PROSTHETICALLY

DRIVEN IMPLANT
PLANNING
TITLE LOREM IPSUM Presented to: Dr. Ahmed Mortada
INTRODUCTION
Dental implants are employed in a range of various forms for several years. Since the mid ‑20th century, there has been a
rise in interest within the implant process for the replacement of missing teeth. Branemark was one of the initial pioneers
who applied scientifically based analysis techniques to develop an endosseous implant that forms an immobile connection
with bone. The requirement for an implant to completely address multiple physical and biological factors imposes
tremendous constraints on the surgical and handling protocol.
Diligence is compulsory during placement of implants. First, the implant should be placed in a way that bottom and sides
are completely covered by bone, or material for bone replacement. Second, neighboring anatomical structures mustn't be
damaged by the implant, especially the infra alveolar nerve and Schneider membrane of the sinus. In most cases dentist
depends their implant placement on the direct inspection after opening the flap and their pre-surgical planning for implant
placement is built on using the conventional radiographic assessments through panoramic and periapical radiographs
which has many limitations such as positional artefacts, distortion, expansion and error setting without getting information
concerning the bucco-lingual dimension of bone.
For that there was positioning errors because of unintended angular and linear deviations during osteotomy or drilling
sequences, reducing the degree of accuracy. Moreover, conventional technique has restricted capability to control precise
depth location of the implant within the apico-incisal position. In addition, as we are aware of, earlier dentists were
predominantly intended to put implants where there is sufficient bone, without taking into consideration the ideal position
for the fabrication of the individual crown or multiple unit prosthesis, which alter the demanded result because we didn’t
take in account the overall integration of prosthetic reconstruction and aesthetic, causing serious complications in
fabrication of final prostheses. That’s why the development of implant placement techniques was necessary for an accurate
placement to achieve a result that is functional and esthetic.
 The development of digital systems CAD/CAM (computer-aided design/computer-aided
manufacturing), the growing popularity and the advent of in-office cone beam CT
(computerized tomography) scanners and their introduction in diagnostic routine with 3D
knowledge of bone topography have improved diagnostics as a whole making a great
advancement in avoiding these type of complications mentioned above by developing the
“Guided surgery” protocol which consist to prepare a 3D surgical template within we can
place an implant in a position and in a depth already planned preceding the surgery in all three
planes: mesio-distal, apico- coronal and bucco-lingual via a software who allow practitioners
to view virtually the implant site with the given anatomical structure, and in the right
positioning for the future prosthesis.
It’s a “prosthetically driven guide”, to determine cement versus screw retained restorations
which will have different trajectory positions for the dentition and prosthesis. And so on, we
can get a pre-fabricated prosthesis capable to be connected to newly implants that are inserted
at the time of surgery, so that the opportunity for an immediate functional and aesthetic
loading. Moreover, in traditional surgical approach, in order to have good visibility of the
alveolar ridge, the surgeon make a muco-periosteal incision which is the origin of discomfort
of the patient while in GIS the surgeon can place the implant without raising a flap decreasing
discomfort of the patient, healing time, operating time, bone loss and increasing implant
stability.
Surgical guides can be divided into “dynamic” and “static”
 Dynamic:
Is characterized by guided navigation methods in which a system” computer-guided navigation”
helps the surgeon during the positioning of the implant via visual imaging tools on a monitor.
These methods are not currently widespread despite it’s very interesting in future perspective.
 Static:
Consist of using a surgical template that can be fabricated by Computer-Aided Design/
Computer-Aided Manufacturing (CAD/CAM) technologies (stereolithography or milling),
conventional procedures or modifying radiographic scan prosthesis.
 IMPLANT PLANNING PROTOCOL
 Radiological template
The radiographic template is a precise replica of the future prosthesis fabricated
from a diagnostic wax up. It permits the clinician to envision the location of
planned implant according to the restorative viewpoint. Many radiopaque
markers such as balls, stripes, gutta percha or metal pins can be placed at
different place on the occlusal plane like on the buccal surface and lingual/palatal
surfaces of the template, aiding in determination of the implant location. During
the fabrication procedure it should be considered some basic requirements, which
are as follows: It must be fabricated at the patient’s centric relation, and occlusal
vertical dimension and the teeth have to be positioned according to aesthetics and Figure 1: Radiographic guide with
phonetics. In addition, it should have adaptation of the soft tissue providing radiopaque gutta-percha markers
suitable stabilization during the scanning process. A vinyl polysiloxane inter
occlusal index is fabricated to stabilize the template during the CT scanning
process.
Currently, in partial edentulous cases, the procedure can be facilitated due to new
procedures and protocols named “surface mapping” allowing the matching
between 4-5 points on the patient’s dental cast, and the corresponding anatomical
surface points in the CBCT data, but provided that the patient have six remaining
teeth at least and distributed on 2 quadrants.
 Image acquisition
A full examination of hard and soft tissue is performed on each patient.
1. CBCT
The imaging information of hard tissues in CBCT is highly accurate. The patient
underwent a CBCT scan with a field of view of 10× 5cm, to collect a sufficient amount of
data that could also be superimposed. By the images obtained, implant surgeon is able to
determine the width and height of available bone, root anatomy and proximity of adjacent
teeth, soft-tissue thicknesses, and other vital structures in 3D.
Before implant planning, a critical principle is setting up an accurate orientation of the
patient’s position. The possibility to reorient patient’s volume with most CBCT and
implant planning software is a necessary feature because any orientation error is translated
to the cross sectional slices, knowing that the most important sections of the images are the
sagittal one, as cross sectional images, because they offer the width and height dimensions
and it shows if a bone graft is necessary in the site of placing the implant.
To recognize the correct position and orientation of the patient, the
orientation of the cranium is viewed from the coronal, sagittal, and
axial perspectives. Sagittal or anteroposterior axis must be at the same
level with occlusal plane. Axial tilt has to center the midline of the
patient in a way that the axial image viewed shows the patient’s face
straight forward not turning to the right or left. In this case, an
anatomic landmark can be used, the alignment of the posterior and
anterior nasal spines. The coronal axis must level horizontally the
occlusal plane so that any of the right or left side is lower or higher.
The cross sections seem to look like sagittal slices nearby the midline Figure 2: Multiplan reconstruction mode
of dental arch and progressively turn into coronal slices at the posterior
regions.
When CBCT software is used, there is an essential skill to know
how to make accurate cross sections at the site of implants such
as cross sections should be perpendicular to the curve of the
dental arch and level with occlusal plane or implant trajectory.
This principle confirms that accurate measurements can be taken
for vertical height and buccolingual width assessments. So in
case the patient’s cranium is sloped too far forward or backward
(chin up or down) the cross sections might obliquely cut
excessively through the vertical dimension, leading again to
measurement errors.
Figure 3: Cross sectional principle. (A) The correct orientation of patient’s cranium. (B) An incorrect orientation
as the patient’s chin is tilted too far down

Figure 4:Cross-sectional measurement errors with oblique slicing of the buccolingual dimension of the arch. (A)
Correctly sliced arch, perpendicular to the arch. (B) An oblique slice resulting distorted image leading to
measurement errors
This cross-sectional error can be particularly dangerous when determining the
length of an implant for a specific site and therefore can lead to unforeseen
clinical complications (nerve damage, sinus invasion).
In DICOM format, the CT data were imported into the software after the CBCT
data are acquired, which will then be used to place implants virtually into their
position.
2. Digital Impression
 The information for soft tissue is inaccurate in CBCT imaging
because of the poor contrast resolution of this technology, for this reason;
implant planning software packages incorporate optical scanning technology.
Like other three-dimensional scanners, they project onto the object, a light
source (structured light, or laser) to be scanned providing accurate information
about teeth contour as well as soft tissue profile.
 A digital impression can be created by 2 ways: intra oral scanning (direct) or
extra oral scanning by scanning casts (indirect).
A. Intra oral scan
 Scanning includes maxillary arch, mandibular arch and the bite taking
particular care when scanning neighboring soft tissue and teeth next to
edentulous section. Then, a 3D surface model is created by triangulated point
clouds generated by scanning software after being captured by a sensor when
scanning tissues.
There are different Intra oral scan in the market:
- Trios 3®, 3-Shape, Denmark; Copenhagen: Trios 3® is the 3 rd IOS fabricated by 3-
Shape. Trios 3® is a powerful and extremely fast structured light scanner. It produces
high quality in color images with its special features integrated, such as: HD Photo
Function®, the Real Color Scan®, and Digital Shade Determination®: these are
interesting in differentiating gingival tissues and the natural tooth structure, helping
dentists to recognize the margin lines.
- True Definition®, 3M Espe, MN, USA, S. Paul
True Definition® is the 2nd IOS fabricated by 3M. It’s a structured light scanner
which uses a pulsating visible blue light, and it works under the principle of active
wavefront sampling, a 3D video technology. This scanner requires “dusting” of the
surface to be scanned, with titanium oxide powders. These titanium dioxide
particles work as randomly distributed landmarks for the optical system.
- CS 3600®, Carestream, NY, USA, Rochester
CS 3600® works according to the principle of the active speed 3D video. CS
3600® is a powerful structured LED light scanner; it does not require powder and is
able to provide high-quality color images. The scanner comes with different sized
tips for scanning the frontal and posterior areas.
- Omnicam®, Sirona Dental System GmbH, Germany, Bensheim
Cerec Omnicam® is the last and more powerful of Sirona IOS. It is a
structured light scanner that uses a white LED and it works under the
principle of optical triangulation and confocal microscopy. It doesn’t
require powder and it offers true-color information. The dimensions of
the scanner (228 x 16 x 16 mm) are limited and the tip is not too big, Figure 5: Four different IOS
therefore it is easier to scan the posterior areas.