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
partiallyedentulous

TissueSupported
edentulous

BoneAnchored/TissueSupported
w/stabilizationpins

BoneSupported/BoneAnchored
fullyflapped

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

Cost

ReturnTimeafter Case
PlanisApproved(days)

GuidedSurgeryKit
Compatibility

Software
Sophistication

$$$

710

Excellent

Excellent

Limited

Good

$$

Good

Good

$$$

OnlyNobel

Good

CTPlanningQuestionsCall
8002286663

Page3

GuideSelectionCriteriacontinued&ScanApplianceBasics

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Thechoiceofsoftwareaffectsthematerialsandstepsinvolvedintheprocess.Thechartbelowprovidesanoverviewof
therequirementsastheyrelatetothesoftwareselected.Pleasenotethattwoofthesystems,SimPlantandBlueSkyBio,
allowustousethemoreefficientandcosteffectivenoscanappliancetechnique.Thisdetailsofthistechniqueare
explainedonpage8.

ScanApplianceTechnique

GotoPage4forinstructions

DICOM3Dataof
ApplianceAlone

DICOM3dataof
patientw/scanapp.

DICOM3dataof
patient

Selectasoftware

Scanappliance

Requirements>

Diagnostictooth
positioninformation

Accuratemodelsor
impressions

NoScanApplianceTechnique

GotoPage7forinstructions

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.

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ScanAppliance

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.

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ScanApplianceFabrication

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

8002286663

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ScanApplianceConvertinganExistingDenture

DuplicatinganExistingProsthesis

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

1
unlessaSimPlantbonesupportedguideistobeused.Achoiceisavailablebetweenaspecialdualdensityscanapplianceortheno
scanappliancetechniquethelatterisinadvisableonedentulouspatientsastoothpositionwillnotbevalidated.

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TheNOScanApplianceTechnique

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
8002286663

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CTScanProcess

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:

Setthetableheightsothatthemandibleormaxillaiscenteredinthescanfield.

Allslicesmusthavethesamefieldofviewandtableheight.

Scanning with a field of view that is too large can compromise the resolution of
thereformattedimages.Scanningwithafieldofviewthatistoosmallcancause
thejawtonotfitinalltheaxialimages.

Notoverlappingtheaxialslicescanreducethequalityofthereformattedimages.

Scanallslicesofthestudyinthesamedirection.

Scanwiththesameslicespacing;theslicespacingmustbelessthanorequalto
theslicethickness.Theslicethicknessshouldnotbelargerthan1mm.

All of the remaining teeth/scan prosthesis should be completely visible in the

imagesuptotheocclusalplane.

Thegantrytiltshouldbe0degrees.

General
0.4 Voxel
Scan Time 20 Seconds
FOV 140 and 170 mm
Stitched scans on small FOV
Matrix 512 x 512
System Specific Instruction
KodakSystem=ScanAppliance
shouldbescannedatKV80Ma2

GalileosSystem = Scan Appliance

must be scanned inside of the
special Sirona aluminum scan
cylinder Part # 6299759 using
settings:
42 MAS
w/o Hi Contrast
VO 1
PlanMeca=ScanApplianceshouldbe
scannedatKV70Ma10

Reconstructionoftheimages:

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

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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

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
youincludetheentireprosthesisinthescannedstudy.Positionthelastslice4to5mm
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.

separatingthearches

Figure2Patientprepared
fortheCTscan

Figure3Styrofoam
platformseparating
theappliancefromthe
chinrest

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CTScanProcessImmediateExtractionTechnique

InstructionsforusingCTScanAppliancewhenthecasewillinvolveextractionsat
thetimeofimplantplacement:

Whenascanapplianceisrequiredandthecaseinvolvestheimmediateextractionofteethatthetimeofsurgery,a
modifiedtechniquemustbeutilized.ROEhasdevelopedaspecialscanappliancethatreducesthetraditionaltwo
appointmentscantojustone.Thefollowing6stepsexplaintheprocess.

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

2.

Seattheprimaryscanappliancecontainingtheguttaperchafiducialsin
thepatientsmouth,withouttheseparatesections.Separatethe
appliancefromtheopposingteethusingtwocottonrolls.

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.

Figure4

CTPlanningQuestionsCall
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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).
DoubleclickonthisfolderandclickSendonthewebpage.

Figure6Asampleofthefilestructurethatshould
besavedanduploadedtoROE.

Figure7TouploadyourDICOM,the
containingfoldermustbezipped.Rightclickon
thefolderandcurserdowntoSendto,curser
totherightandclickCompressed(zipped)
folder.Anewfolderwillbecreatednexttothe
originalfolder.Whenyoubrowsefromour
websitewww.dentalimplantplanning.comyou
willdoubleclickonthiszippedfolderto
attach.

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