Digital Treatment Planning
Marty Jablow, DMD
Digital treatment planning continues to evolve through better imaging modalities. Two-dimensional radiography is a good screening tool for many procedures. Three-dimensional imaging allows us to diagnose and treatment plan in ways we were not able to before. This enhanced digital treatment planning continues to evolve in dentistry. We have seen cone-beam computed tomography (CBCT) go from the realm of assisting oral surgeons to safely remove third molars to providing better treatment outcomes for managing sleep apnea, orthodontics, and implants. Digital impressions of the dental arches can be merged with CBCT data to allow better visualization of the effects of restorative treatment. It no longer puts the implant where there is bone but works backwards from the proper placement of the crown in the arch and towards the optimal location of the implant.
In the United States, it has been estimated that general dentists only place about 25% to 30% of implants compared to the rest of the world where the number approaches 90%.1 Through the use of digital treatment planning, both the planning and surgical placement can be done with a high degree of confidence, thus opening the door to more general dentists placing their own implants. There are many high-quality surgical guide software systems available to general dentists that range from free to a few thousand dollars. These systems support the fabrication of surgical guides, giving the dentist more confidence in the proper placement and outcomes of implant surgery and restorations.
The goal of all restorative dentistry is to obtain optimal esthetics while restoring form and function. The same holds true for implant restorative dentistry. In order to achieve this, the visualization of the final restorative reconstruction is necessary prior to the start of treatment. This visualization drives the restorative treatment planning.2 Once the goal of treatment is established, a sequence for treatment is developed, and the treatment plan is worked backwards, leading to a better understanding of the case and hopefully a reduction in complications.3
Digital treatment planning enhances the diagnostics of implantology by assisting the dentist alone or partnered with a trained laboratory technician to account for anatomical limitations and restorative goals. The crown can be digitally placed and the surgery planned for the most precise plan. Intraoral scans, either from a scanned model from a CBCT or an intraoral digital scanner, combined with CBCT data of the patient’s anatomy, produce a very accurate digital model. After treatment planning is complete, a surgical guide is printed via stereolithography (SLA). This guide provides highly accurate bridging of the digital model to the patient.4
Integration in Practice
Marty Jablow, DMD
With the increase in digital treatment planning among general practitioners, it may seem daunting to take the next step to increase your digital presence. However, integrating this technology doesn’t have to be a difficult task and the overall goal of making your practice run more efficiently and keeping patients happy is worth it in the long term.
The first thing you will need to begin using digital treatment planning is a CBCT. You can purchase a CBCT unit or refer the patient to someone who has one. In many cases, if you are using an implant surgeon they may already have a CBCT machine. There are also mobile CBCT services in many major metropolitan areas that will come to your office or your patient’s home or office. Make sure you specify that you want the standard DICOM image from whoever provides the CBCT. Many systems are closed architecture (SIMPLANT®, Dentsply Sirona, www.dentsplyimplants.com; Sirona CEREC, Dentsply Sirona, www.sirona.com) and you need a specific viewer to look at the images. In most cases, unless you have invested in that specific software, this will be a read-only file and cannot be used to do a complete digital diagnosis. If you have these closed system files, many dental labs have the ability to convert the files for you. It may be necessary to fabricate a guide for the patient prior to scanning, as reference points may be needed, especially if the patient is edentulous. The easiest way is with Suremark’s Scaneez™ stick n’ scan™ cone beam denture markers (www.suremark.com). These radiopaque markers are easily applied to a patient’s denture and are available either in small dots or tooth sized for easier implant planning.
Once you have the CBCT image file you will also need to acquire a 3D model of the patient if you plan on performing a guided surgery. This can be done with an impression or model scanned by a CBCT (such as the CS 9300, Carestream Dental, www.carestreamdental.com) or an intraoral scanner like the TRIOS® (3Shape, www.3shape.com), iTero Element™ (Align Technology, Inc., www.aligntech.com), the True Definition Scanner (3M, www.3m.com), and the CS 3500 (Carestream, www.carestreamdental.com). Make sure you can generate a standard STL file for the model.
The DICOM image from the CBCT and model image STL are then merged, giving you a soft-tissue and a hard-tissue rendering of the patient.