The last five years have seen an unprecedented expansion of technology in dentistry. Now more than ever, we are able to deliver better care through better diagnostics and increased precision. There are now multiple intraoral scanners that allow for direct digital impressions of the mouth, from the Cadent iTero, to the Lava C.O.S., to the CEREC AC. We have also seen the advent of Cone Beam CT, with dozens of systems creating low radiation, high-resolution 3D images. This year will be the first we have a seen a complete fusion of the two: using CAD/CAM technology combined with Cone beam CT to help place implants exactly where we want them to go.
For years, the surgical "placement" of implants in bone was just that: We will drop the titanium anywhere where we can get 360 degrees of bone surrounding that implant. There was often little regard for the final restorative plan, significantly complicating the job of the restorative dentist. Now we understand the importance of placing the implant where a tooth would actually go, especially in the esthetic zone. If there is insufficient bone in that area, then hard tissue augmentation becomes a requisite part of the treatment plan. Up until now, the process of planning the implant based on the restorative position involved several steps: Impressions, diagnostic wax-ups, radiographic guide fabrication with a dental lab, Cone Beam CT scan, surgical guide fabrication, and then final surgery. While accurate, the process is time consuming, especially when involving lab time.
Recently, Sirona was the first to integrate the 3D images from its CEREC AC, with the Cone Beam CT scan from their Galileos. The process significantly improves the efficiency of treatment planning, and guide fabrication.
The first step is to have the patient take a CT scan using their radiographic guide from SICAT. A bite registration material with high shore hardness, such as Futar D, can be dispensed onto the bite plate, and then placed into the patient's mouth for the scan.
Next, the edentulous area can be scanned with the CEREC AC. Using the CEREC software, you can design the tooth for the space that is missing, kind of like a digital denture tooth.
This design gets exported as a specific file type, and then imported into the Galileos software. Now you have a digital replica of the final restoration superimposed over the future implant site. You can now choose whatever type of implant you want from their extensive implant library. Since there is no distortion in a Cone Beam CT like you have with a panoramic radiograph, you can drop a virtual implant in perfect placement in relation to the final restoration proposal.
This takes all the guesswork out of placing in closer proximity to vital structures, such as a nerve or a sinus area.
Next up, burn this information with a click of a button to a disc, and send it to SICAT along with the radiographic guide. SICAT converts this guide then into a surgical guide. You have the option of simply having a pilot hole, or utilizing a fully guided protocol, such as NobelGuide from Nobel Biocare, or Facilitate from Astra.
Keep in mind this did not utilize any dental lab. It did not utilize any outside software or image pre-processing. Plus, all the diagnostic information needed was obtained in one visit, taking less than 10 minutes of the patients time. On the side of the clinician, there is no more guesswork. The final PA radiograph from the case shows how accurate the placement of the implant can be.
Next up for Sirona will be the ability to create custom anatomic abutments using their CEREC software. Instead of using an impression coping, you would place a "digital scan coping". This allows the software to register where that implant is in relation to the rest of the teeth. After designing the full contour crown, the software can perform a "digital cut-back" creating the final abutment. You can send the design of the abutment over the internet to a lab using CEREC connect, and they can make the abutment for you out of zirconia or titanium.
Meanwhile, you can mill your own e.Max crown in the office. When the abutment comes back, there is the reassurance that the crown will fit perfectly since they were fabricated from the same digital file. There is no more need for ill-fitting stock abutments, and you will no longer need to wait for weeks for the final restoration from the lab.
Imaging Sciences and D4D have teamed up as well, and their system is ready for primetime. You can do the same pre-op digital impression, create your tooth using the E4D software, and then blend it with the Cone Beam CT scan from i-CAT using their E4D Compass software.
The CB-500 from Gendex, and the Scanora 3D from Soredex is also compatible with the software. One additional feature they also have in their software is the ability to show relative bone density around the implant itself.
They have also made it possible to make changes to the tooth proposal right there in the software, rather than returning to the original tooth design program.
E4D and Sirona are also looking into FDA approval for fabricating guides using their existing milling machines. Instead of sending anything off for processing, the idea is that you would mill out the specific guide from a block of material based on your surgical design.
If the present looks this exciting, it will be interesting to see what we can do in the future. Already, we are in a position that we can safely, and virtually, treatment plan an implant and place it in exactly the same position, with practically no physical models at all. Keep an eye on Dentalcompare to be the first to see the exciting changes shaping the future of our profession.