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ePaper created 2017-08-25, 17:58:13 | version 1.38.0
guided implant reconstruction case report | the denture and prevent pressure on the nerve. The limitation of available keratinised tissue was initially managed to the comfort and cleansability for the patient. At the time of implant placement, the RFA/ISQ val- ues were recorded. The initial values were actually ac- ceptable if immediate loading was desired (over 70), based upon the excellent stability afforded by the thread design of the implant engaging the buccal and lingual cortex, and apical length into native bone. A two-stage approach was elected due to the large hollow areas in the symphysis, which were grafted and covered with PRF. At three months, the implants were found to be covered with a thin layer of imma- ture bone, and the intermedullary area seemed solid. A second series of measurements were recorded to reflect the status of integration. All values increased significantly, verifying that the process of osseointe- gration was progressing positively, and loading was appropriate. Overdenture abutments (Meg-Rhein) were secured to each implant, and stainless steel housings with retentive caps were embedded into the denture. Discussion As technology becomes more available to clini- cians worldwide, our ability to diagnose and plan with improved accuracy and consistency can only be seen as a huge benefit. The use of 3-D printing has now become an affordable option for both group practices and single practitioners, therefore making it possible to produce accuracy biomedical models that greatly enhance the diagnostic and treatment planning phase. DICOM data can be exported to standard files that can be managed in software that drives 3-D printers to fabricate models of the mandi- ble or the maxilla. The CBCT dataset from the case presentation contained within this article was ex- ported as a standard triangulation language (STL) file and imported into the 3-D printer software (PreForm Formlabs; Fig. 21). The importance of having an actual model in- hand cannot be underestimated. For this particular case presentation, the 3-D printed model was fabri- cated using a process known as stereolithography by an in-office 3-D printer, the Form 2 (Formlabs). The surface detail is excellent, and provides not just an excellent diagnostic aid, but a method to educate our patients on the recommended treatment plan based on a physical model that can be viewed and touched. It has been demonstrated that these models can be successfully used for guided surgery applications, and for other bone grafting guides such as a ‘sinus- lift’ or ‘harvest’ guide. The virtual 3-D reconstructed surface model can be seen in Figure 22a, and the 3-D printed model in Figure 22b. The position of the bi- lateral mental foramina can be clearly seen, as well as the intramedullary bone within the ramus, and the anterior symphysis where the hollow areas were noted. These models can also be utilised to simulate the actual surgical approach to validate the procedure and for surgical guide fabrication. This singular case illustrates many important as- pects about treatment planning for dental implants. To minimise the diagnosis phase, and to suggest that clinicians do not need to use ‘expensive’ equipment as an aid to implant planning is not appropriate in to- day’s world of the digital workflow where we need to avoid complications to insure that we offer our pa- tients the correct treatment. Some have suggested that technology is used in place of sound thinking, or that the computer makes the decisions for the posi- tioning of the implants. To suggest that when we use computers to help plan the case that we are not using our brains, or that computers are making the deci- sions about where implants are placed is an incorrect assessment of the state-of-the-art. Technology, when used properly, expands our brain power by providing clinicians with the necessary in- formation to make educated decisions for our pa- tients. To negate the use of technology due to per- ceived ‘increased costs’ or that 2-D radiography is sufficient for implant planning is a potentially dan- gerous approach—relying on 2-D imaging requires guesswork, and there is no place for guessing when drilling into bone. Whether clinicians use ‘guided’ sur- gery, use surgical templates, or place implants totally ‘freehand’, it is important that our minimal standards be to use 3-D imaging and interactive treatment plan- ning software applications to provide a ‘blueprint for success’, to avoid complications, reduce morbidity, with the ultimate goal to help facilitate the restora- tive phase that provide patients what they want, teeth. Remember: ‘It's not the Scan, it's the Plan’!_ Tab. 1 Table 1: RFA/ISQ values over time. about Dr Scott D. Ganz maintains a private practice for prostho- dontics, maxillofacial prosthet- ics and implant dentistry in Fort Lee, New Jersey, USA. Co-Director of Advanced Implant Education (AIE). He has served as President of the New Jersey Section of the American College of Prosthodontists and of the Computer Aided Implan- tology Academy. Dr Ganz delivers presenta- tions worldwide on both the surgical and restorative phases of implant dentistry, and has published extensively on these topics. He is considered one of America’s leading experts in the evolution of computer utili- sation and interactive software for diagnostic and treatment planning applications using CT and newer-generation CBCT imaging modalities. CAD/CAM 3 2017 31