ConeBeam

ImplantPlanningManual
(EverythingyouwanttoknowaboutCBCTplanning)

Page2 Overview&GuideSelectionCriteria

Page3 ScanAppliancebasicsWhenaretheyrequired?

Page4 ScanApplianceIndicationsandprotocols

Page5 ScanApplianceFabricationInstructions

Page6 ScanApplianceConvertinganExistingDenture

Page7 NOScanApplianceTechnique

Page8 CTScanProcessGeneralinstructions

Page9 CapturingtheCT

Page10ScanApplianceImmediateextractiontechnique

Page11DataExportandUpload

Page12ProvisionalRestorations&ContactInformation

 Page2 OverviewofDentalImplantPlanning GuideSelectionCriteria

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ImplantsurgicalguidesusingConeBeamComputedTomographyisthemostadvancedprocessofpredictablyplanning
dentalimplantplacement.ROEDentalLaboratorysDentalImplantPlanningServiceisanationallyrecognizedallinclusive,
turnkeysolutiontosupportingdentistsinsurgicalguidance.Weoffertreatmentplanning,diagnosticworkupand
evaluation,CBCTtechnicalsupport,liveonlinemeetings,surgicalguides,surgicalreports,andfinalrestorations.By
selectingROEtosupportyourpractice,youchoseanexperiencedteamthathascompletedthousandsofsuccessfulcases.

Significantadvancementsinconebeamplannedsurgicalguidesduringthepastfewyearshaveallowedsurgicalguidance
tobemoreaffordableandaccessible.Withourserviceyoucancreatesurgicalguidesforanytypeoftreatmentfromsingle
unitplacementtoimmediateloadAllon4.Weaccommodateallimplantsystemsandprovidesurgicalguidesthat
accommodateyourexistingarmamentariumandallguidedsurgicalkits.ThismanualwillleadyouthroughtheCTprocess,
beginningwithguidechoice.

Chooseguidetype

Thefirststepintheprocessistochoosethetypeofsurgicalguideandtheplanningsoftwaretobeutilized.Therearefour
basicdesignsfromwhichtochoose.Allplanningsoftwaresystemscanaccommodatetoothortissuesupportedguides,
howeverbonesupportedguidesplacedonafullyflappedridgecanonlybecreatedwithtwoofoursoftwarechoices,
SimPlantandBlueSkyPlan.

ToothSupported TissueSupported BoneAnchored/TissueSupported BoneSupported/BoneAnchored
partiallyedentulous edentulous w/stabilizationpins fullyflapped

Choosethesoftware
Oncetheguidetypeisselectedyouwillneedtodecidewhichsoftwareisthebestchoiceforyourparticularcase.Cost,
returntime,guidedsurgerykitcompatibility,andcasesophisticationareallfactorstoconsider.Thechartbelowliststhe
relatedfeaturesoftheeachofourfoursoftwarechoices.

ReturnTimeafter Case GuidedSurgeryKit Software

Cost PlanisApproved(days) Compatibility Sophistication

$$$ 710 Excellent Excellent

$ 3 Limited Good

$$ 3 Good Good

$$$ 7 OnlyNobel Good

CTPlanningQuestionsCall

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Page3 GuideSelectionCriteriacontinued&ScanApplianceBasics
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Thechoiceofsoftwareaffectsthematerialsandstepsinvolvedintheprocess.Thechartbelowprovidesanoverviewof
therequirementsastheyrelatetothesoftwareselected.Pleasenotethattwoofthesystems,SimPlantandBlueSkyBio,
allowustousethemoreefficientandcosteffectivenoscanappliancetechnique.Thisdetailsofthistechniqueare
explainedonpage8.

positioninformation

patientw/scanapp.
Accuratemodelsor

DICOM3Dataof
DICOM3dataof

DICOM3dataof
Diagnostictooth

ApplianceAlone

Scanappliance
Selectasoftware Requirements>

impressions

patient
ScanApplianceTechnique

X X X X X

GotoPage4forinstructions X X X X X

X X X X X
X X X X X

NoScanApplianceTechnique

X X X
GotoPage7forinstructions
X X X

Whatisascanapplianceandwhenisitrequired?
Ascanappliance(a.k.a.radiographicguide)isarigidacrylicappliancewhichfitsovertheexistingteethandtissue.It
representstheteethtoberestoredandincludesradiopaquemarkersforregisteringtheapplianceintheCT.Theproper
fabricationofthescanapplianceisthecriticalfirststepCTplanning.

Inmostsituationsthefinalsurgicalguideisadigitalduplicateofthescanappliance,sodesignandfitarecrucial.Toensure
surgicalguidesfitatthetimeofsurgery,finalimpressionsandmastercastsmustbeprecise.

Asmentionedabove,properdesignofthescanapplianceisessential.Materialthickness,properplacementofradiopaque
markers,densityofmaterial,andadequatetoothandtissuecoverageforguidesleevesareallimportant.Scanappliance
protocolsareavailablethroughourwebsitewww.dentalimplantplanning.com,howeveritisourexperiencethatbetter
outcomesareachievedwhenourtheyarefabricatedthroughourlaboratory.Turnaroundtimeis4laboratorydays.

Scanappliancesarenotalwaysneeded.Whenacaseinvolves5teethorless,andthereareminimalmetalbased
restorationspresent,ascanappliancecanbeavoided,loweringthecostandsimplifyingtheprocess.Itisimportantto
notethatNobelGuideandiDentalwaysrequirescanappliances.

Page4 ScanAppliance
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ScanApplianceTechniqueIndications&Protocols:
WhenisaScanAppliancerequired?

ReconstructivecasesForsurgeriesinvolvingtherestorationofsignificantdentition,particularlyintheanteriorsegment,
itisbeneficialtohavethetoothpositionverifiedintraorallywithascanappliance.

EdentulouscasesWithoutascanappliance,implantpositionmaynotcoordinatewithfinaltoothpositionandmay
compromisethedefinitiverestoration.

AvoidingexcessivescatterMetalrestorationscausescatter.Excessivescatterrequirestheuseofascanappliance.The
amountofscattercanbedeterminedfromapreliminaryCTorexistingradiograph.

SoftwarechoicesBlueSkyPlan,SimPlant,iDent,NobelGuide

WhatarethestepsrequiredwhenaScanAppliancewillbeutilized?

Step1.RestorativeDoctor:Providequalitymastercasts,fullarchmaxillaryandmandibularsiliconeimpressions,abite
registration,studymodelandcompletedCTOrderForm.

Step2.ROEDentalLaboratory:Createadiagnosticwaxupoftheproposedfinaltoothposition.OnceapprovedaCTscan
applianceisfabricated.Ifthepatienthasanexistingdenturewithdesiredtoothposition,itcanbeusedasthescan
appliance(seepage10).Ifthedentureisillfittingahardrelineisnecessary.

Step3.RestorativeDoctor:Tryinthescanappliancetoverifythefit.Onceapprovedscanthepatientfollowingthe
specificprotocol.Ifthefitisnotideal,adjustaccordinglyorcapturenewimpressionsandremakethescanappliance.

Step4.ImagingLocation:RecordCTscanaspecificprotocolmustbefollowedforeachplanningsoftware.If
youhaveanyconcernsaboutthisprocess,wesuggestcallingROEwhilethepatientisstillintheofficetoconfirm
theaccuracyofthescan.UploadtheDICOMtoROEthroughwww.dentalimplantplanning.com.

Step5.ROEDentalLaboratory:Preplancaseusingplanningsoftwareensuringimplantlocationsmeetsurgicaland
restorativerequirements.

Step6.Specialist,restorativedentist,andlaboratory:Attendalive,interactiveonline
meeting(go.mikogo.com)tomodifyandapprovethesurgicalplanforguidefabrication.The
placingdoctorcompletesandreturnsthesignedCTOrderForm,whichcontainsthedrill
sequence.

Step7.ROEDentalLaboratory:Createthesurgicalguideanddrillingreport.

Page5 ScanApplianceFabrication
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ScanApplianceFabricationInstructions:
ImpressionMaterial&Models
Whetheryoumaketheradiographicguideyourselforusingthelaboratory,theimpressionis
thecriticalfirststepintheprocess.Thiswillultimatelyaffecttheoverallaccuracyofthesurgical
guidethatiscreated.WerecommendVPSorsimilarmaterialtobeusedtotaketheimpression.
Youmusttakeanimpressionthatcapturestheperipheralbordersandfullpalateonthemaxilla
andtheperipheralbordersandretromolarpadareasonthemandible.Thevestibulemustbe
clearandundistorted.Theentireimpressionshouldbefreeofpullsandbubbles.Ifthemodelis
notaccuratethefitoftheradiographicguidewillbecompromised.

GuideMaterial
Theradiographicguideshouldbefabricatedfromclearorthodonticacrylic.Donotusevacuformoranyothernonrigid
material.Thesematerialaretoothinanddonotexhibittheproperdensityforscanning.

MakingtheGuide
Adiagnosticwaxupisusedtofabricatetheradiographicguide.Thecrownsshouldbedistinctlyrepresentedonthe
facial/buccalandocclusalaspectsoftheguide.Facially,thecrownsoftheguideadjacenttoexistingteethshouldadjoin
theguideviaadiagonalspanofacrylic.Theguideshouldcovertheocclusalsurfaceofthefullarch.Theguideshould
extendovergumsonthelingual/palatalside.Theflangeshouldbeatleast3mmthick.Thereplacementteethonthe
guideshouldtouchtissueinedentulousareas.Theguideshouldnothaveanygapsbetweenthegingivaandtheguide.Itis
importanttobeawarethatthesurgicalguidewillbeanexactduplicateoftheradiographicguide.Theonlychangesin
shapewillbethetunnelsmadebythesoftwarefortheimplantsites.

RadiopaqueMarkers
Theapplianceshouldhaveeight,1.5mmroundguttapercharadiopaquemarkersplacedintotheappliance(#5bur).These
markersareutilizedinthedatamergingprocessfollowingtheCTscan.Wesuggestsix
randomlyplacedonthepalateandtwowithinthelabialflanges.Toeliminatethe
possibleeffectsofscatter,markersshouldbeplaced10mmawayfromanymetal
restorations.

ProperFit
Becausethesurgicalguidewillbeanexactduplicateoftheradiographicguide,theguide
shouldfitsecurelyonthepatientsteethand/ortissue.Iftheguidedoesnotfitsecurely,
theguidemustberemade.Theguidedoesnotneedtohaveperfectlybalancedocclusion.Cottonrollsoraradiolucent
bitemustbeusedtoseparatethearchesduringthescan.

CTPlanningQuestionsCall
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 Page6 ScanApplianceConvertinganExistingDenture
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DuplicatinganExistingProsthesis

Thepatientsexistingdenture,orduplicateofthedenture,maybeusedasthescanappliance1.Sixguttaperchamarkers
areplacedonthelingual/palatalsideoftheprosthesisandtwowithinthebuccalflanges.Ifthedenturedoesnotfit
properlyitisrecommendedthatahardacrylicrelineisperformed.Thiswillensureanidealfitofthesurgicalguide.Ifyou
orthepatientprefersnottoaddthemarkerstothepatientscurrentdenture,aputtyflaskofthedenturecanbesentto
usforduplication.Asimpleflaskingtechniqueisshownbelow.Thisminimizesinofficeworkandtheneedforthepatient
tospendtimewithouttheirdenture.

1
unlessaSimPlantbonesupportedguideistobeused.Achoiceisavailablebetweenaspecialdualdensityscanapplianceortheno
scanappliancetechniquethelatterisinadvisableonedentulouspatientsastoothpositionwillnotbevalidated.

 Page7 TheNOScanApplianceTechnique
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NOScanApplianceTechniqueIndications&Protocols:
WhencantheNoScanApplianceTechniquebeutilized?

Nonedentulous treatment plans that replace five or less teeth per arch are candidates for the noscanappliance
technique. A contraindication to this technique is if a patient has multiple metalbased restorations in the arch being
restoredmetalcreatesscatterrenderingadifficultorimpossibleregistration.

The noscanappliance technique uses the virtual placement of teeth, or a scan of a

functionaldiagnosticwaxup,todeterminetoothpositionforvirtualsurgicalplanning.
The scanned model image is superimposed over the conebeam data rendering
accurate hard and soft tissue surfaces in the software from which your clinical
decisionscanbemade.CurrentlythistechniqueisonlyavailablewithBlueskyPlanand
SimPlant.

SoftwarechoicesBlueSkyPlan&SimPlant

WhatarethestepsrequirediftheNoScanApplianceprotocolisused?

Step1.Restorativedoctororspecialist:Providemastercastsorfullarchmaxillaryandmandibularsiliconeimpressions,
biteregistration,studymodel,andcompletedCTOrderForm.

Step4.ImagingLocation:RecordCTscanaspecificprotocolmustbefollowedforeachplanningsoftware.If
youhaveanyconcernsaboutthisprocess,wesuggestcallingROEwhilethepatientisstillintheofficetoconfirm
theaccuracyofthescan.UploadtheDICOMtoROEthroughwww.dentalimplantplanning.com.

Step3.ROEDentalLaboratory:Preplancaseusingplanningsoftwareensuringimplantlocationsmeetsurgicaland
restorativerequirements.

Step4.Specialist,restorativedentist,andlaboratory:Attendaliveinteractiveonlinemeeting(go.mikogo.com)tomodify
andapprovethesurgicalplanforguidefabrication.TheplacingdoctorcompletesandreturnstheCTOrderFormwhich
containsthedrillsequenceandcaseapprovaltoROE.

Step5.ROEDentalLaboratory:Createthesurgicalguideanddrillingreport.

CTPlanningQuestionsCall
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 Page8 CTScanProcess
8|P a g e

CTScan:GeneralInstructions
GeneralOverview:

InordertofabricateaCBCTbasedsurgicalguidewerequireuncompressedDICOM3datafromaConeBeamCTorMedical
CT.Therecordsandtypeofscanwerequiredependuponthesoftwareandthetechniquetobeutilized.Theconebeam
settings and scanning instructions mostly remain consistent regardless of the type of
scan (variances in the box to the right). The models or impressions should be of high
quality because the accuracy of the surgery depends upon these initial records. The
restorativetoothpositionmustbedeterminedusinganexistingapplianceadenture
toothsetup,oravirtualordiagnosticwaxup.Thisshouldbeapprovedbytherestoring
dentist and/or the patient. In order to begin the diagnostic process complete our CT
OrderFormwithexplicitinstructionsontherestorativegoalsandrequirements.

Cone Beam Settings

Generalscanninginstructions:
General
Setthetableheightsothatthemandibleormaxillaiscenteredinthescanfield. 0.4 Voxel
Scan Time 20 Seconds
FOV 140 and 170 mm
Allslicesmusthavethesamefieldofviewandtableheight.
Stitched scans on small FOV

Matrix 512 x 512
Scanning with a field of view that is too large can compromise the resolution of
thereformattedimages.Scanningwithafieldofviewthatistoosmallcancause System Specific Instruction
KodakSystem=ScanAppliance
thejawtonotfitinalltheaxialimages.
shouldbescannedatKV80Ma2

Notoverlappingtheaxialslicescanreducethequalityofthereformattedimages. GalileosSystem = Scan Appliance

must be scanned inside of the
special Sirona aluminum scan
Scanallslicesofthestudyinthesamedirection.
cylinder Part # 6299759 using
settings:
Scanwiththesameslicespacing;theslicespacingmustbelessthanorequalto 42 MAS
theslicethickness.Theslicethicknessshouldnotbelargerthan1mm. w/o Hi Contrast
VO 1

All of the remaining teeth/scan prosthesis should be completely visible in the PlanMeca=ScanApplianceshouldbe
imagesuptotheocclusalplane. scannedatKV70Ma10

Thegantrytiltshouldbe0degrees.

Reconstructionoftheimages:

Useaproperimagereconstructionalgorithmtogetsharp,reformattedimagestoclearlylocateinternalstructuressuch
asthealveolarnerve.Usethesharpestreconstructionalgorithmavailable(usuallydescribedasaboneorhighresolution
algorithm).Onlyaxialimagesarerequired.Nodentalreformattingoftheimagesisneeded.

 Page9
9|P age CapturingtheCT

CTScan:CapturingtheCT
Whenascanappliancewillbeused,twoscansarerequired,oneofthepatientwiththeapplianceseatedandoneofthe
scanappliancealone.Ifsurgicalguideswillbemadeonbotharches,eacharchshouldbescannedseparatelytoprevent
thefiducialmarkersfrominterferingwithoneanother.Ifthepatientisedentulous,tostabilizetheapplianceandprevent
movement,separatethearcheswithcottonrolls.

Preparationofthepatient
Removeanynonfixedmetaldenturesorprosthesisinadditiontoanyjewelrythatmightinterferewiththeregionto
bescanned.Nonmetaldenturesmaybewornduringthescanning.
Ifthepatienthasascanprosthesis(radiographictemplate),itshouldbeworn.
Makethepatientcomfortableandinstructhim/hernottomoveduringtheprocedure.Normalbreathingis
acceptable,butanyothermovement,suchastiltingandturningtheheadcancausemotionartifactsthatcompromise
thereformattedimages,requiringthepatienttoberescanned.

Aligningthepatient
For correct alignment, the transaxial CT slice plane should be parallel to the occlusal
planeoftheupperjaw(seefigure2).Thegantrytiltis0.Ideally,youshoulddetermine
theocclusalplaneusingthepatientsscanprosthesis.Ifthepatientdoesnothaveascan
prosthesis,usetheexistingteethtoalignthepatient.
Stabilizetherelationshipofthejawsduringthescan.
Scanpatientwitharchesopenedusingcottonrollsorabiteregistrationindex(figure2). Figure1Biteregistration
separatingthearches
Scanninginstructions

Positioningforthemandible
Positionthe firstslicejustbelowtheinferiorborderofthe mandible.Positionthe last
slicejustabovethelowerteeth,orintheabsenceofteeth,setthelastslicejustabove
thesuperiorborderofthemandibularridge.Ifthepatientiswearingascanprosthesis,
position the last slice just above the prosthesis. It is critical you include the entire
prosthesis in the scanned study and that no teeth or prosthesis are visible in the last
slice.

Positioningforthemaxilla
Position the first slice just below the upper teeth. In the patient is edentulous, and is
wearingascanprosthesis,positionthefirstslicejustbelowtheprosthesis.Itiscritical Figure2Patientprepared
youincludetheentireprosthesisinthescannedstudy.Positionthelastslice4to5mm fortheCTscan
abovethefloorofthenasalcavity.Ifplanningforzygomaimplants,thelastslicemust
bepositionedinthemiddleoftheorbita,calledthesutura.

PositioningandScanningtheScanApplianceSeparately(withoutpatient)
ThescanapplianceshouldbeplacedonStyrofoam(Polystyrene),foam,orontheguide
holder specifically designed for this purpose and supplied by the Cone Beam
manufacturer (figure 3). The packaging foam included in ROE Dental Laboratory case
boxes works well. The appliance should be positioned in the same orientation as
scannedinthepatientsmouth.
Figure3Styrofoam
platformseparating
theappliancefromthe
chinrest

 Page10
10|P age CTScanProcessImmediateExtractionTechnique

InstructionsforusingCTScanAppliancewhenthecasewillinvolveextractionsat
thetimeofimplantplacement:

Whenascanapplianceisrequiredandthecaseinvolvestheimmediateextractionofteethatthetimeofsurgery,a
modifiedtechniquemustbeutilized.ROEhasdevelopedaspecialscanappliancethatreducesthetraditionaltwo
appointmentscantojustone.Thefollowing6stepsexplaintheprocess.

1. Separatetheprimaryscanappliancefromanyremovablesection(s)
attachedtotheappliance.Theseparatesectionswillrepresenttheareas
involvingtheimmediateextractionofteethatthetimeofimplant
placement.Figure4

2. Seattheprimaryscanappliancecontainingtheguttaperchafiducialsin
thepatientsmouth,withouttheseparatesections.Separatethe
appliancefromtheopposingteethusingtwocottonrolls.
Figure4
3. Requestthatthepatientstaymotionlessandfollowthemanufacturers
instructionstocapturethe1stof2CBCTimages,aspreviouslydiscussed.

4. Removetheappliancefromthepatientsmouthandglue(included)the
removablescanappliancesection(s)backtotheprimaryscanappliance
(patientdoesnotneedtobepresenthenceforth).Figure5

5. Afterthegluedsectionshavecompletelydried,scantheappliancealone
aspreviouslydiscussed.Theapplianceshouldnotbeplaceddirectlyonthe
chinrest.Itmustbeplacedonstyrofoamorafoamblock,suchasthe
Figure5
paddinginsideaROEshippingbox.Theapplianceshouldbeoriented
withinthetableinthesamepositionasthepatientscan.

CTPlanningQuestionsCall
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 Page11
11|P age DataExportandUpload

DataExport&Upload:
1. ExportthedatafromwithinyourCTscannerssoftwaretoanareaof
yourcomputerthatisaccessible.Wesuggestthatafolderiscreatedon
thedesktopwithindividualfoldersinsideoneforeachpatientwith
subfoldersforthescan(s)(Figure6).

2. ExportthepatientsuncompressedDICOM3multifilevolumetothis
folder(namedpatient).Donotexportviewers,iCATvisions,single
file,compressed,orDICOMDIR.Thesefiletypesarenotusable.

3. Repeattheprocessaboveforthedatasetthatcontainsthescanofthe
radiographicapplianceonly(foldernamedappliance),ifthescan
applianceprotocolwasused.

4. Whenbotharchesarebeingplannedforimplants,scanthem
separatelyandsaveintheminseparatelabeledfolders.

5. Placeallfoldersintoonemasterfolderwiththepatientsname.

6. Zipthemasterfolderbyrightclickingit,scrolldownandclickSendTo
Compressed(Zipped)Folder(figure7).ThiswillcreateaZippedfolder
(looksliketheoriginalwithazipperonthefront).Itwillbelocatedin
thesameareaastheoriginalfolder(figure3).

7. VisitROEswebsitewww.dentalimplantplanning.com.Clickthe
Uploadbutton,andfollowtheinstructions.ClickBrowse,searchfor
thezippedfolder(shouldbeonyourdesktopinthefolderyoucreated). Figure6Asampleofthefilestructurethatshould
besavedanduploadedtoROE.
DoubleclickonthisfolderandclickSendonthewebpage.

Figure7TouploadyourDICOM,the
containingfoldermustbezipped.Rightclickon
thefolderandcurserdowntoSendto,curser
totherightandclickCompressed(zipped)
folder.Anewfolderwillbecreatednexttothe

originalfolder.Whenyoubrowsefromour
websitewww.dentalimplantplanning.comyou
willdoubleclickonthiszippedfolderto
attach.








 Page12
12|P age ImmediateImplantProvisionalization

ImmediateImplantProvisionalization
CBCTGuidedsurgeryallowsforimmediateprovisionalizationofimplantstobeaccomplishedwithincreasedaccuracyand
efficiency.Inmostsituations,onceasurgicalguideiscreated,ROEDentalLaboratorycanreverseengineeranalog
placementintothemodelwiththesurgicalguideand
surgicalreport.Weworkwithallkitsthatofferalaboratory
componentforaccurateprovisionals.However,animplant
modelcanbecreatedinalmostanysituationforabutment
selectionandprovisionalfabricationofferingvaryinglevels
ofaccuracy.Pleasecontactustodiscussthespecificsof
yourcase.

ContactInformation

MailingAddress

ROEDentalLaboratory
9565MidwestAve.
GarfieldHts.,OH44125

WorldWideWeb

ROEDentalLaboratory www.roedentallab.com
FullServicedentallaboratory

DentalImplantPlanningwww.dentalimplantplanning.com(www.roeplan.com)
ImplantplanningsitetosupportCBCT

Telephone

8002286663 tollfree
2166632233 local
2166632237 facsimile

Email

info@roedentallab.com
Jason@roedentallab.com JasonCarruthext313TechSupport
joe@roedentallab.com JoeAmbroseCDText303TechSupport/onlineplanning