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N T E S S l~N C E I N T l~R N A T I O N A L

Diagnostic value nt NobelGuide to minimize the need for reconstructive surgery nt jaws before implant placement: A review
Roberto Scotti, MD, DDS'/Gerardo Leonardo Ciocca, DDS, PhD5 Pellegrino, DDS2/ Claudio Marchetti, MD, MS3/Guiseppe Corinaldesi, MD, DDS, PhD4/


To test if using a CAD/CAM system might reduce the necessity of bone augmentaand Materiais:

tion in patients with atrophic maxillary arches before implant therapy. Method

Twenty male and female patients consecutively scheduled for bone augmentation of the jaw before implant surgery were included in this study, with a total of 29 jaws (maxillary and mandibular) to analyze for the implant-supported fixed prosthesis group and 19 maxillary arches for the implant-supported removable prosthesis group. NobelGuide System (Nobel Biocare), Autocad System (Autodesk), and routine manual CT measurements of available bone were used in this study. Results: The total results of the mean values of the fixed prosthesis group plus the mean values of the removable prosthesis group showed a statistically significant difference between the NobelGuide intervention score and both manual (P = .004) and Autocad (P = .001) measurements. Conclusions: The NobelGuide System represents a viable diagnostic device to
Int 2010;41:809-814)

reduce the entity or avoid bone reconstructive surgery before implant placements in the atrophic maxilla and mandible. (Quintessence

Key words:

diagnosis, oral implant, radiology, surgical guides




of osseointegrated

been proposed to eliminate bone regenerative preprosthetic surgery.c8 Howeve r, rehabilitation of extreme atrophy due to age, trauma, or cancer ablative surgery requires bone

dental implants to support fixed partial dentures (FPDs) or full-arch restorations is welldocumented in the dental literature.1-6 New implant system solutions for the severe atrophy of the maxilla and the mandible have


as well. Diagnosis and treatand the may reha-

ment planning are multidisciplinary, use of new CAD/CAM

technologies prosthetic

improve implant-supported
'Profes sor and Dean ot Oral and Maxillofacial Section of Prosthodontics, Department Mater 5tudiorum 'Posrqraduate


bilitation. Borderline patients may be studied during the diagnostic phase using virtual simulation of the surgery, avoiding surgical

of Oral $cience, Alma

University of Bologna, Bologna, Italy.

student,Section ofOral and Maxillofacial $urgery,
af Oral Science, Alma Mater Studiorum University

overtreatments or reducing more aggressive surgeries."-12 In the previous decade, the technology for cone beam computed tomography chances (CT) for

af Bologna, Bologna, Italy. -Professor af Maxillofacial $urgery, Faculty of Medicine, Alma Mater Studiorum University af Bologna, Bologna, Italy. "Re se arche r, 5ection of Oral Surgery, Department of Oral


increased with

diagnostic low radiation

Science, Alma Mater Studiorum University of Bologna, Bologna, Italy. "Asststant Professor of Maxillofacial Prosthodontics, Section of Department of Oral Science, Alma Mater

implant-supported planning,


treatment dosage.'3-'6

Modern CT scans generate DICOM files that may be processed by means of several CAD softwares.'7-'9 Some of these computerized


Studiorum University of Bologna, Bologna, Italy. Correspondence: Dr Leonardo Ciocca, Via S. Vitale 59, 40125

Bologna, Italy. Fax:39 051 225208. Email:

systems can drive the surgery using optical









6. 4. a prototyped others allow clinicians surgical to temar to bone-regenerative main tually results driven procedures is one of the The virof surproce- accurate of CADjCAM angulations systems: and plate for guiding manufacture thesis gery the implant surgery'6 immediate dimensions implant a provisional pros- implants gery dures. Minimal tooth-implant distance. Severe bruxing and clenching habits 7. Local inllammation including untreated periodontitis 2. Anatomical inclusion criteria: Cawood and Howell class IV and V28 8. Bleeding disorders 5. Implant length ~ 8.75 mm 10. Osseous lesion 5. Use 01 any investigational drug or device within the 30 days belore implant surgery on study day O 9. History 01 neoplastic disease requiring use 01 radiation or chemotherapy 6. Patient requires bone grafting in the implant sites at the time 01 surgery or received maxillolacial reconstructive surgery tor oncologic or traumatic injuries belore implant placement.5 mm 9.• NUMBER 10 . Subject desires an implant-supported lixed prosthesis. Condition or circumstances. 3. Metabolic bone disorders 7. Male and lemale patients at least 18 years 01 age. History 01 leukocy1edyslunction and deliciencies 4. Unhealed ex1ractionsites (Iess than 4 months postex1raction) 6. that would prevent completion 01 study participation or interfere with analysis 01 study results.Table 1 Inclusion and exclusion crtterta of the study population Inclusion criteria 1. Implant insertion sites may not have sullicient height such that the implant will not encroach on vital structures and sufficient width that a minimum 01 1 mm 01 bone lingual and buccal will remain. 3 mm 12.• NQVEMBER/DECEMBER 2010 .5-mm-long and a 4-mm-diameter implant. Adequate amount 01 bone should be in doubt to insert a 8. History 01 local irradiation therapy 4. 5. Minimal salety distance lrom vasculonervous anatomical structures. Persistent intraoral inlection 8. At least one quadrant with severe bone atrophy. Minimal distance between implants. Minimal thickness 01 buccal cortical bone. in the opinion 01 the investigator. Alcoholism or drug abuse 10. Inadequate oral hygiene or unmotivated home care tracking create devices20.> Moreover. such as history 01 noncompliance or unreliability Local exclusion criteria 1. Conditions requiring prolonged use 01 steroids 3. Implant diameter ~ 3.23-27 using led clinicians to plan that can be inserted for immediate surgery of the at the end of surof trnptants. Conditions requiring chronic routine prophylactic use 01 antibiotics 2. and atrophic therapy. 2 mm 13.>' main advan- minimizing bone-augmentation loading of the The aim of this study system might was to test if reduce the Flapless tages involved tion is one new a CADjCAM of bane CADjCAM procedures reducof necessity with implant augmentation maxillary in patients before in implant therapy. Uncontrolled endocrine disorder 8. 1 mm 11. 2. 7. Mucosal disease such as erosive lichen planus 3. The tooth at the implant site must have been ex1ractedat least 4 months belore implant placement. arches of the amount of the complexity 810 VOLUME 41 . HIV inlection 11. ~ 1 mm Systemic exclusion criteria 1.

and with more (Nobel VOLUME 41 - NUMBER 10 - NOVEMBER/DECEMBER 2010 811 . Ali patients were scheduled for CT examination before surgery. and two operators used image analysis softwares (Autocad. Radiographic bone levei and 19 maxillary arches for the implant-supported removable prosthesis group. The operator assigned to the manual method measured directly onto the printed images the available bone for implants by means of a ruler. with 29 jaws (maxiliary and mandibular) to analyze for the implant-supported fixed prosthesis group assigned to the operator. NobelGuide System (Nobel Biocare) (Fig 1). as prescribed Protocol by the Manual of CT Scan Biocare). The CT data were examined by a different surgeon for each protocol. Autocad System (Autodesk) (Fig 2). and routine manual CT measurements of available bone were used in this study. These markers were detectable in the CT scan without precluding the use of the template with the NobelGuide System. Inclusion and exclusion criteria are summarized in Table 1. METHOO ANO MATERIALS Twenty male and female patients consecutively scheduled for bone augmentation the maxiliajmandible were included of cylindrical landmarks for the other protocols corresponding to the supposed position of the implants. The parameters used are summarized in the results. who elaborated his diagnostic response about the need and the extent of bone augmentation before implant insertion. randomly before implant surgery in this study. The data were collected in a form to obtain the percentage of negativejpositive responses for the reconstructive preprosthetic surgery. The same operators indicated on a separate form the type of minimal surgical intervention for each defect. The adequate amount of available bone for implants was determined by the investigator according to the different protocols. The manual measurements were considered as a control group. The template was equipped with at least six gutta- percha spheres with a diameter of 1 to 2 mm. Each patient underwent a CT examination with the diagnostic template useful for both the NobelGuide (RBL) was measured on the CT scan. while the assessments were made only System and the other protocols. use of NobelGuide.QUINTESSENCI:: INTl::RNATIONAL Scotti et ai Fig 1 (above left and center) Fig 2 (right) The diagnostic The diagnostic use of Autocad. NobelGuide) to measure the available bone for implants.

7. the total results of the mean values of the fixed prosthesis group plus the mean values of the removable thesis group showed difference pros- 60 O O 60 O O a statistically significant interven.G.79 (manual). 3. 11. Statistical Wilcoxon comparison Autocad. N. 30). 29. Autocad. 17. 8. P. 812 VOLUME 47 • NUMBER 10 • NOVEMBER/DECEMBER 2010 .S. 7. S. The RBL was the main variable 1. 28.0. 24.M.R.G. 27. P.S.S. OV 21. 13.G.A. 8.L. and 17.G. 3. PB 16.M.C. R. S.G. Thus.S. 16. Scheduling software and Autocad soft- the preprosthetic the statistical surgery case was considered unit. However. 25.42 O 17.B.AA 13.R.M. 18. osteodistraction 40). TR.S.M.F 19.\ L Scotti Table Patientf 2 Diagnostic values of fixed prosthesis group Diagnostic Jaw Manual Autocad value NobelGuide via NobelGuide ware.006) scores. 60 O O O analysis was performed signed rank test. P. 6.37 tion score and both manual (P Autocad (P = . 11.38 used in the study to of the diag- evaluate the clinical performance nostic protocols to limit or eliminate the bone regenerative procedures. P.ND. 22. 2. M. TR. 3 Diagnostic values of removable prosthesis group Oiagnostic Jaw Manual Autocad value NobelGuide 28.37 (NobeIGuide).R. F.38 the mean values of the removgroup were 28.A.P. bone regenerative RESULTS The diagnostic values of the intervention (for prosof the sextant) scores for fixed or removable thesis were as follows (as a proportion morbidity for the donor site [intra.019) and .S. 6.S.0.5 relevance as mm was considered of clínical the minimal value for implant insertion.62 (Autocad). 4.G. M.79 90 O 60 O 120 O 90 90 90 60 30 O 90 30 90 O 90 30 O O O 120 O O O O 90 60 60 48. TR. C. C.42 (Autocad). vention difference and NobelGuide 60 O O O O scores. 15. the analysis was calculated for the percentage prosthetic on this variable of cases that need presurgery. 2. M. 23.R. (NobeIGuide). P. 18. titanium veneers (score 30).R. using the allowed (manual.004) and between the NobelGuide = 30 28.A.S. 12. Meanvalue Maxillary Mandibular Maxillary Mandibular Maxillary Mandibular Maxillary Maxillary Maxillary Maxillary Mandibular Mandibular Mandibular Maxillary Mandibular Maxillary Mandibular Maxillary Maxillary 60 O 30 O 60 O 60 O 30 O NobelGuide) two by two.F. et ai C I~ I N T E R N A T I O N .M.G.S. oral] and of the surgical each intervention): sinus lift (score mini sinus lift (score mesh 30).001) scores.42 30 28. 19. which three groups of the case 1. 14.R.AA 12.P 26. The surgical intervention group were prosthesis 43. 10.P. Meanvalue Maxillary Mandibular Maxillary Mandibular Maxillary Mandibular Maxillary Maxillary Maxillary Mandibular Mandibular Mandibular Maxillary Maxillary Maxillary Mandibular Maxillary Mandibular Maxillary Mandibular Mandibular Maxillary Maxillary Mandibular Maxillary Mandibular Maxillary Mandibular Maxillary 90 O 60 O 90 O 90 90 90 60 30 O 90 30 90 O 90 O O O O 120 O O O O 30 30 70 43. 17. The mean values prosthesis group showed between inter- of the removable no statistically significant the manual.G.FG.QUI N T l~S S E.M. 9.l. S.G. 14.or extratime necessary for 10). PS. TR.62 60 O 60 O 90 60 90 90 90 60 O O 60 O 60 O O O O O O 120 O O O O O O 70 31.OV 20. able prosthesis Table Patientf 48. 5. RBL of at least 8.M. 10.M. G.P.M. C.G. 4.S. differ- The mean values of the fixed prosthesis group showed ence between a statistically significant the NobelGuide (P 60 O O O 60 60 60 O 60 O 60 O 60 O O 60 60 60 O 60 O O O O 60 60 90 O O intervention = score and both the manual Autocad (P = .42 (manual).AAM.R. 5. 9. S. Le Fort mean score values of the I osteotomy of the fixed (score (score 90). onlay graftjbone (score inlay graft (score 30). 15.A. and 31.

The difference was statistically significant for the fixed prosthesis group: The fixed implant-supported of implants and success. Piattelli 2005. Corigliano prosthesis treatment planning allowed significant reduction of the bone reconstructive Paolantonio ma-sprayed monkeys. 5carano loading An A. On the contrary." In the total number of diagnoses for fixed plus removable prosthesis treatment plan- ning. Brunski JB. Kohles 55. 54. (10 5.lmmediate implants: Periodontol histologic analysis surgery if the diagnosis was carried out using the NobelGuide System. 2. data group. Dent Relat Res 2003. The results of this study reported extreme accuracy of the NobelGuide protocol in terms of precision of the insertion of the prosthetic abutrnents. interforaminal area of the mandible and four VOLUME 41 - NUMBER 10 • NOVEMBER/DECEMBER 2010 813 . loading of NJ.17(suppl 2):19-34. Costigliola oftitanium G.J 7.38% of the cases show the value "O. Indications implant for immediate scores of the NobelGuide group and the manual and Autocad groups. no statistically significant difference was found for the removable prosthesis group. Immediate/early report World from the study showed a statistically significant differintervention 4. Dent and microImplantol interface. the surgical intervention score was significantly reduced when the NobelGuide System was used.4:77-81. Recently.s? Having extensively used this system for implant-prosthetic rehabilitations of patients with atrophic maxillary arches. about clinical accuracy of different types of CT-derived stereolithographic (SLA) guides in implant placement showed that tooth-supported SLA surgical guides were more accurate than bone. C. Weng distributions of short-Iength mm ar less) machined-surfaced implants. provisional fixed prosthesis placed for the immediate loading of implants. One of the main objectives of the NobelGuide system is to allow a flapless surgery. Attard Spain. 5tach RM. Clin Mater 1992. the entity of bone reconstructive surgery of the atrophic maxilla and ence mandible. at least. Fenner M. These two areas. Boitel survival N. Brunski motion Update 3.OU I NTI~SS ENCE I NTER NAT I ON A L Scotti et ai DISCUSSION The aim of this study was to test the in the anterior region of the maxilla.29 However. using a manual caliper directly on the images. Espanola meeting de Implantes in Barcelona. which also simplifies the prosthetic procedures for the immediate loading of implants. E. D. This may be due to the reduced number and position of implants necessary for the retention of a removable prosthesis: at least two in the 1998.Clin Implant and Osseatite Dent Relat Res 2004. David with results LA. 2002. Feldman Five-year M.69:321-327. Zarb GA. Avoid pitfalls of overloading implants. plasin A. Congress Clin consensos Implant Nkenke loading Implants 5.lmmediate overdentures: implants clinical mandibular One-year Int of a prospective study. Biomechanical implant factors affecting the bone-dental 153-201. The manual measurements were taken on a printed version of the CT scan slices.18:463-470.6:16-23.10: REFERENCES af intraosseous 1993. Aparicio loading Sociedad JB. especially the mandible. 5ennerby implants: A L. Rangert of dental B. J Prosthodont 6. Clin Oral Res 2006. data on the accuracy and the clinical precision of the CONCLUSION NobelGuide system were tested using traditional Bràriernark junction with a System abutments in conprefabricated all-acrylic implant placements in the atrophic and mandible. the authors hypothesized that NobelGuide might reduce the necessity or. between The data collected the surgical in this 1. compared to manual and Autocad assessments. M. are often available for implants without any bone augmentation: In the removable prosthesis NobelGuide system as a diagnostic device to reduce the necessity or the entity of bone reconstructive surgery of atrophic maxillary arches before implant therapy.or mucosa-supported SLA The NobelGuide System represents a viable diagnostic avoid bone device to reduce the entity or reconstructive surgery before maxilla surgical guides.5:57-60.

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