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Continuing Education

Are Radiographic GuidesNecessary?

A Paradigm Shift in Implant Site Assessment,Digital Planning, and Surgical Guide

Fabrication

Authored by Michael D. Scherer, DMD, MS

Upon successful completion of this CE activity 2 CE credit hours will be awarded

Volume 33 No. 8 Page 62

ABOUT THE AUTHORDr. Scherer is a full-time private practiceprosthodontist in Sonora, Calif. He iscurrently an assistant clinical professor atLoma Linda University, a formerassistant professor in residence atUniversity of Nevada Las Vegas (UNLV),

and a Fellow of the American College of Prosthodontists.He has published articles related to clinical prosthodontics,implant dentistry, and digital technology with a specialemphasis on implant overdentures. His in volvement indigital implant dentistry has led him to develop and utilize new technology with CAD/CAM surgical systems,implement student-facilitated CBCT implant planning, and outside-of-the-box radiographic imaging concepts. He has served as the director of the implant dentistrycurriculum at UNLV and is actively engaged inguided surgical placement and prosthetic restora-tion of implants in private practice. He can bereached at (209) 536-1954 or via e-mail at thefollowing address: mds@scherer.net.

Disclosure: Dr. Scherer is a clinical consultant toZEST Anchors.

INTRODUCTIONWe were taught in dental school the axiom “failing toplan is planning to fail,” and that we must thoroughlyplan our treatment and visualize the end-point goalsprior to starting treatment. To get there, we weretaught (and continue to teach) that additive wax-upsfor partially dentate patients and tooth arrangements

on stabilized record bases for edentulous patients isabsolutely the gold standard in diagnosis and treatmentplanning. While for many, this treatment philosophy is still arelevant and critical aspect of treatment planning, the age ofdigital dentistry is rapidly changing this paradigm. For some,this may be uncomfortable, but many recognize that it ispossible to change while still respecting traditionalphilosophies for treatment planning success.

CBCT SCANNING AND IMPLANTOLOGY One of the best examples of the integration of digitaltechnology in dentistry is implant dentistry. The use of conebeam CT (CBCT) has gained popularity as it allows for 3-Devaluation as opposed to traditional 2-D radio graphictechniques. CBCT allows proper visualization of criticalanatomical structures and provides a superior amount ofinformation.1-3 The radiographic visualization of the alveolarridge, tooth position, and the restorative plan are necessarysteps in the treatment sequence and planning of implantrestorations. Figure 1 illustrates a pretreatment panoramicassessment of an edentulous patient interested in dentalimplants to retain his mandibular denture. Many clinicianswould look at this radiograph and the proposed implant siteand think that this patient would be an excellent candidate fordental implants. The first response typically given to this typeof radiographic appearance is, “He has a mile of bone!”Figures 2 and 3, however, illustrate the clinical reality that

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Are Radiographic GuidesNecessary? A Paradigm Shift in Implant SiteAssessment, Digital Planning, andSurgical Guide FabricationEffective Date: 8/1/2014 Expiration Date: 8/1/2017

Figure 1. Panoramic radiograph of a patient showing adequate bone height fordental implants.

exists: a bottle-shaped mandibularridge with incomplete healing.Placement of standard-diameterdental implants would bechallenging, and the clinician wouldpotentially be surgically unpreparedif solely basing the treatmentassessment solely upon thepanoramic radiographic.

Proper evaluation of 3-D toothposition, angulation, and restor-ative space is essential duringtreatment evaluation for implant restorations. This restorativespace is bound by the proposed occlusal plane, mesial-distaldistance between teeth, denture bearing tissues of theedentulous ridge, and orofacial tissues.4 Inadequateattention to analyzing the restorative space may lead toproblems such as an overcontoured restoration, fracturedteeth and/or denture bases, artificially opened occlusalvertical dimension, and the need to perform additionalsurgical and restorative procedures.5-8 Figure 4 shows anexample of implants placed without regard to a restorativegoal or guide. While the implants appeared healthy andproperly within bony contours, the restoration requiredcustom abutments and splinted overcontoured restorations,which ultimately led the patient to feel as if a less thanoptimal result was achieved (Figure 5). Prevent ing errors intreatment planning, as shown in the previous Figures, canbe accomplished by establishing a restorative plan prior toplacing implants.

Various radiographic visualization methods have beenpreviously de scribed with many reports and techniquesinvolving duplicating the existing or proposed restoration andfabricating a radiographic guide.9-12 Many of these radio-graphic guides contain markers such as gutta-percha,13-15

ball bearings,16-17 metal tubes,10 metal strips,18-19 andbarium sulfate.9,11,20-22 These markers can reliably act astooth or restoration outline markers indicating incisal edgeposition, bucco-lingual position aides, and denture basecontour. By using these surfaces and markers, criticalanatomical features are identified, and dental implants maybe digitally planned. While visualization can be achieved withthis approach, some practitioners choose not to fabricate

radiographic guides because of the extra steps and costsinvolved. Lab oratories typically charge between $50 and $200for fabrication of a radiographic guide, in addition toapproximately $50 worth of impression material used, dentalgypsum, and packing material potentially needed to ship tothe laboratory. Additionally, a second clinical appointment isnecessary to try in the prosthesis to confirm adequate fit prior

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Are Radiographic Guides Necessary?

Figure 2. Bottle-shaped mandibular anterior ridgenot visible on the panoramic radiograph.

Figure 3. Volumetric rendering of bone volume illustrating clinical reality of 2-D versus 3-D diagnostic imaging.

Figure 4. Implantsplaced at challengingangulation due to lack ofrestorative-basedplanning.

Figure 5. Finalrestorations showing inadequate tissue form.

Figure 6. Patient missingtooth No. 19, seekingdental implant treatment.

to the CBCT scan. This extra effort necessary to fabricateradiographic guides is challenging to manage in busy clinicalpractices that may or may not have CBCT scanners in theoffice. When referring out to an imaging center, manyclinicians are concerned that their radiographic scanningcenter may not be able to reposition the guide adequately.With full-arch restorations, this can become more of a factordue to the fact that tissue resiliency may cause guides to seatmore in some areas than others.

Clinical procedures that facilitate treatment, reduce costand complexity, and still allow for an appropriate clinicaloutcome are always of interest to private practitioners. It isthe opinion of the author that with the current digitaltechnology and CB software packages, distinct radio graphictemplates are rapidly becoming unnecessary. Virtual wax-upand restorations allow the clinician to initially plan dentalimplants based upon bone volume and then correct basedupon virtual restorative goals. This digital restorative, orcrown-down treatment planning, represents a contemporarydiagnostic methodology for treatment planning dentalimplants. This article aims to describe 2 case reportsanalyzing potential implant sites in partially dentulous andfully edentulous pa tients without the use of traditionalradiographic guides.

CASE REPORTSCase 1: Planning Single Implants Many clinicians encounter patients with a single missingtooth who are interested in a dental implant. Figure 6 showsan example of a patient who lost tooth No. 19 after beingdiagnosed with a vertical root fracture. While some wouldadvocate fabricating a radiographic template and performinga CBCT scan with the template in place, the authordetermined that enough information was available to digitallyplan the restorative goal without this template. Some of thesefactors include: tooth-bound edentulous site, appropriateocclusal plane, no malformed dental restorations that wouldrequire modification or re placement, and adequate tissuehealth. A traditional CBCT scan was made at 0.3-mm voxelresolution with cotton rolls placed on the occlu sal surfaces ofthe teeth and with the patient biting down on the cotton rollsto slightly separate the occlusal plane.

The Digital Imaging and Com munications in Medicine

(DICOM) files were imported into Invivo Den tal (Anatomage)for software analysis. The inferior alveolar nerve was tracedand the mandible was sectioned from the cranial base andvertebral column to remove excess clutter (Figure 7). Animplant was selected from the library with diameter andlength chosen based upon the availability of bone present inthe 3-D view. The implant was tentatively placed according toavailable bone volume with some regard to positioningrelative to the dental arch configuration (Figure 8). A virtualrestoration or wax-up is added to the implant by clicking the“restoration” button on the left side of the screen, whichautomatically takes the user to the restoration feature of thesoftware. The latest version of Invivo Dental (version 5.3, atpress time) will pop up with various preprogrammed toothmorphology options ranging from large, youthful, low-wearto small, mature, high-wear restorations.

In this new screen, one can move and rotate therestoration buccolingually, mesiodistally, and incisal-gingivally to orient the restoration be tween adjacent teeth.By moving this virtual wax-up around, it gives a sense of theavailable space for the proposed restoration within theconfines of the dental arch (Figure 9). The restorationfeature of the software will also allow for dynamic resizing inall dimensions of the wax-up, allowing the user to preciselyplan the restorative goal. Once the restoration is finalized,the implant position can be viewed ac cording to therestorative goals (Figure 10). Using the digital crown-downphilosophy, one can see that the implant position is toolingual and tilted too facially, leading to a potential facialcantilever and improper emergence form. The implantposition can be easily modified to represent a moreappropriate implant position relative to the restorative goal(Figure 11). Based upon the virtual wax-up and plan,measurements can be made and traditional surgery can beperformed based upon the restorative planning. In thispatient case report, it was determined that ideal implantpositioning required buccal grafting of the implant at time ofplacement. Figure 12 illustrates the outcome of digitalcrown-down treatment planning: a screw-retained im plantcrown with the retaining screw located in the central pit,proper emergence form.

One of the biggest drawbacks of CBCT scans is theamount of back scatter from metal-based restorations.

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Are Radiographic Guides Necessary?

Backscatter was evident in this patient presentation and isseen in Figures 8 to 11; this may potentially interfere withproper radiographic visualization. To reduce the effect ofbackscatter on restoration planning, the clinician cansuperimpose an optical scan of a patient’s cast or intraoraloptical scan (Figure 13). To facilitate patient scansuperimposition, the clinician should separate the softtissues from the teeth with cotton rolls to facilitate the

visualization of intraoral soft-tissue profiles (Fig ure 14).Based upon this superimposition, a clinician can order acomputerized surgical guide to perform guided surgery(Figure 15).

Case 2: Planning Multiple Implants While digital implant treatment planning for multiple missingteeth traditionally requires a slightly more complicated

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Are Radiographic Guides Necessary?

Figure 7. Patient CBCT opened in InvivoDental (Anatomage) with nerve tracing andsectioning performed.

Figure 8. Initial implant placementaccording to available bone volume.

Figure 9. Add a virtual restoration to theimplant, then resize and move until satisfiedwith the planned result.

Figure 10. Implant position is inadequateaccording to restorative plan and an error inemergence form and biomechanics potentially could result.

Figure 11. Modifications made to implantposition relative to virtual restoration.

Figure 12. Final result shows ideal implantposition relative to restoration.

Figure 13. Superimposed optical scan ofpatient’s cast or intraoral optical scan onCBCT volume allowing for precise planning.

Figure 14. Cotton rolls added to separatetongue, cheeks, and lips allowing for a creation of air space around dentition andperiodontal tissues.

Figure 15. Computerized surgical guidebased upon a patient cast superimpositionwith virtual restoration.

CASE 1

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Figure 16. CBCT scan without aradiographic template showing incompleterestorative information. Patient was wearingcomplete dentures in occlusion during thisscan.

Figure 17. Traditional barium sulfate radiographic template based upon thepatient’s complete denture.

Figure 18. CBCT scan while wearing complete dentures with soft-tissue separation from the mandibular completedenture. Note the dark areas between thedenture and ridge in the areas of extractionsockets representing ridge resorption.

Figure 19. Dental implant planning with onlysoft-tissue separation from a mandibularcomplete denture.

Figure 20. Mandibular complete denture withradiopaque VPS liner (Green-Mousse[Parkell]) applied to intaglio surface combinedwith soft-tissue and occlusal separation.

Figure 21. Radiopaque VPS applied tointaglio surface of complete denture.

Figure 22. Cotton roll separation of thetongue, cheeks, and lips from themandibular complete denture. Patient wasscanned at 0.3 mm voxel resolution.

Figure 23. Denture scanned at 0.2 to 0.3mm voxel resolution.

Figure 24. CBCT plan with digital registrationof denture and soft tissues on patient scan,allowing for layers to visualize denture in 3-Dvolumetric rendering.

Figure 25.Computerized soft-tissue supportedsurgical guidefabricated basedupon crown-downdigital planning.

CASE 2

approach as compared to planning for single missing teeth,this case report will illustrate a unique and simple approachto im plant treatment planning edentulous patients. Often, aCBCT scan is performed without regard to restorative goalsand the resultant radiographic image depicts sufficientinformation related to bone quality and volume but provideslimited information regarding tooth position (Figure 16). Thetraditional method for radiographic visualization of restorativegoals for edentulous patients is to duplicate the patient’sdenture or diagnostic tooth arrangement with laboratory vinylpolysiloxane (VPS) putty or alginate. Using this impression, abarium duplicate denture can be fabricated which will showup as radiopaque replica on the CBCT scan (Figure 17). Thismethod does provide predicable assessment for dentalimplant treatment planning; however, as mentionedpreviously, this method typically requires 2 clinicalappointments and potentially in creases cost.

Radiodensity of cortical bone (1,700 HU) allows it beeasily visible on CBCT radiographs as compared to air (-1,000 HU) and tissues (50 HU).22 The comparison oftissue radiodensity and that of denture acrylic resin (70 HU)makes it more difficult to discern the differences betweenthe 2.22 Figure 18 illustrates a CBCT radiograph of amandibular complete denture with soft-tissue and occlusalseparation. Looking at this radiographic representation ofthe denture contour, it is easy to see all of the major factors related to essential treatment planning: toothposition, denture base contour, and occlusal morphology.Interestingly, there is also visible air space around recentextraction sites illustrating the healing process associatedwith an immediate denture. Traditional implant planning withmeasurement-based CBCT analysis is facilitated with thissimple yet intuitive approach for fully edentulous patients(Figure 19).

While this traditional surgical approach is facilitated withthis simple solution, digital planning for soft tissue-supported implant surgical guides requires a few additionalsimple steps. Figure 20 shows a mandibular completedenture with a radio paque VPS reline (Green-Mousse[Parkell]) and soft-tissue separation. The VPS liner shown inFigure 21 is applied to the intaglio surface of the denture ordiagnostic tooth arrangement prior to the CBCT scan using

a simple reline technique. The patient is then scanned at0.3 mm voxel resolution using a similar soft-tissue andocclusal separating protocol de scribed earlier (Figure 22).At this point, remove the denture and scan the denture andradiopaque liner separately at 0.2 to 0.3 mm voxelresolution with the denture suspended on a foam block orplate (Figure 23). This is commonly referred to as a dual-scan protocol. After the completion of the second scan, theradiopaque VPS liner can easily be removed and thedenture returned to the patient without having to drill anyholes or have to add any acrylic resin. Depending uponone’s specific dental state board laws and regulations, thisVPS protocol can also be potentially delegated to a dentalassistant or radiology scan center technician to free theclinician to concentrate on other procedures.

The dual-scan protocol produces 2 separate DICOMdata sets: one is of the patient wearing the denture andradiopaque VPS liner, and the second of just the denturewith the radio paque VPS liner. The CBCT radio graphs canbe virtually joined together, dental implants planned, andthey allow for complete visualization of the soft tissue anddenture as separate layers (Figure 24).

Soft tissue-guided surgery re quires a radiographictemplate that is fully adapted to the soft tissues in order toproperly relate dental im plant positions with the digital soft-tissue analogs. The markers within the radiopaque VPScontain unique features that allow the object to be reliablydetected and analyzed with a computer algorithm. Once themarker has been recognized, the algorithm will allow fordigital re-orientation based upon a pair of CBCT scans thatcontain an identical orientation of markers. Based upon thepatient and prosthesis scan registrations, a dentallaboratory technician can reliably separate a soft-tissueprofile from the denture surface. In addition, the markersimparted by the soft-tissue surface-based fiducialregistration allow superimposition of a soft-tissue cast oroptical scan. The combination of these 3 parts (patientCBCT scan, denture CBCT scan, soft-tissue cast opticalscan) allows the dental laboratory to fabricate a soft-tissuesupported dental implant surgical guide to assist in dentalimplant placement (Figure 25).

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CLOSING COMMENTSDigital CBCT software is becoming widely accepted throughoutclinical dentistry for its ability to rapidly and easily make visiblealveolar bone volume and quality. These systems allow cliniciansto manipulate 3-D images of patients’ dentition and restorativetemplates, facilitating dental implant planning. Presented was aunique, radiographic, template-free approach to treatmentplanning dental implants aided in part by soft-tissue and occlusalseparation with virtual restoration planning. These clinicalprocedures that facilitate treatment, re duced cost, andcomplexity and yet still allow for the clinical outcome ofproper dental implant planning is of particular interest toclinicians. Virtual planning of dental implants with these protocolsallows one to ask, “Do we really need a radiographic guide?”While these 2 clinical case reports of patients were planned andtreated using these simple protocols, every patient situation isunique, and there may be times when a completely virtual planmay be challenging. Ultimately, crown-down digital implanttreatment planning challenges the conventional paradigm ofradio graphic visualization for dental implant treatment planning.

REFERENCES1. White SC, Heslop EW, Hollender LG, et al. Parameters of

radiologic care: an official report of the American Academyof Oral and Maxillo facial Radiology. Oral Surg Oral MedOral Pathol Oral Radiol Endod. 2001;91:498-511.

2. Benavides E, Rios HF, Ganz SD, et al. Use of cone beamcomputed tomography in implant den tistry: the InternationalCongress of Oral Implantologists consensus report. ImplantDent. 2012;21:78-86.

3. Dreiseidler T, Mischkowski RA, Neugebauer J, et al.Comparison of cone-beam imaging with ortho -pantomography and computerized tomography forassessment in presurgical implant dentistry. Int J OralMaxillofac Implants. 2009;24:216-225.

4. Ahuja S, Cagna DR. Classification and management ofrestorative space in edentulous implant overdenturepatients. J Prosthet Dent. 2011;105:332-337.

5. Bidra AS. Consequences of insufficient treatment planningfor flapless implant surgery for a mandibular overdenture: aclinical report. J Prosthet Dent. 2011;105:286-291.

6. Bidra AS. Surgical and prosthodontic consequences ofinadequate treatment planning for fixed implant-supportedprosthesis in the edentulous mandible. J Oral Maxillofac Surg. 2010;68:2528-2536.

7. Lee CK, Agar JR. Surgical and prosthetic planning for atwo-implant-retained mandibular overdenture: a clinicalreport. J Prosthet Dent. 2006;95:102-105.

8. Porwal A, Sasaki K. Current status of the neutral zone: aliterature review. J Prosthet Dentt. 2013;109:129-134.

9. Basten CH, Kois JC. The use of barium sulfate for implanttemplates. J Prosthet Dent. 1996;76:451-454.

10. Takeshita F, Tokoshima T, Suetsugu T. A stent for presurgicalevaluation of implant placement. J Prosthet Dent.1997;77:36-38.

11. Kopp KC, Koslow AH, Abdo OS. Predictable implantplacement with a diagnostic/surgical template and advancedradiographic imaging. J Prosthet Dent. 2003;89:611-615.

12. Oh WS, Saglik B. A simple method to duplicate a denturefor an implant surgical guide. J Prosthet Dent.2008;99:326-327.

13. Verde MA, Morgano SM. A dual-purpose stent for theimplant-supported prosthesis. J Prosthet Dent.1993;69:276-280.

14. Pesun IJ, Gardner FM. Fabrication of a guide forradiographic evaluation and surgical placement of implants.J Prosthet Dent. 1995;73:548-552.

15. Stellino G, Morgano SM, Imbelloni A. A dual-purpose,implant stent made from a provisional fixed partial denture.J Prosthet Dent. 1995;74:212-214.

16. Tal H, Moses O. A comparison of panoramic radiographywith computed tomography in the planning of implantsurgery. Dentomaxillofac Radiol. 1991;20:40-42.

17. Engelman MJ, Sorensen JA, Moy P. Optimum placementof osseointegrated implants. J Prosthet Dent.1988;59:467-473.

18. Urquiola J, Toothaker RW. Using lead foil as a radiopaquemarker for computerized tomography imaging when implanttreatment planning. J Prosthet Dent. 1997;77:227-228.

19. Almog DM, Sanchez R. Correlation between plannedprosthetic and residual bone trajectories in dental implants.J Prosthet Dent. 1999;81:562-567.

20. Israelson H, Plemons JM, Watkins P, et al. Barium-coatedsurgical stents and computer-as sisted tomography in thepreoperative assessment of dental implant patients. Int JPerio dontics Restorative Dent. 1992;12:52-61.

21. Mecall RA, Rosenfeld AL. The influence of residual ridgeresorption patterns on implant fixture placement and toothposition. 2. Presurgical determination of prosthesis type anddesign. Int J Periodontics Restorative Dent. 1992;12:32-51.

22. Mah P, Reeves TE, McDavid WD. Deriving Hounsfield unitsusing grey levels in cone beam computed tomography.Dentomaxillofac Radiol. 2010;39:323-335.

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POST EXAMINATION QUESTIONS

1. CBCT allows proper visualization of criticalanatomical structures and provides a superioramount of information.

a. True b. False

2. Proper evaluation of 3-D tooth position, angulation,and restorative space is essential during treatmentevaluation for implant restorations.

a. True b. False

3. Inadequate attention to analyzing the restorativespace does not usually lead to problems such as anover-contoured restoration, fractured teeth and/ordenture bases, artificially opened occlusal verticaldimension, and the need to perform additionalsurgical and restorative procedures.

a. True b. False

4. It is the opinion of the author that with the currentdigital technology and CBCT software packages,distinct radiographic templates are rapidly becomingunnecessary.

a. True b. False

5. Based upon the virtual wax-up and plan, measure-ments can be made and traditional surgery can beperformed based upon the restorative planning.

a. True b. False

6. The traditional method for radiographic visualizationof restorative goals for edentulous patients is toduplicate the patient’s denture or diagnostic tootharrangement with laboratory vinyl polysiloxane (VPS)putty or alginate.

a. True b. False

7. The dual-scan protocol produces 2 separate DICOMdata sets: one is of the patient wearing the dentureand radiopaque VPS liner, and the second of just thedenture with the radiopaque VPS liner.

a. True b. False

8. Soft tissue-guided surgery does not require that aradiographic template be fully adapted to the softtissues in order to properly relate dental implantpositions with the digital soft-tissue analogs.

a. True b. False

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Are Radiographic Guides Necessary?

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