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Creating Surgical Guides Using CBCT and Intraoral Scanning “missing” teeth, and had also lost a number of teeth after failed endodontic procedures. The patient was first seen by the Department of Oral and Maxillofacial Surgery of Virginia Commonwealth University’s School of Dentistry, with a stated desire for using dental implants to restore the missing teeth. The patient was referred to my private practice for an evaluation of his restorative needs. Treatment Plan After a discussion of the alternatives, benefits, and complications of treatment options, the patient stated that he wished to receive implant restorations. Following a discussion of financial considerations, it was agreed that the treatment plan would be divided into several phases. Phase one would be to place two implant fixtures in the area of tooth #29 and tooth #30. It was agreed that a custom surgical guide would be created using CBCT and digital scanning technology, for the ultimate purpose of facilitating guided placement of the dental implants. Scan Procedure A full-arch optical scan of both maxillary and mandibular arches with a centric record of the teeth in maximum intercuspation was taken using the iTero intraoral scanning unit. The resultant generic STL data files, the standard CAD/CAM file format, were exported directly from this user’s “MyAligntech” account. A CBCT scan was taken with a NewTom CBCT scanner (ImageWorks; Elmsford, N.Y.) and the resultant DICOM data files exported to the In2Guide (Cybermed; Irvine, Calif.) software. The DICOM and STL files types were then merged via the In2Guide software to produce a 3-D rendering. Virtual Planning Using the principles of “crown down” planning, a virtual waxup added the crown morphology to represent a mandibular right second bicuspid (tooth #29) and a mandibular right first molar (tooth #30) (Fig. 2). Using the implant placement planning features of the In2Guide software, an optimized position for each of the implant fixtures was developed. This case demonstrates the value of virtual planning, as there were several anatomical and dental issues requiring close attention to fixture placement detail. The mandibular second molar is mesial-tipped, presenting a clearance and path of insertion issue for the prosthetic restoration of the implant fixture. Further, the hard tissue anatomy exhibits limited freedom of placement, given the position of the inferior alveolar canal, mental foramen, and lingual Figure 2: In2Guide planning software with virtual wax-up of tooth #29 and #30 mylohyoid concavity. With the virtual planning complete, the completed implant fixture placement was submitted for CAD processing. Surgical guide In a 100 percent digital environment, a model-less printed surgical guide was produced by the Cybermed In2Guide manufacturing process. The surgical guide was delivered in a sealed package for patient try-in. Planned visual cutouts allowed verification of proper seating of the surgical guide (Fig. 3). Prior to the surgical appointment, the surgical guide was trial fitted to the mandibular dentition (Fig. 4), and optimal fit confirmed (Fig. 5). Surgical Procedure After a review of the patient’s health history, including basic vital signs such as blood pressure and pulse, informed consent was received. The patient was given two 1.7 ml carpules of Lidocaine Hydrochloride 2% with 1:100,000 Epinephrine. Upon profound local anesthesia, with the surgical guide in place, a single disposable tissue punch (Fig. 6) was used to remove a precise cylinder of tissue to access the mandibular ridge of bone at the planned implant surgical site. NobelGuide drill guides and guided drills (Nobel Biocare; Yorba Linda, Calif.) were used to perform the surgical procedure. The drill series consisted of an initial “flare” drill (Guided Start Drill) (Fig. 7), a 2 mm depth drill (Guided 2.0 Twist Drill) used with a precise drill guide (Fig. 8), and sequential full-depth drills (Guided Tapered 84 – www.inclusivemagazine.com –
Figure 3: In2Guide surgical guide created with cutouts to verify full seating Figure 6: Disposable tissue punch used with surgical guide in place Figure 4: Intraoral occlusal view of In2Guide surgical guide during try-in. Note the seating verification cut-outs. Figure 7: First sequence flare drill used to perform the surgical drill procedure Figure 5: Occlusal view of In2Guide surgical guide. Note full seating and excellent retention. Figure 8: In2Guide with collimator for the 2 mm surgical drill – Creating Surgical Guides Using CBCT and Intraoral Scanning – 85
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Inclusive Restorative Driven Implan
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Contents 19 Restoring Mandibular Si
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Publisher Jim Glidewell, CDT Editor
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Contributors ■ Bradley C. Bockhor
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Trends in Implant Dentistry Average
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my first implant with Jack A. Hahn,
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The House that Jack Built Inspired
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Hygienist’s Corner A Probing Ques
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Probe using only 0.15 Ncm of pressu
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Restoring Mandibular Single Teeth w
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Figure 4: Cross-sectional view of p
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Figure 13: Seated provisional resto
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Figures 26a, 26b: Acrylic abutment
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IMPLANT POSITION IN THE ESTHETIC ZO
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type of connection between implant,
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SMALL DIAMETER implants Planning fr
Page 35: Mandibular Spacing Maxillary Spacin
Page 38: used before the patient even presen
Page 42 and 43: BB: Sounds like it’s a truly inte
Page 44 and 45: Figure 6: Double-cord tissue retrac
Page 46: It’s a great time to be in dentis
Page 51 and 52: CLINICAL TIP Go online for in-depth
Page 53 and 54: 5a Figures 5a, 5b: A new bite regis
Page 55 and 56: Photo Essay: Immediate and Post-Pla
Page 57 and 58: 4a On the day of surgery, the risks
Page 59 and 60: With the implant securely hand-thre
Page 61: Case #2: Post-Placement Utilization
Page 65 and 66: 7a Once an appropriate osseointegra
Page 67 and 68: CLINICAL TIP When a Flapless Approa
Page 69 and 70: LAB SENSE Go online for in-depth co
Page 71 and 72: Digitally (CAD) Designed vs. Waxed
Page 73 and 74: mitigate the painful and disruptive
Page 77 and 78: Go online for in-depth content Trea
Page 79 and 80: BB: For the sake of our audience, c
Page 81 and 82: A lot of times, having the prosthes
Page 83 and 84: the time, and then I will prescribe
Page 85: Go online for in-depth content Crea
Page 89 and 90: Figure 13: Implants torqued to full
Page 91 and 92: Figure 22: Teflon plumber’s tape
Page 93 and 94: “Rules of 10” Guidelines for Su
Page 95 and 96: Some added concern is focused on th
Page 97 and 98: The all-on-four concept generally r
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