Implant Tribune UK No. 2, 2017
Straumann successfully concludes digital dentistry roadshow / UK News / Digitising your implant practice / Dynamic navigation for precise implantation in cases of critical anatomy
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Untitled
IMPLANT TRIBUNE
The World’s Implant Newspaper · United Kingdom Edition
www.dental-tribune.co.uk
Published in London
Vol. 11, No. 5+6
Straumann successfully concludes
digital dentistry roadshow
By DTI
MANCHESTER, UK: Swiss company
Straumann has massively expanded its digital workflow solutions over the past few years. At
and has been available from Straumann since March, thanks to a
new distribution agreement. Overall, the 10-day digital performance
roadshow took place in seven locations across the UK including Lon-
Straumann has invested heavily in digital solutions in the last
few years. Under the CARES umbrella, equipment, state-of-the-art
materials and digital technology
have been combined with the aim
to offer dental professionals an efficient and validated workflow,
whether they just need something
for their case planning or want to
produce customised dental prosthetics in-house. The compact, yet
powerful Straumann CARES M Series milling and grinding system,
for example, allows the dentist to
mill almost any kind of prosthetics from a wide range of materials,
including zirconia, glass ceramic
or PMMA. With its comprehensive
portfolio that also includes an outsourced scan and design platform,
Scan & Shape, the company is now
able to offer a digital workflow for
almost any practice or lab in the
country.
“Dentistry always used to be
behind a bit in the implementation of digital technology. In the
last few years, however, we have
seen a real explosion of interest,”
Annett said. “Straumann is wellpositioned for the future as it not
only offers a full digital portfolio,
but also the support that, especially beginners, need.”
Straumann already has plans
for another tour that will probably
take place next year. Dates will be
announced on the Straumann
website, where professionals can
also find more information about
the company’s digital portfolio
and product offering.
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and anytime
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© Daniel Zimmermann, DTI
– a focused discussion forum
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– no time away from the practice
– interaction with colleagues and
experts across the globe
– a growing database of
scientific articles and case reports
– ADA CERP-recognized
credit administration
Justin Annett (fourth from left) with the Straumann road show team.
the recent International Dental
Show in Cologne, for example, 3D
printers, which were created
through a partnership with German developer Rapid Shape, were
added to its already extensive
portfolio. At a roadshow recently
held in several locations throughout the UK, dentists and technicians had the opportunity to get
their hands on the company’s new
products and find out how these
could benefit their practices.
In addition to the new P Series
3D printer, which garnered the
most interest according to Straumann’s Marketing Director Justin
Annett, the company had all of its
digital equipment on display, including the Straumann Cares IO
Portable Intraoral Scanner, the
desktop lab scanner and the milling system series. Participants
were also able to get their hands on
the TRIOS intraoral scanner from
3Shape, which is used for taking
powderless chairside impressions
www.DTStudyClub.com
don, Coventry and Leeds. The
roadshows consisted of product
demonstrations presented by
Straumann staff and clinical experts inside a purposely built
2,000 horse power truck.
“The feedback to this has been
extremely positive,” Annett told
Dental Tribune at the event in
Manchester last week. “In addition
to a high number of labs and technicians who are already using our
equipment and are looking for
new areas to invest in, we had a lot
of participants who are completely
new to the digital workflow.”
According to Annett, however,
the tour was about far more than
having products on display. “With
this roadshow we are able to not
only showcase our latest solutions
for a digital workflow, but also explain in detail how it can benefit
every single practice. And we offer
some great deals on the products
too,” he said.
Join the largest
educational network
in dentistry!
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providersof continuing dental education.
ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
[2] =>
Untitled
IMPLANT NEWS
14
Implant Tribune United Kingdom Edition | 5+6/2017
Award-winning seaweed drug could help fight
peri-implantitis
By DTI
CARDIFF, UK: Together with the
Norwegian biopharmaceutical
company AlgiPharma, researchers at Cardiff University have
been working on new drugs to
combat antibiotic-resistant diseases and infections. In the study,
the team at the School of Dentistry has shown how alginates—
found in seaweed—can disrupt
the formation of microbial biofilms.
Biofilms form when a community of bacteria assemble in some
form of watery environment, be-
gin to excrete a glue-like substance
and adhere to a surface. Biofilms
have been found to be involved in
a wide variety of microbial infections in the human body. An example is dental plaque, which can
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lead to caries and periodontal disease if undisrupted.
In an interview with Dental
Tribune International, study
leader Prof. David Thomas explained that specialised alginates
work in two ways: “Firstly, they directly interact with the ‘sticky’ biofilm matrix, which encases the
bacteria, and modify the biofilm’s
structure by binding to calcium.
These effects make the biofilm
less robust and more easily disrupted. Secondly, they work directly on the bacteria themselves,
changing their expression of quorum-sensing molecules (which
control biofilm development) and
making them more sensitive to
the effects of conventional antibiotic therapy.”
The researchers have used the
information about how alginates
work to develop an inhalation
therapy being tested on cystic fibrosis patients. If successful, the
treatment could be applied to help
clear mucus obstructions in the
lungs and potentially slow the progression of the disease. In addition, it could be used in other,
more common respiratory diseases, such as chronic obstructive
pulmonary disease. The studies
are also paving the way towards
improved treatment of chronic
skin wounds and combat of organisms that cause periodontal disease, for example.
Thomas explained that “the alginates may be useful in dentistry
as an adjunct in the management
of chronic biofilm infections”,
such as “peri-implantitis, where
the non-toxic agent may be applied directly to aid disruption of
biofilms and stop biofilms reforming on treated surfaces”.
The project was launched with
funding from AlgiPharma in 2007
for exploratory microbiology
studies, but developed into a nineyear collaboration between the
university’s Advanced Therapies
Group (ATG), AlgiPharma, and Cardiff and Vale University Health
Board. The ATG’s collaborative network helped attract researchers
with expertise in specialist areas,
paving the way for human clinical
studies across the EU and Scandinavia.
Dr Philip Rye, Research and Development Director at AlgiPharma,
said: “The collaboration has enabled us to make significant advances in the development of a
new drug, which is now in human
clinical studies, and has recently
been included in the US Cystic
Fibrosis Foundation drug development pipeline.”
The project is a winning finalist in Cardiff University’s 2017 Innovation and Impact Awards.
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IMPLANT TRENDS
16
Implant Tribune United Kingdom Edition | 5+6/2017
Digitising your implant practice
By Dr Ross Cutts, UK
Undoubtedly, digital dentistry is
the current topic. Over the last five
years, the entire digital workflow
has progressed in leaps and bounds.
There are so many different digital
applications that it is sometimes
difficult to keep up with all the advances. Many dentists are excited
about the advantages of new technologies, but there are an equal
number who doubt that the improved clinical workflow justifies
the expense.
I have many times heard the argument that there is no need to try
to fix something that is not broken.
It is so true that impressions have
their place and there are certainly
limitations to the digital workflow
that anyone using the technology
should be aware of. For me, however, the benefits of digital far outweigh the disadvantages. In fact,
the disadvantages are the same as
with conventional techniques.
Chairside
CAD/CAM
single-visit restorations have been
possible for over 20 years, but it
was only recently that we became
able to mill chairside implant
crown restorations after the release of Variobase (Straumann)
and similar abutments. I made my
first CEREC crown (Dentsply
Sirona) back in 2003 with a pow-
dered scanner, and the difference
from what I remember then to
how we can make IPS e-max
stained and glazed restorations
(Ivoclar Vivadent) now is amazing.
An investment
not an expense
The results of a survey regarding the use of CAD/CAM technology were published online in the
British Dental Journal on 18 November 2016. Over a thousand
dentists were approached online
to take part in the survey and the
385 who replied gave very interesting responses. The majority
did not use CAD/CAM technology,
and the main barriers were initial
cost and a lack of perceived
advantage over conventional
methods.
Thirty per cent of the respondents reported being concerned
about the quality of the chairside
CAD/CAM restorations. This is a
valid point. We must not let ourselves lose focus that our aim should
always be to provide the best level of
dentistry possible. For me, digital
dentistry is not about a quick fix; it
is about raising our performance
and improving predictability levels
by reducing human error.
1
In the survey, 89 per cent also
said they believed CAD/CAM technology had a major role to play in
the future of dentistry. I really cannot imagine that once a dentist
has begun using digital processes
that he or she would revert to conventional techniques.
What is digital
implant dentistry?
Many implant clinicians have
probably been using CAD/CAM
workflows without even realising it,
as many laboratories were early
adopters, substituting the lost-wax
technique and the expense
of gold for fully customised cobalt–
chromium milled abutments (Fig. 1).
One of my most important
goals in seeking to be a successful
implantologist is to provide a
dental implant solution that is
durable. We have seen a massive
rise in the incident of periimplantitis and have found
that a large proportion of
these cases can be attributed to
cement inclusion from poorly designed cement-retained restorations (Fig. 2). Even well-designed
fully customised abutments and
crowns can have cement inclusion if the restoration is not care-
2
fully fitted (Fig. 3). This has led to
a massive rise in retrievability of
implant restorations, with screwretained crowns and bridges now
being the goal. However, making
screw-retained prostheses places
even greater emphasis on treatment planning and correct implant angulation.
With laboratories as early
adopters, we have been milling
titanium or zirconia customised
abutments for over ten years
(Fig. 4). What has changed recently
in the digital revolution is the rise
of the intra-oral scanner. We now
have a workflow in which we can
take a preoperative intra-oral
scan and combine this with a CT
scan using coDiagnostiX (Dental
Wings) in order to plan an implant
placement accurately and safely.
We can also create a surgical guide
to aid in accurate implant placement, have a temporary crown
prefabricated for the planned implant position and then take a final scan of the precise implant position for the final prosthesis.
Accuracy
of intra-oral scanners
Figures 4–13 show the workflow
for preoperative scanning, which
3
4
8
5
6
7
9
10
11
12
13
includes the implant design, guide
fabrication and surgical placement
of two fixtures. Intra-oral scanners
have improved over the last few
years, and their accuracy and speed
provide a viable alternative to conventional impression taking. The
digital scan image comes up in real
time and you can evaluate your
preparation and quality of the scan
on the screen immediately. Seeing
the preparation blown up in size
no doubt improves the technical
quality of your tooth preparations.
The scan can then be sent directly
to the laboratory for processing.
While we do not think of intra-oral scanners as being any
more accurate than good-quality
conventional impressions, there
are many benefits of scanning,
such as no more postage to be paid
for impressions, vastly reduced
cost of impression materials, almost zero re-impression rates and
absolute predictability.
Of course, there are steep
learning curves with the techniques, but once a clinician has
learnt the workflow, there really is
no looking back.
We have three different
scanners in the practice: the iTero
(Align Technology), the CEREC
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IMPLANT TRENDS
Implant Tribune United Kingdom Edition | 5+6/2017
14
17
15
16
17
18
19
20
21
22
23
24
25
26
software. We extract our files into
CT planning software, model production software, chairside milling for stents, temporaries and definitive restorations, and now orthodontic planning software. I am
convinced there will be yet more
advances with time. The size of the
camera is critical—some can be
very cumbersome—and it is worth
asking the salesperson what developments are underway.
27
28
Omnicam (Dentsply Sirona) and
the Straumann CARES Intraoral
Scanner (Dental Wings; Fig. 14). The
CEREC Omnicam is fantastic for
simple chairside CAD/CAM restorations, such as IPS e.max all-ceramic
restorations on Variobase abutments. For truly aesthetic results,
we, of course, still have a very close
working relationship with our laboratory, but, undoubtedly, patients
love the option of restoration in a
day. Being able to scan an implant
abutment and then an hour later
(to allow for staining and glazing)
fitting the definitive restoration is a
game-changer. Patients also love
watching the production process as
they see their tooth being milled
from an IPS e.max block.
of the final prosthesis. However,
for more than single units or aesthetic single-unit cases, we use the
iTero and Straumann scanners.
The latter we have only had at our
disposal since February. While it is
a powdered system at the moment,
this is due to change this month.
Particularly with implant restorations, the need to apply a scanning
powder is a limitation, owing to a
lack of moisture control contaminating the powder. The technology,
however, is superb, as is the openness of the system, which provides
the advantage of being able to export files into planning software. A
colleague of mine even uses it for
his orthodontic cases now instead
of wet impressions.
tive bridgework, we use Createch
Medical frameworks for screwretained CAD/CAM-milled titanium and cobalt–chromium frameworks. Even though intra-oral
scanning appears extremely reproducible and accurate, I still use
verification jigs where needed to
ensure our frameworks are as accurate as possible. There are many
intricacies that we consider and
tips and techniques that we employ to make the scans more accurate that we have developed over
time. The closer the scan bodies
are together, the more accurate
the scan is. Also, the more anatomical detail, such as palatal rugae or
mucosal folds, the better the scans
can be stitched together.
Figures 15–19 show the production process, including the exposure of the implant, the abutment
seating, the scan flag on top of the
abutment, the healing abutment
during fabrication and the delivery
We invested in the iTero scanner five years ago and have used it
for everything, from simple conventional crowns and bridges to
scanning for full-mouth rehabilitations. When fabricating defini-
Figure 20 shows a CBCT volume to aid in planning for mandibular implant placement and
realising the implant placement
Fig. 21). We exposed the fixtures
and placed Straumann Mono
Scanbodies (Fig. 22). Then, we took
an iTero scan of the fixtures in situ
(Fig. 23) and made a verification jig
from this (Fig. 24) to ensure passive implant positioning. The iTero
models were made (Fig. 25) and a
Createch titanium framework was
used to support porcelain in a
screw-retained design (Fig. 26). The
last two figures show the excellent
outcome and accurate framework
seating (Figs. 27 and 28).
Some companies are more on
the cutting edge than others.
My favourite at the moment is
the Straumann scanner. Its design
is light and user-friendly and
it synchronises perfectly with
coDiagnostiX implant planning
software. Furthermore, while it offers a chairside milling unit, it also
synchronises perfectly with my
laboratory for larger cases.
To conclude, digital implant
dentistry is the future and so why
not take advantage of it and help
improve your clinical outcomes?
Choosing
your workflow
There are many different systems on the market now, each offering a one-stop shop. If you are
considering investing in a digital
scanner, then take some advice
from colleagues. One of the most
important things is to ensure the
system you opt for is an open one
that allows you to extract the digital impression data into different
Dr Ross Cutts is the principal dentist at
Cirencester Dental Practice in Cirencester in the UK. He can be contacted at
cuttsrg@aol.com.
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IMPLANT TRENDS
18
Implant Tribune United Kingdom Edition | 5+6/2017
Dynamic navigation for precise
implantation in cases of critical anatomy
By Dr David Burgess, UK
Introduction
Info
Using the CBCT image as a map,
dynamic navigation guides surgeons just like a GPS guides drivers. The clinician virtually plans
where implants should be placed.
During surgery, the navigation
system dynamically tracks the
drill and the patient’s jaw, providing guidance and visual feedback
to ensure the implants are placed
according to plan.
There are several advantages with dynamic navigation.
The technology allows clinicians to place implants more accurately than free-hand. This
results in improved safety and
aesthetics, as it helps the clinician to anticipate and to avoid
potential complications. Other
advantages are the ability to
have more minimal invasive
treatments, which means less
chair time, less patient discomfort and less recovery time. This
treatment option has generally
been seen as a “blind” procedure in the past, but the ability
to avoid delicate anatomical
structures due to the real-time
surgical feedback makes socalled flapless surgery a valuable option.
In the following case report,
Dr David Burgess describes
how using computer-guided
dynamic navigation helped
him overcome clinical challenges for dental implant placement in the lower posterior region.
Dr Burgess is holding four
hands-on courses in 2017 for experienced implant dentists who
want to incorporate dynamic navigation into their digital workflow.
For further information, course
reservations or other related requests, e-mail: dns@claronav.com
previously been able to, using conventional protocols. Whilst there
is no physical guide, a simple scanning template (NaviStent) is used
to hold the fiducial in place whilst
taking the CT scan, and secure
the jaw reference (JawTag) for the
navigated osteotomy.
Case report
A 75-year-old male patient
had endured a gap for five years,
following removal of his lower
left second molar, due to an
acute apical infection. He was
finding mastication increasingly difficult and sought advice about the treatment options available.
Planning for optimum
implant positioning
implant treatment as he did not
wish to have any form of removable prosthesis.
As there was no tooth distal to
the space, conventional fixed
bridgework was not possible. The
treatment options were either a
unilateral single saddle lower partial denture or restoration of the
space with two dental implants.
The patient chose to have dental
What makes Navident dynamic navigation stand out is it
precisely guides the surgeon to
prepare and place the implant in a
pre-determined position (Fig. 1).
This allows me to achieve greater
accuracy and certainty than I have
In this case, the NaviStent was
fabricated, the fiducial marker attached and a CBCT scan taken two
weeks prior to surgery (Fig. 2). The
treatment plan was created immediately after the scan (Fig. 3), with
the patient present. He was able to
see the proposed treatment displayed by the Navident software
and appreciated that great care was
being taken to achieve the optimum implant positioning, with
minimal risk of potential complications (Fig. 4). The patient was
impressed with, and reassured by,
the state-of-the-art technology.
Confidence from
continuous feedback
Treatment was carried out
under local anaesthesia. Prior to
preparation of the implant sites,
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Implant Tribune United Kingdom Edition | 5+6/2017
IMPLANT TRENDS
19
1
2
Fig. 1: An illustrative image of Dr Burgess using Navident. — Fig. 2: A CBCT scan was
taken two weeks prior to surgery. — Fig. 3: The treatment plan was created immediately after the scan. — Fig. 4: The patient was able to see the proposed treatment
displayed by the Navident software. — Fig. 5: The author was able to achieve the
best buccal and lingual position of the implants, and their relation to each other and
to adjacent teeth.
the simple Navident protocol for
calibration and verification of
the drill axis and drill tip was
carried out. A crestal incision
was made, with a minimal flap
reflected. The software shows
the drill position on the scan
in real time, as it enters the
jaw. This allows adjustments to
be made, if necessary, whilst
the site is being drilled. Two
Dentsply Ankylos® CX 3.5 mm diameter dental implants were
placed subcrestally in the lower
left fi rst and second molar sites,
with implant lengths of 11 mm and
9.5 mm respectively.
3
Avoiding damage to the inferior alveolar nerve was a crucial
factor in the treatment planning
of this case. Access was difficult,
due to the limited opening of the
patient’s mouth. The issue was
compounded by the plan to place
an implant as distal as the second molar. These challenges
were overcome using Navident’s
continuous internal visual feedback, which gave the author the
confidence to use the optimum
length of implant, whilst staying
within a safe distance from the
inferior alveolar nerve and
avoiding post- surgical complications, such as paraesthesia.
Navident provided guidance
for accurate implant location,
even with restricted visibility
and the drill being impeded by
opposing teeth. Tactile feedback
can often be reduced when using
a physical drill guide. Dynamic
navigation removes this obstacle. The author was able to
achieve the best-possible buccal
and lingual position of the implants, and their relation to each
other and to adjacent teeth
(Fig. 5). This would allow for optimal shape, position and occlusal
function of the fi nal restorations.
4
5
Ankylos® Balance posterior
sulcus formers were fitted and
the incision was closed with simple interrupted sutures. There
was no need for bone augmenta-
tion. Two to three months after
surgery, the implants will be restored with Atlantis® custom
made CAD/CAM titanium abutments and screw-retained linked
zirconia crowns.
Conclusion
The clinical outcome was excellent. The planned placement
was restoratively driven and the
implants were well positioned,
with good primary stability. Having used the Navident dynamic
navigation system for more than
a year, the author would not want
to go back to preparing and placing dental implants without its
3-D visual guidance. The patient
was comfortable and reassured,
with no postoperative pain,
swelling, bruising or paraesthesia. He was delighted and, if he
needed any implant treatment in
the future, would insist on dynamic navigation.
Dr David Burgess
BDS DPDS MScConSed
has been principal of Carbis Bay
Dental Care in Cornwall since 1988
and has placed over 2,000 implants.
Throughout his career, David has
striven to combine clinical perfection
with the ultimate in patient care.
He has been a willing pioneer of
new technology, particularly in the
field of digital dentistry. David was
the first UK clinician to introduce
the Navident dynamic navigation
system into his implant treatment
workflow, with the objective of
achieving a higher degree of precision and greater patient comfort.
David Burgess is also a member of
the Dynamic Navigation Society as
a Master Clinical Trainer, providing
courses for implantologists who
wish to experience how dynamic
navigation can help to simplify their
digital workflow. More information
can be found on http://dns.claronav.
com.
[8] =>
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