bridges to be made. As an
end result, more dental technicians will be needed to cope
with the rising needs.
You have touched on some advantages of digital technology, but what are its limitations?
Gurel: Well, there are always limitations. First of all, it
won’t work in extremely crowded dentition. We shouldn’t
expect miracles. Rebel can cope with cases with a reasonable initial situation, for example minor crowding or minor
spacing. It is not mandatory for the restorative technique to
be additive for every case. That’s another great advantage
of Rebel, meaning that if a part of a tooth is protruding out
of the aesthetic arch, the software doesn’t take that into
account. It will place the original shape over the ideal arch
position, leaving that part outside. The advantage of this is
that in a traditional system in order to put the wax-up into
the patient’s mouth we have to first cut the protruding edge
of the tooth and then make the mock-up, which means we
have already started prepping the teeth and if the patient
is not satisfied, it will be a problem. With Rebel, you can
transfer the mock-up into the mouth even with this crowding and then explain to the patient that if he or she doesn’t
want the dentist to prep this tooth then he or she needs to
undergo an orthodontic treatment. The possibility of having
this visual information and communicating with the patient
enables you to achieve superb outcomes.
Koubi: We need to have a very clear vision regarding the
digital technologies because it is a reality already. In order
to be good with digital technologies, you need to be a skilful
driver and manager of the whole process because, as we
have already mentioned, digital technology serves you as
a tool. But you and your lab technician need to be well
educated. That’s the basis of your teamwork. Sometimes,
people are confused because they believe digital technologies will provide them with all of the clinical solutions,
but that’s not true. It only supports us in our work; it speeds
it up and improves its quality. We use artificial intelligence
to simplify our life, but not to replace the human with his or
her mind and knowledge.
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[10] =>
| special
Kuday: I would like to talk through it from a human perspective. If we retain the human factor in the technology,
then everything will be alright. Nowadays, we are talking
about self-driving cars replacing drivers. Sooner or later, it
is going to happen. But if we would like to do something as
a team, we need to integrate the human factor to control
the whole process. From an ethical point of view, human
touch is mandatory during the digital workflow. The operator needs to be either the dental technician or the dentist, not the engineer. The human, not the technology, has
to be the creator and leader. The new digital technologies
are developing very, very rapidly. For example, if you buy an
iPad today, tomorrow it will be out of date. This is dictated
by today’s economic situation.
Do we need major reforms in dentistry? If so, what
might those be with regard to digital technology?
Koubi: We need many reforms in dentistry. I will speak
also on behalf of my friends and colleagues. In France, two
types of dentistry have been established for years: mass
dentistry and elite, boutique dentistry. Digital dentistry is
very useful for mass dentistry because it makes aesthetic
treatment faster and more affordable, but we have to keep
“The human, not the
technology, has to be the
creator and leader.”
10 CAD/CAM
4 2018
in mind that we work in the medical field, not in economics, for example, and we are treating patients. We have
to take responsibility for all our actions. Digital technologies will improve the average quality of our work, but will
never be better than an exceptionally good dentist. It is the
same in other medical fields: surgical robots perform better
than an average surgeon, but robots will never be more
skilled than an experienced and well-trained surgeon.
Most dentists cut too much tooth structure. If you examined 1,000 impressions, you would see that most teeth
are over-prepped. Thus, the risk of complications rises.
Thanks to robots, we can standardise quality. Is it the best
quality? No, it is not, but that’s not the purpose. So it needs
to be clear that digital dentistry is certainly our future, but
I don’t believe everything will become digital. We need
to implement also the human touch in order to exploit all
advantages that digital technologies provide, but at the
same time to avoid their weaknesses.
What does the future hold for dentistry in your opinion?
How do you see the dental world in 20 years?
Koubi: Our future is digital for sure! We will have less useless stuff; the impression trays and impression materials
will be forgotten. Everything in the dental office will be
clean, white and clear as it is now in our clinic. My wish and
hope for the future is that dental students will receive better
training and be better prepared for the digital workflow. The
digital process needs to be better integrated into university
curricula. Universities all over the world have to make a
significant shift and to implement digital education in every
[11] =>
special
dental specialty so that students graduate already prepared
to work with digital technologies because nowadays they
have to learn how to do it after graduation by attending
additional courses and lectures. Education, not only university education but also continuing education, will become more and more relevant and it will be key to success.
Gurel: My short-term project is to see our robot
DIGICUTO working. Five years ago, nobody believed that
the iPhone would be so small and able to multitask so
quickly. Now, it is a reality: your phone, your computer, your
camera, everything is becoming even smarter. Our idea
has already been born. When we will realise it depends on
two things: technical issues, which in my opinion will be
solved soon, and patient acceptance—people usually ask
me not how it will be done technically, but how patients will
allow a robot to prep their teeth instead of a dentist. In the
near future, cars will be driven without drivers by artificial
intelligence. Our concept is the same; it is even safer. I think
the near future will look like that. I hope, as Stefan said,
that digital technology will enable us to offer even more
affordable treatment plans. I hope that new 3-D printable
materials like ceramics will speed up treatment and once
again make it cheaper so that more people worldwide will
have access to high-quality dental care instead of what
they are getting now. Everybody deserves to be treated in
a precise and predictable manner.
|
Kuday: Regarding future development, I think “affordable” is definitely the key word. Everybody deserves to
have unique restorations, not only wealthy people. I would
like to emphasise that, if the quality of 3-D printed restorations is high enough, then I will accept it.
What do you think the role of leading brands will be in
the future?
Gurel: We are all professionals with many years of
experience, working with big companies. In my opinion,
the companies should not sell materials only, but should
sell complete storylines, and by that, I mean things connected with each other, so that if somebody starts working with some system he or she should not even think
about leaving it. Just like Apple. Once you buy an iPhone,
then you buy an iPad, then a MacBook Pro, so you
always stay in the family. Why? Because they are very
nicely connected with one another. Many people nowadays are afraid of the word “digital”. They are concerned
that they don’t have advanced computer skills, and don’t
know how to use the software or how to shape the teeth
digitally. Working in a digital workflow doesn’t require all
of this. A digital protocol should be very user-friendly and
intuitive so that once you start using it, you will feel the
urge to dive even deeper into it and to also try a scanner,
for example. And if it is easy to work with, then you won’t
even think about buying a device from another company.
Koubi: The aim of artificial intelligence is to simplify our life, not to replace the human with his or her mind and knowledge. Digital technologies will improve
the average quality of our work, but will never be better than an exceptionally good dentist. It is the same in other medical fields: surgical robots perform better
than an average surgeon, but robots will never be more skilled than an experienced and well-trained surgeon.
CAD/CAM
4 2018
11
[12] =>
| special
Kuday: Affordable dental treatment is definitely the key word. Everybody deserves to have unique restorations, not only wealthy people. And digital technology
will make it come true.
If you follow the Ivoclar storyline and you are satisfied with
all of its products, then you won’t buy another brand’s
porcelain blocks, for example, because you are sure that
quality of the end result is guaranteed only if you stay in the
family. And if the brand you are satisfied with also offers
you a robot to prep the teeth, it will complete the whole
storyline and you won’t look for different solutions. Getting a milling machine from one company, porcelain from
another and a scanner from a third will create a higher risk
of mistakes and complications, so adopting one brand
is more convenient for everybody.
Koubi: Dentists want to buy solutions, not ingredients.
If you go to an Italian restaurant, you order a whole plate,
not the pasta itself, and you are sure that it will be cooked
al dente. It is similar to some of the brands on the market:
they stress the qualities of some ingredients, some materials, but customers are looking for integrated solutions.
This is important for producers to keep in mind and for
them to develop and improve their sale strategy according to it.
Kuday: At the beginning of the congress, Ivoclar Vivadent
launched IvoSmile, an application for smile design that
gives you the final outcome after aesthetic rehabilitation of
the smile. Anybody can download it from Ivoclar Vivadent’s
website; even patients can download it and give it a try. This
means companies are thinking ahead and they are already
12 CAD/CAM
4 2018
trying to establish and improve the connection with each
other.
Gurel: When a company delivers a product to patients
or to dentists, it should be connected in a clear workflow. If the patient sees the smile design and approves it,
the dentist shouldn’t have any fear or uncertainty regarding how to achieve it. In my opinion, dentists won’t even
try it because they might be afraid of how to proceed,
how to create such a smile design. That is the reason
why I am saying we should have a well-established
workflow and every new product launched on the market needs to be connected with the rest. When a patient
wants a particular smile design, the dentist needs to be
certain which 3-D design programme to use. I believe defining a very clear treatment process lies in the near future
of companies.
Thank you very much for this interesting conversation!
It has been a pleasure having all three of you!
Acknowledgement
This conversation was held with the kind support of
Ivoclar Vivadent, who provided its lecture room for the
speakers to comfortably sit and chat after their lecture
at the Competence in Esthetics congress in Belgrade.
The conversation was transcribed by Dr Pavlina Koleva.
[13] =>
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[14] =>
| case report
The fully digital Pro Arch protocol
Drs Luis Cuadrado de Vicente, Andrea Sánchez Becerra & Cristina Cuadrado Canals, Spain
ig. 7
Fig. 1
Fig. 2
Introduction
The Straumann Pro Arch concept involves different
treatment solutions for the fully edentulous patient. The
objective is to provide a predictable, reproducible and
simple treatment that restores patients’ oral health and
consequently improves their quality of life dramatically.
The possibility of immediate, same-day rehabilitation by
means of temporary fixed prostheses offers maximum
treatment quality and satisfaction for both the dental
team and patient. The objective of the treatment with
an immediately loaded fixed prosthesis on implants is to
improve the patient’s quality of life by providing function,
aesthetics and health until osseointegration is established.
Owing to the fully digital workflow, which starts with
the use of an intraoral scanner, the work team is able
to offer a treatment of extreme precision in a simple
way. This marks the beginning of a completely digital
treatment right up to the final prosthesis. This could be
considered as a new form of implantology in which the
different elements of treatment are optimised to obtain a
spectacular result.
With this objective in mind, at i2 Implantología, we have
developed a number of solutions and protocols covering
the different clinical situations in fully edentulous patients
Fig. 4
Fig. 5
14 CAD/CAM
4 2018
Fig. 3
and based on classical implantology principles to obtain
predictable and reproducible results, with the use of the
intraoral scanner as the principal element. Our protocols
include the use of certain elements (adequate implant
system, Osstell, etc.) and action protocols for scanning,
surgical and prosthetic procedures and laboratory operations, including the production and maintenance of the
provisional prosthesis.
In this case report, we present the i2 Standard protocol. This can be applied to patients requiring the removal
of terminal dentition. In summary, this involves selected
extractions, implant placement, intraoral digital impressions, and the design and production of the temporary
fixed prosthesis in PMMA, with placement in the patient
on the same day.
It is important to note that our fully digital protocol to
reach the final prosthesis is based, if needed, on the production of subsequent different temporary prostheses
until osseointegration is established. We will modify the
initial design (and produce further temporaries) always
according to a fully digital approach, in order to obtain the
final mock temporary prosthesis that fulfils the functional
and aesthetic parameters in the patient. The information
provided by this final mock temporary will be copied on
to the final prosthetic design. A trained dental team, clinic
and laboratory are mandatory.
Fig. 6
ig. 10
[15] =>
case report
Fig. 7
Fig. 8
Fig. 10
Fig. 11
Initial situation
A 68-year-old patient with no medically relevant history
and hopeless dentition was referred by his periodontist.
A panoramic radiograph and dental CT scan were taken
to evaluate the bone availability, disposition and density
(Figs. 1 & 2). After the different treatment options were
discussed, and in view of the patient’s overall dental,
social and financial situation, an implant treatment with
a same-day fixed temporary restoration was the first
choice for both the dental team and the patient.
Treatment planning
The goal was to load the implants immediately with
a fixed screwed temporary prosthesis. To achieve this,
the strategic extraction of some dental elements was
planned, with the temporary preservation of those key
elements that, in the intraoral scanning, determined
the patient’s aesthetics, vertical dimension of occlusion
and prosthetic arch. We decided to perform minimally
invasive surgery, where possible, with a flapless technique to avoid any mobile tissue that could affect intraoral scanning. The placement of six Straumann Bone
Level Tapered, Roxolid, SLActive implants with screwretained abutments (SRAs) was planned for the restoration.
|
Fig. 9
Fig. 12
preoperative situation, including teeth, aesthetics, vertical dimension of occlusion and occlusion (Fig. 3).
The surgery was performed under local anaesthesia and with patient monitoring by an anaesthesiologist
using conscious intravenous sedation with midazolam
and pulse oximetry monitoring. Removing failing teeth
was the first task, keeping in place those teeth with less
mobility and in strategic positions to maintain antagonist
contacts, and trying to keep the same preoperative bite
(Fig. 4).
Extraction sockets were fully debrided with a bur to
remove all of the granulomatous tissue. Gingival trimming
was also performed on those gingival parts with deep
pockets. Cleaning with hydrogen peroxide and saline
was the final step, obtaining fresh places for the implants.
Keeping in mind the bone anatomy, availability and expected density, the final implant locations were selected
Surgical procedure
Before starting the surgery, an initial study model scan
was obtained with the intraoral scanner and sent to the
laboratory as the patient’s original file (File 1). This file
contained all of the information concerning the patient’s
Fig. 13
Fig. 14
CAD/CAM
4 2018
15
[16] =>
| case report
. 20
Fig. 16
Fig. 15
Fig. 17
and the implant beds were prepared at 800 rpm with
continuous saline irrigation. The implant beds have to be
prepared such that parallelism is maintained between
all the implants. When placing tilted and/or non-parallel implants, the preparation angle should be either 17°
or 30° to match the available SRA custom angulation.
Accordingly, the dentist is constantly striving for the
least divergent implant preparation, drilling at 0, 17 or 30°.
The Pro Arch guide is very useful for this purpose.
SRAs were connected to all of the implants: two 17º
Type A angulated SRAs were placed on the anterior implants to correct the angulation for immediate prosthetic
rehabilitation. Straight SRAs were placed on the remaining
implants (Fig. 9). New ISQ levels were measured at abutment level using the convenient BLT Type 25 SmartPegs.
It is important to record the ISQ level at implant and
abutment level in the surgery so that the values can be
extrapolated in future Osstell readings at SRA level.
Furthermore, undersized drilling with continuous bone
density assessment according to the operator’s own
experience is mandatory to achieve the highest insertion
torque, taking account of the biological bone situation
and the mechanical properties of Roxolid. In this case,
six implants (Straumann BLT, Regular Neck, Roxolid,
SLActive, four of Ø 4.1 mm and two of Ø 4.8 mm) were
placed with the handpiece at 45 Ncm, with a final manual
setting and monitoring of the insertion torque (Figs. 5 & 6).
Careful orientation of the Loxim orientation marks is
mandatory to maintain the desired parallelism of the
SRA prosthetic screws.
To obtain the final intraoral surface scan, original
Straumann SRA scan bodies were connected to the SRAs
under visual control (Fig. 10). A new intraoral scan was
taken to record the patient’s current oral situation, showing the scan bodies and the preserved strategic teeth. This
file (File 2) was also sent to the laboratory (Figs. 11 & 12).
When the laboratory confirmed receipt of both files, the
preserved teeth were extracted and healing caps placed
on the abutments, completing the surgery.
After final implant seating, BLT Type 54 SmartPegs
from Osstell were placed on each implant, and the
ISQ level was measured and recorded at implant connection level. Values between 75 and 85 out of 100 were
obtained, confirming the immediate loading possibility on
all the implants (Figs. 7 & 8).
Fig. 18
Prosthetic procedures
On receipt of the scan body file (File 2), the laboratory imported it into 3Shape’s Dental System and created
a virtual model, matching the virtual SRA scan bodies
from Straumann’s original library with the intraoral SRA
scan bodies (Figs. 13 & 14). A working file was created
for designing the temporary prosthetic emergence profile for the SRA.
Fig. 19
16 CAD/CAM
4 2018
[17] =>
case report
Fig. 20
Fig. 21
To perform the design of the temporary full-arch prosthesis and maintain (or modify) the vertical dimension
of occlusion and occlusion, the patient’s pre-preparation study model scan file (File 1) was imported as a
pre-preparation scan (blue) and merged with the implant
file scan (File 2), using the preserved teeth present on
both scans. The software allowed us to mark the same
points on the preserved teeth on both files, the study
model scan and the implant scan (both contained the
preserved teeth). Thus, the laboratory was able to work
on a single file containing both Files 1 and 2, merged by
means of the preserved teeth. Designing the temporary
prosthesis is an easy task using the image of the patient’s
own teeth as a mock to be copied (Fig. 15). Any design
modification can easily be done (Figs. 16 & 17).
Finally, the designed temporary was sent to the milling
unit and produced on a convenient PMMA disc (Telio CAD,
Ivoclar Vivadent), resulting in a perfect full-arch bridge
about 2 hours later. In this case, using SRAs, a monolithic
Telio CAD bridge was produced without any Variobases
(Straumann) for the SRAs. Final temporary production
steps included characterisation and polishing (Fig. 18).
Returning to the patient, the healing caps were removed (Fig. 19), and the prosthesis was placed, allowing
for a passive fit on the abutments, with an initial handpiece tightening of each SRA screw to 5 Ncm. After the
seating was checked, the torque of each SRA screw was
increased, also with the handpiece, to 35 Ncm (Fig. 20).
The occlusion was checked and contacts were inspected
(Fig. 21). The screw holes were sealed with PTFE and a
temporary filling material. A panoramic X-ray was taken,
and SRA screw positions were evaluated to confirm the
perfect temporary bridge fit (Fig. 22). The patient was
discharged on 500 mg of amoxicillin every 8 hours and
25 mg of dexketoprofen every 12 hours for one week.
Oral hygiene and diet instructions were given, and a
one-week follow-up appointment was scheduled.
Treatment outcomes
Bearing in mind that this is a one-day treatment, the
overall treatment time per jaw is about 3 to 4 hours from
the beginning to the end of the procedure. With this minimally invasive protocol, postoperative pain, swelling and
|
Fig. 22
discomfort are minimal. Patients are able to recover their
health and social life immediately, without the psychological and social impairment associated with longer
classical procedures.
about
Dr Luis Cuadrado de Vicente
is a plastic, reconstructive and
aesthetic surgeon. He is director of
the i2 Implantología clinical training
centre and of the postgraduate training
programme in implantology at the
Universidad a Distancia de Madrid in
Spain. He is a member of Academy of
Osseointegration, European Association
for Osseointegration, Sociedad Española de Implantes [Spanish
society of implants], Sociedad Española de Cirugía Bucal
[Spanish society of oral surgery], Sociedad Española de Cirugía
Plástica, Reparadora y Estética [Spanish society of plastic,
reconstructive and aesthetic surgery], International Team
for Implantology and 3Shape World Advisory Board. He has
presented at over 200 national and international courses and
conferences and written more than 100 scientific articles.
He runs a practice focused on oral implantology,
and extraoral and reconstructive surgery.
Dr Andrea Sánchez Becerra
obtained her degree in dentistry from
the Universidad del Zulia in Venezuela
and a degree in clinical implantology at
the Universidad a Distancia de Madrid.
She is a 3Shape TRIOS 3 and Design
Studio specialist at i2 Implantología,
as well as a sales department support
technician and trainer in GO3D.
Dr Cristina Cuadrado Canals
has a degree in dentistry and a
Master in Advanced Oral Implantology,
both from the Universidad Europea
de Madrid. She has co-authored
several articles on implant dentistry,
prosthodontics and oral surgery.
She teaches clinical implantology at
the Universidad a Distancia de Madrid.
CAD/CAM
4 2018
17
[18] =>
| case report
Fixed or removable?
That is the question.
Dr Alessio Casucci & Alessandro Ielasi, Italy
Edentulism is considered to be a disability and a major
oral health problem worldwide.1, 2 Replacing missing teeth
with a well-designed and -fabricated complete denture
can satisfy the patient who has both a suitable clinical
condition and adaptability. However, complete dentures
do not restore function in all patients, especially in the
case of the rejection of a removable solution for psychological reasons.
The increased awareness, survival, and success of implants and implant restorations have expanded the options for restoring the edentulous mouth from conventional
dentures to implant-assisted prostheses. Furthermore,
numerous studies have demonstrated that restorative approaches involving implants improve edentulous patients’
masticatory function, quality of life and self-esteem.3, 4
Implant restorations have to be planned properly, evaluating different parameters to achieve long-term success.
Bone resorption, aesthetics and phonetic parameters can
be determinants in establishing a proper treatment plan.
Several patient-related parameters such as hand ability,
maintenance and other functional aspects, have to be
considered before starting patient treatment. Scientific
literature too has to be considered by the clinician in order
to evaluate clinical protocols, especially for the mandible
where the possible standard of care must be established.
A consensus regarding this standard of care for the fully
edentulous maxilla based on a critical appraisal and comparison of the cost-effectiveness of different prosthodontic solutions has not yet been achieved.5
Fig. 1a
For the maxilla, the literature abounds with descriptions of technical solutions, ranging from a fixed solution
retained by four axial or tilted implants and upwards to a
removable solution supported by two to ten splinted or
free-standing implants. It has been reported that patient
expectations are higher regarding treatment with fixed
restorations.6
Fig. 1b
For some patients, a removable maxillary restoration
would be the best solution providing facial scaffolding and
especially for patients with a wide smile and/or high smile
line covering the prosthesis-tissue junction. In addition, it
is beneficial to adverse ridge relations or discrepancies
and gives more latitude if the palatal contour for phonation has to be adjusted.7 Furthermore, it can be challenging to properly clean a fixed restoration in patients with severe maxillary resorption.8 It has been reported that fixed
restorations result in phonetic disturbances in 42 % and
aesthetic problems in 37 % of the treated patients.9
Fig. 2
The case described in this paper reports on the treatment of an edentulous patient in whom implants were
Figs. 1a & b: Intraoral photographs. Fig. 2: Dental panoramic tomogram.
18 CAD/CAM
4 2018
[19] =>
case report
|
Fig. 3
Fig. 3: Patient during speaking and smiling.
placed and prosthetic solutions were defined before the
surgical procedures. The patient was rehabilitated with a
fixed restoration in the mandible as established. For the
maxilla, the finalisation moved from a fixed to a removable solution because of aesthetic and phonetic aspects.
Clinical case
A 63-year-old male patient edentulous in both arches
was evaluated for definitive implant supported restorations.
Case history
The patient had lost his remaining teeth a few years
before our visit. He had been restored with complete
dentures fabricated on the basis of his repaired previous
partial dentures. The patient did not report a significant
medical history and occlusal or temporo-mandibular
disease. At the preliminary appointment the patient communicated mainly a functional discomfort due to the
instability of the mandibular denture during mastication.
He reported several problems using the mandibular
denture, complaining of its instability in almost every situation (during speech, eating, etc.). The maxillary denture
had low retention and the palatal extension was poorly
tolerated. The previous dentist had planned to rehabilitate
the patient with fixed implant restoration in both arches,
but after the implant placement, the patient had had several health problems due to an ischaemic stroke and this
had delayed the prosthetic finalisation. At the same time,
he had been forced to move to our city because he was
living with his daughter and she had changed her job.
Clinical evaluation
At the first visit the patient informed us that the implants
had been placed the year before. He reported some sore
spots due to the maladaptation of the bearing base to the
tissue. The complete dentures were found to be unstable
during static evaluation (Figs. 1a & b).
Radiographic evaluation
The dental panoramic tomogram revealed six implants
in the maxilla and five implants in the mandible, and slight
bone resorption was detected around the fixtures (Fig. 2).
Prosthetic evaluation
The patient’s lips revealed a lack of support when wearing the complete dentures, the free-way space was more
than 5 mm and it was mainly the mandibular teeth that
were displayed during speaking. The maxillary teeth were
not displayed even during smiling (Fig. 3). The lower third of
the face was too short when the patient closed the mouth
when wearing the complete dentures, revealing more than
10 mm between the vertical rest position and the vertical
dimension of occlusion. The occlusal plane also needed
to be parallelised to the bi-pupillary and Camper’s planes.
The centric occlusion position was not repeatable.
Prosthetic goals
In order to improve the aesthetic, phonetic and functional aspects with definitive restorations, we decided to:
– improve the upper lip support,
– increase vertical dimension of occlusion,
– improve exposure of the maxillary teeth,
– reduce exposure of the mandibular teeth,
– improve occlusal plane parallelism to the bi-pupillary
and Camper’s planes,
– establish a stable and repeatable occlusal position,
– verify parameters during adaptation time.
Treatment plan
In order to manage all of the prosthetic goals that may
have effected important changes in patient function and
adaptation, it was decided to divide the treatment plan
into different steps:
1. Restoration of all of the prosthetic parameters with new
temporary complete dentures.
2. Verification of all of the parameters during patient
adaptation time.
3. Fabrication of two copies of the dentures that could be
used to register implant impressions and the inter-arch
position in order to retain all of the data required for
finalisation.
4. Construction and delivery of the definitive rehabilitation.
Clinical and laboratory procedures
Preliminary impressions
In the first appointment, two alginate impressions were
taken (normal-setting alginate Neocolloid, Zhermack)
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4 2018
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[20] =>
| case report
Fig. 4a
Fig. 4b
Fig. 5a
Fig. 5b
Fig. 6
Figs. 4a & b: Preliminary models. Figs. 5a & b: Individual trays. Fig. 6: Occlusal plane setting.
using Schreinemakers trays. In order to stabilise and support the impression material, a moulding wax was adapted
to their surface (Cera Azzurrina Morbidissima, Zeta). The
adhesive for the alginate was applied to the surface of
the prepared trays (Fix Adhesive, Dentsply Sirona).
The first impressions were taken according to a twophase technique and a high-consistency alginate was
used. After removing the impression, it was prepared by
removing the undercuts in order to support relining with
a low-viscosity alginate. The adhesion between the alginates was promoted by drying the first material.
Preliminary models and tray construction
Preliminary models were poured using Class III plaster
(Elite Model, Zhermack) according to the manufacturer’s
instructions (Figs. 4a & b).
20 CAD/CAM
4 2018
Once the models had been squared and finished, the
extension of the individual impression trays was drawn.
Undercuts were eliminated with Tenasyle wax (Imadent)
and models isolated using Separating Fluid (Ivoclar Vivadent). The trays were prepared with a self-curing resin
(SR Ivolen, Ivoclar Vivadent). The trays were finished to
a thickness of 2 mm, except for the borders in the sublingual areas and the retro-zygomatic areas, where they
were about 3–4 mm thick.
On the basis of the trays, the wax rims were melted
simulating the dental arches’ volume in order to aid the
clinician in taking a closed-mouth-impression. For the
lower base, Tenasyle wax was used and Moyco Beauty
Pink X-Hard Wax (Moyco Industries) for the upper base.
For the upper wax rim, the average of distance between
the vestibular sulcus and the incisal edge was set to
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[22] =>
| case report
Headline
Headline
Fig. 7a
Fig. 7b
Author, Country
Fig. 8a
Fig. 8b
Fig. 10a
Fig. 9
Fig. 10b
Figs. 7 & 8: Bordering and definitive impressions. Fig. 9: Definitive impressions and centric relation registration. Figs. 10a & b: Positioning models in the articulator.
22 mm at the level of the central incisors and 18 mm at
the molar region. The incisal edge of the upper wax rim
was positioned about 8–10 mm forward of the centre of
the incisive papilla, with an inclination of about 20° on the
sagittal plane.
Regarding the lower jaw, the rim was prepared maintaining a distance between the labial sulcus and the incisal edge of 18 mm in the anterior and posterior regions.
It was positioned corresponding to the mandibular alveolar ridge and tilted about 8–10° on the sagittal plane.
The rims were realised simulating an arch in accordance
with the anatomical trend of the residual ridges. Moreover, they were taken to a thickness of about 2–4 mm
in the incisal region and about 8–10 mm in the molar region. Finally, the lower wax rim was extended posteriorly to the point where the ramus of the mandible be-
22 CAD/CAM
4 2018
gins to curve up. The posterior limit of the upper wax
rim was set to the mesial limit of the maxillary tuberosity
(Figs. 5a & b).
Closed-mouth definitive impressions
The stability and the adaptation of the impression trays
were checked. After that, the border length and thickness were verified using a silicone-based paste (FIT
CHECKER II, GC).
In the next phase, evaluating the support of the patient’s lips, the rims were adapted. The upper rim was
orientated parallel to the Camper’s plane and the midline was recorded on it. Thus, phonetic tests were
performed (“f”, “v” and “s”) in order to establish the
position of the anterior teeth, and to allocate the space
between the upper and lower planes. The vertical di-
[23] =>
case report
|
mension of occlusion was also determined.10 Finally, the
centric relation was recorded (Fig. 6).
At this point, the trays were trimmed with different
thermoplastic sticks (ISO FUNCTIONAL, GC and Impression Compound, Red, Kerr Italia) in order to determine a selective pressure in the inner peripheral seal.
The patient was also trained to activate the muscles of
lips, cheeks and tongue to define three-dimensionally
the extension of the prosthetic margin. During the trimming phase, owing to the ability to bring the rims into
contact, the patient could complete swallowing movements. Furthermore, the repeatability of the centric occlusion position was verified several times using this
approach.
Before taking the impression, the external areas of
the border were released to avoid hyperextension related to the overlap of the impression material. These
procedures did not affect the areas of inner seal. The
upper tray was drilled to facilitate the outflow of the
impression material. The final impressions were recorded with zinc oxide paste for the upper arch (Luralite,
Kerr Italia) and polysulphide material for the lower
arch (Permlastic Light Bodied and Regular, Kerr Italia;
Figs. 7 & 8).
Finally, the vertical dimension of occlusion and centric
relation were confirmed. Thus, a face-bow transfer was
also indicated (UTS 3D, Ivoclar Vivadent) set according
to the Camper’s plane. In order to complete information about the size and shape of the anterior teeth, the
Form-Selector (Ivoclar Vivadent; Fig. 9) was used.
Fig. 11a
Fig. 11b
Fig. 11c
Fig. 12a
Fig. 12b
Fig. 13a
Fig. 13b
Functional impressions were poured with Class IV
plaster (Vel-Mix Classic Die Stone, Pink, Kerr Dental
Laboratory Products) maintaining the peripheral border. The plaster was mixed under vacuum with distilled
water and following manufacturer’s instructions. Before
removing the impressions, models were mounted in
the articulator (Stratos 300, Ivoclar Vivadent) using the
face-bow (Figs. 10a & b).
Before removing the trays from the master models,
the length and position of the rims were recorded using
a silicone key. The models were then isolated using Separating Fluid and the undercuts rectified using a resilient
resin (Flexacryl Soft, Lang Dental Manufacturing), being
careful to avoid flow to the fornix. Once the resin was
polymerised, the base was prepared using Ivolen. The
anterior teeth were set using the information recorded
from the rims (Figs. 11a–c).
Figs. 11a–c: Anterior tooth set-up. Figs. 12a & b: Aesthetic evaluation and
posterior seal probing. Figs. 13a & b: Occlusal contacts before polymerisation. Fig. 14: Potsdam ditching and flasking preparation.
Fig. 14
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[24] =>
| case report
Fig. 15a
Fig. 15b
Fig. 15c
Figs. 15a–c: Post-polymerisation occlusal grinding.
Tooth set-up
This appointment was focused on the evaluation of
the aesthetics, phonetics, vertical dimension of occlusion and repeatability of centric relation. The patient observed and accepted the set-up with a member of his
family. It was decided to create two embrasures on the
anterior teeth in order to reduce incisal edge convexity. The posterior seal area was evaluated by probing
the compression of the tissue using a ball condenser
(Figs. 12a & b).
Temporary complete denture construction
The posterior teeth were mounted using a static laser
(CANDULOR). Posterior tooth contacts were obtained
according to lingualised occlusion concepts and the Gerber occlusal scheme (Figs. 13a & b).11
Curing and finishing the complete dentures
The posterior seal area was ditched on the model using the clinical information of the different levels of compression of the tissue. The prostheses were waxed for
Fig. 16a
Fig. 16b
Fig. 17b
Fig. 17c
deposit. The polymerisation was performed using the
IvoBase system (Ivoclar Vivadent), a fully automatic injection system. The shrinkage of the specific PMMA resin is
fully compensated for during polymerisation, thus obtaining the most accurate denture base adaptation (Fig. 14).
After polymerisation, the prostheses were replaced
into the articulator and the occlusal grinding was performed in order to maintain all of the occlusal contacts that were established before polymerisation
(Figs. 15a–c).
Temporary denture delivery and follow-up
Upon delivery, the prostheses were placed into the oral
cavity and left to adapt for 10 to 15 minutes with the patient clenching two cotton rolls placed bilaterally between
the arches. After that, the adaptation of the bases was
checked with FIT CHECKER II. The patient was instructed
to perform functional movements and to speak. The length
and thickness of the borders were verified with the silicone-based paste and corrected when it was required.
Fig. 17a
Fig. 17d
Figs. 16a & b: Information registration and realisation of denture copies. Figs. 17a–d: Definitive impression registration.
24 CAD/CAM
4 2018
[25] =>
[26] =>
| case report
(Occlufast, Zhermack). The copies were obtained using
self-curing transparent resin (ProBase, Ivoclar Vivadent;
Figs. 16a & b).
Closed-mouth implant impression registration
After the implant surgery, a multi-unit abutment was
placed. At the impression appointment, pick-up copings
were attached to the implant abutments. Denture copies were prepared in order to be positioned with perfect
adaptation to the oral mucosa.
Finally, definitive impressions were taken with polyether
material (Permadyne and Impregum, 3M ESPE). The intermaxillary position was as registered after removing all of
the implant pick-up copings that could determine occlusal
interferences. A face-bow was also taken before removing the maxillary impression (Figs. 17a–d). Master models were prepared using a removable soft resin to reproduce peri-implant tissue. The impressions were poured in
Class IV plaster, and the obtained models were placed in
the articulator using the face-bow measurements.
Fig. 18
Before removing the impressions from the master
model, a silicone key was prepared in order to record the
position of the anterior teeth (Fig. 18). Two occlusal bases
were prepared with wax rims in order to verify the intermaxillary position. Additionally, implant pick-up copings
were splinted using stone (Elite Arti, Zhermack; Fig. 19).
Fig. 19
Fig. 18: Silicone key recording tooth position. Fig. 19: Occlusal keys and
pick-up stone position.
Finally, the occlusion was checked, revealing bilateral
symmetrical contacts. The patient was instructed on
managing and cleaning the complete dentures in the initial days. Follow-up visits were planned at 24 hours and
one and two weeks after delivery. The patient reported a
rapid adaptation to the new dentures, only a few points
of pressure caused ulcerating lesions. Phonetics and stability were improved after the treatment. Control appointments were conducted in the weeks after delivery and
excellent levels of adaptation were reported, regarding
both aesthetic and phonetic aspects.
Fabrication of denture copies
The successful adaptation to the temporary dentures
confirm that all the parameters (vertical dimension of
occlusion, centric relation, aesthetics and phonetics)
could be maintained in the definitive restoration. It was
decided to fabricate copies of the temporary dentures
and to use them as a closed-mouth tray. The temporary bearing bases were rebased with a polysulphide
impression material (Permlastic Light). The intermaxillary
position was registered using a bite registration silicone
26 CAD/CAM
4 2018
Implant and inter-arch position check
The intermaxillary position was confirmed, but the upper stone key was fractured during screwing procedure.
Thus, it was splinted with stone, and after repositioning
the implants, replaced on the model. The implants’ position was definitely confirmed (Figs. 20a–d).
Tooth set-up
The tooth set-up was performed according to the information of the denture copies, using the silicone key. The
complete set-up was evaluated with the patient and all
occlusal, aesthetic and phonetic aspects confirmed. The
tooth set-up approved during the patient try-in was sent
to the laboratory for framework design.
Fixed or removable?
Depending on the discrepancy between the position
of the clinical crown and the alveolar ridge contour in the
bucco-oral dimension, compensation with the denture
base of a removable reconstruction may be necessary.12
However, for a fixed complete denture, the clinical crown
should ideally be at the soft tissue level of the alveolar
ridge. For this solution, minimal bone resorption and a
limited inter-arch space with an optimal tooth–lip relationship are required (Fig. 21).13
These parameters, mainly determined by tooth position and the amount of residual alveolar bone, have to
[27] =>
case report
Fig. 20a
Fig. 20b
|
Fig. 20c
Fig. 20d
Figs. 20a–d: Occlusal check and implant pick-up coping splinting.
be considered before planning a maxillary implant-supported restoration.14 In this case, the patient was informed before implant surgery that his dentition was to
be restored with fixed restorations in both arches. However, our prosthetic evaluation determined that it was not
feasible because of the horizontal distance between the
teeth and implants.
The patient was informed about the advantages and
disadvantages of fixed or removable protheses. Moreover, a tooth set-up was prepared without a buccal flange
in order to analyse potential problems regarding facial
support, phonetics, aesthetics and hygienic access. With
the patient’s consent, it was decided to realise a removable solution for the maxilla and a fixed restoration for
the mandible.
Clinical case finalisation
The implant overdenture was prepared maintaining
the insertion path perpendicular to the occlusal plane.
Two bars were fabricated in order to reduce the volume
required for primary and secondary frameworks. In both
bars were placed two different ball retentive systems
(Rhein’83). The mesial one was mini, and the distal one
of normal size. This kind of solution could guarantee
enough retention for the restoration and durability of the
attachment system. Moreover, owing to the number and
position of the implants, complete palatal support was
reduced, including the maxillary tuberosities as determinant support areas (Figs. 22a & b).
Delivery and follow-up
Definitive restorations were realised maintaining all of
the prosthetic parameters of the temporary restoration.
Patient adaptation was excellent concerning the aesthetic, phonetic and hygienic parameters, despite at the
beginning of treatment having been oriented to a max-
Fig. 21
Fig. 22a
Fig. 22b
Fig. 21: Space evaluation. Figs. 22a & b: Implant overdenture framework
fabrication and try-in.
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4 2018
27
[28] =>
| case report
Fig. 24a
Fig. 23a
Fig. 24b
Fig. 23b
Fig. 25
Figs. 23a & b: Definitive restorations. Figs. 24 & 25: Three-year follow-up.
illary fixed rehabilitation (Figs. 23a & b). The prosthesis-bar-supported solution could guarantee enough retention and stability to the patient in both functional and
psychological aspects. At the three-year follow-up, the
tissue was healthy owing to the patient’s hygiene compliance (Figs. 24 & 25).
Discussion and conclusion
While this clinical case reported good patient adaptation to the definitive restorations, modifying the initial
treatment plan can be a challenge, especially when patients chose to be treated with implants because they
are maladapted to removable solutions. As reported in
this case, with a sufficient number of implants of adequate length, the superstructure can be purely implant-supported in construction. However, when bone is
severely resorbed,15 the distance between the implants
and the incisal edge position cannot be solved with a
fixed restoration because of the lack of lip support or
poor phonetics.
Current criteria for planning and deciding on treatment have been reported in literature and are considered a fundamental guide for establishing the treatment plan.16, 17 This case treatment would emphasise
28 CAD/CAM
4 2018
the importance of not promising the patient a fixed
maxillary restoration until the final wax trial has been
accepted.18–20
Acknowledgements
Thanks to Marco Vannini and Rhein’83 for their support and for sharing their experience with us in solving
this clinical case.
contact
Dr Alessio Casucci
Private practice
Via Bari 31
53045 Montepulciano
Italy
alessio.casucci@gmail.com
Alessandro Ielasi
Dental lab Ielasi
Snc, Via Mazzella Luigi
80077 Ischia
Italy
alessandroielasi@libero.it
[29] =>
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[30] =>
| cone beam supplement
Computer-assisted implant
rehabilitation of tumour patients
Ioannis Papadimitriou, Dr Petros Almagout, Dr Erich Theo Merholz & Dr Stefan Helka, Germany & Greece
Implantology has become a fundamental, if not
routine, component of oral rehabilitation and the most
reliable procedure in the discipline’s attempt to realise restitutio ad integrum. In modern dentistry, implant-supported restorations are considered to be the
usual and best care options. However, particularly in
patients with malignancies of the oral cavity, there are
fundamental changes to the anatomy of the oral cavity due to the extensive surgical procedures and adjuvant radiotherapy. In the post-irradiated jaw, a purely
mucosa-supported prosthesis is not indicated owing to xerostomia and the necrosis risk of irradiated
bone. The only practical way to prevent load on the
mucosa is the insertion of dental implants and the subsequent incorporation of an implant-supported fixed
denture.1, 2
Traditionally, determining implant position, size, number, direction and placement depended on the preoperative diagnostic imaging, which was limited to 2-D
radiographs and guiding templates. Three-dimensional
imaging and navigational aids offer the treating implantologist enhanced certainty and additional options, especially in high-risk cases, such as patients with extreme
alveolar ridge atrophy or patients with malignancies of
the oral cavity. With 3-D imaging, implant prosthetic
dentistry has taken a major step forward. The dentist
can plan the surgical procedure virtually in combination
with 3-D planning programmes.5–7 This has been made
possible mainly by the steady improvement of specific
implant planning programmes, such as CTV (computer
tomography visualisation) software.
With navigated implantology, it is possible to pass
through the alveolar crest, locate structures and assess the existing bone at all levels. On the basis of the
available data obtained on computer, the length, inclination, diameter and ideal position of the implants can
be determined.1–4 Prerequisite for navigated implantology is the use of appropriate imaging techniques, particularly the 3-D radiographic method of cone beam
computed tomography (CBCT; Table 1).6–8 This modern 3-D diagnostic enables detailed surgical planning
of implantation, taking into account prosthetic considerations. Navigated implantology offers several advantages:7–9
– precisely guides the osteotomy drills, through a secure,
reproducible positioning of the template, directing the
surgeon on the exact location and angulation to place
the implant based on the virtual treatment plan;
Effective dose
in µSv
Multiple doses of a dental
panoramic tomogram
Dose as % of annual
natural radiation
Dental panoramic
tomogram
~6
1
0.2
GALILEOS default
29
5
1.0
ILUMA default
331
52
11.0
I-CAT
68
11
2.3
Planmeca ProMax
210
33
7.0
NewTom
39
6
1.3
CT scan
2,100
323
70.0
Table 1: Comparison of radiation exposure of various methods and systems.
30 CAD/CAM
4 2018
Table 1
[31] =>
cone beam supplement
Fig. 1
|
Fig. 2
Fig. 1: Radiographic template with three reference balls. Fig. 2: Dental panoramic tomogram after augmentation with iliac crest bone.
– allows flapless, minimally invasive surgery, avoiding
unnecessary bone exposure, which entails less bleeding, less swelling, and a reduced healing time and postoperative pain;
– low-distortion and detailed radiographic analysis and
an improved learning curve for the dentist, surgeon
and dental technician team;
– provides greater safety for patients and dentists
through 3-D planning, especially with complicated jaw
conditions or low bone volume and the risk of postoperative complications is significantly reduced;
– virtual planning provides the conditions for considerably increased accuracy of implant placement and
avoidance of vital structures, followed by the prosthetic
restoration of masticatory function;
– the operation period is significantly shorter.
helps in treatment predictability, and promotes the maintenance of aesthetic and biomechanical principles.11–13
The backward planning for a computer-aided implantation includes the following steps:
1. Impression and model fabrication.
2. Planning of prosthetic restoration.
3. Preparation of a scan template with three reference
balls (aluminium, 2 mm in diameter; Fig. 1).
4. CT/CBCT scan of the patient with the inserted scan
template.
5. Reading the radiographic data into the CTV system
and virtual planning of the implantation.
6. Transfer of the planning data to the drilling template.
7. Guided implant placement.
However, computer-assisted implant surgery is not
free of risks. Navigated implantology also has certain
drawbacks and limitations, which have to be considered
as well:10–12
– problems with the template positioning in edentulous
jaws and inaccurate fixation of the surgical guide, resulting in displacement during the surgery;
– fracture of the surgical guide;
– dependence between the guide system and software
and usually the learning curve for the dentist, surgeon
and dental technician team is complex;
– reduced mouth opening can lead to changed positioning of surgical instruments;
– the total cost of the tools needed, including the software programme and surgical templates, is higher in
comparison with that of traditional methods;
– intra-operative modification of implant position is not
allowed.
In this section, we present two clinical cases of prosthetic rehabilitation of a patient with extreme alveolar ridge
atrophy and a tumour patient with iliac crest bone grafting and computer-aided implantation using the CAMLOG
Guide System. The preoperative planning, the operation
phases and the patient’s postoperative wound healing
are described. The study was conducted in the oral and
maxillofacial surgery department of St. Lukas Hospital in
Solingen, Germany. The patients concerned presented
for implant rehabilitation in our department after surgical
resection and irradiation and before augmentation of the
extreme alveolar ridge atrophy of the lower jaw with iliac
crest bone. The insertion of implants was performed after
obtaining CBCT scans and virtual planning of the implantation using CTV software.
In computer-aided implantology, the treatment procedure is very precise, but for a successful outcome and
a predictable end result, backward planning is essential, since it allows the implants’ alignment in the arch,
Case presentation
Case 1
A 67-year-old female patient was referred to our department for implant rehabilitation. She was generally
healthy, totally edentulous in the upper jaw and partially edentulous in the lower jaw. The initial clinical examination and the CBCT scan showed a very extensive
vertical and horizontal bone defect in regions #34–37
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[32] =>
| cone beam supplement
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 3: Sagittal section in region #46 of the planned implantation. Fig. 4: Virtual dental panoramic tomogram with the digitally determined 3-D implant
positions. Fig. 5: Fully navigated drilling template for the lower jaw after CBCT planning. Fig. 6: Preoperative view of the mandible.
and 44–47 as consequence of progressive resorption.
After the final diagnosis and planning, we discussed the
possible restorative options and alternative solutions. The
patient was not satisfied with her removable denture in
the lower jaw and wished for a fixed denture.
In order to make treatment possible with bridge constructions on osseointegrated titanium fixtures, bone
grafting was necessary in the edentulous regions of the
lower jaw. The patient was explicitly informed of the possible risks and dangers from the functional and aesthetic
perspective during and after the treatment period and
the treatment steps were explained. Five months after
the reconstruction of the alveolar jaw with iliac crest bone
(Fig. 2), we were able to continue our therapy planning,
which included preoperative prosthetic planning and
navigated implantation.
After taking impressions, a wax set-up was produced.
The aesthetic set-up in wax served for the shape speci-
32 CAD/CAM
4 2018
fication for the preparation of the provisional restoration,
the final restoration and the implant planning. The virtual planning followed. The radiographic template for
CBCT imaging was prepared on a duplicate of the
master model with light-curing tray material. Three
radiographic balls made of aluminium were inserted into
the radiographic template (Fig. 1). The use of the three
balls increased the precision of the planning, because
in this procedure, the ball midpoints and not edges
were adjusted. A CBCT scan was performed with the
patient wearing the radiographic guide. The basis for
the implant planning was the data set obtained from the
CBCT scan.
The minimally invasive, transgingival implantation was
planned using the 3-D data set with the CTV software.
Anatomical conditions had to allow the placement of at
least four implants in the ideal position for prosthetic rehabilitation (Fig. 3). Once an implant had been planned, it
was easy to see the vestibular and lingual cortical bone.
[33] =>
cone beam supplement
Fig. 7
Fig. 8
Fig. 9
Fig. 10
|
Fig. 7: Insertion of the template in the lower jaw. Fig. 8: Guided drilling through the drilling sleeve according to the surgical protocol. Fig. 9: Manual insertion
of the guided implants with the locked torque wrench. Fig. 10: All guided implants in situ with gingiva formers.
After bone volume analysis, implants were planned on
the lingual aspect, and the implant platform virtually positioned at the level of the coronal part of the vestibular
alveolar crest (Fig. 4). The main feature in the production of the surgical guide was the secure positioning and
stable fixation of the drilling sleeves in the template. For
the production of the drilling template, the drilling sleeves
were placed on the plastic models produced by an additive process (Fig. 5).
The surgical procedure was performed under local anaesthesia with Ultracain® D-S forte 1:100,000. Cefuroxim
(500 mg) antibiotics were given one hour before surgery
and twice a day for six days thereafter. The patient rinsed
with chlorhexidine gluconate (0.2 %) for one minute
before the intervention (Fig. 6).
The surgical template was placed intraorally in the
correct position and in relation to the opposing arch.
Considerable care was taken when placing the surgical
template (Fig. 7). After correct placement and stabilisation of the surgical template, flapless implant surgery was
performed in accordance with the drilling protocol for the
type of implant used (Fig. 8). At the regions #34 and 44,
two CAMLOG fully guided implants of 4.3 mm in diameter and 13.0 mm in length were inserted, and in regions
#36 and 46 implants of 4.3 mm in diameter and 11.0 mm
in length.
Moreover, two small full-thickness flaps were raised
in order to remove the osteosynthesis screws used
to stabilise the autogenous bone graft in the previous
augmentation surgery (Fig. 9). The insertion of the implants was carried out with the standard placement head
and the DRM ratchet to the maximum primary stability, with a preset insertion torque of 35–45 Ncm. The
gingiva formers were inserted to a torque of 20 Ncm
(Fig. 10) and the flaps were sutured after the implant insertion with non-resorbable sutures (Prolene 5/0). The
sutures were removed after seven days. A postoperative
CAD/CAM
4 2018
33
[34] =>
| cone beam supplement
dental panoramic tomogram showed the inserted implants in the lower jaw and the areas of augmentation
on both sides were also clearly recognisable (Fig. 11).
After the operation, the patient was instructed to cool
and protect the operating area; a chlorhexidine gluconate mouthwash (0.2 %) was prescribed for one minute
twice a day for two weeks after surgery and painkillers,
if necessary. The patient was instructed on oral hygiene.
Scheduled visits after surgery were after one week,
two weeks and one month. At these visits, the healing
process was found to be very good and painless. The
definitive prosthetic restoration was planned for four
months after the implantation.
Case 2
A 75-year-old male patient was referred to our department for dental examination and for implant rehabilitation. In 2011, he had been diagnosed with squamous cell
carcinoma on the right side of the tonsil. After the tumour
resection and neck dissection and an adjuvant radiation
therapy of up to 65 Gy, the patient was in the ambulatory tumour follow-up phase of care. This was the case
Fig. 11
because the tumour resection was inconspicuous and
without signs of recurrence. Through the previous tumour
surgery, the anatomy of the oral cavity had changed fundamentally: owing to xerostomia and radiation-induced
caries in 2013, all of the remaining teeth in both jaws had
had to be extracted.
The first clinical examination in our department found
a totally edentulous upper and lower jaw with a loss
of taste and xerostomia. The dental panoramic radiograph showed about 10 per cent vertical and 15 per
cent horizontal bone loss in both dimensions in the
upper and lower jaw. After the final diagnosis and planning, we discussed the possible restorative options and
alternative solutions. Because of the post-irradiated
jaw, a purely mucosa-supported prosthesis was not indicated, and owing to the xerostomia, the maintenance
of a purely mucosa-supported prosthesis was not guaranteed. Therefore, the only medically reasonable and
practical solution was the insertion of dental implants,
six implants in the maxilla and six in the mandible, with
subsequent incorporation of an implant-supported fixed
denture.
Fig. 12a
Fig. 12b
Fig. 13
Fig. 11: Dental panoramic tomogram of the patient after the surgery for control of the implants’ positions. Figs. 12a & b: Virtual dental panoramic tomogram
showing the digitally determined 3-D implant positions in the maxilla (a) and in the lower jaw (b). Fig. 13: Fully navigated drilling templates after CBCT planning
(drilling sleeves, fully guided 4.3 mm, violet).
34 CAD/CAM
4 2018
[35] =>
cone beam supplement
After taking the impressions in our department, the master models were made in the dental laboratory in a model
tray socket and a wax set-up was produced and customised according to the aesthetic and functional evaluations. The patient was prepared for the computer-guided
implant procedure. He underwent a CBCT with the radiographic template and the acquired DICOM images were
processed with the aid of the CTV software. The planning
with this software produced a report in which the coordinates of each of the three ball midpoints were determined, allowing the laboratory technician to orient and
reproduce the surgical template (Figs. 12a & b). The drill
guides were produced via a thermoforming technique on
a duplicate model of the master model. Subsequently, the
drilling sleeves were incorporated with the sleeve holders
in the drilling template using the additive-produced plastic model. The transparent base of the template enabled
intraoperative assessment of the template placement
on the tegument through an even ischaemia due to the
contact pressure during implantation (Fig. 13).
The surgical procedure was performed under local anaesthesia with Ultracain® D-S forte 1:100,000. Cefuroxim
|
(500 mg) antibiotics were given one hour before surgery
and twice a day for six days thereafter. The patient rinsed
with chlorhexidine gluconate (0.2 %) for one minute
before the intervention. After infiltration anaesthesia in
the upper and lower jaw, and bilateral nerve block anaesthesia in the lower jaw and upper palate, the surgical
template was carefully inserted and stabilised correctly
in the lower jaw.
In the mandible, the mucosa was punched out with
a rotating punch at regions #36, 34, 32, 42, 44, and 46
(Fig. 14). After disassembling the template, the gingiva
points marked with the punch were cut down and the
punches removed in order to obtain a punched and prepared lower jaw (Fig. 15). Thereafter, the drilling template
was used again. According to the manufacturer’s instructions, cannon drills (6 mm pilot drill; 9, 11 and 13 mm form
drills) were used to prepare the implant osteotomies at
regions #36, 34, 32, 42, 44 and 46 (Fig. 16).
The insertion of the implants was carried out with the
standard placement head and the DRM ratchet to the
maximum primary stability, at about 30–35 Ncm (Fig. 17).
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Fig. 14: Insertion of the template in the mandible. Fig. 15: Punched and prepared mandible. Fig. 16: Implant placement. Fig. 17: Manual insertion of
the CAMLOG implant with the locked torque wrench. Fig. 18: All guided CAMLOG implants in the lower jaw. Fig. 19: Implantation result with all of the
implants in situ.
CAD/CAM
4 2018
35
[36] =>
| cone beam supplement
Fig. 20
Fig. 20: Dental panoramic tomogram of the patient for control of the final result.
Subsequently, the implant navigation posts and the surgical template were removed in order to insert the gingiva
formers in the maxilla, which were inserted to a torque
of 25 Ncm (Figs. 18 & 19). The procedure in the maxilla
was analogous to the operative implant bed preparation
and insertion of the implants in the lower jaw, where six
fully guided CAMLOG implants of 4.3 mm in diameter and
11.0 mm in length were inserted in regions #15, 14, 12, 22,
24 and 25. A postoperative dental panoramic tomogram
showed the inserted implants in the maxilla and mandible (Fig. 20).
After the operation, the patient was instructed to cool
and protect the operating area; a chlorhexidine gluconate mouthwash (0.2 %) was prescribed for one minute
twice a day for two weeks after surgery and painkillers,
if necessary. The patient was included in our implant
maintenance programme and instructed on oral hygiene.
Scheduled visits after surgery were after one week,
two weeks and one month. At these visits, the healing
process was found to be very good and painless. The
definitive prosthetic restoration was planned for five
months after the implantation.
Modern 3-D diagnostics enable detailed surgical
planning of implantation, including prosthetic considerations. This achievement is mainly due to the continued
improvement of implant planning programmes such as
CTV software. CTV is used to display digital image data
for diagnosis and precise prosthetic implant-oriented
planning, with subsequent template-based implant
placement.8, 13, 14
In conclusion modern implant navigation is based on
sound systematic, prosthetic and surgical knowledge. It
can optimise implant treatments and safely achieve the
desired result, but it can never compensate for a lack of
knowledge and surgical skill of the operator.11, 12, 14
Discussion and conclusion
The advancements in the field of implantology, such
as 3-D imaging, implant planning software, CAD/CAM
technology, and computer-guided and navigated implant surgery, have led to the digitalisation of implant
dentistry and have taken implant prosthetic dentistry
a major step forward. With significant achievements
accomplished in the field of digital implant dentistry,
implant placement has become highly predictable,
even in patients where implant surgery was previously
contra-indicated.6, 7, 14
36 CAD/CAM
4 2018
contact
Ioannis Papadimitriou
St. Lukas Hospital
Department of Oral and
Maxillofacial Surgery
Schwanenstraße 132
42697 Solingen
Germany
giannis.papadimitriou_4@hotmail.com
[37] =>
SPRING
MEETING
Register now
29 - 31 March 2019
Spring Meeting will give the opportunity to
provide the best forum for showcasing the
latest developments by renowned experts in
their fields. The program will be defined by
Innovative Technologies in Aligner Therapy.
Spring Meeting hosted a full session of lectures
on Friday, March 29th and workshops on March
31st 2019 provided by Companies involved with
Aligner provision.
Saturday, March 30th 2019 will host a full day
Plenary Session with Speakers having a more
extended lectures presentation program.
Register on
www.eas-aligners.com
Early bird registration deadline
31st January 2019
Venice, Italy
Hilton Molino Stucky Hotel
[38] =>
| industry news
Fig. 1: X-Guide with DTX Studio Implant enables the clinician to scan, plan and perform computer-navigated surgery on the same day. Fig. 2: X-Guide’s
impressive tracking technology even makes it possible to control the drill when it is out of sight.
X-Guide empowered by DTX Studio suite
DTX Studio suite not only helps clinicians acquire and
consolidate diagnostic data at their practice, but also
connects the dental team to collaborate on treatment efficiency. To take speed, precision and accuracy to a whole
new level, clinicians can plan their treatments in DTX Studio
Implant and proceed to implant surgery with the very
latest 3-D navigated surgery technology: X-Guide.
plan, providing a 360°, real-time view of the drill and anatomy during osteotomy and implant insertion. The ability
to oversee every movement of the handpiece helps
achieve a more exact implant placement compared with
freehand surgery. X-Guide’s impressive tracking technology even makes it possible to control the drill when it is
out of sight.
Scan, plan and navigate in a day
This alternative to surgical templates does not just save
time; the clinician retains complete control throughout
the surgery, with the power to immediately adapt the
treatment plan at any time.
X-Guide is a dynamic 3-D navigation system that can
become part of a streamlined workflow for same-day
guided surgery. On the day of treatment, the clinician
carries out the CBCT/CT scan and intraoral surface
scans, creates the treatment plan in DTX Studio Implant,
and immediately exports it with all the planning components to X-Guide. The practice can be ready to perform
3-D navigated dental implant surgery on the very same
day. Furthermore, DTX Studio Implant gives the clinician
direct access to the Nobel Biocare implant library when
creating his or her treatment plan.
Like GPS
for freehand
surgery
Stand out with innovation
Nobel Biocare’s prominence in innovation is demonstrated once again by this exclusive distribution partnership with a pioneer in computer-navigated surgery, X-Nav.
With the new X-Guide technology, which is already supported by peer-reviewed studies,1–3 clinicians can leverage
new digital dentistry and impress patients and peers alike.
Dentists can find more information about X-Guide at
www.nobelbiocare.com/x-guide.
References
Dynamic 3-D
navigation makes
same-day guided
surgery possible
without the need
for a conventional
surgical template.
X-Guide guides the
Fig. 3: X-Guide provides a 360°, real-time view of clinician through
his or her treatment
the drill and anatomy.
38 CAD/CAM
4 2018
1 Block MS, Emery RW, Cullum DR, Sheikh A. Implant placement is more
accurate using dynamic navigation. J Oral Maxillofac Surg. 2017 Jul;75(7):
1377–86.
2 Emery RW, Merritt SA, Lank K, Gibbs JD. Accuracy of dynamic navigation
for dental implant placement—model-based evaluation. 2016 Oct;42(5):
399–405. Epub 2016 Jun 6.
3 Block MS, Emery RW, Lank K, Ryan J. Implant placement accuracy using
dynamic navigation. Int J Oral Maxillofac Implants. 2017 Jan–Feb;32(1):
92–9.
[39] =>
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[40] =>
| interview
Dental professionals at the Dentsply Sirona World 2018 in Orlando, USA, could profit of up to 200 breakout sessions.
Azento brings the clinician
financial and time-saving benefits
By DTI
© Dental Tribune International
The recent Dentsply Sirona World 2018 conference
in Orlando saw the launch of Azento, a single tooth
replacement. Dental Tribune International spoke with
Jo Massoels, Director of Digital Implant Solutions at
Dentsply Sirona, and Dr Daniel Butterman, a general
Dr Daniel Butterman (left) and Jo Massoels, Director of Digital Implant
Solutions at Dentsply Sirona, with the Azento system.
40 CAD/CAM
4 2018
and cosmetic dentist practising in Colorado in the US,
about how Azento can benefit clinicians and what the
future holds for implant dentistry.
Mr Massoels, Dr Butterman, what distinguishes the
Azento system from competitors, and what are its
advantages?
Butterman: For me, it’s the simplicity at all stages,
from ordering to inventory, that sets the Azento system
apart. Being able to design a final restoration straight
from the treatment plan is so different from anything
that we’ve ever seen, and this streamlined workflow has
many time-saving benefits in terms of patient chair time,
number of visits and so on. In many dental of fices, the
team will take either a film or digital X-ray of a patient’s
mouth. Then, they’ll show the patient this tiny X-ray and
point out certain areas of concern, perhaps begin to
draw on it or use templates to show how the implant will
be placed. The patients will say that they understand,
but mostly because they are being polite—there’s
really no comprehension. But when I show a patient
their custom digital treatment plan, created with Azento,
it’s far easier to highlight the issues that the implant
placement will aim to correct. It allows the patient to
[41] =>
interview
co-diagnose with me, to see what the course of treatment can and should be.
Massoels: The streamlined workflow offered by Azento
brings with it tangible financial and time-saving benefits
by reducing administrative responsibilities, number of
visits and patient chair time. It is designed to help dentists select the best-fitting implant, determine optimal
implant positioning, healing environment and restoration
for each case.
This spring, Dentsply Sirona celebrated the grand
opening of its new, state-of-the-art training facility,
the Dentsply Sirona Academy, in Charlotte in North
Carolina. Will there be any training available at this
centre for dental professionals interested in using
Azento in their workplace?
Massoels: Absolutely. There will be hands-on training
courses as part of Azento’s rollout in the US and we have
been working very hard on developing a digital training
option as well. We’ve found that many clinicians don’t
necessarily want to have to go to a physical training
course, but would rather be able to view it on their
mobile phones or computers. As a result, we have a
lot of training material for Azento that is now online and
available for users of this solution.
Are there any cases that can’t be treated with Azento?
What are its limitations?
Massoels: Currently, Azento is available for single
tooth replacements in situations where there are two
neighbouring teeth already. There are also certain clin-
|
ical situations that are outside of Azento’s scope, and
experts looking at the scans will identify these during the
planning stage. Having these extra sets of eyes looking
at each case and helping to categorise them is a clear
benefit for clinicians.
Butterman: It’s a great safety net to have for dentists—
a second opinion that comes with the purchase of an
Azento box.
Technology is shifting really quickly these days. How
do you see it evolving in the next few years within
implantology and 3-D printing?
Butterman: Well, I have a 3-D printer in my practice
and I do use some workflows for 3-D printing, but I’ll be
honest—there are a lot of places where inexperienced
users of this technology can make mistakes. I think there
will be a place for it in the near future for the clinician,
but it’s still more reliable for new users to have implants
fabricated.
Massoels: I think 3-D printing is a very exciting development. Another interesting field that is close to my
heart is treatment planning. Though our current solutions
for this are good, there are areas that we can improve
with the assistance of artificial intelligence technology.
We have data from hundreds of thousands of successful implant cases from all around the world that we will
be able to use in the future to help generate treatment
plans within seconds.
Thank you very much for the interview.
Introduction of the newly launched Azento™ system.
CAD/CAM
4 2018
41
[42] =>
| interview
Bringing a turnkey restoration
solution to dentists
At the 2017 Greater New York Dental Meeting, 3DISC
launched its Heron IOS intraoral scanner to the world.
Three months later, in February 2018, the US-based
imaging company presented an improved device to attendees of the Chicago Dental Society Midwinter Meeting (Fig. 1). In an interview, Thomas Weldingh, 3DISC
Deputy Group CEO, took the time to present the key
benefits of the Heron IOS for dental professionals.
Mr Weldingh, what can you tell us about the new
scanner?
We seek to cater to the segment of solo and midsize
practices with an easy-to-use and affordable solution.
With the Heron IOS, we have aimed to solve three major challenges that we know of from the existing scanners on the market: dimensions, ergonomics and affordability. We have succeeded in bringing a scanner to the
market that is extremely easy to use, featuring a small,
lightweight hand- and mouthpiece with a rotatable tip for
providing the best possible ergonomic grip (Fig. 2).
The Heron intraoral scanner is one of the lightest
weight colour scanners in the market, weighing only
145 gramme, which is considerably below the average
weight of other colour scanners. The ability to use scanners comfortably is important for dentists and, with its
light weight, combined with the rotatable tip, the Heron
provides one of the best ergonomic solutions in the industry.
“With the Heron IOS, we have
aimed to solve three major
challenges: dimensions,
ergonomics and affordability.”
What are the key benefits of the 3DISC intraoral
digital impression solution?
Our digital scanning product is a uniquely simple hardware and software solution. The dentist simply connects
the Heron to his or her laptop or PC in the clinic, using
the accompanying practical base for desktop use. The
scanner comes with our QuantorClinic software, built on
Fig. 1: Thomas Weldingh presenting the Heron IOS intraoral scanner in Chicago. Photo: © Matthias Diessner, DTI
42 CAD/CAM
4 2018
[43] =>
interview
|
“The Heron intraoral scanner
is one of the lightest
weight colour
scanners
in the
market.”
Fig. 2: The lightweight hand- and mouthpiece with a rotatable tip provides the best possible ergonomic grip.
exocad’s software platform, which is one of the most
widely used CAD/CAM software platforms in the dental
industry. The Heron IOS was developed and produced at
our facilities in Virginia, USA.
What is planned in terms of clinical testing of the
product?
The Heron IOS has been tested by dentists in the USA
and Europe since spring 2018. We want to ensure that
the product works as intended in the clinical environment
while looking for improvements we can add to the workflow of the clinic and integration with dental laboratories.
Why did you decide to enter the intraoral scanner
market?
The market is dominated by a few larger manufacturers. We believe there is room for an alternative intraoral
system in the marketplace, a system that brings immediate value into the dental practice, making impression
taking simple, hassle-free and cost-effective. Device and
maintenance costs are among the challenges restraining
the adoption of current intraoral scanners, as well as demand for an open and license-free software architecture.
We believe in the need and opportunity to bring a product
to market that meets these challenges.
Why does 3DISC aim to cater for solo to midsize
practices, and what are the benefits such practices
can expect from your products?
Solo and midsize practices are the segment that is currently hesitant to incorporate digital dentistry. Among the
reasons are complexity in the existing solutions and high
prices and maintenance costs. We see a gap and a need
for a product in this segment with first and foremost a
noncomplex and simple price model, and a technology
that is easy to adopt and get started with, without compromising on the performance and quality of the final fit.
Dental practices can expect both high-quality intraoral
imaging and an affordable price point $25,990 without
any annual licensing fees for the Heron intraoral scanner.
For the solo or midsize practice wanting to enter into digital dentistry, we believe that 3DISC is bringing the best
solution to dentists with our Heron IOS.
When and where is the launch and when will the
product be available?
Product shipping will start in the third quarter of 2018
in the Americas, Europe, the Middle East, Africa, Korea,
Southeast Asia, Australia and New Zealand.
Mr Weldingh, thank you very much.
contact
3DISC Europe ApS
Gydevang 39–41
3450 Alleroed, Denmark
Phone: +45 88 276650
sales@3disc.com
www.3disc.com
CAD/CAM
4 2018
43
[44] =>
| manufacturer news
Planmeca
Successful digital implant workflow
Planmeca’s software-driven solution for implant dentistry
provides a kind of freedom and flexibility that is hard to
match. Users can efficiently manage their entire implant
workflow with the Planmeca Romexis® software: from CBCT
imaging to intraoral scanning and from implant planning to guide
design. As it is a truly open software, it allows users to utilise
data from Planmeca or other equipment. There are no hidden or
extra fees for importing and exporting files.
Taking an implant plan to actual surgery is now easier than ever,
as the software’s new Planmeca Romexis® Implant Guide module lets users design their own surgical implant guides. This
elevates implant planning to another level, as virtual plans can
accurately be brought to reality. Creating implant guides with
the software requires few simple steps. Users can also flexibly
select their preferred workflow, as completed guide designs can
either be 3-D printed in-office or exported as STL files to a partner lab for 3-D printing.
Planmeca Oy
Asentajankatu 6
00880 Helsinki, Finland
www.planmeca.com
SEVEN implant system
Newly enhanced implant system
This past June, at the EuroPerio9 congress in Amsterdam,
Netherlands, MIS launched the enhanced SEVEN implant
system. Several key features have been added, that make the
internal hex implant even better. Its biological stability and
predictable aesthetics combined with the extensive R&D process which has led to these new improvements, have given
the SEVEN a potential advantage in soft-tissue preservation
and growth, as well as an array of restorative benefi ts. The
combination of its unique features may provide the dentist with
higher predictability, better aesthetic results and bone preservation.
The implant incorporates the platform-switching design concept.
Implants with a platform-switched configuration have been shown
to exhibit less bone loss when compared to non-platform-switched
implants, which may lead to soft-tissue preservation and growth.
The SEVEN’s root-shaped geometry and unique thread design
enable excellent primary stability, allowing for a simpler and
faster implant placement. With a new, comprehensive concept
for enhanced aesthetics and better bone preservation in mind,
and in order to support the advanced new implant features, an
additional line of concave abutments has also been added. The
concave emergence profile was designed for a larger gingival
volume, and along with its gold shading, offers a better aesthetic
result.
MIS Implants Technologies
www.mis-implants.com
44 CAD/CAM
4 2018
[45] =>
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[46] =>
| meetings
Sometimes faster, sometimes
safer, sometimes both—
The digital practice at IDS 2019
By DTI
The digital world is creating numerous opportunities
for dental practices. To the practitioner, these may seem
countless and it may not be easy to keep pace with relevant developments. The 2019 International Dental Show
(IDS), which is to be held from 12 to 16 March in Cologne
in Germany, will present the state-of-the-art technology
and help clinicians determine the most suitable solutions
for their practices and focus of work following the motto
“It depends on which innovation brings me and my practice forwards here and now.”
The impetus for digital processes is often triggered as
a consequence of today’s patient. A typical situation: the
patient needs a crown replaced; however, his time con-
46 CAD/CAM
4 2018
straints demand same-day treatment. One solution could
be a chairside system and another a particularly fast digital workflow that includes the practice and the laboratory.
Considerations regarding the ideal restorative materials
also play a role. IDS will present the entire palette of options to the visitor and thus also lays the basis for wellfounded investment decisions.
Whereas in the above-mentioned case, the priority
was above all speed, digital technologies assist with both
complex and difficult treatments. For example, in the
field of implantology: a patient requires a fixed prosthesis for his edentulous mandible. Based on radiographs
and model scan data, the dentist–dental technician team
[47] =>
meetings
plans the treatment together in the scope of backward
planning from the final prosthesis to the positions of the
individual implants. The digital availability of the data facilitates this process and if necessary also enables a further professional to be involved—even at short notice.
There are various ways of implementing the planned
treatment, including many options that involve digital
support. For example, for a safe surgical treatment, drilling templates can be ordered from the dental laboratory
or from an industry partner that provides the service. External support is also available for the virtual design and
production, so that the individual work steps can be more
flexibly divided up among the team (surgeon, prosthodontist, dental technician) today than ever before. In this
way, the practice aims to achieve quality assurance or,
indeed, an improvement in the quality, while at the same
time possibly saving time and money. Experts predict a
|
pace of progress that will mean that by IDS 2019 or IDS
2021 at the latest more digital implant treatments will take
place than analogue treatment using standard products.
“The current trends for the digital technologies for the
practice, as well as extensive workflows for surgeons,
prosthodontists and dental technicians, will be presented in a unique form at IDS,” said Mark Stephen Pace,
Chairman of the Board of the Association of the German
Dental Industry. “The opportunities of digital dentistry
have now arrived in all disciplines—from implantology
and prosthetics, through to endodontics and orthodontics. As such, it is certainly worthwhile for representatives from all specialised areas to experience the current
innovations at IDS in a diversity that can be found in no
other place.”
Pictures courtesy of Koelnmesse GmbH.
CAD/CAM
4 2018
47
[48] =>
| meetings
International Events
The largest Annual Dental
EVENT IN THE WORLD!
Waiting for
you in 2019!
Organizer:
Support:
International Media:
Information:
Exhibit Inquiry:
CIOSP
14th CAD/CAM & Digital
Dentistry Conference
30 January – 2 February 2019
São Paulo, Brazil
www.ciosp.com.br
12–13 April 2019
Dubai, UAE
www.cappmea.com
AEEDC
Dental Salon
5–7 February 2019
Dubai, UAE
www.aeedc.com
22–25 April 2019
Moscow, Russia
www.dental-expo.com/dental-salon
CDS Midwinter Meeting
AACD 2019
21–23 February 2019
Chicago, USA
www.cds.org
24–27 April 2019
San Diego, USA
www.aacd.com
INTERNATIONAL
OSTEOLOGY
SYMPOSIUM
IDS 2019
BARCELONA
25 – 27 APRIL 2019
International Osteology
Symposium
RG
WWW.OSTEOLOGY-BARCELONA.O
12–16 March 2019
Cologne, Germany
www.ids-cologne.de
48 CAD/CAM
4 2018
THE NEXT REGENER ATION
Programme Highlights
Latest developments of techniques
therapies
and technologies in regenerative
oral
Young experts focusing on
regeneration in a nutshell
Hands-on Workshops
Research Forum
Case Session for practitioners
SEPA
Joint Sessions with DGI and
MEETS IN BARCELONA.
Scientific Programme Committee
Maurício Araújo, Brazil (Chairman)
Christoph Hämmerle, Switzerland
Pamela K. McClain, USA
Mariano Sanz, Spain
Istvan Urban, Hungary
BE PART OF IT!
(Chairman)
ATION
EGENERATION
#NEXTREGENER
#NEXTR
25–27 April 2019
Barcelona, Spain
www.osteology-barcelona.org
KRAKDENT
APDC & SIDEX
10–13 April 2019
Krakow, Poland
www.krakdent.pl
8–12 May 2019
Seoul, Korea
www.apdc2019.org
[49] =>
© 32 pixels/Shutterstock.com
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m.wojtkiewicz@dental-tribune.com
CAD/CAM
4 2018
49
[50] =>
| international imprint
Imprint
Publisher/President/CEO
Torsten R. Oemus
t.oemus@dental-tribune.com
Editor-in-Chief
Dr Scott D. Ganz
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Dr Scott D. Ganz (USA)
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International Administration
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Copyright Regulations
CAD/CAM international magazine of digital dentistry is published by Dental Tribune International (DTI) and appears in 2018 with four issues. The magazine and all articles and
illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable to prosecution. This applies in particular to duplicate copies,
translations, microfilms, and storage and processing in electronic systems. Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary,
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published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply.
Legal venue is Leipzig, Germany.
50 CAD/CAM
4 2018
[51] =>
[52] =>
Dentsply Sirona does not waive any right to its trademarks by not using the symbols ® or ™. 32671431-USX-1801 © 2018 Dentsply Sirona. All rights reserved
Planning and
guided surgery
Digital
impression
Restorative
solutions
Digital implant workflow
Connect to the future
From data capturing, planning, guided surgery to the final restorative
solution, with the digital implant workflow from Dentsply Sirona you have
all the support you need to save time, grow your business and provide
patients with the best possible care.
www.dentsplysirona.com
)
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