1. IMPECCABLE IMPLANTS:
The use of computer-aided design/computer-aided manufacturing, cone beam
computed tomography, and surgical guides to create more accurate and suc-
cessful implants.
Mary White and Morgan Card
April 14, 2011
Central Piedmont Community College
Dental Hygiene Program

2. For years, dentists and lab technicians have placed dental implants and fabri-
cated crowns and bridges. Traditionally, the process of fabrication involves diag-
nostic casts, impressions and clinical records (Patel, 2010). These methods in-
volve “multiple patient appointments and separate laboratory procedures involv-
ing the clinician and the laboratory technician” before an implant may be placed
(Patel, 2010, p.21S ). In an effort to make this process more accurate and time
efficient, two technologies have now been combined to produce a more accurate,
safe, and successful implant: dental computer aided design/computer-aided
manufacturing (CAD/CAM) and cone beam computed tomography (CBCT).
In 1985, the first chairside CAD/CAM system was put into use (Poticny and Klim,
2010). This system offers “dentists the opportunity to design, mill and place ce-
ramic or porcelain restorations in a single appointment” (Patel, 2010, p. 20S).
Since 1985, approximately 20 million restorations have been produced using
these chairside units and according to the results of a 2001 literature review,
“restorations made with CAM/CAM performed better than any other restorative
material and equivalent to cast gold for restorations of the same type” (Poticny
and Klim, 2010, p. 5S). Other benefits of this technology include: “higher and
more uniform quality material by using commercially formed blocks of material,
standardize restoration-shaping processes and reduction in production cost”
(Strub, Rekow & Witkowski, 2006, p. 1290). A CAD/CAM restoration creates “op-

3. timal function, esthetics and biomechanics” (Patel, 2010, p. 21S).
The second technology used in guided implant placement is CBCT. Introduced to
the U.S market in 2001, CBCT allows the clinician to “evaluate subjacent anat-
omy, test the feasibility of the proposed implant placement and make needed
modifications to the plan to optimize the spatial and functional relationships be-
tween the planned prosthetic treatment and the anatomy” (Worthington, Ruben-
stein, & Hatcher, 2010, p.20S). According to Worthington, Rubenstein and
Hatcher (2010), the following may be seen using the 3-D tomography: thickness
of the soft and hard tissues, height, weight and quality of the bone, inner arch
space, occlusion and the temporomandibular joint. Using this information, a clini-
cian may avoid mental nerve damage, perforation of the maxillary sinus, and un-
intended lingual perforation of the mandible (leading to possible hematoma or
damage to the sublingual gland) (Worthington, Rubenstein, & Hatcher, 2010).
Also, these images are never distorted or magnified because the software corre-
lates one to one, ensuring accuracy in the designing and manufacturing of a sur-
gical guide (Patel, 2010).
In a clinical setting, integration of CAD/CAM and CBCT for the use of a dental
implant would be used as follows. At the first appointment, the dentist would coat
the teeth with powdery optical reflective medium and take digital impressions of
the edentulous area in which the implant is needed, the opposing arch, and the
occlusion using a “buccle bite technique”. Then a stock scanning bite plate is

4. seated in the patientʼs mouth with bite registration material and possibly trimmed
to better fit the patientʼs mouth. The stock scanning bite plate contains small ra-
diopaque markers that allow the CBCT to attain an image. Then the 3-D cone
beam image is taken revealing the patientʼs surrounding hard and soft tissue and
surface anatomy. The dentist can then virtually plan the placement, shape, and
type of implant body, abutment, and crown. The dentist may assess the quality of
the bone and the placement of anatomical structures at this point. Next, the vir-
tual implant plan and the stock bite plate are shipped to a manufacturer who
makes the stock bite plate into a surgical guide according to the dentistʼs specifi-
cations. At the second appointment, the implant and abutment are placed. The
crown is milled in the office using the chairside CAD/CAM technology and may
be placed the same day. This process not only saves time, but is highly accurate
and safer for the patient (Patel, 2010). According to Worthington, Rubenstein and
Hatcher, “Implant planning, surgical fabrication and implant placement have been
tested to an accuracy of 0.9 millimeters at the ridge crest and 1.0 mm at the apex
of an in vitro model,” using this type of system (Worthington, Rubenstein &
Hatcher, 2010, p.22S).
According to Howerton and Mora (2008), the future of these technologies will be-
come more widely used throughout different fields of dentistry. They say, “con-
sider a patient with a congenital deformity in the oral and maxillofacial region,
malocclusion and missing teeth”, using this technology, “the oral surgeon, ortho-

5. dontist, implantologist and restorative dentist can link their communication such
that pretreatment expectations equal posttreatment results.” (Howerton & Mora,
2008, p. 23S-24S) They believe the future of the CBCT technology depends on
an increase of imaging centers and more trained oral and maxillofacial radiolo-
gists (Howerton & Mora, 2008). Strub, Rekow and Witkowski (2006) also agree
that the expansion of these technologies may change dramatically, but it will rely
on the specialized training of dental professionals in order to use them to their full
capacity. As of now, these technologies are substantially beneficial to both pa-
tients and dental professionals. Implant placement is and will likely become safer,
more timely and overall more successful with the combined use of CAD/CAM,
CBCT, and surgical guides.

6. Work Cited
Hatcher, D.C. (2010). Operational Principles for Cone-Beam Computed Tomo
graphy. The Journal of the American Dental Association, 141, 3S-6S.
Howerton, W.B. Jr., & Mora, M.A. (2008). Advancements in Digital Imaging: What
is New and on the Horizon?. The Journal of the American Dental Associa
tion, 139, 20S-24S.
Patel, N. (2010). Integrating Three-Dimensional Digital Technologies for Com
prehensive Implant Dentistry. The Journal of the American Dental Associa
tion, 141, 20S-24S.
Poticny, D.J., & Klim, J. (2010). CAD/CAM In-office Technology: Innovations Af
ter 25 years for Predictable, Esthetic Outcomes. The Journal of the Ameri
can Dental Association, 141, 5S-9S.
Strub, J.R., Rekow, E.D., & Witkowski, S. (2006). Computer-aided design and
fabrication of dental restorations: Current systems and future possibilities.
The Journal of the American Dental Association, 137, 1289-1296.
Worthington, P., Rubenstein, J., & Hatcher, D.C. (2010). The Role of Cone-Beam
Computed Tomography in the Planning and Placement of Implants. The
Journal of the American Dental Association, 141, 19S-24S.