Tạp chí nha khoa CAD/CAM Vol4 tháng 2/2013

Tạp chí nha khoa CAD/CAM Vol4 tháng 2/2013

issn 1616-7390 Vol 4 • Issue 2/2013

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_This year’s most important event in the dental industry—the International Dental

Show (IDS) in Cologne is behind us IDS once again succeeded in showcasing the highest level

of innovation in dentistry, and IDS 2013 was all about digital dentistry

CAD/CAM procedures now not only offer improvements in preventative care, treatments,

and laboratory procedures so important for dental professionals, but also give patients a

virtually unprecedented opportunity to see the desired treatment outcome, and experience

the benefits of engineering expertise and medical advancement directly

Backward planning, as it is called, is increasingly becoming integrated into dental

procedures and dental laboratory processes The more complex the medical procedures

it is used with, the greater the benefits it offers will be Dental implants are a good example

because the treatment outcome depends greatly on consultation Dentists and dental

technicians can now work with data from 2-D and 3-D radiographs captured using CBCT

and facial scanners, as well as with data obtained from classic or digital dental impressions

This allows the creation of precise digital surgical guides, for example, that ensure dental

implants will be placed in exactly the right position and at precisely the right angle Any

crowns or bridges subsequently seated will be in the optimal position too In addition, the

emergence profile can be designed to have as natural an appearance as possible

This issue of CAD/CAMdiscusses some of these new procedures, and I hope that these

articles will aid you in applying these methods in your practice to improve your work to your

patients’ benefit in particular

Yours sincerely,

Magdalena Wojtkiewicz

CAD0213_03_Editorial 20.06.13 11:29 Seite 1

06 Stem cellsin implant dentistry

| Dr André Antonio Pelegrine, Brazil

10 CAD/CAM and growth factors

—Key areas of dental innovation

| Dr Nilesh R Parmar, UK

12 Straumann’s coPeriodontiX:

3-D digital bone measurement using cross-sectional

CBCT image datain periodontal issues

| Drs Jonathan Fleiner, Andres Stricker & Dirk Schulze, Germany

Iopinion

16 Time provenclinical success of the SHORT™implant

| Prof Dr Mauro Marincola, MDS Angelo Paolo Perpetuini,

Dr Stefano Carelli, Prof G Lombardo, Italy & Dr Vincent Morgan, USA

Icase report

20 One-visit guided treatment thanks to

CAD/CAM and CBCT

| Dr Josef Kunkela, Czech Republic

26 Fabrication of a customised implant abutment using

CAD/CAM: A solution specific to each clinical case

| Dr Thierry Lachkar, France

30 Improving esthetics in CAD/CAM dentistry

| Drs Nelson RFA Silva & Paulo Kano, Brazil, Dr Eric Van Dooren,

Belgium, Dr Cristiano Xavier, Brazil, Dr Jonathan L Ferencz, USA,

Emerson Lacerda, Brazil

Iindustry report

34 Produce therapy splints via CAD/CAM

with Schütz Dental technology

| Daniel Kirndörfer, Germany

38 Newest Developmentsin the European dental prostheticsand CAD/CAM devices segments

| Dr Kamran Zamanian & Ceren Altincekic, Canada

40 “Innovation is in our corporate DNA”

| An interview with 3Shape chief technology officer Tais Clausen

Iindustry news

42 Straumann’s new service:CARES Scan & Shape

| Straumann

Imeetings

44 Conceptsin implant therapy discussed

| Osteology Foundation celebrates anniversary meeting in Monaco

46 Singapore hosts secondAsia Pacific CAD/CAM and Digital Dentistry International Conference

| Dr Dobrina Mollova, UAE

48 InternationalEvents

Iabout the publisher

49 | submission guidelines

50 | imprint

Cover image courtesy of Institut Straumann AG

issn 1616-7390 Vol 4 • Issue 2/2013

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Ispecial _ science & practice

_The human body contains over 200 different

types of cells, which are organised into tissues and organs that perform all the tasks required tomaintain the viability of the system, including re-production In healthy adult tissues, the cell popu-lation size is the result of a fine balance between cellproliferation, differentiation, and death Followingtissue injury, cell proliferation begins to repair the

damage In order to achieve this, quiescent cells(dormant cells) in the tissue become proliferative, orstem cells are activated and differentiate into theappropriate cell type needed to repair the damagedtissue Research into stem cells seeks to understandtissue maintenance and repair in adulthood and the derivation of the significant number of cell typesfrom human embryos

It has long been observed that tissues can dif ferentiate into a wide variety of cells, and in the case

-of blood, skin and the gastric lining the ated cells possess a short half-life and are incapable

differenti-of renewing themselves This has led to the idea that some tissues may be maintained by stem cells,which are defined as cells with enormous renewalcapacity (self-replication) and the ability to gen -erate daughter cells with the capacity of differen -tiation Such cells, also known as adult stem cells,will only produce the appropriate cell lines for thetissues in which they reside (Fig 1)

Fig 1_A stem cell following

either self-replication

or a differentiation pathway.

Fig 2_Different tissues originated

from mesenchymal stem cells.

Fig 3_The diversity of cell types

present in the bone marrow.

Fig 4a_Point of needle puncture

for access to the bone marrow space

in the iliac bone.

Fig 4b_The needle inside

the bone marrow.

Fig 5a_A bone graft being

harvested from the chin (mentum).

Fig 5b_A bone graft being harvested

from the angle of the mandible

(ramus).

Fig 5c_A bone graft being harvested

from the angle of the skull (calvaria).

Fig 5d_A bone graft being

harvested from the angle of the leg

(tibia or fibula).

Fig 5e_A bone graft from

the pelvic bone (iliac).

Fig 6_A critical bony defect created

in the skull (calvaria) of a rabbit.

Fig 7_A primary culture of adult

mesenchymal stem cells from the

bone marrow after 21 days of culture.

Fig 8a_A CT image of a rabbit’s skull

after bone-sparing grafting without

stem cells (blue arrow) Note

that the bony defect remains.

Fig 8b_A CT image of a rabbit’s

skull after bone-sparing grafting with

stem cells Note that the bony defect

has almost been resolved.

Fig 9_A bone block from

a musculoskeletal tissue bank

CAD0213_06-09_Pelegrine 20.06.13 11:31 Seite 1

Not only can stem cells be isolated from both

adult and embryo tissues; they can also be kept

in cultures as undifferentiated cells Embryo stem

cells have the ability to produce all the

differenti-ated cells of an adult Their potential can therefore

be extended beyond the conventional mesodermal

lineage to include differentiation into liver, kidney,

muscle, skin, cardiac, and nerve cells (Fig 2)

The recognition of stem cell potential

un-earthed a new age in medicine: the age of

regener-ative medicine It has made it possible to consider

the regeneration of damaged tissue or an organthat would otherwise be lost Because the use ofembryo stem cells raises ethical issues for obviousreasons, most scientific studies focus on the ap -plications of adult stem cells Adult stem cells arenot considered as versatile as embryo stem cellsbecause they are widely regarded as multipotent,that is, capable of giving rise to certain types ofspecific cells/tissues only, whereas the embryostem cells can differentiate into any types ofcells/tissues Advances in scientific research havedetermined that some tissues have greater diffi-

combined with a bone marrow concentrate.

Fig 10a_A histological image

of the site grafted with bank bone combined with bone marrow Note the presence of considerable amounts of mineralised tissue.

Fig 10b_A histological image

of the site grafted with bank bone not combined with bone marrow Note the presence of low amounts

Fig 5d Fig 5e Fig 6

Fig 5a Fig 5b Fig 5 c

CAD0213_06-09_Pelegrine 20.06.13 11:31 Seite 2

Ispecial _ science & practice

culty regenerating, such as the nervous tissue,whereas bone and blood, for instance, are consid-ered more suitable for stem cell therapy

In dentistry, pulp from primary teeth has beenthoroughly investigated as a potential source ofstem cells with promising results However, the regeneration of an entire tooth, known as thirddentition, is a highly complex process, which de-spite some promising results with animals remainsvery far from clinical applicability The opposite hasbeen observed in the area of jawbone regeneration,where there is a higher level of scientific evidencefor its clinical applications Currently, adult stemcells have been harvested from bone marrow andfat, among other tissues

Bone marrow is haematopoietic, that is, ble of producing all the blood cells Since the 1950s,when Nobel Prize winner Dr E Donnall Thomasdemonstrated the viability of bone marrow trans-plants in patients with leukaemia, many lives have been saved using this approach for a variety

capa-of immunological and haematopoietic illnesses

However, the bone marrow contains more thanjust haematopoietic stem cells (which give rise

to red and white blood cells, as well as platelets, for example); it is also home to mesenchymal stem cells (which will become bone, muscle and fattissues, for instance; Fig 3)

Bone marrow harvesting is carried out underlocal anaesthesia using an aspiration needlethrough the iliac (pelvic) bone Other than requir-ing a competent doctor to perform such a task, it is

not regarded as an excessively invasive or complexprocedure It is also not associated with high lev-els of discomfort either intra or post-operatively(Figs 4a & b)

Bone reconstruction is a challenge in dentistry(also in orthopaedics and oncology) because re-building bony defects caused by trauma, infec-tions, tumours or dental extractions requires bonegrafting The lack of bone in the jaws may impedethe placement of dental implants, thus adverselyaffecting patients’ quality of life In order to rem-edy bone scarcity, a bone graft is conventionallyharvested from the chin region or the angle of the mandible If the amount required is too large,bone from the skull, legs or pelvis may be used Unlike the process for harvesting bone marrow, theprocess involved in obtaining larger bone grafts

is often associated with high levels of fort and, occasionally, inevitable post-operativesequelae (Figs 5a–e)

discom-The problems related to bone grafting have couraged the use of bone substitutes (syntheticmaterials and bone from human or bovine donors,for example) However, such materials show infe-rior results compared with autologous bone grafts(from the patient himself/herself), since they lackautologous proteins Therefore, in critical bony defects, that is, those requiring specific therapy

en-to recover their original conen-tour, a novel concept

to avoid autologous grafting, involving the use ofbone-sparing material combined with stem cellsfrom the same patient, has been gaining ground

as a more modern philosophy of treatment

Con-Fig 11a_Bone marrow.

Fig 11b_Bone marrow transfer

into a conic tube in a sterile

environment (laminar flow).

Fig 11c_Bone marrow

homogenisation in a buffer

solution (laminar flow).

Fig 11d_Bone marrow combined

with Ficoll (to aid cell separation).

Fig 11e_Pipette collection

of the interface containing

the mononuclear cells (where the stem cells are present).

Fig 11f_Second centrifuge spin.

CAD0213_06-09_Pelegrine 20.06.13 11:31 Seite 3

I 09

special _ science & practice I

CAD/CAM

2_ 2013

sequently, to the detriment of traditional bone

grafting (with all its inherent problems), this novel

method of combining stem cells with mineralised

materials uses a viable graft with cells from the

pa-tient himself/herself without the need for surgical

bone harvesting

Until recently, no studies had compared the

different methods available for using bone marrow

stem cells for bone reconstruction In the fol lowing

paragraphs, I shall summarise a study conducted

by our research team, which entailed the creation

of critical bony defects in rabbits and subsequently

applying each of the four main stem cell methods

used globally in order to compare their

effective-ness in terms of bone healing:1

_fresh bone marrow (without any kind of

process-ing);

_a bone marrow stem cell concentrate;

_a bone marrow stem cell culture; and

_a fat stem cell culture (Figs 6 & 7)

In a fifth group of animals, no cell therapy

method (control group) was used The best bone

regeneration results were found in the groups in

which a bone marrow stem cell concentrate and

a bone marrow stem cell culture were used, and

the control group showed the worst results

Con-sequently, it was suggested that stem cells from

bone marrow would be more suitable than those

from fat tissue for bone reconstruction and that

a simple stem cell concentrate method (which

takes a few hours) would achieve similar results to

those obtained using complex cell culture

proce-dures (which take on average three to four weeks;

Figs 8a & b)

Similar studies performed in humans have

corroborated the finding that bone marrow stem

cells improve the repair of bony defects caused

by trauma, dental extractions or tumours The

histological images below illustrate the potential

of bone-sparing materials combined with stem

cells for bone reconstruction (Fig 9) It is clear thatthe level of mineralised tissue is significantlyhigher in those areas where stem cells were applied (Figs 10a & b)

Evidently, although bone marrow stem celltechniques for bone reconstruction are very close

to routine clinical use, much caution must be exercised before indicating such a procedure Thisprocedure requires an appropriately trained surgi-cal and laboratory team, as well as the availability

of the necessary resources (Figs 11a–h, taken ing laboratory manipulation of marrow stem cells

dur-at São Leopoldo Mandic dental school in Brazil)._

1 André Antonio Pelegrine, Antonio Carlos Aloise, Allan Zimmermann et al., Repair of critical-size bone defects using bone marrow stromal cells: A histomorphometric study in rabbit calvaria Part I: Use of fresh bone mar- row or bone marrow mononuclear fraction, Clinical Oral

Implants Research, 00 (2013): 1–6.

2 André Antonio Pelegrine, Antonio Carlos Aloise & Carlos Eduardo Sorgi da Costa, Células Tronco em Implan to -

dontia (São Paulo: Napoleão, 2013).

Fig 11g_The pellet containing

the bone marrow mononuclear cells after the second centrifuge spin.

Fig 11h_A bovine bone graft

combined with a bone marrow stem cell concentrate.

All images courtesy of Células Tronco em Implantodontia 2

Dr André Antonio Pelegrine

is a specialist dental surgeon

in periodontology and implantdentistry (CFO) with an MSc

in Implant Dentistry (UNISA),and a PhD in clinical medicine (University of Campinas) He completedpostdoctoral research in transplant surgery (Federal University of São Paulo) He is an associatelecturer in implant dentistry at São Leopoldo Mandic dental school and coordinator of the perio-prosthodontic-implant dentistry team

at the University of Campinas in Brazil He can becontacted at pelegrineandre@gmail.com

Ispecial _ dental innovations

_Dentistry has come a long way since our

col-leagues were forced to use foot powered drills andmix amalgam from its bare components Modernday dental equipment and materials are at the cutting edge of medical and dental innovation, andit’s trade shows such as the International DentalShow (IDS) where the developments of the future are announced Modern dentists no longer have merely

a straight probe and a dental drill at their disposal

We now have scans, 3-D images, growth factors and an almost unlimited choice of materials avail-able to use

In writing this piece, I made a tough decision to cus on what I believe to be key areas of dental inno-vation It is in these areas of imaging, CAD/CAM tech-nology and growth factors that I believe are going

fo-to be important in the dental surgery of the future

The appearance of these restorations, althoughstill needing a well-trained (and artistic) dentist,could be said to be on par with certain lab-basedfabrications whilst maintaining the advantages ofbeing a chairside single visit restoration CAD/CAMtechnology is now almost universally used in thefabrication of dental implant abutments and bars,reducing construction times, designs and fit Den-tists are now beginning to use chairside CAD/CAM

Photos courtesy of

Dr Nilesh R Parmar, UK

CAD/CAM and growth

of dental innovation

Author_ Dr Nilesh R Parmar, UK

Fig 2 Fig 1

CAD0213_10-11_Pamar 20.06.13 11:32 Seite 1

devices to restore dental implants without the need

for any impressions

_CBCT 3-D scanners

and CAD/CAM integration

Cone beam computed tomography (CBCT) scans

are now commonplace in dentistry, particularly in

implant dentistry where Grondahl (2007) found

that 40 per cent of all CBCT scans were taken for

im-plant treatment Where 3-D scans were reaching a

shortfall was in actually relaying the information

obtained into the mouth during the surgical pro

-cedure One recent innovation has been to overlay

scans of the patient’s own teeth and soft tissues

onto the CBCT scan data This gives an accurate

rep-resentation of the hard and soft tissues and their

re-lationship to each other For example, an implant

can be planned in the implant software with the

angulation of the implant taking into account the

ideal position of the final crown, which can also be

shown in the CBCT scan

In order to do this previously, the dentist would

have to make a study model and then wax up

the ideal final restoration contour, ensuring some

barium sulfate within the wax in order for it to

show up in the scan This was both costly and time

consuming Recent developments have allowed one

to take an intra-oral scan using a suitable device,

such as a CEREC or iTero machine, and overlay this

with the CBCT scan No models, no wax ups; the

procedure is almost instant and can be done with

the patient in the chair As a patient education tool,

this visual format is invaluable, allowing patients

to fully understand the proposed work and its

execution

Taking this one step further, guided implant

sur-gery now allows us to not only plan implant

place-ment using ideal restoratively driven protocols, but

actually allows us to make a guided surgical stent,

made in-house or by a lab, and place the implant

through the stent Studies have found that this is

an accurate treatment modality that can be reliably

executed Flapless surgery with immediate

tempo-risation has the ability to revolutionise the patient

journey and help us to meet their expectations

_Facial scanners

A small but rapidly developing area of digital

dentistry is facial scanners These are in their infancy

at the moment, with a lot of companies still trying

to iron out the bugs in the machines Their potential

applications in the field of plastic surgery, facial

aesthetics, orthodontics, implant surgery and

or-thognathic surgery are endless

I have been fortunate to see a prototype facial ner from Sirona and even managed to have my facescanned (Figs 1 & 2) The detail achievable with theseunits is impressive Once this information is combinedwith 3-D scans, teeth scans and jaw ar ti cu lation, a fullyworking and movable representation of the patient’shead can be compiled on the computer screen Allow-ing for treatment planning and assessment to be car-ried out without any need to see the patient One ap-plication of this may be in developing countries, wherevarious experts from around the world can examinecomplicated facial reconstruc tion cases without themactually seeing the patient As already mentioned, theopportunities for patient education are huge, and withpro cedures such as plastic surgery and orthognathicsurgery being so difficult to properly consent for, facialscanners will greatly aid clinicians

scan-_Growth factors

Available for a long time in medicine and dentistry,growth factors have been the reserve of PhD studentsand professors until recently The resurgence of theusage of platelet rich plasma (PRP) has come aboutwith added research showing that using PRP cangreat ly improve osteoblast proliferation (Parmar2009) and accelerate soft-tissue healing Companiesare now offering clinical courses for dentists to make,produce and use PRP in their own surgeries within15–30 minutes The main advantage of PRP is that it’s free; is obtained from the patients’ own blood,thus removing the risk of rejection; and can be made

in vast quantities As more research is published, coupled with simpler production kits, PRP use will increase in all aspects of invasive dental surgery

The above is just a short description of what

is being developed for the future Dentistry has never been so intertwined with technology The next

10 years will prove to be exciting and I eagerly await

to hear, see and use the new technologies that are being developed today._

is a visiting implant dentist to

a central London practice

His main area of interest is indental implants and CERECCAD/CAM technology

He can be contacted at drnileshparmar@gmail.comMore information can be found on his website,www.drnileshparmar.com; Twitter: @NileshRParmar;

or Facebook: Dr Nilesh R Parmar

CAD/CAM

_about the author

CAD0213_10-11_Pamar 20.06.13 11:32 Seite 2

Iindustry report _ guided surgery

_coPeriodontiX (Straumann) is the first software

to offer the 3-D evaluation of periodontal bone statususing cross-sectional CBCT image data The aim is the measurement of bone progression prior to, during,and after treatment, as well as monitoring to measurethe effectiveness of regenerative treatment X-ray images have always proven a valuable tool in perio -dontal diagnostics.1, 2Usually 2-D imaging processes,such as bitewing images, intra-oral images of singleteeth, or panoramic tomograms, are used for this purpose All these processes are able to provide impor-tant diagnostic pointers, but none of them are withoutfundamental limitations,3even at a high quality It isagainst this background that cone-beam computedtomography (CBCT) has gained increasing importanceover the past few years and is now firmly entrenched

in certain areas of modern dentistry.4, 5In today’s perio dontology, CBCT allows for precise answers to a num-ber of diagnostic issues relating to structural bonechanges in the dentoalveolar area.12High-resolution

-and overlap-free imaging of teeth -and bone tures, as well as their pathological deterioration, play

struc-a mstruc-ajor role in distruc-ag nostics.6, 8–10

_Principle of radiological bone measurement

As there have been no satisfactory software-basedsolutions existed to date for standardized use in the parodontological evaluation of cross-sectional data(obtained using CBCT or CT), software was developed

in collaboration with Straumann under the name ofcoPeriodontiX and is now presented for the first time inits current version (8.0) for daily clinical use The principle

of standardised evaluation follows the X-ray six-pointmeasuring principle in analogy to clinical assessment Bypositioning a digital 3-D coordinate system centrally onthe tooth to be measured, the software automaticallygenerates transverse cross-sections of the tooth (Figs.1a & b) Using settable, defined landmarks, the distance

Straumann’s coPeriodontiX:

3-D digital bone measurement using cross-sectional

Authors_Drs Jonathan Fleiner, Andres Stricker & Dirk Schulze, Germany

CAD0213_12-14_Fleiner 20.06.13 11:37 Seite 1

I 13

industry report _ guided surgery I

CAD/CAM

2_ 2013

along the axis of the tooth is measured automatically at

six measuring points circumferentially around the tooth

(vestibular and oral, with mesial, central and distal

meas-urements in each case) to give a 360-degree evaluation

of crestal bone status The dentino-enamel junction and

crestal alveolar bone serve as reference landmarks (Figs

2a & b) In the case of multiple-rooted teeth, any

possi-ble pathological furcation involvement can be clearly

evaluated using a special 360-degree panoramic view

and by metrically measuring the degree of furcation

in-volvement (Fig 3) All findings can be presented

individ-ually in graphic or table format as desired (Figs 4a & b)

_Imaging processes in dentistry:

2-D versus 3-D

The main disadvantage of conventional 2-D image

processing is the 2-D display of 3-D anatomical

struc-tures Important morphological aspects and their

pathological changes to the tooth-supporting alveolar

ridge can only be detected at advanced stages of de

-terioration, or perhaps not at all, owing to overlapping

images The amount of bone available can only be deter

-mined with a certain degree of accuracy in the

approximal spaces The detection and quantitative determi

-nation of double- to triple-walled bone defects is often

a diagnostic challenge, even in the case of high-quality

X-ray images.7In this context, coPeriodontiX is intended

to be a valuable tool that allows precise and

standard-ised evaluation of 3-D cross-sectional images as part of

periodontal diagnostics in addition to the indispensable

clinical exploration The focus is the measurement of

available bone mass prior to, during, and after

treat-ment, as well as monitoring following the regenerative

treatment of vertical periodontal defects and furcation

involvement, for example

_Limitations of CBCT

Artefacts

A major problem with all cross-sectional imaging

methods is the generation of image artefacts Typically,

highdensity structural elements in the object inves ti gat

ed (e.g metallic restorations, root pins, implants, osteo

-synthesis plates) lead to obliterating and hardening facts in beam direction.13Under certain circumstances,these may impair the diagnostic assessment of directly ad-jacent structures (e.g approximal spaces, peri-implant re-gion), and may in part even mimic pathological structures

arte-Effective radiation dose

The radiation dose for patients undergoing dentalCBCT largely depends on the CBCT system, the type ofdetector used, and the exposition parameters of the X-ray itself As a rule, image-intensifier systems pro-duce a slightly lower dose than flat-panel detector sys-tems do.11The effective dose, in terms of risk manage-ment, can be reduced considerably by selecting an im-age volume adjusted to the area of exploration.14Scien-tific studies have shown that the dose15–18of CBCT maywell be similar to the magnitude of intra-oral film sta-tus for a single tooth (with up to 14 individual images)and that CBCT may offer considerably higher informa-tion content in direct comparison.6Nonetheless, strictindications according to the ALARA (as low as reason-ably achievable) principle should be adhered to under all circumstances when employing CBCT to minimisethe exploration risk for the patient

Imaging accuracy and precision

When defining the precision and measuring accuracyfor periodontal diagnostics, a certain degree of deviationbetween the clinical situation and the resulting radio-logical information is inevitable but can be regarded as

Fig 3

Fig 4a Fig 4b

CAD0213_12-14_Fleiner 20.06.13 11:37 Seite 2

Iindustry report _ guided surgery

being clinically acceptable.6, 19, 21Regarding the reliability

of radiological measurements, initial study results22

showed an overall measuring imprecision of two to threetimes the voxel size, regardless of the prior knowledge ofdental radiology of the users involved Depending on thenumber of roots, measuring accuracies of between 0.26and 0.34 mm have been recorded for single-rooted teeth,and between 0.27 and 0.55 mm for multiple-rootedteeth The effect of the individual user did not prove to besignificant In principle, these values permit the conclu-sion that a basic accuracy at this level, compared withmeasuring imprecision during clinical diagnosis of thepatient, can well be considered consistent and regarded

as being acceptable from a clinical point of view

_Conclusion

Especially for complex issues, the use of CBCT can

be viewed as a valuable diagnostic tool in modern perio dontology applying the ALARA principle The undistortedand non-overlapping 3-D imaging of the tooth-sup-porting alveolar ridge by methods such as CBCT has significant potential in periodontal diagnostics—underthe precondition of robust scientific evidence In thiscontext, the coPeriodontiX software described in this article is the first to offer support to users in the detec-tion of dental, periodontal, and ossary deterioration, particularly in highly complex cases, and coPeriodontiXmay be an interesting option for surgical restoration(Straumann Emdogain, BoneCeramic, MembraGel) Fi-nally, it should be mentioned explicitly that the softwaredescribed in this article does not replace clinical diagno-sis, but should rather be viewed as a useful radiologicalmeans of support This includes the option of portrayingthe soft tissue of the intra-oral gingival profile using sur-face scan data obtained with iTero for example (AlignTechnology; Fig 5) A number of further clinical studiesare being conducted using numerous diagnostic param-eters to examine the technical features of current CBCTsystems (e.g image resolution, image quality, creation ofartefacts) and to exploit the diagnostic potential of CBCTfully, especially for its use in periodontal diagnostics._

-Editorial note: A complete list of references is available from the publisher.

Dr Jonathan Fleiner worked

in the Division of Oral and Maxillofacial Surgery at the University Medical Center Freiburg of the University ofFreiburg in Germany from 2007until 2009 Between 2007 and 2008, he completed his postgraduate education in implantology through theGerman Association of Oral Implantology (DGI) andthe Academy for Practice and Science (APW)

In 2008, he opened the Dental Diagnostic Center(DDZ) in Weil am Rhein, Germany, which focuses

on dental CBCT Since 2008, he has been a regularspeaker at national and international events, as well

as a reviewer of international scientific journals in thefields of dental radiological diagnostics, CBCT and 3-D template-guided implant treatment (guided surgery) He has worked at the Center for Implantology, Periodontology and 3-D Diagnostics

in Constance, Germany, since 2010

Dr Andres Stricker has a

PhD in Dentistry (1997) and inMedicine (2002) Since 2003,

he has run a referral practicewith a focus on implantologyand periodontology in Constance, Germany, and hasbeen a lecturer and scientificstaff member at the University Medical Center Freiburg He has been a lecturer at the Danube University Krems in Austria since 2004 He was

a member of numerous research terms in the USbetween 1998 and 2001 He opened his practice,the Center for Implantology, Periodontology and 3-D Diagnostics, in Constance in 2010 He has written many publications on various topics, includingaugmentation methods, distraction, immediate loading,tissue engineering, soft-tissue management, and stemcell regeneration He is an international and nationalspeaker, and holds various licences and patents

Dr Dirk Schulze was, until

2009, Head of X-ray department

at the clinic and polyclinic fororal, maxillofacial and facialsurgery at the Albert LudwigUniversity in Freiburg/Breisgau(Germany) He has run his own practice in Freiburg/Breisgausince 2010 He has written numerous scientific publications and serves as a reviewer He has been the Secretary of the European Academy of DentoMaxilloFacial Radiology since 2010

CAD/CAM

_about the authors

Fig 5

CAD0213_12-14_Fleiner 20.06.13 11:37 Seite 3

Iopinion _ short implants

_Introduction

In 1892, Julius Wolff, a German surgeon, lished his seminal observation that bone changes its external shape and internal, cancellous archi -tecture in response to stresses acting on it (Wolff’slaw of bone modelling and remodelling) Therefore,

pub-it is a significant engineering challenge to design ashort implant that biocompatibly transfers occlusalforces from its prosthetic restoration to the sur-rounding bone It requires the understanding andapplication of many basic biological, mechanical,and metallurgical principles It is paramount thatthe entire design of a SHORT™ implant optimises the effectiveness of each of its features within theimplant’s available surface area and length Clinicalsuccess cannot be met by any single implant designfeature such as surface area, but rather requires theappropriate integration of all of its features

Since an implant’s design dictates its clinical andmechanical capabilities, it is scientifically approvedthat bone healing around a plateau-designed im-plant is different than the appositional bone (the

bone that is formed by osteoblasts after cell ated interfacial remodelling) around threaded im-plants The plateaued, tapered and root-formed implant body provides for 30 % more surface areathan comparably-sized threaded implants Butmore importantly, the plateaus provide for an

medi-in tra mem branous-like and faster bone formation(20–50 microns per day), resulting in a uniqueHaversian bone with clinical capabilities differentfrom the slower forming (1–3 microns per day) ofappositional bone around threaded implants.1,2

Additionally, the plateaus provide for the transfer

of compressive forces to the bone throughout theentire implant.3,4

_Description

We analysed the most time-proven short plant on the market that was called the Driskol Precision Implant in the early 1980s, than Strykerand the Bicon Dental Implant from 1993 (Boston,USA)

im-The Bicon implant has a bacterially-sealed 1.5

de gree locking taper (galling or cold welding) nection5,6between the abutment and implant, withthe ability for 360 degrees of universal abutmentpositioning Having a bacterially-sealed connectioneliminates the bacterial flux associated with clinicalodours and tastes and reduces inflammation andbone loss consistently

con-Another unique characteristic is the slopingshoulder that facilitates the appropriate transfer ofocclusal loads to the bone when positioned belowthe bony crest But more practically, the slopingshoulder facilitates aesthetic implant restorations,

opinion _ short implants I

Figs 1–12_Radiographic long-term control helps maintain the implant’s bone/soft tissue stability.

for it provides space for the interdental papillae with

bony support even when an implant is contiguous

to another implant or tooth The sloping shoulder de

sign has been, since 1985, the basis of a sensible bio

-logical width and the origin of platform switching

The 360 degrees of universal abutment posi

-tioning provides for the extraoral cementation of

crowns; the use of the cementless and screwless

Integrated Abutment Crown (IAC™)7, the intraoral

bonding of fixed bridges, which eliminates the need

for cutting, indexing and soldering of bridge

frame-works, multiple and easy removal of abutments over

time; and the slight aesthetic rotational adjustments

during and prior to the seating of a restoration

_Clinical long-term results

In the following long-term case description we

can observe the stability of the crestal bone around

the sloping shoulder of the plateau implant

Clini-cally, the soft tissue contour around the Integrated

Abutment Crowns indicates a healthy and stable

epithelial tissue

The single-tooth implant is a viable alternative

for single tooth replacement.8 Single-tooth re

-placement with endosseous implants has shown

satisfactory clinical performance in different jaw

locations

Minimal or no crestal bone resorption is con

-sidered to be an indicator of the long-term success

of implant restorations Mean crestal bone loss

ranging from 0.12 mm to 0.20 has been reported

one year after the insertion of single-tooth implant

restorations.9 After the first year, an additional

0.01 mm to 0.11 mm of annual crestal bone loss has

been reported on single-tooth implant restorations

Some implants demonstrate no crestal bone loss

and/or crestal bone gain after insertion of definitive

restorations.10

Crestal bone gain has been documented on

immediate and early loaded implants with a

chemi-cally modified surface after one year of follow up.11

A six-year prospective study reported that 43.8 %

of splinted Morse taper implants experienced some

bone gain.12Crestal bone gain has been

document-ed around immdocument-ediately loaddocument-ed Bicon implants.13

The factors that lead to periimplant bone gain in

dif-ferent implant designs have not been investigated

It would be beneficial for the dental practitioner to

understand what factors are associated with crestal

bone gain on single-tooth implants after crown

insertion Radiographic long-term control also as

a clinical observation of the soft tissue structures

surrounding the abutment emergence profile can

CAD0213_16-18_Marincola 20.06.13 11:38 Seite 2

provide the clinician with a better understanding of

an implant’s bone/soft tissue stability (Figs.1–12).The ideal scenario in modern implant dentistrywould be the implant replacement for every missingsingle tooth (Figs.13 & 14) The single tooth replace-ment guarantees good aesthetics, consequently tothe fact that a single crown that follows all criteria

of a natural-looking soft tissue emergence profilecan support the soft tissue in order to recreate papillae anatomy

Another important aspect of single crownrestorations on implants is that the patient can follow a better oral hygiene compared to bridge-works Nevertheless, bridgeworks are commonlyused as alternatives to single tooth replacement.The reasons are multifactorial, with the cost- benefit factor at first place (Figs.15 & 16) Anothersig nificant facet is the atrophic bone situation of the patient, were complicated and expensive bone graft procedures are needed before even thinking

of placing single implants

Alternatively to sophisticated and expensivebridgeworks (Figs.17 & 18), cost-effective and sim-ple prosthetic techniques were developed in the lastyears One of this techniques, the Fixed on SHORT™,allows to provide the patients with bone atrophies

or partial bone deficiencies with a fixed, metal freeprosthetic that can be supported by four to six short implants (Figs.19–22)

_Conclusion

In this short and synthetic article, the authors like to show the variety of treatment options whenimplants and prosthetic materials are used with the criteria of long-term crestal bone preservation,recreation and long-term stabilisation of the bio-logical width around the implant/crown and the use of short- and ultra-short implants in all clinicalsituations The proper selection of an ultra-short

or short implant depends strictly on the implant design which dictates the implant’s function._

Editorial note: A complete list of references is available from the publisher.

Iopinion _ short implants

Fig 22 Fig 21

Figs 13–16_Bridgeworks.

Figs 17 & 18_Complex bridgeworks.

Figs 19–22_Fixed-on-SHORTTM technique for fixed, metal free prosthetics.

Fig 20 Fig 19

Fig 18 Fig 17

Fig 16 Fig 15

Fig 14 Fig 13

Prof Dr Mauro Marincola

Via dei Gracchi, 285I-00192 Roma, Italymmarincola@gmail.com

CAD/CAM

_contact

CAD0213_16-18_Marincola 20.06.13 11:38 Seite 3

Icase report _ guided implantology

_Until very recently, my patients would have

considered undergoing complete treatment cluding a ceramic crown or a bridge in one visit science fiction The science of CAD/CAM technol-ogy has progressed at a staggering pace, enabling

in-me to treat a case that represents a new level in the field

This case report demonstrates a procedure thatallows the treatment of a patient who has lost atooth or had one extracted In one visit, he or shecan receive an implant using a while-you-wait,

made-on-demand implant guide Furthermore,modelling of the individual abutment or placing of

a solid titanium abutment with a temporary crown,

or a permanent ceramic crown, based on the in dication and diagnosis, can be performed in thesame visit

-The implant guide that is produced while thepatient waits (CEREC Guide, Sirona) speeds up the entire process incredibly, owing to a preciselymapped location in a 3-D CBCT scan using GALAXISand GALILEOS Implant (both Sirona) visualisation

software Moreover, it also

enables implantation using

the flapless technique Im

-mediate fabrication and use

of the implant guide is even

more important in

imme-diate implant placement after

extraction of multi-rooted

teeth, for which free-hand

implantation is extremely

dif-ficult (or near impossible)

In addition to CEREC

Guide, we can order and use

the CLASSICGUIDE (SICAT),

made on the basis of a

conventional impression, or

OPTIGUIDE (SICAT), a stent

that is manufactured without

bite plates and impressions,

requiring only a digital scan

of the patient’s mouth with

CEREC AC (Sirona) and a CBCT

scan of the patient’s jaws

(us-ing GALILEOS or ORTHOPHOS

XG 3D) Of all three guides

that could be used, that is, a

pilot drill, sleeve in sleeve or completely guided

stents, only CEREC Guide can be produced in office

immediately CEREC Guide was used in the

follow-ing clinical case report

_Clinical case report

A 55-year-old male patient

refused orthodontic

treat-ment to move tooth 13 into

proper position while making

space for a replacement of

tooth 12 The patient had been

chewing on primary tooth 53,

which was extracted about

14 days before implantation

Figure 1 shows the gap after

extracting tooth 53 Tooth 12

was missing and tooth 13

had moved mesially into the

space (Fig 2) Overall, the

patient was healthy and had

no hereditary disease

In this case, we began the

treatment by taking a

conven-tional impression of the jaw in

which we were considering

placing an implant to replace a

missing tooth We used

quick-setting plaster well suited to

fabricating the stone model (Fig 3) We placed a erence body in the location of planned implantation

ref-on the stref-one model to determine the correct size(three sizes are available: small, medium and large)

Fig 6

Fig 5

Fig 12 Fig 11

Fig 10 Fig 9

CAD0213_20-24_Kunkela 20.06.13 11:39 Seite 2

Icase report _ guided implantology

The reference body should about against the cent teeth and fill the gap with the largest possible area but it should not become lodged between the

adja-ad jacent teeth during placement Once we hadja-ad termined the optimal size, we wet the stone model with water and applied thermoplastic stent materialsoftened with warm water to cover one to two ad-jacent teeth on each side ideally The properly heatedstent compound appears to be glassy/transparent,which by its transparency also indicates plasticityinterval Once the colour changes to opaque, settinghas begun While the stent compound was stillwarm and adapted to the stone model, we insertedthe reference body (medium in this case; Fig 4)

de-When the thermoplastic is still clear, it is possible toobserve and review how the reference body relates

to the edentulous space Corrections can still be

made until the material comes opaque Undercuts onthe stone model can beblocked out before using, forexample, a composite com-pound (not wax) to allow easier detachment of the ther-moplastic stent material withthe reference body from themodel Personally, I do notblock out undercuts to ensurethe most accurate mounting.Even in the ensuing test in the patient’s mouth, one musthear the characteristic clicksound

be-Once satisfied with theplacement and retention ofthe stent with the referencebody in the patient’s mouth,

we captured a CBCT scan ofthe patient using GALILEOS

or ORTHOPHOS XG 3D Oneneeds to ensure that the largefiducial-containing portion

of the reference body facesorally as depicted in Figure 4 and not buccally in ORTHOPHOS XG 3D, as there may be a tendency

to cut this portion off in its 8 cm × 8 cm field of view While waiting for the image to load on the

PC, we scan the implant space layout on the model using an intra-oral scanner (CEREC AC) and soft-ware modelling of the proposed crown follows,

in terms of suitable shape, size and location in thefuture implant position.1

Once the CBCT scan has loaded, we open theGALAXIS software and begin the planning The firststep is to insert the exported CEREC crown proposal

in *.ssi format because this is the only CEREC crownproposal format that GALAXIS software can read(Fig 5) The exact placement of the proposedCAD/CAM crown in the CBCT scan will allow precise

I 23

case report _ guided implantology I

CAD/CAM

2_ 2013

read-out of borders between

hard and soft tissue (Figs 6–8)

and the digital implant

place-ment under the crown in such

a way that the future

connec-tion of the implant and crown

using an abutment is

prostho-dontically possible (Fig 9)

After the digital implant had

been imported into GALAXIS,

the need to use CEREC Guide

(or another guided-surgery

technique) became apparent

in this case owing to a drama

-tic conical apical narrowing of

the roots of the adjacent teeth

14 and 13 in the intended

implant space (Fig 10) Owing

to the lack of space between

these roots, we chose a

3.3/8 mm implant (SwishPlus,

Implant Direct) After digital

implant placement, we select

to continue and edit the

sleeve system After selecting

this option, a new dialog

box marked “reference body”

appears On this screen, we mark the fiducial points

using the lever underneath the image and move

the lever until the fiducials appear to be as round

and clear as possible Finally, we double click on the

three most clear fiducial points and the software will

then automatically search for and determine the

remaining fiducials (Fig 11) Next, we confirm that

the fiducials have been found and the reference

body appears on the 2-D and 3-D images (Fig 12)

In order to better visualise the interaction of the

drill path and drill body with the implant, the final

drill path and pilot drill path must be turned on in the

2-D views (Fig 13) The reference body must fit

exactly within the drill path in order to be milled

The most important part of CEREC Guide

pro-duction is setting the D2 value The D2 value, also

known as the drill stop length, is the distance fromthe apex of the implant to the top of the guide

If we measure the length of the drill from its cuttingtip to the drill stop, the D2 value will be that lengthminus 1 mm, which is the thickness of the implantguide handle In our case, for the 8 mm implant used,this value was 23 mm (the 24 mm drill minus the

1 mm handle) The D1 value changes with the D2value automatically (Fig 14)

In order to continue, we export this arrangementdata back to the CEREC AC unit as a *.cmg or *.dxdfile After opening the correct file in CEREC Software4.xx, the drill body proposal will appear in the millingpreview (Fig 15) Now we can place the appropriateblock size (in our case this was “M”) into the millingunit (MCXL on inLab MC XL, Sirona) and select “mill”

Fig 22 Fig 21

Fig 20 Fig 19

Fig 24 Fig 23

CAD0213_20-24_Kunkela 20.06.13 11:39 Seite 4

Icase report _ guided implantology

Milling time is approximately 12 to 16 minutes (Fig 16) We break the drill body out of the block andremove the sprue carefully

Next, we remove the reference body from thethermoplastic stent and, using a scalper or bur at

a very low speed, cut away a thin layer of the moplastic material from the bottom of the guide toallow the drill to pass through the guide When snap-ping the drill body into the thermoplastic stent, it isimportant to ensure that the drill body is insertedwith the correct vestibulo-oral orientation (Fig 17)

ther-Sirona produces specific guide handles for eachblock size (again in small, medium and large) and for several implant guide kits In our case, we usedthe guide handles for Straumann for the next stepbecause these handles are compatible with the Implant Direct implant used

Surgery

We begin with anesthetising the tissue aroundthe work area and placing the cleaned and disin -fected CEREC Guide in the mouth, followed by the fitevaluation The guide should feel secure and notmove over the teeth As we performed the flaplesstechnique, we began by punching the tissue withthe appropriate puncher (Fig 18) We then removedthe guide and easily separated and removed thepunched tissue (Fig 19) We placed the CEREC Guideback into position and continued with subsequentdrills and guide handles

Using the guide kit for Straumann (Sirona CERECGuide Drill Key Set ST), we started with the M 2.2handle and 2.2 mm pilot drill (Fig 20), followed bythe M 2.8 handle and 2.8 mm drill (Fig 21) Finally,

we removed the CEREC Guide and inserted the 3.3/8 mm SwishPlus implant without the guide, that is, free hand (Fig 22)

Temporary

We screwed a solid abutment (Implant Direct;

Fig 23) into the inner part of the implant, and

cov-ered the screw-hole with Teflon This was ately followed with an intra-oral scan As scanningpowder cannot be used for an unhealed soft-tissuemargin, we used the new powder-free CEREC Omnicam camera Next, we proceeded through thesteps of CEREC Software 4.xx (Fig 24) to mill thetemporary crown from a LAVA Ultimate block (3MESPE; Figs 25 & 26) While it is acknowledged thatdentistry is not Formula One, the patient was verysatisfied with a total treatment time of 115 minutes

immedi-_Conclusion

This case report has demonstrated the flow and manufacture of CEREC guides Anyone interested in this procedure and its processes is invited to visit our training centre in the Czech Republic, where one can view patient surgeries liveand participate in a practical demonstration course.For further details and course schedules, please visit www.gototraining.cz._

work-1 Important note: If immediate casting of a plaster model

is not possible at your practice, it is possible to utilise

a hydro-plastic stent material with a reference body

of the correct size together with intra-oral scanning of the mouth to be placed directly in the mouth without

Tel.: +420 737 210 565kunkela@dentalpoint.cz

Icase report _ customised implant abutments

Fig 1_Single crown on an

anatomical titanium abutment.

_The multiplicity and sophistication of the

offering in the field of prosthetic elements in implantology allow the practitioner to make achoice appropriate to the clinical particularities

of each case If the practitioner chooses a dard implant abutment, the dental technician willhave to make adjustments, which implies con -siderable losses in precision and time Moreover,with such abutments it is difficult to create ananatomical emergence profile because it cannot

stan-be modified and the base of the abutment cannot

be changed This observation is equally applicable

to the angulation, which might even be selected

by default

A customised abutment created with CAD/CAM

is the most accurate and simplest solution for an

optimal result The abutment is individually signed in order to ensure the homothety of thethickness of the materials and therefore the over-all strength of the prosthesis The dental technicianhas in this case maximum freedom in terms of design in order to create an abutment with the optimum emergence profile and angulation In thismanner, the abutment is specifically designed andfabricated for each patient

de-Titanium has been established in dental plantology as the reference material owing to itsbiomechanical properties and its biocompatibility.Today, we are able to benefit from over 40 years

im-of clinical and experimental experience in tology Customised abutments can be fabricatedfrom titanium, zirconia or hybrid materials, such

implan-as a combination of titanium and zirconia, which

in certain clinical circumstances improves theaesthetics of the visible areas while respecting the requirements of biocompatibility and bio -mechanics

_Seating a four-unit bridge on three anatomical implant abutments

Clinical case

A 40-year-old male patient presented for ment He had no particular medical conditions orany contra-indications concerning the placement

treat-of implants In 2009, the patient had undergone asinus lift (an increase of the maxillary bone volumeand the displacement of the sinus membrane toensure implant success by increasing the height ofthe available bone) at a hospital prior to the place-ment of implants to replace teeth 15–17 The post-operative sequelae (pain, oedemas, etc.) resulted

Fig 1

Fabrication of a customised

implant abutment using

to each clinical case

Author_ Dr Thierry Lachkar, France

CAD0213_26-28_Lachkar 20.06.13 11:45 Seite 1