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QUI

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/

Objective:

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

The

long-term

success

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

reconstruction,

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
Department

Rehabilitation,

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

scans

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,

rehabilitation

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

Prosthodontics,

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

Bologna, Italy. Fax:39 051 225208. Email: leonardo.ciocca@unibo.it

systems can drive the surgery using optical

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Table

Inclusion and exclusion crtterta of the study population

Inclusion criteria 1. Male and lemale patients at least 18 years 01 age. 2. At least one quadrant with severe bone atrophy. 3. 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. 4. Subject desires an implant-supported lixed prosthesis. 5. The tooth at the implant site must have been ex1ractedat least 4 months belore implant placement. 6. Adequate amount 01 bone should be in doubt to insert a 8.5-mm-long and a 4-mm-diameter implant. 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. 7. Anatomical inclusion criteria: Cawood and Howell class IV and V28 8. Implant length ~ 8.5 mm 9. Implant diameter ~ 3.75 mm 10. Minimal salety distance lrom vasculonervous anatomical structures, 1 mm 11. Minimal distance between implants, 3 mm 12. Minimal tooth-implant distance, 2 mm 13. Minimal thickness 01 buccal cortical bone, ~ 1 mm Systemic exclusion criteria 1. Conditions requiring chronic routine prophylactic use 01 antibiotics 2. Conditions requiring prolonged use 01 steroids 3. History 01 leukocy1edyslunction and deliciencies 4. Bleeding disorders 5. History 01 neoplastic disease requiring use 01 radiation or chemotherapy 6. Metabolic bone disorders 7. Uncontrolled endocrine disorder 8. Use 01 any investigational drug or device within the 30 days belore implant surgery on study day O 9. Alcoholism or drug abuse 10. HIV inlection 11. Condition or circumstances, in the opinion 01 the investigator, that would prevent completion 01 study participation or interfere with analysis 01 study results, such as history 01 noncompliance or unreliability Local exclusion criteria 1. Local inllammation including untreated periodontitis 2. Mucosal disease such as erosive lichen planus 3. History 01 local irradiation therapy 4. Osseous lesion 5. Unhealed ex1ractionsites (Iess than 4 months postex1raction) 6. Severe bruxing and clenching habits 7. Persistent intraoral inlection 8. Inadequate oral hygiene or unmotivated home care

tracking create

devices20; 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.23-27 using

led clinicians

to plan

that can be inserted for immediate surgery of the

at the end of surof trnptants.>' 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.> Moreover, and

atrophic therapy.

arches

of the amount

of the complexity

810

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QUINTESSENCI::

INTl::RNATIONAL Scotti et ai

Fig 1 (above left and center) Fig 2 (right) The diagnostic

The diagnostic use of Autocad.

use of NobelGuide.

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. These markers were detectable in the CT scan without precluding the use of the template with the NobelGuide System. The CT data were examined by a different surgeon for each protocol, randomly

before implant surgery

in this study, with 29 jaws

(maxiliary and mandibular) to analyze for the implant-supported fixed prosthesis group

assigned to the operator, who elaborated his diagnostic response about the need and the extent of bone augmentation before implant insertion. The parameters used are summarized in the results. 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. Radiographic bone levei

and 19 maxillary arches for the implant-supported removable prosthesis group. Inclusion and exclusion criteria are summarized in

Table 1. NobelGuide System (Nobel Biocare) (Fig 1), Autocad System (Autodesk) (Fig 2), and routine manual CT measurements of

available bone were used in this study. The adequate amount of available bone for

implants was determined by the investigator according to the different protocols. Ali patients were scheduled for CT examination before surgery. Each patient underwent a CT examination with the diagnostic template useful for both the NobelGuide

(RBL) was measured on the CT scan. The operator assigned to the manual method

measured directly onto the printed images the available bone for implants by means of a ruler, and two operators used image analysis softwares (Autocad; NobelGuide) to measure the available bone for implants. The manual measurements were considered as a control group, while the assessments were made only

System and the other protocols. The template was equipped with at least six gutta-

percha spheres with a diameter of 1 to 2 mm, as prescribed Protocol by the Manual of CT Scan Biocare), and with more (Nobel

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QUI

N T l~S S E, et ai

C I~ I N T E R N A T I O N ,\ L

Scotti

Table
Patientf

Diagnostic values of fixed prosthesis group


Diagnostic Jaw Manual Autocad value NobelGuide

via NobelGuide ware. Scheduling

software

and Autocad

soft-

the preprosthetic the statistical

surgery

case

was considered

unit. The RBL

was the main variable 1.S.R. 2. S.R. 3. C.G. 4. C.G. 5. TR. 6. TR. 7.M.R. 8.A.A.M. 9. PS. 10.P.S. 11.ND. 12.AA 13.0.G. 14.0.G. 15.FG. 16.M.M. 17.M.M. 18.C.F 19.OV 20. OV 21. P.B. 22. P.S. 23. N.S. 24.S.A. 25. R.P 26. S.G. 27.S.G. 28. P.L. 29. P.l. 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 43.79 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 48.62 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 31.38

used in the study to of the diag-

evaluate the clinical performance

nostic protocols to limit or eliminate the bone regenerative procedures. RBL of at least 8.5 relevance as

mm was considered

of clnical

the minimal value for implant insertion. Thus, the analysis was calculated for the percentage prosthetic on this variable

of cases that need presurgery.

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- or extratime necessary for 10);

oral] and of the surgical each intervention): sinus lift (score

mini sinus lift (score mesh

30); titanium veneers

(score 30);

30); onlay

graftjbone

(score

inlay graft (score 30); osteodistraction 40); Le Fort mean score values of the I osteotomy of the fixed (score

(score

90). The

surgical

intervention group were

prosthesis

43.79 (manual), (NobeIGuide); able prosthesis Table


Patientf

48.62 (Autocad),

and 31.38

the mean values of the removgroup were 28.42 (manual), and 17.37 (NobeIGuide). using the allowed (manual,

Diagnostic values of removable prosthesis group


Oiagnostic Jaw Manual Autocad value NobelGuide

28.42

(Autocad),

Statistical Wilcoxon comparison Autocad, 60 O O


O

analysis was performed signed rank test, which three groups of the

case

1. S.R.
2. S.R. 3. G.G. 4. C.G. 5. TR. 6. TR. 7. F.M. 8. M.R.

9.AAM. 10.P.S. 11.AA 12.F.G. 13. M.M. 14. M.M. 15. PB 16. P.S. 17.S.A. 18.R.P. 19.S.G. 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. 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


=

.019) and

.006) scores. The mean values prosthesis group showed between inter-

of the removable

no statistically significant the manual, Autocad, vention

difference

and NobelGuide

60
O

O O
O

scores. However, 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.004) and

between the NobelGuide


=

30 28.42

30 28.42

O 17.37

tion score and both manual (P Autocad (P


=

.001) scores.

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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. These two areas, especially the mandible, 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. One of the main objectives of the NobelGuide system is to allow a flapless surgery, which also simplifies the prosthetic procedures for the immediate loading of implants. Recently, data

group, 54.38% of the cases show the value "O." In the total number of diagnoses for fixed plus removable prosthesis treatment plan-

ning, the surgical intervention score was significantly reduced when the NobelGuide

System was used, compared to manual and Autocad assessments.

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- 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.29 However, data on the accuracy and the clinical precision of the

CONCLUSION

NobelGuide system were tested using traditional Brriernark junction with a System abutments in conprefabricated all-acrylic

implant placements in the atrophic and mandible.

provisional fixed prosthesis placed for the immediate loading of implants. The results of this study reported extreme accuracy of the NobelGuide protocol in terms of precision of the insertion of the prosthetic abutrnents.s? Having extensively used this system for implant-prosthetic rehabilitations of patients with atrophic maxillary arches, the authors hypothesized that NobelGuide might reduce the necessity or, at least, the entity of bone reconstructive surgery of the atrophic maxilla and ence mandible. between The data collected the surgical in this
1. Brunski JB. Biomechanical implant factors affecting the bone-dental 153-201. 2. Brunski motion Update 3. Aparicio loading Sociedad JB. Avoid pitfalls of overloading implants. Dent and microImplantol interface. Clin Mater 1992;10:

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