Dental Tribune Pakistan Edition No. 6, 2015

Editor - Online Haseeb Uddin CLINICAL PRACTICE6 DENTAL TRIBUNE Pakistan Edition November 2015 Digital implantology— Predictable aesthetics and functional results oday we are standing on the verge of a digital revolution in dentistry. The digitalisation will offer a new infrastructure in the treatment of our patients. This article will focus on the digital treatment planning that is possible in an ordinary general dental practice today. There will be some remarks about the needed hard- and software in order to get an over view of the possibilities and pitfalls before acquisition. We will look at the possibilities with tooth-borne surgical guides, since the topic regarding treatment of edentulous patients with surgical guides has been covered extensively in the past. Before treating any patient, we need a treatment plan. In a simple composite case, a plan in the mind of the dentist might be enough. But when we move to more complex cases, the need for a thorough blueprint becomes essential. The following sequence is based on the assumption that the patient has healthy joints, relaxed muscles with a balanced occlusion in centric relation (CR). If this is not the case we recommend you take care of these issues before any final prosthetic treatment. In order to achieve the most predictable treatment outcome, we recommend the following protocol, which can be used with and without implants. 1. Photos – extraoral and intraoral. DSD (Digital Smile Design) 2. Video (optional for emotional patient communication) 3. Models (digital or stone) 4. Facebow registration 5. CR bite registration 6. Protrusive bite registration or a digital movement analysis 7. Cone beam scan in implant cases 8. Wax-up. It is most important to get the patient expectations in alignment with the dentist before starting detailed treatment planning. We need to know what the patient wants in order to deliver it to the patient. To be able to communicate effectively with the patient, we need to know ourselves and we need to know our clinical abilities and limitations before applying our work. In my opinion, the patient experience is essential in case presentation. Clinical photos both extraorally and intraorally are the first step in the treatment planning process. We recommend that you start with the protocol from AACD (American Academy of Cosmetic Dentistry) or DSD (Digital Smile Design by Christian Coachman). These are well documented protocols and contain all the basic photos needed. The photos will be used following the DSD protocol to visualise the end result to the patient and in communications with specialists and the dental lab (if needed). The DSD protocol enables a multidisciplinary treatment planning process without seeing the patient in the practice. Every step is done through a free cloud-based service. It is inexpensive, flexible and easy to do. The data from the DSD is transferred to a model of the patient (Figs. 1a–d). This can be done on a stone model or a digital model. With the models aligned, it is possible to make an additive wax-up with the exact proportions of the DSD. With a stone model, we make a silicone stent that is carefully trimmed. We fill it with a bis-acrylic material and position it in the mouth of the patient. With a digital wax-up we need to make a composite shell that is either milled or printed on a 3-D printer. The shell can be glued into position with bis-acrylics or flowable composite. With the try-in smile we take a series of photos. The photos will be used to verify with the patient that we are on the right track. If needed, the try-in smile can be adjusted until the wanted result is achieved. If we make any corrections, a new impression is taken for our final treatment plan. Once the patient has accepted the treatment plan, we proceed with a functional wax-up. The functional wax-up will guide the treatment of the patient. It will enable us to visualise the final restorations. At this point we can decide exactly what will be: the ideal implant position; the ideal abutment; the ideal restorative material; the ideal shape of the restoration; the need for grafting (hard and soft tissue). The easiest way to achieve the most precise functional setup is by using the Arcus Digma (KaVo; Fig. 2). It is the only system that enables you to make a very detailed motion analysis (10 microns) that replicates the jaw movements exactly by utilising computer technology. Arcus digma has a bite-fork that makes it easy to position the upper jaw in the articulator.Afully adjustable articulator or a digital articulator is preferred. It is critical to get a perfect bite registration in CR. The functional wax-up can be generated semi- automatically in the CAD/CAM software by using the data gathered from the models and functional movements. Alternatively, we do it the old fashioned way by adding wax to the stone model. (Note that the precision of the wax-up will reflect the care taken to acquire the diagnostic information.) With the wax-up approved by the dentist, the placement of the implant can be performed in the cone beam imaging software. We use the OnDemand software by Cybermed Inc. The software has a fair price. It can handle all DICOM based cone beam images. The In2Guide plugin (in OnDemand) enables you to do the implant planning with whatever guide system you prefer (i.e. Straumann, Nobel Biocare, Zimmer, etc.). Usually we use the universal drill kit developed for the In2Guide system. It gives the user the ability to place any implant on the marked with this single drill kit. The only brand specific tools needed is the implant driver and a prosthetic kit. Another advantage of the In2Guide software is that you don’t have to segment the cone beam image or export it into third party software. The planning is done in the same software as where you do your diagnosis. In my opinion, this makes it easier to implement in the practice. One note about guide sleeves. The In2Guide software enables you to choose whatever guide sleeves you want to use. There is a huge difference between the distance from the coronal implant surface and the guide sleeve among the different guide systems (Figs. 3a-d). Care should be taken not to place the guide sleeves in contact with any hard or soft tissue. It is a great feature to be able to choose the system that fits your preferences. In order to make a tooth-retained guide, we make a cone beam image of the patient. (Note the required size of the field of view [FOV]. You need enough teeth and bone to make a guide.) A model of the soft tissue and high precision surface of the teeth is merged with the cone beam image in order to make a good fitting surgical guide. The model can be scanned by a labscanner or by the cone beam scanner.An option to make an intraoral scan is available, but currently only for treatment planning. The intraoral model will be displayed as a green outline in the In2Guide software (Figs. 4a & b). Since we know the ideal distance from a bone level implant to the surface of the soft tissue is 3mm, we place the chosen implant type (from the In2Guide library with almost all commercially available implants) and plan the positioning in the third dimension. Now we are able to measure the distance from the implant to the surface of the soft tissue. Hereby we can achieve an ideal emergence profile. We can measure the distance from the implant to the top of the guide sleeve to verify correct depth of the implant during surgery. At the same time, we get to know if there is sufficient bone support for the implant or if we have to graft. The ability to plan any grafting procedure in advance of the operation gives a better predictability, patient compliance and effective scheduling of the surgery. Looking at the intraoral photos and Fig-1a Fig-1b Fig-1c Fig-1d Fig-2 Fig-3a Fig-3b Fig-3c Fig-3d Fig-4a Fig-4b Fig-5a Fig-5b Fig-5b By Dr Jesper Hatt, Denmark T

Dental Tribune Pakistan Edition No. 6, 2015

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