VIRTUAL IMPLANT PLACEMENT SOFTWARE

Fig. 1

Some implant placement software programs require the raw data from the CT or CBCT scan to be converted from a DICOM (Digital Imaging and Communication in Medicine) file format to a file format that can be processed and rendered (Fig.1) by the virtual implant placement software. File conversion is in some instances built in or offered as a extra service by the software provider. Almost all major implant manufacturers are providing virtual implant placement software and are limited to their own and in some cases competitors implant libraries.

Scatter in the CT images caused by pre existing metal restorations poses a challenge, especially once the images are rendered in 3D. Each software provider developed solutions to this problem in various degrees of success. Materialise requires manual erasing (segmentation) of the scatter in 3D volume rendering mode while others minimize the effect of scatter through built in algorithms. Software packages incorporating true digital manufacturing (Nobel Biocare™, SICAT OPTIGUIDE) of the surgical guide are sensitive to the scatter elimination process.

Fig. 2

Once the virtual implant placement is complete a surgical guide (Fig.2) is ordered electronically through the software program or the CT appliance is converted in to the drill template. Guided surgery requires extra long drills (Fig.3, right) specifically designed for guided surgery. These drills are much longer than standard drills (Fig.3, left) and can make access to the surgical site difficult the more posterior the osteotomy is planned. Although guided surgery is precise, a margin of error of at least 0.5mm should be built in to the virtual plan.

Fig. 3

Some software program purveyors require a stone model to be sent along with the finished virtual plan for the guide manufacturing process. Full arch impressions should be taken with a high quality PVS impression material the same day the CT scan is taken for accuracy. The impression needs to be void and distortion free, clearly capturing all teeth and tissue contours, including the full palate. Under no circumstances should the dentition or tissue of the patient be altered after the CT scan is taken!

Anatomage Invivo5

Fig. 4

Invivo5 ($5900, optional upgrade and unlimited support fee of $950 after the first year of ownership) does not require DICOM data conversion or pre processing, potentially resulting in time and cost savings. DICOM data is loaded directly in to the software program and rendered in 3D (Fig.4) immediately with the accompanying panoramic and sectional slice windows. The extensive implant library covers a significant number of implant brands

STL files generated from intraoral scanners or scanned models may be imported and merged with the CBCT, CT or MRI images in 3D to further enhance diagnostic capabilities. A consumer grade computer with a graphics accelerator should suffice to render the 3D images in real time without sacrificing Invivo5 performance.

Fig. 5

Anatomage produces the surgical guides ($275, flat fee) through vacuum form methods. Templates are either mucosa or dentition supported and can be fabricated with a simple pilot drill sleeve or for true guided surgery with guide bushings (Fig.5) in combination with drill keys ($950). Only location and angulation are controlled with drills from the implant manufacturer. To achieve depth control special drills ($750) from Anatomage need to be ordered except for Nobel Biocare™ NobelGuide™ and Biomet 3i™ Navigator® systems. Each template is delivered with a detailed "cookbook" of drill dimensions and sequence.

Send a model produced the same day the CT was taken and the virtual plan transferred to a CD to Anatomage to initiate the surgical guide production.

Nobel Biocare™ NobelClinician

Fig. 6

NobelClinician ($6135, annual service fee including support $1199) is available for both Windows and MAC OS X. A medium grade computer in combination with a high end graphics accelerator is capable of running NobelClinician without performance issues. DICOM files can be loaded directly in to the software for rendering and processing without prior DICOM file conversion (Fig.6). Designed exclusively for Nobel implants in combination with NobelGuide™ surgical guides ($ 415 one implant site, $555 two to four implant sites, $695 five or more implant sites). Treatment plans may be shared, evaluated and modified with other NobelClincian users world wide through NobelConnect (free service).

A Free viewer may be downloaded from Nobel Biocare™ to facilitate treatment collaboration between the surgeon, restorative dentist and laboratory. No treatment changes can be made with the viewer program.

Fig. 7

CT appliances are mandatory and should represent the future restoration in the edentulous area for diagnostic and planning purposes. The scan process requires a dual scan protocol where the patient is scanned with the installed CT appliance once and a second scan of the CT appliance itself. CT and CBCT scanners utilized for NobelClinician need to be calibrated with a unique calibration object ($575, Fig.7)) every 6 months to ensure data accuracy and simplify segmentation of the CT appliance. The CT appliance is copied electronically from the patient scan data and printed through a stereolithographic mechanism at Nobel Biocare™. This copy of the CT appliance is then modified and transformed in to the surgical guide (NobelGuide™).

Fig. 8

NobeGuides are light, heat and moisture sensitive devices and should be handled with care. Do not heat, steam or a chemclave the guide. Each guide is delivered in a light blocking pouch along with a detailed drill protocol for each osteotomy site. NobelGuides are either dentition or mucosa supported. Mucosa supported guides are stabilized with auxiliary fixation pins (Fig.8) pushed in to utility osteotomes.

Fig. 9

Specialized guided surgery drills are utilized along with drill keys (Fig.9) to achieve osteotomies congruent with the pre planned diameter, position, angulation and depth of the implants to be installed. Implants are inserted through the guide with separately purchased implant mounts.

No models need to be sent to Nobel Biocare™ and the virtual plan is transmitted electronically to the production facility.

Materialise Dental™ SimPlant®

Fig. 10

The pioneer in the virtual implant placement and guided surgery field, offering a impressive array of 8000 implants in the implant library in addition to corresponding prosthetic components (Fig.10). DICOM files do need to be converted depending on the SimPlant® version before the data can be rendered through the SimPlant® software. SimPlant® is offered in four versions with differing capabilities. Online tutorials, manuals and mentoring are available through the SimPlant® Academy.

Fig. 11

CT appliances are recommended for edentulous cases and optional for partially edentulous cases. STL files generated from intraoral scanners or scanned models may be imported and merged with the CT images in 3D to further enhance diagnostic capabilities (Fig.11, 12 and 13, optional module $2295). Merging STL files with the CT images makes the ordering status of surgical templates eligible for fast track status, expediting the manufacturing process. Otherwise stone models need to be sent to Materialise Dental in addition to the treatment plan files to facilitate template production.

Fig. 12

Drawing a mandibular canal, importing STL files and examining the spatial relation ships between anatomical structures and virtual implants in 3D requires sufficient processing power in combination with a video gaming class graphics accelerator (video card).

SimPlant® View (free download) enables the user to examine a treatment proposal created with one of the other three versions of SimPlant® but not make modifications to the treatment plan.

Fig. 13

SimPlant® Planner ($4490) capacitates the user to virtually place any of the implants and corresponding prosthetic components (abutments) included in the implant library, facilitating a top down treatment plan. Stock abutments may be chosen from the library and SimPlant® automatically selects a corresponding virtual implant to support the chosen abutment. The DICOM file needs to be converted by a third party ($120) before use in the SimPlant® Planner program either by a facility with the SimPlant® Master software or Materialise™ itself.

SimPlant® Pro ($8720)offers all the features of SimPlant® Planner without prior DICOM processing by a third party. Built in file conversion is the major differentiating feature from SimPlant® Planner to SimPlant® Pro.

SimPlant® Master ($31500) is a enterprise grade software solution for anybody wanting to develop a business model converting DICOM files, preprocessing, virtual implant placement and treatment planning services. All features of SimPlant® Planner and Pro are combined and files may be saved and transmitted (CD, FTP) to Planner and Pro clients.

Fig. 14

Surgical guides are digitally fabricated by Materialise™ through stereolithographic printing, making for a true digital plan and execution. Three levels of SurgiGuide® drill templates are offered through Materialise™ either as bone (Fig.14), mucosa (Fig.16) or dentition (Fig.15) supported. Each template is delivered with a detailed "cookbook" of drill dimensions and sequence. SurgiGuides are light, heat and moisture sensitive devices and should be handled with care. Do not heat, steam or a chemclave the guide.

Send a model produced the same day the CT was taken and the virtual plan transferred to a CD or electronically transmitted to Materialise™ to initiate the surgical guide production.

Pilot SurgiGuides (Fig.14, $275 plus $25 for each implant site) provide position, angulation and depth guidance for pilot drills only if used in conjunction with Materialises LongStop Drills (purchased separately). Depth control is left to the surgeons judgment if standard implant manufacturer supplied drills are utilized for Pilot SurgiGuides.

Fig. 15

Universal SurgiGuides (Fig.15, $395 plus $15 for each implant site) necessitate the use of drill keys ($475), empowering the surgeon to utilize not just the pilot drill but all drills in the prescribed drill sequence with the same drill template. Drill diameter specific drill keys are inserted in the metal bushings incorporated in the SurgiGuide® and drills are maneuvered through the drill keys. Depth control is left to the surgeons judgment if standard implant manufacturer supplied drills are utilized for the drill sequence. To achieve depth control Materialises™ LongStop drills ($1295) need to be employed.

Fig. 16

Safe SurgiGuides (Fig.16, $395 plus $30 for each implant site) provide a true guided surgery experience in combination with implant brand specific (ANTHOGYR Guiding System, Facilitate™ AstraTech, Navigator™ BIOMET 3i™, ExpertEase™ DENTSPLY Friadent, Straumann® Guided Surgery Kit, NobelGuide™, CAMLOG® Guide System, and Zimmer Guided Surgery Instrumentation) guided surgery drill kits. Position, angulation, diameter and depth are controlled through Materialises™ drill keys with a single drill template.

Straumann® coDiagnostiX™

The Straumann® Guided Surgery (SGS) system is designed to work with the proprietary stand alone virtual implant placement software coDiagnostiX™ in combination with Starumann's goniX™ surgical guide drill unit operated through local dental laboratories. CT appliances are fabricated at a laboratory and converted in to the actual surgical guide, affording a verified fit of the surgical guide and faster turnaround times. Position, angle and depth control of the osteotomy are achieved through a dedicated surgical kit ($8500) including drill keys. Implants are delivered through the guide, effectively executing precision delivery of the implants as planned through the coDiagnostiX™ virtual implant placement software. 26 other implant systems may be planned with coDiagnostiX™ in combination with implant brand specific surgical guides. Transfering files and collaboration with other coDiagnostiX™ users can be accomplished through Staumann's caseXchange™ network connectivity.

STL files generated through an iTero intra oral scanner or any other scanner capable of producing STL files can be imported and stitched in to the DICOM file without additional software modules for diagnostic purposes.

Automatic nerve detection, Hounsfield unit detection, intuitive controls and menus are some of the other key features of the coDiagnostiX™ software. Screw retained and cementable temporaries can be produced through a goniX™ laboratory before the actual surgery. Custom final titanium and zirconia abutments with the accompanying final restoration can be manufactured prior to the surgery to accommodate immediate load situations.

Four versions of the software are offered with differing capabilities;
coDoctor ($2300) represents a entry level solution with limited functionality. DICOM files need to be processed through one of the other coDiagnostiX™ versions (PPP, PPG and Station) and coordinate sheets for the goniX™ surgical guide drill unit can not be printed from the coDoctor license. Printing coordinate sheets requires the transfer of the digital plan file back to one of the other license versions.

PPP ($3000) licenses trigger a $60 fee for every DICOM file import and a $120 fee to print a case specific goniX™ drill guide coordinate sheet. Importing already created virtual case plans induces additional fees.

PPG ($8000) enables the user to import a unlimited number of DICOM files without fees and a $120 fee to print a case specific goniX™ drill guide coordinate sheet.

Station ($18000) licenses can import an unlimited number of DICOM files and print goniX™ coordinate sheets without triggering any fees.

Astra Tech Facilitate™

Facilitate™ is a rebranded version of Materialise™ SimPlant® with a reduced number of implants in the library. Offered in two iterations as Facilitate™ Planner ($4490, plus 15% maintenance fee annually after the first year)) and Pro ($8720, plus 15% maintenance fee annually after the first year), mirroring SimPlant® Planner and Pro features and capabilities respectively. A free viewer program may be downloaded and distributed to facilitate treatment planning collaboration between the surgeon, restorative dentist and laboratory. The viewer can not modify a proposed treatment plan. Facilitate™ OneShot is a downloadable version of the full function Planner software package intended for one time use.

Authors note: OneShot may be used an unlimited time and number of cases for diagnostic and full function treatment planning purposes as long as no surgical guide is ordered through the software. Once a surgical guide is ordered, fees are charged for the OneShot program and surgical guide.

Surgical guides ($395 plus $50 per implant site) are produced by Materialise™ also and delivered with a "cook book" detailing the drill sequence for each osteotomy site. Templates may be osseous, mucosa or dentition supported. The Facilitate® instrument kit ($4400) contains all necessary drills, drill keys and implant holders for a successful surgical outcome. Only OsseoSpeed™ TX S type implants can be placed through the surgical guides bushings.

Send a model produced the same day the CT was taken and the virtual plan transferred to a CD or electronically transmitted to Materialise™ to initiate the surgical guide production.

sirona. SICAT

Fig. 17

SICAT (Fig.17, $8800, annual software upgrade $1100 optional) is offered as a stand alone software program and as an integral solution with Sirona Galileos scanners. DICOM data can be loaded directly in to the SICAT program without prior data conversion and processing. A free viewer program is available upon request from SICAT.

STL files generated from intraoral scanners or scanned models may be imported and merged with the CBCT and CT images in 3D to further enhance diagnostic capabilities (additional software module required, $3100). SSI files generated from Cerec scanners can be imported without additional software modules. A consumer grade computer with a graphics accelerator should suffice to render the 3D images in real time without sacrificing SICAT performance.

Fig. 18

CT appliances (Fig.18) are mandatory for edentulous patients and optional for partially edentulous patients depending on the surgical guide production method. CT appliances are fused with a special, single use CT template (sold as a kit including one template, one blank CD and a shipping container, $45) containing fiducial and physical reference markers. Send the model the CT appliance was fabricated on, the CT appliance and the virtual plan transferred to a CD to SICAT to initiate the surgical guide production.

Fig. 19

CLASSICGUIDES (Fig.19, $240 regardless of the number of implant sites, sleeves for guided surgery $40 each) are generated by converting the CT appliance in to the actual drill template. Simple pilot drill sleeves are incorporated in to the drill template or fully guided sleeves can be ordered. CLASSICGUIDE guided sleeves are compatible with Astra Tech Facilitate™, BIOMET 3i™ Navigator®, CAMLOG® Guide, Dentaurum tioLogic® pOsition, Friadent ExpertEase™, MEISINGER 3D-Navigation-Control, MIS®, Nobel Biocare™ NobelGuide™, SIC® Invent, Straumann® and Zimmer®.

Fig. 20

OPTIGUIDE (Fig.20, $290 regardless of the number of implant sites, sleeves for guided surgery $40 each) surgical drill templates may be produced through the incorporation of STL files in to the SICAT planning software. Full arch STL files are imported from intraoral scanners or scanned stone models. The guide is then fabricated based on digital data alone without conversion of the CT appliance. Drill guide holes are fashioned in to the drill template in the same manner and to the same specifications as CLASSICGUIDES.

BioHorizons® VIP 3

Fig. 21

BioHorizons® virtual implant placement software ( Fig.21, $3495, optional upgrade and unlimited support fee of $495 after the first year of ownership) includes a large variety of implants in the library. DICOM files are loaded directly in to the software without prior conversion. The user interface resembles SimPlant® and guides the user through the planning process. Basic tools such as marking of the mandibular canal (Fig.22, generating a panoramic curve and Hounsfield unit readings are intuitive and easily accessible.

Fig. 22

CT appliances are mandatory and fabricated at a dental laboratory on a diagnostic cast. The appliance itself is converted in to the Pilot Compu-Guide at BioHorizons® after the virtual planning is complete. Converted drill template guides guide specially designed pilot drills (Fig.23, purchased separately, catalog # 122-000, $360) in to the preplanned location, angulation and depth. After creation of the initial osteotomy the Pilot Compu-Guide is removed and successively larger drills are utilized according to the drill protocol associated with the implant to be installed.

Fig. 23

STL files can not be imported and merged with the data in the software program for diagnostic purposes. A consumer grade computer with a graphics accelerator should suffice to render the 3D images in real time without sacrificing VIP 3 performance.

Send the model the CT appliance was fabricated on, the CT appliance and the virtual plan transferred to a CD to BioHorizons® to initiate the surgical guide production.

Biomet 3i™ Navigator®

The Navigator® system does not have its own virtual implant placement software. Materialise™ SimPlant®, SICAT and iDent software packages may be utilized for the virtual planning. A complete surgical kit containing all drills, drill keys, fixture mounts and all necessary surgical instruments sells for $9500.

Surgical guides are produced by the same company as the software used for the planning. Only Certain® Parallel-Walled 3.25, 4 and 5mm Implants, OSSEOTITE XP® 4/5mm Implants, PREVAIL® 3/4/3, 4/5/4 and straight PREVAIL 4/3 and 5/4mm Implants may be placed with the Navigator® system. A unique feature of this system is the ability to not only control position, angulation and depth of the osteotomy but also the rotational orientation of the indexing feature of the implant. Each surgical guide is delivered with a instruction sheet detailing the drill sequence and tools to use for each osteotomy site.

Image Fig.1, Fig.4 and Fig.5 courtesy of Anatomage
Image Fig.2, Fig.3,  Fig.7,  and Fig.9 courtesy of Nobel Biocare™
Image Fig.11, Fig.12, Fig.13, Fig.14, Fig.15 and Fig.16 courtesy of Materialise
Image Fig.17, Fig.18, Fig.19 and Fig.20 courtesy of SICAT
Image Fig.23 courtesy of BioHorizons®