Digital Implant Dentistry Workflow

Transcription

1 Digital Implant Dentistry Workflow Ahmad Kutkut, DDS, MS, FICOI, DICOI Director of Predoctoral Implant Program Chair UKCD Implant Board Disclaimer Neither I or any of my immediate family have any financial interest that would create a conflict of interest or restrict my independent judgment with regard to the content of this course. Disclaimer Participants should be cautioned about the potential risks of using limited knowledge when integrating new techniques into their practice. Objectives To treatment plan implant cases based on CBCT. To learn intraoral or/and dental model surface scan. To learn virtual computer based implant planning. To learn 3 D printing surgical guide (fully guided or Pilot drill guided) and 3 D printing model. To Learn guided implant surgery. To learn how to design and CAD/CAM fabrication implant prosthetics. Where are we in 2017? Selection Criteria on the Use of Radiology in Dental Implantology with Specific Reference to Cone Beam Computed Tomographic Imaging Clinical considerations and selection criteria in implantology: The most reliable method for gaining knowledge of the patient s presenting bone architecture in the diagnostic phase of dental implant therapy is through CBCT. Based on AO and ITI CBCT appears to be the diagnostic method of choice for straightforward or complex case type based upon the patient bone morphology. Tyndall DA, Price JB, Tetradis S, Ganz SD, Hildebolt C, Scarfe WC; American Academy of Oral and Maxillofacial Radiology. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Jun;113(6):

2 Where are we in 2017? Selection Criteria on the Use of Radiology in Dental Implantology with Specific Reference to Cone Beam Computed Tomographic Imaging Anatomic considerations: Esthetic zone: exact morphology and dimension of the nasopalatine canal the location of the floor of the nasal fossae the cortical bone dimensions Precise location of the floor of the maxillary sinus: the location of the septae. Presence of neurovascular bundle associated with: the lingual foramen the extension of the incisive canal the inferior alveolar canal Where are we in 2017? Selection Criteria on the Use of Radiology in Dental Implantology with Specific Reference to Cone Beam Computed Tomographic Imaging Imaging modalities: Periapical Films Panoramic Films Lateral skull projection (Cephalometric film) Computed Tomography Cone Beam Computed Tomography Tyndall DA, Price JB, Tetradis S, Ganz SD, Hildebolt C, Scarfe WC; American Academy of Oral and Maxillofacial Radiology. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Jun;113(6): Where are we in 2017? Selection Criteria on the Use of Radiology in Dental Implantology with Specific Reference to Cone Beam Computed Tomographic Imaging Preoperative site specific imaging: For definitive diagnosis and treatment planning, cross sectional imaging is required to evaluate not only the height and mesiodistal dimensions of the residual alveolar ridge but also the topography of the alveolar crest, the ridge width, cortical bone thickness, concavities, and bone density. Information gained from panoramic and intraoral images alone is inadequate to completely evaluate the alveolar bone at the planned implant site. Where are we in 2017? Cone Beam Computed Tomography (CBCT ) in Implant Dentistry Indications for CBCT use in implant dentistry vary from preoperative analysis to postoperative evaluation, including complications. A clinically significant benefit for CBCT imaging over conventional two dimensional methods resulting in treatment plan alteration, improved implant success, survival rates, and reduced complications. CBCT imaging exhibits a significantly lower radiation dose risk than conventional CT, but higher than that of twodimensional radiographic imaging. Tyndall DA, Price JB, Tetradis S, Ganz SD, Hildebolt C, Scarfe WC; American Academy of Oral and Maxillofacial Radiology. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Jun;113(6): Bornstein MM, Al Nawas B, Kuchler U, Tahmaseb A. Consensus Statements and Recommended Clinical Procedures Regarding Contemporary Surgical and Radiographic Techniques in Implant Dentistry. Int J Oral Maxillofac Implants Aug 15. Anatomic Considerations The objective of preoperative dental implant imaging is to gain the following information about the potential implant site: Location of osseous morphology: knife edge ridges Location and depth of the submandibular gland fossa Developmental variations Post-extraction irregularities Enlarged marrow spaces Cortical integrity and thickness Anatomic Considerations The objective of preoperative dental implant imaging is to gain the following information about the potential implant site: Presence of disease. Location of anatomical features that should be avoided when placing the implant. maxillary sinus nasopalatine canal inferior alveolar canal mental canal and foramen 2

3 Anatomic Considerations The objective of preoperative dental implant imaging is to gain the following information about the potential implant site: Amount of bone available for implant placement Quality of bone (according to Lekholm and Zarb) 1. Composed of compact bone 2. A thick compact bone surrounds a trabecular bone 3. A thin compact bone surrounds a trabecular bone 4. A thin layer of compact bone surrounds a trabecular bone Cone Beam Computed Tomography (C.B.C.T.) Lekholm U, Zarb G. Patient selection and preparation in Tissue Integrated Prostheses. Quintessence 1985 Computed Tomography (C.T.) Cone Beam Computed Tomography (C.B.C.T.) Traditional C.T. uses a very narrow, fan beam that rotates around the patient acquiring one thin slice (image) with each revolution To image a section of anatomy, many rotations must be completed which means higher radiation exposure With Cone Beam Computed Tomography, the entire volume is acquired in a single pass around the patient Resulting in much less radiation exposure! Cone Beam Computed Tomography (C.B.C.T.) MAIN DIFFERENCE Cone Beam Computed Tomography (C.B.C.T.) MAIN DIFFERENCE Conventional CT Cone Beam CT 3

4 Cone Beam Computed Tomography (C.B.C.T.) The 3D Digital Volume Once the scan is completed, the CONE BEAM CT software reconstructs the 360 images into a 3D database representing the patient s anatomy Cone Beam Computed Tomography (C.B.C.T.) The Reconstructed Volume consists of a series of axial images. The thickness of each axial image can be set to a value from 0.2 mm to 5 mm. ADVANTAGES OF CBCT Cost Rapid scan time Beam limitation Image accuracy ( mm) CBCT LIMITATIONS Artifacts Poor soft tissue contrast Measurement accuracy Reduced radiation dose 4

5 Pre Operative PAN Ridge Modification of Mandibular Cast Surgical Phase 5

6 Healing Phase Post Surgical Panoramic View Preparation for Mandibular Master Impression Final Impression Verification Jig Maxillo mandibular Relationship 6

7 Wax try in Fabrication Of Mandibular fixed implant denture Fabrication Of Mandibular fixed implant denture Fabrication Of Mandibular fixed implant denture Maxillary & Mandibular Dentures Completed treatment Frontal View 7

8 Occlusal View Patient Frontal View Frontal View of Patient Smiling Lateral Profile Implant Planning and Surgical Guides Implant Treatment Planning Computer Guided surgery is defined as the Biomedical Modeling Inc. use of a static surgical template that reproduces the virtual implant position directly form computerized tomographic data and does not allow for intra operative modifications of the implant position Computer technology Application in Surgical Implant Dentistry: A Systematic Review Int J Maxillofac Implants 2014:29(suppl)

9 Where are we in 2017? Computer-Guided Implant Surgery Implants placed utilizing computer guided surgery with a follow up period of at least 12 months demonstrate a mean survival rate of 97.3%, which is comparable to implants placed following conventional procedures. The accuracy of computer guided implant surgery revealed on: a mean error of 0.9 mm at the entry point, a mean error of 1.3 mm at the implant apex, a mean angular deviation of 3.5 degrees. Bornstein MM, Al Nawas B, Kuchler U, Tahmaseb A. Consensus Statements and Recommended Clinical Procedures Regarding Contemporary Surgical and Radiographic Techniques in Implant Dentistry. Int J Oral Maxillofac Implants Aug 15. Where are we in 2016? Computer-Guided Implant Surgery Treatment Guidelines: Guided surgery should be considered as an adjunct to, not a replacement for, appropriate diagnosis and treatment planning. Guided surgery should always be prosthetically driven. This includes a radiographic template generated from a wax up, or appropriate software application to create a digital wax up. Bornstein MM, Al Nawas B, Kuchler U, Tahmaseb A. Consensus Statements and Recommended Clinical Procedures Regarding Contemporary Surgical and Radiographic Techniques in Implant Dentistry. Int J Oral Maxillofac Implants Aug 15. Where are we in 2016? Computer-Guided Implant Surgery Treatment Guidelines: Information from the combination of CBCT images and digital planning should include locations of vital structures, desired implant positions and dimensions, the need for augmentation therapy, and the planned prostheses. Additional 2 mm should be taken into consideration when planning implant position with relation to vital structures and adjacent implants in all directions. Bornstein MM, Al Nawas B, Kuchler U, Tahmaseb A. Consensus Statements and Recommended Clinical Procedures Regarding Contemporary Surgical and Radiographic Techniques in Implant Dentistry. Int J Oral Maxillofac Implants Aug 15. Where are we in 2016? Computer-Guided Implant Surgery Treatment Guidelines: Guided surgery may be utilized with a flapless or flap approach. Mucosal and/or tooth or implant supported surgical templates should be utilized. For accuracy, implants should be inserted in a fully guided manner. Guided surgery may be used with different loading protocols. Bornstein MM, Al Nawas B, Kuchler U, Tahmaseb A. Consensus Statements and Recommended Clinical Procedures Regarding Contemporary Surgical and Radiographic Techniques in Implant Dentistry. Int J Oral Maxillofac Implants Aug 15. Where are we in 2016? Computer-Guided Implant Surgery Treatment Guidelines: Indications for guided surgery include: to aid in treatment planning, when encountering complex anatomy, to perform minimally invasive surgery, and to improve patient understanding of therapeutic needs and treatment options. Computer-Guided Implant Surgery Traditional implant placement technique often results in a successful prosthetic outcome: Yet pink acrylic / porcelain is often used when implants are not in ideal position Bornstein MM, Al Nawas B, Kuchler U, Tahmaseb A. Consensus Statements and Recommended Clinical Procedures Regarding Contemporary Surgical and Radiographic Techniques in Implant Dentistry. Int J Oral Maxillofac Implants Aug 15. 9

10 Computer-Guided Implant Surgery Computer guided surgery is a new technology available today CT scan imaging combined to computer software provide us with new advanced tools for implant positioning Virtual Implant Placement Software (Implant Logic Systems). Advantages of this technology 1 Correct positioning of the implant 2 Avoid critical anatomical structures 3 Perform safe flapless procedures 4 Perform prosthetically driven implant dentistry 5 Preparation of the prosthesis prior to surgery Advantages of this technology One of the commonly overlooked criteria for success is to have a restorable and esthetically positioned implant that is acceptable to both patients and dentists Konal Lal J Prosth 2006, Traditional manual placement, in inexperienced hands, may result in poor implant position Advantages of this technology The overall frequency of operative complications was 1% (7/677) Mc Dermott IJOMI 2003, 18: Computer Assisted Implant Surgery may be the solution to avoid vital anatomical structures. Advantages of this technology Flapless procedure is a blind technique!!! Computer guided planning transforms blind technique into a precise, predictable, atraumatic procedure. Advantages of this technology Prosthetically driven techniques: Computer planning allows us to select the best implant position for the final restoration while taking in consideration the volume of available bone. 10

11 Advantages of this technology Preparation of prosthesis before surgery is possible: A precise transfer of the Implant planning to the surgical field allows us to predetermine final implant position Different Systems of Computer Guidance: Computer generated template fitted on soft tissue, on bone or on teeth. Materialise SurgiGuide i Dent Scan2Guide Implant Logic Solutions (ILS) Nobel Guide Straumann CARES Easy Guide Computer Generated Template Treatment Concept: CT scan derived customized surgical template IMPLANT LOGIC SYSTEMS 1. Models are sent to ILS. 2. ILS performs a diagnostic wax up. 3. ILS creates a CT Scan Appliance. Van Steenberghe Clinical Implant Dentistry and Related Research, Volume7, Supplement1, Doctor creates a surgical plan in VIP. 5. The plan and model are returned to ILS for milling. 6. The Compu Guide Surgical Template is returned to the doctor. IMPLANT LOGIC SYSTEMS IMPLANT LOGIC SYSTEMS OK OK X X X X X X OK

12 IMPLANT LOGIC SYSTEMS IMPLANT LOGIC SYSTEMS IMPLANT LOGIC SYSTEMS IMPLANT LOGIC SYSTEMS IMPLANT LOGIC SYSTEMS The i Dent Solution 1. Dentist or lab makes stent with markers 2. CT Scan (with stent) data saved to disk or sent to dentist over the internet 3. Implant planning by dentist with Implant Master 4. Template design sent to I Dent service center over the internet 5. Manufacture of template 6. Placement of implants using template 12

13 Description of the Teeth In An Hour concept I Image acquisition Denture or prosthesis replica with radiopaque markers and index for repositioning Scan the patient with occlusal plane parallel to the axial slice Scan of the Prosthesis Van Steenberghe Clinical Implant Dentistry and Related Research, Volume7, Supplement1,2005 Description of the Teeth In An Hour concept II Three dimensional Image based treatment planning Implant position chosen with 1.5 mm security zone Three horizontal stabilizing pins Send to manufacture a Stereolithographic model and a surgical guide Van Steenberghe Clinical Implant Dentistry and Related Research, Volume7, Supplement1,2005 Description of the Teeth In An Hour concept III Surgical Template The template sleeves correspond to the location and inclination of the planned implants Lateral metallic sleeves guide the positioning of the lateral fixation pins Van Steenberghe Clinical Implant Dentistry and Related Research, Volume7, Supplement1,2005 Description of the Teeth In An Hour concept IV Surgical Procedure The drilling was pursued in the usual manner The implants are inserted through the surgical template sleeves Van Steenberghe Clinical Implant Dentistry and Related Research, Volume7, Supplement1,

14 Description of the Teeth In An Hour concept Description of the Teeth In An Hour concept VI Expanding abutments Adjustable abutment with small variability in the Z axis are placed. Interlocking cylinder sleeve with 2 pieces that slide within one another Van Steenberghe Clinical Implant Dentistry and Related Research, Volume7, Supplement1,2005 Description of the Teeth In An Hour concept V Prefabricated Customized Temporary or final bridge: Temporary is inserted immediately after surgery Implant Planning with Digital Technology Digital technology for implant treatment planning requires: 1. CBCT to provide Dicomm Data (where available) 2. STL file or other Surface Scan of the clinical situation &Diagnostic Final Tooth Position 3. Implant planning software to integrate these images together and plan the case Van Steenberghe Clinical Implant Dentistry and Related Research, Volume7, Supplement1,2005 CBCT Dicomm Data STL. File or surface scan Straumann Guided Surgery Procedure Flow Straumann Guided Surgery Procedure Flow Import the DICOM Data From: Scanner CBCT Scanning Diagnostics & 3D implant planning Master model fabrication Guided surgery & guided implant insertion Surgical template fabrication To: codiagnostix Guided implants codiagnostix IO Scanning gonyx Guided surgery kit Straumann STRAUMANN January 26, 2012 Straumann STRAUMANN January 26,

15 Straumann Guided Surgery Procedure Flow Straumann Guided Surgery Procedure Flow Prosthetic Targets Virtual Teeth Implant Alignment Straumann Guided Surgery Procedure Flow gonyx Digital Surveyor Drill in position 15

16 Sleeve in position press fit into place Final surgical guide H6 H4 H2 Model prepared for analog through guide Transfer mount, analog, depth key H4 Analog to depth and position controlled by key and indicators Analog to depth and position 16

17 Temporary abutment and lab analog Temporary abutment in position Temporary abutment modified Temporary crown fabricated Screw retained temporary crown Temporary crown polished 17

18 # 9 Edentulous # 9 Edentulous 18

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20 ebite Digital denture Dicomdata 20

21 EDENTULOUS DIGITAL GUIDE Video 21

22 Guided Surgery Video 22

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25 CBCT Scan Isolating the arch of interest in the CBCT may be required so that subsequent position of the surface scan can be accurately performed. Consideration to the following: Retraction of the lips from the teeth Separating the upper and lower teeth STL or Surface Scan The surface scan can be produced in 2 ways: Directly from an intra oral scan of the patients mouth A conventional impression is made of the patients mouth which is either:» scanned itself in an impression scanner»poured with dental stone to produce a physical model which is subsequently scanned Int J Comput Dent. 2011;14(1): Full arch scans: conventional versus digital impressions an in vitro study. Ender A1, Mehl A. 25

26 STL or Surface Scan Accuracy for both techniques is similar, however the presence of large edentulous sites would be preferably managed with a conventional impression Direct Intra Oral Scan An intra oral scanner can be used to create the surface scan in the patients mouth directly Some of these scanners will require a powder application prior to scanning while others can scan without powder. Int J Comput Dent. 2011;14(1): Full arch scans: conventional versus digital impressions an in vitro study. Ender A1, Mehl A. Scan of the Model Implant Planning Software Implant planning software will enable the user to virtually plan the optimal implant position regarding the surrounding vital anatomic structures and the future prosthetic needs Computer technology Application in Surgical Implant Dentistry: A Systematic Review Int J Maxillofac Implants 2014:29(suppl)25 42 Implant Planning Software The design of the prosthesis can be: Virtually Planned A physical wax up or the final tooth position is also scanned Implant Planning Software The CBCT scan and the Surface scan of the clinical situation will be merged in the Implant Planning software to create the virtual patient Computer technology Application in Surgical Implant Dentistry: A Systematic Review Int J Maxillofac Implants 2014:29(suppl)

27 Implant Planning Software Accurate alignment is critical to ensuring that the resulting positioning of critical Implant Planning Software Alignment of the surface scan to the CBCT can be finely adjusted after automatic adaption based on software registration anatomical structures is precisely seen Implant Planning Software A virtual prosthesis design would be considered when there is adequate surrounding teeth to guide the clinician to the final tooth position. Implant Planning Software The virtual tooth plan can then be approved specifying the Implant Type, length and location This virtual prosthesis may be able to be imported to match with patient photographs providing a virtual patient for the previewing This is most likely indicated in: Single tooth replacement sites Short span posterior bridges Implant Planning Software Treating Clinicians will confirm the implant position When confirmed a virtual surgical guide can be designed for production Implant Planning Software Planning software can be useful tool to communicate to the patient and other clinicians involved in the treatment and the impact of boney deficiency and the requirement for augmentations 27

28 Implant Planning Software Decisions can then be made on the most optimal treatment sequence: Simultaneous implant placement and grafting Stage grafting procedures Implant Planning Software Implant Planning Software The virtual plan also allows for various implant types to be tried which may allow for less invasive treatment procedures to be performed Implant Planning Software The definitive prosthetic plan can be confirmed in the virtual treatment plan prior to implant surgery with virtual abutments being installed Bone Level Taper Implant Straight wall Implant Implant Planning Software Correct Emergence profiles can be planned Decision on Implant depth can be confirmed Screw vs cement retention can be decided upon Mean deviation in entry point 1.07mm ( mm) ACCURACY Mean deviation in Apex point 1.63mm (1.26 7mm) Schneider et al. Clin Oral Implants Res 20 (Suppl 4) 2009;73 86 A Systematic review on the accuracy and the clinical outcome of computer guided template based implant dentistry 28

29 ACCURACY Error in angulation 5.26 degree Surgical complications 9.1 % ACCURACY Meta Analysis review of the mean errors for implant placement using computer planned surgical guides are: Entry Point mean error 0.9mm (n=1530) Implant Apex mean error 1.3mm (n=1465) Angular deviation 3.5 degree (n= 1854) Schneider et al. Clin Oral Implants Res 20 (Suppl 4) 2009;73 86 A Systematic review on the accuracy and the clinical outcome of computer guided template based implant dentistry Computer technology Application in Surgical Implant Dentistry: A Systematic Review Int J Maxillofac Implants 2014:29(suppl)25 42 Limitations of the Computer generated surgical guides 1 The surgical armamentarium is long and access may be difficult. 2 No trial to approve the function and esthetics of the final prosthesis. 3 Planning of the implants too deeply into the osseous tissues may result in misfit of the flared abutments or the prosthesis Limitations of the Computer generated surgical guides 4 No flexibility of planning; No intra operative modifications of the plan 5 Accurate positioning of the guide in the mouth is critical 6 Cost benefit ratio to be considered 7 Limitations in accuracy 7 Limitations in accuracy Accuracy of Surgical guides is around 1 mm The average distance between the planned implant and the actual osteotomy was 1.5 mm at the entrance and 2.1 mm at the apex when the conventional guide was used. The same measurements were significantly reduced to 0.9 mm and 1.0 mm when the computer generated guide was used. Sarment et al. IJOMI 2003;18: Simple steps for success Fabrication of the acrylic resin template Dental CT scan Pre surgical digital implant plan Registration: correlate patient position to CT scan Computerized Guided procedure following virtual plan 29

30 Conclusion This technology today cannot replace clinical judgment. In all available systems we are still dependent on the CBCT scan accuracy. Computer guidance systems need more clinical studies on procedure s accuracy and reliability. Conclusion In well selected cases Computer guidance allows surgeons today to be precise, safe and time efficient. This technology brings benefits for the patient, the surgeon and the restorative dentist Conclusion Implant Planning can be readily performed using digital technology that allows: Comprehensive assessment of local factors to assist in identifying risks and enhancing outcomes Clinicians have the opportunity to trial different product prior to clinical treatment Fabrication of surgical guides consistent with the pre surgical plan Thank you for your attention 30