G IUS EPP E LUO NG O

GIAMPIERO CIABATTONI
ALESSANDRO ACOCELLA

DIGITAL
IMPLANTOLOGY
CONTRIBUTORS
FABRIZIA LUONGO
CARLO MANGANO
FRANCESCO MANGANO
PIERFRANCESCO PICCININI
RUGGERO RODRIGUEZ Y BAENA
CRISTIANO TOMASI

� QUINTESSENCE PUBLISHING
Berlin, Barcelona, Chicago, Istanbul, London, Milano, Moscow,
New Delhi, Paris, Prague, Seoul, Singapore, Tokyo, Warsaw
Preface V
U')

z
I-
Contributors VI
Acknowledgments VIII

LU
l Introduction
z
2 I-
Immediate Loading 4

0
u
Flapless Surgery 12
References 14

2 Digital Radiology
Digital Imaging
18
18
Intraoral 20
Panoramic 21
Tomography 21
Computed Tomography 21
CBCT or CBVT 22
3D Image Formation 23
Fil� Export and Processing 24
Accuracy and Precision of the CBCT 25
References 27

3 Virtual Diagnosis and

Treatment Planning
Import of CT Images in DICOM Format
34
36
Segmentation to Convert DICOM Files into 3D Objects 40
Integration oflnformation from Various Files 44
Diagnosis and Planning 49
Superimposition of Postoperative CT Scan and Planning File 56
Communication Between Clinicians and with Patients 56
References 59

4 Computer-Assisted Surgery
Introduction
62
62
Technique 73
Image Acquisition 73
Information Acquisition 77
Virtual Planning 78
Manufacture of a Provisional Prosthesis 81
Surgical Stage 82
Prosthetic Stage 83
Clinical Cases 86
Conclusion 96
References 97

■
 5 Guided Surgery for Treating
Edentulous Patients 100
100
Epidemiology
Guided Surgery in the Mandible 103
Biomechanical Considerations 115
Surgical and Prosthetic Stages 119
Clinical Cases 126
References 158

6 Guided Surgery in the Maxilla 166

168
Virtual Planning
Surgical and Prosthetic Stages 183
Clinical Cases 189
References 207

7 Guided Surgery in
Postextraction Cases
Introduction
210
210
Virtual Planning 217
Surgical and Prosthetic Stages 223
Clinical Cases 230
References 289

8 Custom-Made Bone
Reconstructions
Introduction
294
294
Grafe Materials 294
Synthetic Materials 295
Concept ofBiomimetics 295
Custom-MadeBone Regeneration 299
Clinical Applications 301
References 314

9The Road to Full Digital

Management in Guided Surgery
Clinical Cases
316
320
References 384

■ Digital lmplantology
 Preface
A science book is usually written to fill a gap This book sets out to cover state-of-the-art im­
in the sum total of scientific knowledge, and this plant and prosthetic restoration techniques with
book is no exception to the rule. due scientific rigor and even includes information
While new technologies and scientific process­ on computer-guided maxillary bone regeneration.
es have given great impetus to computer-guided The last chapter looks forward to the immediate
surgical techniques in dentistry and maxillofacial future, showing the execution of complex cases by
surgery, few books have yet been published on this means of an entirely digital process.
topic; in particular, there are no specialist reference The authors of this book have more than 20 years
books. The authors believe that those who read this of experience and are passionate about this disci­
volume will be able to increase their knowledge of pline: They practice it almost exclusively on a daily
the subject by using the book as a reference manual basis. Their achievement makes dear reference to
in professional clinical practice. the scientific evidence, which must underpin the
In the following pages, readers will find an all­ introduction of any innovative technique.
inclusive approach to computer-guided implant I cannot deny that it is a great source of pride
dentistry, from the first visit and treatment plan to for me to write the preface to this book because
a detailed description of specific surgical techniques, Giuseppe Luongo is one of my closest friends and
including a thorough examination of currently avail­ also one of the most respected names in the im­
able state-of-the-art three-dimensional (3D) x-ray plant world. He has devoted many years of his life
technologies and design software. to the study of this discipline and has achieved
With the development of head and neck im­ outstanding results both clinically and scientifi­
aging techniques, it is now possible to obtain an cally. The experience and quality of the coauthors,
extremely accurate 3D representation of the jaw for Giampiero Ciabattoni and Alessandro Acocella,
better and simpler diagnosis and surgical planning. will certainly make this textbook a benchmark for
Cutting-edge implant dentistry has particularly the application of digital technologies to modern
benefited from the latest radiologic and informa­ implant dentistry.
tion technology developments, which means that
computer-guided techniques have made incredible
progress and are now accessible to most clinicians.
To ensure that these techniques are easier to
understand and consult, the book includes illustra­
tions of each design and surgical step involved in ProfLuigi Califano
the various clinical conditions with great emphasis President of the Federico II University
on clarity and quality. School of Medicine, Naples

■
 Contributors
FABRIZIA LUONGO FRANCESCO M GANO
Fabrizia Luongo graduated with a Francesco Mangano graduated with
degree in dentistry and prosthet­ honors from Milan Scace Univer­
ic dentistry from the Sacro Cuore sity in 2003 and went on to earn a
Catholic University in Milan, Italy, research PhD in biotechnology, bio­
2011. Between 2011 and 2012, she sciences, and surgical techniques
attended the Postgraduate Program at the University of Varese. He is a
in Periodontology at the University of California, lecturer and scientific secretary in digital dentistry at
Los Angeles. During the same period, she put her Varese University and a research associate at the Dig­
professional experience into practice at the gIDE In­ ital Dentistry Research Centre, San Raffaele IRCCS
stitute in Los Angeles. In 2014, she received a Master research hospital in Milan. He is an active member and
of Science in Periodontology at La Sapienza Univer­ founder of the Digital Dentistry Society, a Fellow of
sity in Rome. Fabrizia Luongo runs a private practice the International College of Dentists, and the found­
in Rome, dealing exclusively with periodontology er and administrator of the online platform "Digital
and implant dentistry. She has written publications Dentistry Universe." Francesco Mangano is also an
on the use of diagnostic software and virtual design in associate editor for BMC Oral Health and the Inter­
periodontology, implant dentistry, and oral surgery. national Journal of Dentistry and a reviewer for the
International Journal of Medical Robotics and Com­
CARLO MANGANO puter-Assisted Surgery and Lasers in Medical Science.
Carlo Mangano has a degree in He has authored over 75 publications in internation­
medicine and surgery and spe­ al journals and has spoken at numerous international
cializations 1n oral medicine, conferences. He maintains a dental practice in Grave­
anesthesiology, and resuscitation. dona, Italy, specializing in digital dentistry.
He is an adjunct lecturer in digital
dentistry at V ita-Salute San Raffa­ PIERFRANCESCO PICCININI
ele University and a manager of the digital dentiscry In 1993, Pierfrancesco Piccinini
research group at San Raffaele IRCCS research hos­ earned a degree in Economics and
pital in Milan, Italy. He is an active member of the Business from Tor Vergata Uni­
Italian Society of Oral Surgery and Implant Dentistry versity, Rome. He has worked as
(SI CO I) and the Society of Osseo integrated Implant an Italian Parliament budget com-
Dentistry (SIO), and he is a founding member and mittee officer and an operations
board member of Digital Dentistry Society as well manager at Creative Surfaces Incorporation in Van­
as a board member of the Italian Journal of Osse­ couver, Canada. Since 2008, he has worked as a
ointegracion. Carlo Mangano has been a speaker digital dentistry specialist for companies specializ­
at numerous international conferences and has au­ ing in computer-guided surgery, first in Belgium and
thored more than 250 publications, including seven then in Italy. His present focus is on the management
books and seven book chapters on biomaterials and of software dedicated to 3D surgery in implant den­
implant surgery. tistry and reconstructive and orthognathic surgery.

■ Digital lmplontology
 RUGGERO RODRIGUEZ CRISTIANO TOMASI
YBAENA Cristiano Tomasi is a specialist
Ruggero Rodriguez y Baena earned in clinical periodontology and
his degree in medicine and surgery an associate professor in the De­
and specialization in oral medi­ partment of Periodontology at
cine at Pavia University in Italy. Goteborg University in Sweden.
Since September 2000, he has been He graduated with honors in
a member of the Pavia University Clinical-Surgical, dentistry and periodontology in 1991 from the
Diagnostic and Pediatric Science Department as an University of Verona and earned a certificate in
associate lecturer in clinical oral medicine. He is in­ clinical periodontology, a Master of Science, and a
volved in research on biomaterials, mesenchymal PhD from the University of Goteborg. In 2005, he
stem cells, and the modification of titanium surfac­ won the first European Federation of Periodon­
es for implant use, and he manages the oral surgery tology (EFP) award for periodontal research for
and implant dentistry unit in the same department. specialists, and in 2007, he won the first award
He is the aurhor of more than 100 publications in for research from the Scandinavian Society of
international journals and various books on dental Periodontology in Stockholm. He is an adjunct
surgery as well as coauthor of a book on biome­ lecturer in periodontology at Padua Universi­
chanics in implant dentistry and editor of a book on ty in Italy and an active member of the SIO and
dental radiography. He has been a speaker at numer­ SidP. He has also published numerous articles on
ous international conferences and an active member periodontal and implant subjects in internation­
of several organizations dedicated to osseointegra­ al peer-reviewed journals. Since 1992, Cristiano
tion and dental surgery. Tomasi has worked in his own dental practice in
Trento, Italy, where he deals exclusively with peri­
odontics, minor oral surgery, and implant therapy.

■
 Acknowledgments

The authors would like to thank the following individuals for their invaluable contributions:

ProfStefan Lundgren, Umea University, Sweden

Dr Roberto Sacco, Oral Surgery Specialist, Senior Clinical Teaching Fellow
UCL-Eastman Dental Institute, King's College Hospital NHS Trust (London)
Dr Stefano Piras, Rimini, Italy
Dr Giancarlo Gioacchini, Porto Recanti, Ancona, Italy

Mr Mauro Berardi (dental technician), Rome

Mr Giacomo Calcinai (dental technician), Florence
Mr Pasquale Cozzolino (dental technician), Rome
Mr Alessandro Ranfagni (dental technician), Florence
Mr Maurizio Rigucci (dental technician), Florence
Mr Francesco Rueca (dental technician), Rome
Mr Francesco Turchini (dental technician), Florence

■ Digital lmplontology
 [Link] design must consider these and ocher parameters

w
and is therefore the most delicate part of the treat­
ment. It has been shown chat in about a quarter of
l­
o...
cases, implant failure is caused by design errors. 5-7
Because of this, particular attention has always

<(
been devoted co the development of instruments
that will provide detailed information on the
I
u
anatomy of the jaw to be treated. During conven­
tional formulation of a treatment plan, these data
are interfaced with prosthetic design and carried
out using all of the diagnostic tools available to
the proschodontist. Since the practice of restoring
teeth using implants became widespread, the sur­
geon, prosthodontist, and dental technician have

Introduction
cooperated closely with one another to come up
with a treatment plan, each contributing his or
her own expertise.
Over the last decade, improvements in the
accuracy of radiologic equipment and the in­
troduction of special data analysis software have
allowed the development of highly sophisticated
Rehabilitation therapy of masticatory function systems. These allow operators to carry out accu­
through the use of osseointegraced implants is a rate evaluations of jaw morphology on computers
tried-and-tested procedure and is currently a rou­ and simulate the various treatment options with
tine option in dental practices. The success of constant reference to the ideal prosthetic result.
implant dentistry has been widely documented This technologic progress is part of the more
in all clinical edentulous conditions. Long-term complex development of digital applications in
longitudinal studies have demonstrated a suc­ dental practice. This all means that nowadays the
cess rate greater than 95%. Where indicated, the whole process-including data acquisition, data
therapeutic result is as predictable as other con­ processing, and prosthetic construction-is en­
ventional solutions, to the extent that implant tirely digital.
therapy is currently the treatment of choice for State-of-the-art three-dimensional (3D) x-ray
many clinical conditions. 1-4 equipment, which emits much less radioactivi­
For chis type of restoration to be successful, ty than previous devices did, allows clinicians to
a number of factors must be taken into account, easily and accurately gather all of the necessary
including the quality and quantity of available information on the anatomy of the structures in­
bone; the soft tissue health status and availabili­ volved. Laboratory scanners capture data from
ty; the number, size, and distribution of implants models and dental casts with great fidelity. New
to be used; and loading conditions. The clinical and more refined intraoral scanner casts are now

■ Digital lmplantology
available on the market. These machines record sent directly to special devices that generate the
shapes and colors directly inside the patient's definitive prostheses through subtractive or addi­
mouth with great ease, making all of the complex tive processes (Fig 1 ). This wholesale revolution
procedures involved in taking impressions using in the approach to prosthetic restoration sup­
conventional systems obsolete. ported by osseointegrated implants has led to the
Dedicated software allows information from development of a new discipline termed digital
different sources to be processed and made avail­ implantology.
able to clinicians and dental technicians for the These new digital technologies have spread
production of individual treatment plans and quickly from dentistry to other fields. In fact
highly accurate virtual prostheses. Virtual models dentists have always been among the first to intro­
contained in stereolithography (STL) files are duce applications derived from new inventions
into their own practices (Fig 2).

DIGITAL DENTISTRY
FLOWCHART

ii ..,.
I --
..,. DATA PROCESSING ..,. SOFTWARE
m
_,. CBCT
DATA
ACQUISITION _,. INTRAO RAL SCANNER
1g"AI ....
-
.... LA B SCANNER

-
SUBTRACTIVE -

-
MILLS
MANUFACTURING
PROCESSES
3D PRINTERS ADDITIVE

Figure I
Flow chart showing the entirely digital process from data acquisition to production of the prosthesis.

Figure 2
New technologies have always been very quick to become established in dentistry, from the lost wax technique
in the early 1920s to present-day 3D computerized reconstruction technologies.

Chapter l ► Introduction ■
 In the field of implant dentistry, technical IMMEDIATE LOADING
developmentofcomputer-aideddesign/computer­
assisted manufacturing (CAD/CAM) proce­ Conventional implant loading protocols were de­
dures and the availability of dedicated therapeutic veloped by Branemark and his working group in
design software together with the acceptance of the 1960s. 8 These required the technique to be
new surgical and prosthetic procedures (includ­ carried out strictly in two stages with a healing
ing flapless and immediate loading techniques) period during which the implants had to remain
have essentially revolutionized the landscape of submerged. After a variable period of between
fixed restorations supported by osseointegrat­ 3 and 6 months, the implants were exposed, the
ed implants, allowing clinicians and patients to abutments attached, and the prosthesis finalized.
achieve functional and esthetic solutions while This procedure had its own biologic and
I minimizing the time and inconvenience asso­ biomechanical rationale. It was believed that
ciated with such procedures. Guided surgery transmucosal healing would expose the implant
represents one of the most attractive applications to the possibilit!y of infection and apical migra­
of digital dentistry and was made possible by the tion of soft tissues, which could then become
development of extremely sophisticated 3D ra­ interposed between fixture and bone. Overheat­
diographic equipment able to provide highly ing caused by preparation using burs was thought
accurate anatomical information. The next chap­ to lead to peri-implant bone necrosis, which nec­
ter is devoted entirely to the new 3D radiograph essarily required enough time to be resorbed and
methods. remodeled by new vital bone to allow perfect in­
Guided surgery also owes at least part of its in­ tegration. It was believed that any movement at
creasing popularity among practitioners to the this stage could irreparably disturb the process,
progressive acceptance of clinical protocols in­ leading to fibrous encapsulation of the implant.
volving immediate loading and flapless surgery From that time, this strict protocol was routinely
techniques. One of the benefits of this method adopted by most clinicians, supported by find­
is undoubtedly the fact that it allows for access ings published in the literature over the years that
without creating a flap and for immediately left little doubt as to its soundness.
finalizing the case with the application of a pro­ However, at the same time, an idea was gaining
visional restoration after surgery, which can also ground that loading times could be significantly
be produced using integrated digital procedures shortened and even take place at the same time as
if required. the surgical stage, provided that micromovements
Before a detailed description of the principles gov­ of the bone-implant interface could be contained
erning the digital approach to implant-supported within a threshold of between 50 and 150 [Lm. 9-11
prosthetic restorations is provided, the principles During the 1990s, more and more scientific evi­
behind immediate loading and flapless surgery pro­ dence was building up that the osseointegration
cedures are briefly reviewed. process could advance and be improved, even if
the implant was loaded, as long as the movements
that loading inevitably transmitted to the implant
could be maintained at minimal levels (Fig 3).

■ Digital lmplantology
 Thorough histologic studies confirmed the implants interconnected with a bar, with ex­
soundness ofthis procedureby comparingbone-to­ tremely encouraging success rates. Based on these
implant contact (BIC) percentages between im­ initial experiences and other evidence, the es­
plants that were left submerged and those that sential prerequisite for procedures involving the
were loaded immediately. Short-term ( 4-week) immediate application of prosthetic load was suf­
histologic assessments of the peri-implant bone ficient implant stability. Over subsequent years,
showed no statistically significant differences be­ attention was focused on achieving this crucial
tween implants loaded immediately and those result, suggesting various adaptations to surgi­
inserted using the submerged protocol, 12 with cal implant placement procedures. Although it is
a BIC percentage between 78% and 85% after impossible to discuss each individual variable in­
4 months for immadiately loaded implants.1 3 troduced or compare the many studies published
After 8 to 9 months, the percentage of contact in the literature and draw definitive conclusions,
between the bone and the implant was found to the major changes proposed in preparation of the
be significantly greater in implants that had been implant bed were the following:
loaded immediately, achieving values up to twice
as high as those reached by submerged implants • Partial or total removal of tapping in soft bone,
after 15 months.14- 1 6 It is now believed that im­ reserving this procedure for implant sites in
mediate loading stimulates bone remodeling and particularly dense bone 19-24
peri-implant bone density by mechanical stress. • Avoiding the use of a countersunk bur for the
Even before this scientific evidence began implant neck23-25
to accumulate, by the end of the 1970s and the • Engaging both cortices with the implant to
beginning of the 1980s, direct loading of im­ ensure a bicortical anchorage 19·26-28
plants appeared to be .a possibility.17· 1 8 Some • Underprepare the implant osteotomy using
aurhors published their own experience of treat­ burs that are undersized in relation to the
ing fully edentulous mandibles through the use implant diameter to increase insertion
of overdentures anchored to four transmucosal torque21,22,24,2 s

Figure 3
The loads to which an immediately loaded implant is subjected must not create micromovements that would
disturb the osseointegration process during the more delicate initial stages of bone formation.

Chapter l ► Introduction ■
 • Using osteotomes instead of burs to compact maxilla in which half of the implants were insert­
trabecular bone29·30 ed with an insertion torque of� 20 Nern (test
• Using a larger-diameter implant when it has group) and the other half with an insertion torque
not been possible to achieve primary stability of 25 to 50 Nern (control group). Out of a total of
values with an implant previously placed in the 81 implants placed (51 test and 30 control), the
same site2 1·3 1 rate of implant survival afi:er 1 year was 98% for
implants inserted with low insertion torque and
It is impossible to say which of these factors 100% for implants inserted with a higher inser­
takes precedence over the others or even to com­ tion torque.
pare combinations of these factors. Clinicians are Conversely, Rizkallah et al36 recently report­
free to choose between these variables according ed their findings from a study on 390 tapered
to their own experience when bone conditions are implants with immediate loading of the maxil­
particularly sofi:, adapting preparation techniques la, showing a failure rate of 2.3% even though the
to site-specific conditions present at the time. implants were inserted with high torque values
Although to date no controlled studies have between 45.8 and 134 Nern. Therefore, even if
been reported that exactly correlate primary sta­ the insertion torque level remains an important
bility values with implant survival following term of clinical reference, there is no consistent
immediate loading, there has been much dis­ direct correlation between this parameter and
cussion about the possibility of obtaining an implant success.
objective assessment of this stability through the Among the various methods for measuring im­
various measures described above. Various meth­ plant stability apart from insertion torque, one of
ods of measuring the primary stability of implants the most accredited methods and the only one to
have been suggested, but it has not yet been possi­ allow substantial objectivity and repeatability is
ble to compare the results of the different studies resonance frequency analysis (RFA). This tech­
and draw final conclusions for measuring this pa­ nique, developed by Meredith et al, 37 is based on
rameter.3 2 recording the micromovements of an implant
Many authors have tried to define the mini­ when it is stressed: The greater the movement, the
mum insertion torque values necessary to carry lower the stability (Fig 4).
out immediate loading, coming up with guide­ Barewal et al 38 measured implant stability quo­
lines between 32 and 40 Ncm.33·34 However, tient (ISQ) values and followed implant stability
under certain conditions, even implants inserted with reevaluation throughout the implant healing
with a torque of 15 Nern have demonstrated high period. The recorded values showed a reduc­
success rates.23 Because primary stability values tion in stability during the 3 weeks following the
have not been proven to correlate with implant procedure, and high stability values gradually re­
survival following immediate loading, it has not turned as the osseointegration process progressed.
been possible to define with any certainty an ac­ The extent of these variations is closely related to
curate insertion torque value to indicate that this bone density. High-quality (type 1 or 2) bone
procedure will lead to success. showed less significant changes than moderate­
In 2011, Degidi et al35 reported a study on 13 quality bone (type 3 or 4). This means that im­
patients treated with immediate loading of the plants placed into cortical bone are surrounded by

■ Digital lmplontology
a high area of intimate contact with dense lamellar Figure 4
bone over the entire implant surface. This ensures Frequency resonance
a high level of stability even during the process of measurement equip­
ment (Osstell). These
remodeling and laying down of new bone, which
values are correlated
takes place over the next few months. Conversely, (, ., 1<:q 11') 00 with implant stability.
ij 11 00
with trabecular bone, when the bone remodeling faro H, ?.OJ1
12 <.O ?2

effects take place, there is a downturn in implant ISO

stability levels, which only rise again following

the development of secondary stability as the os­
seointegration processes proceed.
Attempts have been made to establish a correla­
tion between insertion torque levels andISQ While
some authors39 have reported a close correlation
between these two parameters, this has been ques­
tioned in other cases. Bayarchimeg et al40 recently
evaluated insertion torque and ISQ parameters in These data lead to some significant clinical con­
vitro using different-density blocks to simulate the siderations: Implants that are inserted without a
various clinical situations. The study demonstrated very high insertion torque but in dense intrafo­
that insertion torque and ISQ values increase with raminal bone can have sufficient primary stability
increasing bone density and that there is a strong cor­ values for immediate loading, but in the maxilla,
relation between them. This appears to confirm that underpreparation of the site and high insertion
primary implant stability is directly dependent on torque levels may not be sufficient on their own.
bone density. However, wit[! a well-represented ex­ The selection of a site with higher bone density or
ternal cortex and an adequate marrow component, a well-represented cortical portion as well as the
insertion torque levels fall-but not significantly use of biocorcical anchorage may, together with
and in a manner entirely unrelated to ISQ values, underpreparation of the implant site, guarantee
which do not display equally significant variations. higher and more predictable primary stability in
For the same bone density, as the final diameter of immediate loading in the maxilla.
the bur increases, torque insertion values fall, but These considerations have subsequently been
the same does not apply to the ISQ values. This borne out by other scientific works, which have
study therefore demonstrates that the only paran1e­ shown that, for the purposes of primary implant
ter showing a positive correlation between insertion stability, bone density is the most important
torque and primary stability is the presence of cor­ factor to be considered over the degree of implant
tical bone throughout the implant osteotomy route underpreparation and the selected implant diam­
or at least the presence of a well-represented cortex. eter.4 1
Outside of these clinical situations, both parame­ Tabassum et al42 reached the same conclusions
ters are poorly correlated. An implant inserted with when they reported data on 48 implants mea­
a high insertion torque in an underprepared site may suring 4.2 mm in diameter placed into the iliac
not have sufficient primary stability in terms ofISQ crest of eight goats with different degrees of im­
in soft bone. plant underpreparation: 4.0-mm final bur (5%

Chapter l ► Introduction ■
 underpreparation), 3.6-mm final bur (15% un­ and implants placed using a flapless technique
derpreparation), and 3.2-mm final bur (25% with the aid of STL templates. In the flap group,
underpreparation). Upon implant placement, 110 implants were placed in 23 patients, and in
insertion torque values were recorded using a the flapless group, 85 implants were placed in
digital meter. Three weeks later, removal torque 17 patients using computer-aided techniques.
values were recorded and histologic and histo­ ISQ values were recorded after the procedure
morphometric analyses of the inserted implants (baseline) and 12 weeks later. All of the implants
were carried out. Surprisingly enough, there were were found to be integrated with no significant
no statistically significant differences in removal difference between the groups, even in terms
torque values and peri-implant bone percentage of peri-implant bone resorption. The average
after 3 weeks despite the different degrees of un­ ISQ values for the flapless group were signifi­
derpreparation. cantly higher at baseline as well as when the
Ahn et al43 analyzed the primary stability of measurements were repeated compared with
implants inserted in polyurethane blocks to simu­ those recorded for conventional technique. The
late soft bone in the maxilla using various implant ISQ values were also significantly lower when
preparation techniques: underpreparation with the measurements were repeated compared
small-diameter burs, use of osteotomes to com­ with baseline for the flap group, but this was
pact bone, and mono- and bicortical insertion. not observed in the flapless group. This study
Insertion torque, removal torque, and stability demonstrates that when implants are placed with
values were recorded for each implant by means computer-guided flapless surgery, at least in the
of RFA. The results showed a significant correla­ maxilla, the resulting primary and secondary sta­
tion between underpreparation and engagement bility is higher than with conventional surgery.
of both cortices and primary stability, insertion, These data support observations reported previ­
and removal torque values. However, the use of ously by other authors on animal models.45
the osteotomy technique did not give rise to any Another debatable aspect is the role of the im­
statistically significant improvement compared plant area and geometry in immediate loading
with underpreparation-if anything, it led to a procedures. In a recent study, Dos Santos et al46
reduction in primary implant stability. These data evaluated the effect of implant surface design and
led to a reevaluation of the absolute importance treatment on primary fixture stability in vitro.
of underpreparation, which provides adequate Thirty implants with different morphologies
primary stability immediately but does not have (cylindrical and tapered) and different surface
any direct effect on secondary stability in the treatments (machined, acid-etched, and anod­
short term (3 weeks) and long term. ized), were inserted in high-density polyethylene
We have only very limited information on pri­ cylindrical blocks to measure insertion torque
mary stability values assessed by means of RFA and ISQ by means of the Osstell Mentor (Integra­
when implants are placed using computer-guided tion Diagnostics AB). The authors reported that
flapless surgery. In 2012, Katsoulis et al44 carried the implants with machined surfaces had ISQ
out a study on the maxillae of 40 patients and re­ values lower than those of the treated implants,
ported comparative results between implants but the only statistically significant difference was
placed using conventional open-flap technique recorded between one rough surface and another.

■ Digitol lmplontology
However, the role of geometry was found to be are 1 and 2. Bone D 1 has an extremely compact,
more significant: Tapered implants showed a pri­ poorly vascularized microscopic architecture. It is
mary stability far higher than that of cylindrical more dependent on the periosteum for its nour­
implants. ishment, and its regenerative capacity is therefore
New-generation 3D x-ray imagers and image slower than that of trabecular bone. Bone D2 is
processing software have made a significant con­ characterized by a combination of an adequate
tribution to ensuring that immediate loading cortical component and a well-represented un­
protocols are more predictable. Information ob­ derlying crabecular pattern. RFA showed how
tained from this process allows clinicians to implants placed in these bone types do not pre­
obtain extremely accurate data on all factors that sent substantial variations in ISQ values over time
have appeared to have a great [Link] on the compared with those measured at the time of im­
success of immediate loading procedures. Accu­ plant placement. 51•52 Thus, even if regenerative
rate anatomical reproduction makes it possible to bone is denser and potentially biologically less
clearly assess the amount of bone and thus make well suited, its extremely compact structure per­
an accurate consideration of the maximum usable mits appropriate interlocking with the implant
implant length to achieve the correct distribution surface and allows healing with the interposi­
along the edentulous segment for each site while tion of a scant quantity of woven bone, allowing
simultaneously displaying the impact on the final a gradual transition from mechanical primary sta­
prosthetic result. This software also provides fur­ bility to biologic secondary stability. 53-55 These
ther information on bone quality, which is less
accurate but also of great assistance when formu­
lating a treatment plan.
The software can be used to measure bone
quality in terms of Hounsfield units (HU) at in­
dividual surgical sites47.48 (Fig 5). The computed
tomography (CT) data allocate a number to each
voxel that is dependent on average tissue density
in that specific unit volume. This number, which
can be highlighted on radiographic regions of in­
terest (ROI), is part of a standard density scale
expressed in HU. This can assume values of be­
tween -1,500 and +2,595 and allocates a density
of O to water while that of air is in the region of
-1,500. The bone structures on the Hounsfield
scale range between + 150 and + 1,500. The data
in HU can be related to the two classifications 00.t./t,
Figure 5
most commonly used today: the Lekholm and Virtual measurements reflecting ideal implant osteotomy routes in the
Zarb49 and Misch 50 classifications (Table 1 ). intraforaminal area. Recorded HU values confirm an ideal bone density,
The most favorable bone-quality ratings for the guaranteeing adequate implant stability for the fixtures to be inserted
performance of immediate loading procedures in this site.

Chapter l ► Introduction ■
 Lekholm and Zarb Misch Regardless of bone quality and the implant
HU> 1250 Dl
stability achieved, rigid implant splinting is an
essential prerequisite for a successful procedure
850 <HU< 1250 D2
if loading is to be immediate. While encourag­
350 <HU< 850 D3
ing results have been reported with prostheses
150 <HU< 350 D4 made entirely out of resin with no clear scientif­
HU< 150 HU<0 D5 ic evidence in this regard, many clinicians believe
Tahle I that the use of a metal framework in the prosthe­
Radiographic bone-quality classification showing
sis guarantees greater system stability during the
the correspondence between HU and bone d ensity
classifications according to Lekholm and Zarb and Misch implant healing stage and is better able to with­
as reported by Norton and Gamble.47 stand the forces generated during chewing while
minimizing the risk of micromovements at the
bone-implant interface. 61 The use of all-resin
prostheses should therefore be reserved exclu­
characteristics are typical of mandibular bone, sively for situations with a high interarch distance
particularly in the area between the emergences with appropriate thicknesses of resin in nonbrux­
of the inferior alveolar nerve. ing patients and when implants have been placed
In the maxilla, much more modest bone qual­ in dense bone with good stability. It is also of
ities often have to be contended with. Qualities the utmost importance that the prosthetic struc­
D3 and D4 are often present, particularly in pos­ ture be totally passive during immediate loading
terior sectors of the maxilla. This characteristic procedures. The presence of even modest misfits
means that, in general, the maxilla is less suit­ between the prosthetic structure and implants
able for immediate loading. In accordance with may cause harmful micromovements that could
this finding, recommendations expressed by the compromise the implant osseointegration pro­
various systematic reviews of the literature and cess, even under conditions of rigid splinting.
consensus conferences recommend greater cau­ Screw-in prosthetic structures are general­
tion during immediate loading of implants placed ly used in immediate loading. These appear to
in the maxilla where bone quality is modesc.56-58 offer better guarantees than cemented struc­
As we have seen, however, there are many com­ tures for at least two reasons. The first and most
pensatory tools that make it possible to achieve important is that removal is less traumatic if
satisfactory primary stability even in cases of poor it needs to be carried out during the immedi­
bone quality. By using these measures and the ac­ ate postoperative period. The second is linked
curate information that up-to-date planning to the fact that cemented provisional prosthe­
software provides, apparently equivalent success ses may undergo partial decementation during
rates can be achieved for both jaws. 59•60 the first critical healing period, affecting the

■ Digital lmplantology
stability of the prosthesis and generating dan­
gerous movements during the most delicate
stage of osseointegration (Fig 6).
In conclusion, with guided surgery the pro­
cedures used to achieve the prerequisites for
performing immediate loading do not differ
from the prerequisites for the conventional ap­
proach. Planning software packages currently on
the market are a great help to clinicians in identi­
fying characteristics of bone quality and quantity
present at and within each site. This information
is essential for implementing a correct combina­
tion of different measures to achieve the essential Ficrure 6
,:-,
stability conditions of this procedure. Under Provisional complete prosthesis prepared for immediate loading. In this
conditions where some implants do not achieve procedure, it is advisable to use a screw-retained design because it can
be easily removed for inspection without damaging the implants.
sufficient primary stability, interconnection of
multiple implants guarantees appropriate rigidi­
ty of the entire prosthetic structure.

Chapter 1 ► Introduction ■
 FLAPLESS SURGERY A randomized prospective study compared a con­
ventional surgical approach with Bapless access.6s
Revealing the operative area by ra1smg a mu­ Both access methods were found to be equivalent
coperiosteal Bap represents the safest surgical from the viewpoint of long-term implant survival
approach. This access reduces the risk of develop­ and marginal bone resorption.
ing bone fenestration and dehiscence as a result The greatest difficulty in using this surgical
of failing to control direction and depth. Raising access lies in the impossibility of displaying the
a Bap is nevertheless associated with exacerbated direction of the osteotomy lines with regard to
morbidity and discomfort and requires sutures the possible presence of concavities or recesses in
for wound closure, which inevitably means a the bone profile. This limitation means that this
greater commitment for both surgeon and pa­ method can only be used in cases with high bone
tient. 62,63 volumes where orientation is easy even without a
Loss of bone tissue with consequent gingival direct view of the entire available bone volume.
recession after raising a Bap has an obvious down­ The introduction of guided technologies that can
side in terms of the esthetic outcome of treatment, be used to trace and test directions beforehand on
particularly in anterior sites.64 These observations the computer, considering all variables, has made
have progressively led to changes in implant sur­ it easier to use this type of access even where the
gery Bap design over the last 30 years in a quest bones are thinner. The Bapless surgical approach
for less aggressive solutions. When feasible, the involves carving a small access openings using a
use of small access openings without raising any circular scalpel. A circular full-thickness muco­
mucoperiosteal Baps has also been suggested. periosteal Bap is removed to gain direct access to
This method, referred to as flapless, has gradual­ the underlying bone (Fig 7).
ly become more widespread, and many surgeons For the reasons stated, computer-guided Bap­
have routinely adopted it for immediate im­ less surgery offers several objective advantages:
plant positioning to preserve the vascular supply
and maintenance of surrounding soft tissues.6s • Reduction in intraoperative bleeding
• Reduction in surgical time and no need for su­
tures
• Better maintenance of vascular supply
• Reduction in postoperative complications,
particularly swelling and pain

Certain disadvantages must nevertheless be

carefully evaluated under different clinical con­
ditions:

Figure 7 • It is impossible for the surgeon to view ana­

Clinical example of flapless access. This approach is tomical boundaries and vital structures
indicated in cases where the resulting keratinized • Reduced possibility of controlling the direc­
tissue loss is negligible. tion and depth of implant placement

■ Digitol lmplontology
• Difficulty in performing a simultaneous cor­ considered the first therapeutic option in all
rective action on hard and sofi: tissues where cases where there is a sufficient volume of bone
necessary and sofi: tissue. A computer-guided surgical ap­
• Inevitable loss of a portion ofkeratinized tissue proach also be used through the preparation of a
mucoperiosteal flap that exposes the underlying
By analyzing each individual case proper­ bone. In this case, the guide template is rested
ly, operators will be able to discern and select on and secured directly to the bone plane before
cases that can be treated using this type of ap­ carrying out the osteoromy (stent with bone
proach. Flapless surgery should certainly be support).

Chapter l ► Introduction ■
 conducted in the United States in 2006, only
Q::: 30% of the dentists sur veyed reported using a
w digital x-ray system.1 The need to computerize the
t­ dental practice to use images taken in the dental

o_ chair and thus manage and maintain a computer

network could be factors that hinder the spread
<( of these technologies. 2-4 The introduction of dig­

I ital radiography has unquestionably improved

presurgical anatomical assessments, enabling cli­
0 nicians to obtain much clearer and more precise
images 5-9 (Fig 1 ).

Digital DIGITAL IMAGING

Radiology
Although the image displayed on a computer
screen as a set of darker and lighter areas looks
similar to those of a conventional radiograph
printed on film, a digital image is completely dif­
ferent in nature. A conventional radiographic
Even though digital radiography was introduced image is made up of radiolucent areas (dark) in
to dentistry more than 25 years ago, its use is still which the silver grains of the emulsion are denser
not well established in dental practices. In a study and radiopaque areas (light) where the granules
are less concentrated because they have been re­
moved in the development process. A digital
image, on the other hand, is made up of a series
Figure I
of cells (pixels) that are arranged into lines and

--
Schematic view of an x-ray tube.
The high potential difference Cathode(-) columns. Each cell is allocated three numbers: the
Focal Point
(kV) between anode (+) and x-coordinate, the y-coordinate, and the grayscale
Aluminum filter
cathode (-) accelerates the elec­
tron current (mA). The electrons
value (corresponding to the intensity of radiation
collide on the focal spot and
Primary
collimator received by the sensor). The essential difference
generate x-rays. The aluminum between these images is that, whereas the conven­
filter (total 2.5 mm) removes tional image cannot be changed, the digital image
low-energy radiation that is
dangerous for the subject. can be processed by means of mathematic opera­
Collimation takes place in two tions (algorithms) that alter the value associated
stages: The primary collimator with the pixels. This makes it possible, for exam­
defines the shape of the beam,
ple, to optimize image brightness and contrast,

--------------
Secondary
and the secondary collimator collimator

limits the radiation on the sen- depending on diagnostic needs.10-12

sor, reducing background noise. Digital sensor The main determinants of radiographic image
quality are resolurion and noise. Just as image

■ Digital lmplantology
properties in conventional radiography depend 16-bit (from 1,024 to 65,536 shades of gray). This
on the physical properties of the film and the in­ high number of gray shades is normally saved in
tensifying screens, in digital radiography, the 8-bit images for reasons of space (256 shades of
properties depend on the type of sensor used to gray), but it must be considered that the human
convert radiation to a digital signal. The resolution eye cannot discern more than 100 shades of gray.
has two components: spatial resolution (the abili­ Noise depends on statistical fluctuations of the
ty to distinguish two nearby objects) and contrast film emulsion density, random microcurrents,
resolution (the ability to distinguish between two and ray dispersion in the digital image. The most
similar shades of gray). In solid-state sensors (eg, significant parameter is the signal-to-n9ise ratio
charge-coupled device [CCD], complementa­ (SNR). In general, digital sensors are much more
ry metal oxide semiconductor [CMOS]), spatial effective than x-ray emulsion with regard to this
resolution is given by the number of pixels col­ parameter. 15· 16
lected in the sensor: The smaller the pixels, the Digital images can be processed after their
greater the number of pixels on the sensor and acquisition to improve diagnostic potential,
consequently the greater the spatial resolution. making them easier to interpret by the human
The size of pixels currently available in solid-state eye. 17 Changes in intensity, achieved by adding or
sensors ranges from approximately 20 µ,m (intra­ subtracting a fixed amount from the value of each
oral) to 160 µ,m (panoramic). 13•14 pixel, mean that the image can be made more or
In sensors using phosphor technology (photo­ less bright, while changes in the range of gray
stimulable and phosphor), the resolution depends shades make it possible to vary the contrast. Image
on the diameter of the scanning laser and light reversal, converting light to dark and vice versa,
diffusion. Finer sensors and smaller lasers increase can be used to obtain a negative image, making
the resolution, which is currently approximately use of the fact that the human eye is more able to
40 µ,m for intraoral imaging plates. Spatial res­ distinguish two dark gray shades than two light
olution is evaluated by asking an observer to gray shades. This operation allows, for example,
distinguish between fine line pairs and measuring more effective highlighting of root canal treat­
the number of lines per millimeter (Ip/mm) that ment with insufficient radiopacity. Image zoom
can be distinguished. For example, a convention­ can be used to enlarge details, but it is limited by
al panorama allows a resolution ranging from 4 to image resolution. It is also possible to apply filters
5 lp/mm, while a digital panorama ranges from 4 that remove noise or intensify peaks, making the
to 6 lp/mm. A digital intraoral image reaches 12 image more detailed. 18-20
lp/mm, while a level of20 lp/mm can be achieved When digital imaging was first introduced,
with an intraoral image on conventional film. various studies questioned its diagnostic po­
The contrast resolution is limited by the tential. Subsequent technologic improvements,
number of gray shades available (dynamic range) particularly to sensor quality, made it clear that
for the system used. In digital systems, this is di­ these methods are superior to conventional meth­
rectly correlated with the number of bits (bit ods. Moreover, these results can be achieved
depth) comprising the information (eg, 8-bit or with a simultaneous reduction in radiation: The
16-bit). Most of the digital sensors available today patient is subjected to approximately 47% the ra­
allow a contrast resolution ranging from 10- to diation used in convertional imaging in intraoral

Chapter 2 ► Digital Radiology II

 on the market, and these offer the advantage of
using thin and flexible plates similar to conventional
analog plates. It is also possible to use the centering
devices used with conventional plates. The plate
nevertheless has to be read by a special scanner
after exposure, with an average scanning time of
15 to 20 seconds. The other available system is an
intraoral sensor with CMOS or CCD technology. This
sensor is much thicker than a plate and is connected
via a cable to a computer, making it somewhat
difficult to position in certain sectors. However, one
of its benefits is immediate imaging. A study on the
Figure 2 diagnostic soundness of the two systems showed
I Digital intraoral radiographs make it possible to that the phosphor technologies allow greater
obtain high-definition images with optimum quality anatomical detail because of the high number of gray
detail. Systems using phosphor sensors are available shades that can be obtained using this technique.

radiographs and approximately 17% in conven­ INTRAORAL

tional panoramic radiographs.21·22 All of chis is
achieved with radiation exposure times reduced lntraoral radiographis are characterized by their
by approximately 90%, with the radiographic wealth of observable details as they offer very
image appearing on the computer monitor in real pronounced spatial resolution compared with
time.1 2,23- 25 examinations using an extraoral technique. 4·26
As will be explained at length, the dedicated These images can be used to assess a single site
software makes it possible to detect linear mea­ in detail because they make it possible to diag­
surements, angles, or surfaces from radiographic nose any abnormalities and evaluate trabecular
images. It should be noted, however, chat in the bone. However, it is very often not possible to po­
case of two-dimensional (2D) radiographs, such sition the sensor parallel to the long axis of the
as intraoral and panoramic images, digitization bone ridge to be evaluated, and chis makes it dif­
does not prevent the presence of projections. This ficult-if not impossible-to calculate sizes and
is because of positioning of the sensor or defor­ distances from adjacent anatomical structures. In
mations owing to the nature of the examination, a cadaveric study, Klinge et al 27 found that, with
as in the case of panoramic images. this type of radiograph, the mandibular canal
could not be identified in 25% of cases. When
the canal of the mandibular nerve was visible,
the measured distance between the upper bone
ridge and the upper cortex of the canal depicted
on the radiograph showed an error of less than 1
mm in relation to the actual measurement in only
53% of cases. Another study showed that chis

II Digital lmplantology
radiographic examination leads to low agreement
between observers over the mandibular nerve lo­
cation. Intraoral radiographs, particularly when
carried out using standardized techniques, are an
ideal examination for checking implant marginal
bone levels during maintenance visits, particular­
ly with a limited number of implants (Fig 2). Figure 3
In a panoramic radiograph, it is of fundamental
importance to position the subject to obtain
accurate correspondence of the focus area (shown
in yellow in the drawing on the right). Because
PANORAMIC the area of focus is characterized by a gradient,
structures that are distant from it do not overlap the
With the introduction of digital radiography, structures of interest, except to a minimal extent.
panoramic radiographs can be obtained with a Some anatomical structures such as the spine or
hard palate are still projected on the final image,
considerable reduction in time and patient ex­ creating noise that means the anterior area is not as
posure to radiation (reduction of approximately well defined as the posterior areas.
17% ). 2s-3o This form of radiographic examination
is very worthwhile when carrying out a treatment
plan. 31
However, one particular feature of this tech­
nique must be taken into account: On a vertical
plane, the ray source is the x-ray tube spot; on a
horizontal plane, the actual source is the x-ray
beam center of rotation. This produces an image TOMOGRAPHY
that reflects the object projected on the vertical
plane with constant deformation but leads to a Conventional spiral or linear tomography is
magnification on the horizontal plane, which an examination that allows sectional images to
varies continuously because of the variable dis­ be obtained. 32 The introduction of cone beam
tance between the center of rotation and the jaws, volumetric techniques has made this type of
particularly in anterior areas. This leads to the risk examination obsolete for implant planning be­
of errors when evaluating the horizontal distances cause of the unfavorable ratio between the x-ray
of sites subject to analysis in relation to adjacent dose for the patient and the quality of images ob­
anatomical structures. One technique used to tained, which are difficult to interpret.
partially overcome this problem is that of pre­
paring a radiographic template to be used when
scanning the patient. COMPUTED TOMOGRAPHY
Despite these limitations, a panoramic ra­
diograph remains the examination of choice for This technique, particularly well _known for
achieving an initial idea of the overall condition the axial computed tomography ( CT) projec­
of the teeth and of the maxillary and mandibu­ tion, was introduced in medicine in 1970 and
lar bone (Fig 3). was originally developed to study the skull. The

Chapter 2 ► Digital Radiology ■

 first machines were able to produce a couple of by the patient during this examination, ranging
cross-sectional images of the skull that were 1 from 180 to 2,100 fLSV for an examination of
cm thick with an exposure time of 5 minutes. As both arches and 1,400 fLSV for a mandibular ex­
early as 1980, technologic developments led to amination.34-39
machines that could produce 2-mm thick contig­ Introduction of the cone beam CT (CBCT )
uous sections, and a few years later, multiplanar technique resolved many of these problems40 (Fig4).
reconstruction software was developed that made
it possible to obtain a virtual reconstruction of
the skull and longitudinal sections of areas of in­ CBCT OR CBVT
terest.33
One weakness of the CT scanner is the du­ Cone beam volumetric tomography (CBVT) or
ration of the examination (several minutes), CBCT was originally developed for angiogra­
during which time it is essential for the patient phy in 1982 at the Mayo Clinic.40 Its first use was
to keep still or artifacts will be created because to determine centering in patients undergoing
of interpolation of the data obtained by the re­ radiotherapy. At the end of the 199Os, techno­
construction software. For this reason, patients logic development led to the construction of the
are placed in a supine position with their heads first machines dedicated to radiologic imaging
secured with special supports. Another factor to of the skull. The first commercial version was de­
be taken into consideration is the dose absorbed veloped by NewTom (Verona) in 1998. 4 1

CT Figure 4
The essential difference between a conventional CT
scan and a CBCT scan is that in the CT (a), the x-ray beam
that passes through the patient is linear and received
by one or more linear sensors. Each complete rotation
around the subject generates a number of sections,
which depends on the number of linear sensors. The
beam is emitted continuously. In the CBCT (b), the

II. Source
sensor is a square flat panel (whose size determines the
field of view) and the beam is pulsed. During rotation
around the subject (with a circumference that varies
from 200 to 360 degrees according to the machine), the
sensor gathers as many as 300 images from different
angles. The computer then processes these images
to form a three-dimensional (30) model made up of
isotropic voxels whose size is proportional to that of
the panel. This virtual model of the exposed bone
structures can then be rotated and sli'ced in the three

II
spatial directions.

IJ Digital lmplantology
 Since then, many other companies have devel­
oped this type of imager at increasingly reduced
costs.42.43 CBCT machines can essentially be sub­
divided into three groups:

1. Devices that can image broad areas or the

entire maxillofacial system with exposure de­
termined by the broad field of view (FOV).
2. Dedicated systems with a reduced FOV. 44
3. Hybrid panoramic/CBCT systems chat
Figure 5 Measurement Figure 6 Measurement
include sensors, which may or may not be sep­ of bone height available of bone height available
arate, for different functions. Some can also in the maxillary premolar in a posterior section of
produce 2D panoramic radiographs and cel­ site. the maxilla.

eradiograms.

The image generated by chis machine is a 3D

reproduction made up not of pixels, as in 2D
images, but of voxels. The size of the voxels de­
fines the 2D image resulting from the 3D model sensor in a reciprocal position between the two.
sections. Because the CBCT voxels are isotropic The FOV depends on the size of the sensor and
( ie, with identical dimensions in che three spatial the geometry of the beam, which may be colli­
directions), the reconstruction thickness is sub­ mated in some machines if required by the user. 45
millimetric and the multiplanar reconstruction CBCT scanning results in a series of 2D
is actual size. This means chat che accuracy of che images with different projections, which are
images and therefore of the measurements has a immediately used for the volumetric recon­
very limited margin of error (± approximately struction. The number of projections can vary;
0.1 mm) (Figs 5 and 6). the greater the number of sections, che more in­
formation will be available for reconstruction.
Conversely, che more sections there are, che
3D IMAGE FORMATION smaller che SNR will be per individual section.
The dose to which the patient is exposed also de­
Image formation cakes place in two stages: (1) ac­ pends on the number of projections when the
quisition and (2) reconstruction. beam source is pulsed. 46-49

Acquisition Reconstruction
The cone technique generally includes a single The 2D projections produced in this way
rotation around the patient (from 180 to 360 de­ are transferred to the machine management
grees depending on che machine used) by an arm software, which reconstructs them in three
holding an x-ray source and a flat panel digital dimensions using a special algorithm. The

Chapter 2 ► Digital Radiology ■

 reconstruc�ion time depends on several factors • A 3D reconstruction is immediately available
including the number of projections, the voxel on the computer. Because voxels are isotropic,
size, the computer processing power, and the al­ the model can be reoriented in space and virtu­
gorithm used. al sections can be obtained in any direction.
CBCT produces images with high contrast • CBCT imaging software makes it possible to
and is therefore ideal for calcified tissue such as work on three sectional planes and carry out
bone and teeth. Moreover, because the FOV can various image processing operations.
be modulated according to specific requirements, • 3D model sections can be imaged by means of
it is ideal for dental and maxillofacial applica­ oblique or even nonlinear planes or multipla­
tions.50-57 CBCT therefore offers considerable nar methods. This makes it possible to image
advantages when compared with a conventional specific anatomical structures and evaluate im­
CT scan: plant sites in depth.8•67-75 It is also possible to
vary the thickness of the imaged sections and
• The FOV can be modulated using special colli­ render a 3D model.
mators and sensors.
• The resolution is generally higher than with
images obtained from a CT scan. In CBCT FILE EXPORT
machines with solid-state sensors, voxel resolu­ AND PROCESSING
tion can range from 0.25 to 0.07 mm.
• Scanning time is reduced and may be as little CBCT machines produce a scan output file in
as 10 seconds. This reduces the risk of invol­ digital imaging and communications in med­
untary movements by the subject during the icine (DICOM) format. This format is now a
examination. standard used in guided implantology software.
• The dose is much lower than with a conven­ The patient's 3D images can therefore be export­
tional CT scan. A CT scan of both jaws with ed in this format and subsequently imported into
a conventional multidetector CT device (So­ guided implantology software to allow implant
matom R 64 MDCT w/CARE Dose) exposes planning, as will be fully described later.
the patient to an effective dose of 285 to 534 Another software option used by CBCT
fLSV, while a CBCT examination of the same machines is to import laser scans of the pa­
area may deliver a dose of 44 to 400 fLSV, de­ tient's plaster models in dedicated stereotactic
pending on the device used. An examination radiotherapy format and lay them over the radio­
with reduced FOV or reduced resolution can graphic image to show the soft tissues. There is
deliver as little as 10 f,lSV. For the purposes of also an option of segmenting the image or pro­
comparison, a full set of intraoral radiographs cessing the DICOM images by partitioning them
may deliver 84 fLSV. 24·58-66 into a set of pixels with common characteristics
• Voxels are isotropic, while in a CT scan the to make them easier to interpret. This processing
sizes of the voxels are identical on the section­ can be carried out by the operator or outsourced
al plane but bigger in the axial plane because of to dedicated services.76-78
the distance between the scanning sections.

■ Oigitol lmplontology t
ACCURACY AND PRECISION x-ray scanning. One recent study by Pettersson96
OF CBCT reported that approximately 40% of subjects un­
dergoing 3D x-ray examination moved during
For obvious reasons, there must be maximum scanning, creating distortion. Another factor that
correspondence between the anatomical situa­ can create distortion or difficulty in distinguish­
tion to be examined and the 3D image obtained ing certain structures is the presence of noise
from the x-ray scan. In other words, the image (scattering) caused by metals such as fillings or
must be as accurate and precise as possible. The reconstructions.97
accuracy essentially depends on the bias, which is For the reasons explained, CBCT exam­
usually reduced by machine calibration. Precision ination is increasingly gaining ground as an
depends on random error and is therefore deter­ essential analysis tool for the drawing up of a
mined by the care taken over image scanning and dental treatment plan. This instrument is ex­
processing. tremely useful for the accurate diagnosis of
Various studies have evaluated the accuracy various diseases, from exact tooth positioning
and precision of CBCT using different exper­ even at the anatomical limits of cystic lesions
imental models. The systemic error measured to the perfect interpretation of periodontal le­
in these studies is approximately 0.15 mm (ie, sions (Figs 7 to 9). However, the main impetus
a level on par with the resolution of these ma­ that has led to the gradual adoption of these
chines) .32,79-95 The random error evaluated by machines in routine clinical practice is the po­
the standard deviation of the errors is estimat­ tential for obtaining highly accurate 3D images
ed to be approximately 0.25 mm and is therefore of jaw anatomy, which allows practitioners to
very low. One source of random error that is plan highly complex implant-supported pros­
often overlooked is patient movement during thetic procedures.

Figures 7 to 9 CBCT images

offer a clear view of various ab­
normal processes.

Chapter 2 ► Digital Radiology ■

 As we shall see m the next chapter, when These tools represent an irreplaceable clinical sup­
processed by special software, the information ob­ port in routine dental work and for the exchange
tained from these state-of-the-art x-ray devices can of information between the different types of
be used to draw up thorough treatment plans and practitioners who contribute to treatment plans.
show with great clarity the final treatment result
that can be achieved by varying each parameter.

■ Digital lmplantology
 Q::'.
w
As outlined in the previous chapter, the main
diagnostic and planning software packages cur­
Jo­ rently available on the market use a digital process
o... to convert computed tomography (CT) images

<(
into three-dimensional (3D) images that can be

:r: used to draw up a detailed treatment plan based

u
on all the necessary anatomical information. 1
Many of these programs offer so many functions
and such excellent compatibility with CT devic­
es currently on the market chat they can be used
to display jaw anatomy in great detail, separating
and clearly identifying bones, teeth, roots, sock­
ets, nerves, soft tissue, and airways2-7 (Figs 1 to 3).

Virtual Diagnosis
These software packages can also identify and pair
information from plaster model scans, wax-ups,
and prosthetic reproductions to allow clinicians

and Treatment
to plan complex implant-supported prosthetic
restoration projects 8 (Fig 4). More advanced ver­
sions of these programs also make it possible to

Planning
design treatment plans for cases that require bone
reconstruction, orthognathic surgery, and ortho­
dontic procedures9-11 (Fig 5 ).

Figure 1
3D image of a mandible showing indi­
vidual anatomical structures.

■ Digital lmplontology
 Figure 2
Sagittal section of a 3D image.

Figure 3
Axial section of a 3D image.

Figure 4
3D image of a maxilla with planning
of the future prosthetic restoration.

Chapter 3 ► Virtual Diagnosis and Treat11ent Planning ■

 • Segmentation to convert DICOM files into
3D objects
• Preparation for planning by pairing files of
different format
• Diagnosis and planning
• Displaying and ordering of surgical guides for
implantology or orthognathic surgery
• Postsurgical check on precision by superim­
posing pre- and postoperative CT scans
• Communication between clinicians and with
patients via smartphones and tablets

Figure 5
Virtual jaw repositioning in an orthognathic surgery
plan. IMPORT OF CT IMAGES IN DICOM
FORMAT

The various functions of state-of-the-art design As discussed in chapter 2, certain conditions

software can be summarized as follows: must be respected to successfully acquire radio­
graphic images (Fig 6).
• Import ofCT images in digital imaging and com­
munications in medicine (DICOM) format

Figure 6 Required alignment and Acquisition parameters

Alignment protocol
range of images
and acquisition pa-
rameters most com- Mandible Matrix 512 X 512
monly used for CT Field of view (FOV) Between 140 and 170 mm
examinations.
Section thickness Between 0.4 and 0.7 mm, max 1mm
Rotation step 1mm
Reconstruction step 1mm '

Reconstruction Bone or high resolution

Maxilla algorithm
Gantry tilt 0 degrees
Remove parts of teeth, prostheses, or metal jewelery
Acquire both teeth and prosthesis
Only axial scans are required

■ Oigitol lmplontology
 Data produced by state-of-the-art imaging devic­ standards, etc). A DICOM file also contains in­
es are assembled in DICOM format. formation such as the image size and position, the
This format is now an international standard type ofscanning, and the patient's personal details.
used to transmit biomedical data and medical in­ Data from the CT scan are generally not im­
formation between a series of devices such as ported in full. To avoid overburdening the system
computers, scanners, printers, and so on. 12-14 This and to enhance image clarity, it is a good idea
transmission is achieved through the transmission to select the area of interest with the cursor and
control protocol/Internet protocol (TCP/IP) and limit data import to this specific section 15 (Figs 7
allows the sharing of data in DICOM files. The file and 8). Once the area of interest has been selected
standard is open and also very efficient because it and imported, the various sections will be clear­
allows detailed processing of digital images. ly displayed. Planning software generally allows a
When applied to file coding, the DICOM stan­ single screen divided into squares as well as axial,
dard is a method for grouping data and establishing sagittal, and coronal sections of the selected ana­
how they must be coded or interpreted, but it does tomical area together with a 3D overview. Cursors
not define any new compression algorithm. On at the side can be moved to edit these fields, navi­
most occasions, the image is filed in compressed gate within the structures, and analyze all of their
form according to the code used to produce it, but characteristics (Figs 9 to 12).
many software programs are able to produce or in­
terpret DICOM files containing data compressed
in accordance with various algorithms (JPEG,
JPEG Lossless, JPEG Lossy, various JPEG2000

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DICOM import of a maxilla. DICOM import of a mandible.

■
t Chapter 3 ► Virtual Diagnosis and Treatment Planning
 «c&JCT
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Detail of a sagittal section.

■ Digital lmplantology
 Figure 11
Various design components can be displayed
on the computer in all projections.

Figure 12
DICOM data entered in the software allow an­
atomical parts and the diagnostic prosthesis
to be displayed with great clarity.

I
Cn/Jp-e r 3 ► V ,-�c D1cgnos!S enc Trectment Planning ■
 SEGMENTATION software packages are able to resolve this problem
TO CONVERT DICOM FILES by removing such interference. This is achieved by
INTO 3D OBJECTS using a bar that adjusts the density levels of the pa­
tient's various anatomical structures, thus making
Segmentation describes the operation involved in the target image sharper and more well defined.
cleaning DICOM images and converting them Where it is not enough to use the bar (which
into 3D format. The final outcome of this op­ often helps to remove the background noise typi­
eration is to provide very detailed 3D images cal of some volumetric CT scans), the mouse can
containing all the information necessary to carry be used directly to remove artifacts from the two­
out thorough case planning. 15. 61
dimensional (2D) or 3D images (Figs 14 and 15).
Images obtained by CT scanning often contain Many software packages are also able to cal­
a series of alterations mainly attributable to the culate bone density (and take measurements) in
presence of metal prosthetic artifacts, preexisting axial, sagittal, and panoramic images with spiral
implants, or any radiopaque materials used in root and volumetric CT scans. This function is very
canal treatment 17-20 (Fig 13). Many present-day useful for planning2 1 (Fig 16).

Figure 13
Axial section showing artifacts generated by the pres­
ence of prosthetic structures.

Figure 14 Figure 15
3D view of a mandible. Some artifacts caused by the 3D image df the mandible after cleaning away arti­
presence of prosthetic structures are evident. facts.

■ Digital lmplantology
•

Figure 16
Coronal section of a mandible
showing the density value at the
bottom right (in this case, D4).

t
l During the segmentation stage, all relevant an­
atomical structures can be identified with great
accuracy. In the case of the mandible, for example,
it is very important to identify the inferior alveo­
area where the nerve emerges. This is easily iden­
tifiable as a break in the vestibular cortex of the
mandible in the space between the first and second
premolars. Each section of the canal can be identi:.
lar nerve and the mandibular canal in relation to fied by moving backward in a mesiodistal direction.
the external bone structure. Allocating this struc­ By clicking on each of these points with the mouse,
ture a different color will make it easier to identify it is extremely easy to trace the entire route of the
its path until it emerges through the mental fo­ nerve (Figs 17 and 18).
ramen.22·23 This can be achieved by designing a In the same way, within the maxilla, it is possi­
panoramic curve, choosing the most visible axial ble to delineate the boundaries and overall volume
section of the mandibular canal, and selecting the of the patient's maxillary sinuses. During the

Figure 17
Definition of the panoramic curve on the axial image.

Chapter 3 ► Virtual Diagnosis and Treatment Planning ■

 Figure 18
Reconstruction in orange showing
the pathway of right and left infe­
rior alveolar nerves to the point of
their emergence through the re­
spective mental foramen.

Figure 19
3D image of an atrophic maxilla
showing airway cavities.

Figure 20
Different densities make it possible
to distinguish tooth structure from
bone.

segmentation stage, it is also possible to distinguish prosthetic elements by adjusting threshold inter­
all of the areas occupied by the nasal and parana­ vals (ie, anatomical density ranges)25 (Fig 20). The
sal sinuses.24 This instrument is ofgreat importance clinician defines tooth and bone areas on the com­
in the event of major maxillary atrophy because it puter, always assigning different colors to ensure
allows for the study ofimplant positioning areas in that they are more readily identifiable during the
great detail (Fig 19). subsequent 3D reconstruction.
During this segmentation stage, the bone Afi:er reaching the end of the segmenta­
tissue can be separated from sofi: tissue, teeth, and tion module, a 3D image of all reconstruction

■ Digital lmplantology
structures can be displayed in the window at the addition of teeth or an overall view of the maxil­
bottom right. Icons of the various 3D images can lary bones, teeth, and the anatomical structures
be recognized with the aid of the colors allocat­ of the inferior alveolar nerve and paranasal sinus­
ed. Clicking on each of these will modify the 3D es (Figs 21 to 23).
image, highlighting the selected structure. In this The 3D images obtained using the major guided
way, it is possible to observe, for example, the surgery software packages are navigable in the
bony parts alone or the bony structures with the sense that they can be sectioned (at the axial, sag-

Figure 2 I
3D view of a mandible.

Figure 22 Figure 23
3D view of the same mandible. Transparency of the Here transparency of the bone makes it possible to
bone makes it possible to view the residual teeth in view the teeth and reconstructed nerve structures.
orange.

Chcoter 3 ► Vduoi Jiognos:s one Treatment [Link] ■

 ittal, and coronal level) to observe hidden features. these operations can be used to create individual
They can also be made transparent to reveal the an­ teeth, sockets, or a barium sulfate scan prosthesis
atomical structures concealed within them to very (single-scan procedure). For example, if a tooth is
striking visual effect (Figs 24 and 25). subtracted from the dental template, this leaves the
The segmentation module of these software associated socket (Figs 26 to 29).
packages may also be very useful for physically
extracting and separating teeth to simulate postex­
traction surgery procedures. After isolating the IN TEGRATION OF INFORMATION FROM
tooth to be extracted from the corresponding al­ VARIOUS FILES
veolar bone, the tooth can be hidden to simulate
extraction and apply an implant in the correspond­ State-of-the-art planning programs are able to in­
ing socket. All of this is achieved through a simple tegrate and standardize information from various
Boolean equation (bone minus tooth subtraction). files. To carry out optimum planning, it is useful
Boolean operations are addition or subtraction for clinicians to be able to call on prosthetic learn­
operations that take place between 2D templates; ing information as well as anatomical information.

Figure 24 Figure 25
3D sagittal section of a maxilla with cheekbone and 3D sagittal section of a full face.
orbital floor. The section can be used to analyze the
entire internal anatomy of bone structures.

■ Oigitol lmplontology
 Figure 26
11 .,. .,
.:,1�J!(E;".::.:JB,, \i,,li;l, ��.• i 'Yccw Axial view showing segmentation
·'Mali, ,
,., of a canine tooth.

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11.,. Execution of Boolean subtraction
operation between two 2D tem­
plates

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Figure 28
Virtual tooth extraction to view the
socket.

C::rooser 3 ► V1rt:.x:i: C1ognos1s ond Treatment Plonnir,g ■

 Figure 29
Sagittal section through the maxil­
la with a barium sulfate scan pros­
thesis.

The latter are acquired by scanning the patient's wax-ups. The first option is to scan a model of the pa­
prosthesis or a duplicate prosthesis or plaster casts tient's arch. The software then pairs these data with
with associated wax-ups (Fig 30 ). The input of ref­ anatomical data from the CT scans (Fig 35). The
erences identifiable by the software will make it second option is co scan the plaster cast and the
possible to obtain a unique image representing the wax-up of residual teeth separately. These data must
various items of information 6· (Figs 31 to 34).
2 27
also be integrated with the CT data (Fig 36).
Three different import procedures are available for Because these software packages include a
acquiring data from models and associated diagnostic model chat can produce a completely virtual

Figure 30
Optical scanning: Final registration
between the bone and the plaster
cast.

■ Digital lmplontology
 Figure 3/
Dual scanning: Identification of
landmarks.

Figure 32
Dual scanning: Import of the scan
prosthesis.

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Figure 33
Dual scanning: Automatic registra­
tion of landmarks.

c:�cc•er 3 ► V r��o! Diagnosis end Treotr1ent Plonr,ing ■

 Figure 34
Dual scanning: Final pa1nng be­
tween the bone and the scanned
prosthesis.

Figure 35
Optical scanning: Import of the plas­
ter cast.

-------
I

Figure 36
Separate scanning of the plaster
cast and the wax-up.

wax-up, the third option is to apply virtual teeth associated with those of the virtual wax-up. The
in the sites corresponding to the patient's missing virtual teeth can be modified in terms of size, site,
teeth. In this case, the data obtained from scan­ and angle to determine the correct positioning,
ning the edenculous model are imported and exactly as in a real wax-up25 (Fig 37).

■ Digital lmplantology
DIAGNOSIS AND PLANNING

A common mistake is to consider virtual design

software only for use in implantology. It is im­
portant to recognize that the capacities of such
systems go well beyond simple planning of
implant positioning because they are actually so­
phisticated and comprehensive surgical planning
F('l,11re 37
tools. After reconstructing a 3D image of the pa­
3D scanning of plaster cast and execution of a wax-up
tient's jaws fully and accurately, the practitioner by applying virtual teeth.
is free to try out all the various system functions
to discover their various potentials. For example,
because the anatomy can be seen perfectly, the
different morphologies can be viewed, identify­
ing each individual area requiring reconstruction.
This can be thoroughly planned, virtually mod­
eling the graft with an analysis of morphology
and the necessary sizes. Another chapter dis­
cusses how it is now possible to make a block of
biomaterial directly from a virtual design that can
be used to reproduce each individual detail with
great precision.
An intrasinusal filling can be planned in the
same way. In this case too, it is possible to define
the dimensions of the access window, the extent
of the graft, the amount of material needed, and
the dimensions of any implant to be positioned at
the same time (Figs 38 to 40). Figure 38
Sagittal view of an intrasinusal graft plan with simul­
At present, this software is mainly used when taneous implant placement.
preparing for guided implant surgery. 28•29 Such
programs can be used for the virtual placement of
implants, choosing and customizing abutments,
positioning guide fixing screws, and viewing the
final outcome of the entire procedure. 30-32 to be used and, within this, the specific morphol­
Many software packages form closed platforms, ogy, diameter, and length, testing the consistency
meaning that users can only choose components of each variable.
from one specific company. Others are more or Once the implant has been chosen, its position­
less open, with an extensive library that includes ing in the chosen site can be simulated using one of
most implant systems currently on the market. the various software windows, each corresponding
These menus allow a choice of the implant system to a different section plan. Whenever this operation

Cr,opte, 3 ► v,nucil J,cig�os:s end Trectment Planning ■

Fig11n! 3<J
Creation of a bone graft.
.erutt0<�•too.w
'""

Figure 40
Bone graft characteristics.

�=�-,,�-;.;cf
6.:N mm Mlqlt: 1.08 ffWTI Oepth: 5.16 mm j

·-'

is carried out, the virtual position allocated to the possible for optimum prosthetic restoration (Fig
implant is automatically made visible in all sections, 41). The emergence profile of each implant is ge­
allowing clinicians an immediate perception of the nerically displayed as a cylinder, which represents
insertion in the various projections. the rectilinear extent of its axis (Fig 42).
During this stage, it is also possible to test the For any given emergence profile, an ideal pros­
emergence profile of the implant when its po­ thetic abutment can be chosen from another
sitioning is varied and examine the impact in special library containing all possible options in
relation to the prosthesis, which can also be viewed terms of morphology, shoulder height, and in­
in the same screens. It is possible to display the 3D clination 33 (Fig 43). Many options are available
prostheses in the various jaw sections and move the when choosing these components. One of these
chosen implants around to ensure that their pro­ is an option that makes it possible to use fully
file emerges under the most acceptable conditions computer-designed customized abutments, giving

■ Digital lmplantology
 Frguri' ./ I
Virtual planning with implant po­
sitioning with a view to future ap­
plication of prostheses through an
analysis of their emergence pro­
files (yellow cylinders).

Figuri' .f:}
3D sagittal section of a mandible
after implant positioning. The yel­
low cylinder indicates the implant
prosthetic emergence profile.

the emergence profile an ideal morphology for ad­ ·-·-- tz::1�

aptation to peri-implant tissues33-37 (Figs 44 to 47).

In general, implants can be placed in any of
the four planes available at the planning stage:
sagittal, panoramic, axial, and 3D planes. Some
software offers the option of viewing the implant
at the sagittal level as well as in a classic and x-ray
sagittal position or in an implant-centric posi­
tion (Figs 48 to 50). The implant-centric view can
therefore be used to navigate virtually within the
bone, always keeping the central axis of the im­
. ..
. ,
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• ,,.......,..-�-�[l,,lr.,,_,.,
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plant as a reference point. Figure ../3

Implant abutment library.

Chapter 3 ► Virtue' Diagnosis and Treatment Planning ■