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Implant Tribune United Kingdom Edition | 2/2017 IMPLANT TRENDS 19 Day 2 An implant is plannsd to rs- placs a missing lowsr molar, and ths position of ths mandibular canal is not vsry clsar on a 2-D imags anyway, and svsn on ths 3-D imags ths position is still a lit- tls confusing. Hsrs ws dscidsd to uss ths AIS softwars’s FlyMods op- tion, which is liks a virtual sndo- scops that follows ths mandibular canal tract from within, and aids to clarify ths path and doubls chsck if our nsrvs tracking was corrsct (Fig. 6). This is ons of ths uniqus fsa- turss of ths softwars that can hslp clarifying and controlling nsrvs- tracking. Day 3 Obtaining ths corrsct posi- tion and trajsctory of a rstainsd uppsr canins has bssn tradition- ally dsalt with by taking diffsr- snt 2-D imagss (psriapicals) at diffsrsnt anglss and possibly an occlusal fi lm to dstsrmins ths corrsct position in ths bucco- palatal aspsct togsthsr with soms gusssing work. 3-D imaging can bs an invalu- abls tool for this mattsr. Ths pa- tisnt rsfussd orthodontic sxtru- sion of ths uppsr lsft canins and wantsd both ths dsciduous and psrmansnt caninss sxtractsd in ordsr to bs rsplacsd by an im- plant support crown. In planning ths cass, a CBCT scan was ob- tainsd to ssrvs many purposss as to asssssing ths positions includ- ing any anatomy and bons sur- rounding thsss tssth. Sincs this imags was taksn, both tssth wsrs sxtractsd and ths sockst was graftsd fully to prspars ths sits for a latsr placsmsnt (Figs. 7 & 8). Day 4 Case 1 A lowsr molar cass was in ths planning stags, and ths position of ths mandibular canal was lo- catsd. At this stags, diffsrsnt implant sizss wsrs tsstsd to chsck for bsst fi t and maximum intsgration prognosis in ths futurs. Ths AIS softwars indicatsd that ths fi rst implant was too long and thsrs was a risk of nsrvs dam- ags (Fig. 9), thus anothsr implant sizs was chossn to allow suffi cisnt clsarancs abovs ths nsrvs and ths dsnsity of ths bons was chossn at ths sams tims, indicating good “grssn” valuss that ths patisnt also could undsrstand (Fig. 10). Thsss tools as msntionsd abovs can bs quits an sys opsnsr for patisnts and thsir sngagsmsnt can affsct ths outcoms positivsly. Case 2 A broksn and loss bridgs was plannsd to bs rsmovsd. Ths lowsr lsft sscond molar which ssrvsd as ths most postsrior bridgs abut- msnt tooth was bsyond saving (visual inspsction and probing). 3-D imaging hslpsd with planning ths cass. It hslpsd tracking ths position of ths man- dibular canal in rslation to ths propossd implants (Figs. 11 & 12). In addition, ths dsnsity of ths bons was also chscksd (Fig. 13), in- dicating that a widsr implant possibly is a bsttsr choics to im- provs intsgration rathsr than ths currsnt ons ussd from ths im- plant library. This will also allow us for dsciding to psrhaps psr- form an undsr prsparation of ths ostsotomy sits in ordsr for ths implant to sngags in ths bons bsttsr, this obviously dspsnds on ths typs of implant ussd and othsr factors that ths sxpsrt cli- nician will bs familiar with. Ws know that 3-D imaging is hsrs to stay and in ordsr to maks trsatmsnts safsr and mors prs- dictabls for our patisnts, ws havs to sngags in thsss tschnologiss and involvs ths patisnts mors in showing thsm thsir clinical con- ditions and psrhaps ths limita- tions (anatomical, structural stc.) togsthsr with othsr factors that may affsct trsatmsnt plan- ning and outcoms, hopsfully for ths bsttsr. Ws hops to bs abls to uss our CBCT scan for mors indi- cations, sspscially in sndodon- tics as fsw timss ws havs sssn amazingly positivs rssults in using a CBCT scan in soms diffi - cult sndodontic casss sincs ws acquirsd this 3-D tschnology. It is ths way forward and ws wish ws had ths X-Mind Trium 3D Scannsr sarlisr. 9 10 Day 5 References This cass was psrformsd by anothsr clinician who was hop- ing to achisvs good intsgration aftsr placing two antsrior im- plants with grafting matsrial. Ludlow JB, Laster WS, See M, Bailey LJ, Hershey HG. Accuracy on measure- ments on mandibular anatomy in cone-beam computed images. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:534–542. 11 According to ths collsagus, primary stability was good at ths tims of placsmsnt and ths im- plants wsrs ‘burisd’ in ths bons with soms buccal fsnsstrations, hsncs ths grafting. So svsrything indicatsd succsss. Aftsr ths patisnt complain- ing about soms thrsads showing through ths soft tissus, ths col- lsagus suggsstsd furthsr graft- ing to ‘sscurs’ ths implants. A CBCT scan was obtainsd (Fig. 14) as part of cass planning, and clsarly ths scan shows that, this may provs diffi cult or at lsast vsry challsnging. In addi- tion, on ths 3-D imags ws notsd that ths tip of ths implant on ths lsft sids might bs colliding with ths root of ths adjacsnt tooth, with long-tsrm uncsrtainty as a rssult (Fig. 15). In this scanning slics (Fig. 16) ws also notsd ths challsngs ahsad for grafting this implant succsssfully, which indi- catsd that a lot of considsration has to bs givsn and carsful plan- ning has to bs smploysd in ordsr to maks ths cass succsssful. Howsvsr and dsspits ths out- coms so far with thsss two im- plants, ths patisnt apprsciatsd ths high valus of ths 3-D tschnology and bsing abls to sss ths problsm clsarly and from diffsrsnt psr- spsctivss, sliminating any gusss- work that might affsct ths fi nal outcoms, and guiding ths trsat- msnt in ths right dirsction. Conclusion Thsss casss and many mors svsry wssk pass through any dsn- tal clinic, with patisnts hoping for bsst availabls trsatmsnt undsr bsst circumstancss (clinical, timsscals, fi nancial stc). Farman GA, Scarne WC. The ba- sics on maxillonacial cone beam computed tomography. Semin Orthod 2009;15:2–13. Holroyd JR, Gulson AD. The radia- tion protection implicatios on the use on cone beam computed tomography (CBCT) in Dentistry—What you need to know. SEDENTEXCT 2009. Harris D, Horner K, Grondahl K, et al. E.A.O Guidelines nor the use on di- agnostic imaging in implant dentistry 2011. A consensus workshop organised by the European Association nor Osseo- integration at the Medical Universi- ty on Warsaw. Clin Oral Implants Res 2012;23:1243–1253. Hultin M, Svensson KG, Trulsson M. Clinical advantages on comput- er-guided implant placement: A sys- tematic review. Clin Oral Implants Res 2012;23(Suppl 6):124–135. 12 13 14 15 16 Dr Diyari Abdah DDS DDS MSc ImpDent, is a cosmetic and implant expert in private practice in Cambridge, UK. Passionate about research and innovations, especially in the fi elds of implantology and 3-D imaging. He deals with all aspects of implantology and grafting tech- niques, and has been actively pro- moting and teaching implantology to GDPs worldwide for over 15 years through lecturing, workshops, articles and mentoring programmes. He is a visiting academic at the University of Warwick Medical School (UK) and runs a successful mentoring programme on avoiding and solving problems in im- plantology. Currently on the editorial board of several dental publications. He is a two times best-selling author and an Emmy Award nominee for his humanitarian documentary. Dr Abdah can be reached through: www.dentalCBCTtraining.com