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An Excerpt from Guided Implantology Made Easy Dr. August de Oliveira

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The field of implant dentistry is growing and adapting to the digital world at an extraordinary pace. Dr. August de Oliveira’s recently released second book Guided Implantology Made Easy – a follow up to Implants Made Easy – provides general dentists a comprehensive overview of the process of placing implants via guided surgery. In this book excerpt, de Oliveira discusses the use of CEREC to generate a simple crown proposal.

CEREC Integration
I think that there is a misconception that you need to use CEREC in order to get Guides from SiCAT. By utilizing Guide Sleeves in the posterior, you can get a pretty good idea of where to place your implant. However, I can say from not only using Galileos, but many other Guided Surgery systems, that having access to CEREC greatly increases the safety and predictability of guided surgery.

There are many uses restoratively for CEREC when it comes to implants. You can not only mill the final restoration, but temporaries and abutments. Unlike Implants Made Easy, this is not a book on implant restoration so I won’t go into restoring your implant with CEREC.

In my office I use CEREC with Galileos in five ways:
  1. To generate a simple crown proposal to aid in the placement of the implant.

  2. To decrease the effect of noise and increase the resolution of the teeth and soft tissue by importing a stone model.

  3. To import a model of a duplicate denture.

  4. To use the Opti Guide system by importing a full arch image of the patient’s respective arch.

  5. To mill out a CEREC Guide.
Generating a Simple Crown Proposal
The difference between perfect implant placement, from a restorative point of view, and “acceptable” is only a matter of a few degrees. This is especially true in the anterior where the size of the tooth root and the size of the implant are not that different. In the posterior we can get away with more as the average implant diameter is 5mm and the average root 10mm (Fig. 2).

In the example below (Figs. 3&4) an implant was planned using a simple Guide Sleeve. The one on the lower right was planned with CEREC. I think you can see that in both examples it is pretty easy to get a good result when one has a mesial and distal neighbor. When one lines up the Guide Sleeve with the adjacent teeth’s central grooves, you can feel pretty confident that the final restoration will be in harmony with the adjacent teeth. Although much nicer to look at, the CEREC restoration more or less does the same thing.

The following example (Figs. 5&6) really shows the benefit of having a simple crown proposal. In the example below an implant was planned looking at the adjacent teeth and the available bone. The Guide Sleeve is lingual to the ridge and should yield a crown with a screw access hole in the cingulum.

The image below (Fig. 7) shows the case with the CEREC proposal entered. As you can see, I thought I planned this case well. If this implant was placed in that orientation I would either need an angled abutment and could not do a screw retained restoration or if a screw retained restoration was planned the screw hole would be on the incisal edge. In the next picture (Fig. 8) I repositioned the implant, leaving the apex where it was but rotated the platform to the lingual.



Like the anterior, another area where CEREC really shines is when you have a distal end case. When you have a mesial and a distal neighbor, you have a lot of references to plan your implant. However things get complicated when no distal tooth is present. Also there is a tendency to place second molar implants too far to the distal. This may lead to a large mesial cantilever. Due to high occlusal forces in this area, that can lead to screw loosening or breakage, or bone loss around the implant (Figs. 9-11).

The images (Figs. 12-15) clearly demonstrate the benefits of this crown proposal. The Cross Sectional image on the upper left demonstrates that there is no clear indication of where to place the implant. However, it’s very obvious when superimposing the CEREC data. In the lower you can see that by having that crown form in the image, one can place the implant in a position that avoids the distal root of the first molar, while still placing the Guide Sleeve, and the eventual screw hole, in the ideal restorative position.



For two or less adjacent teeth proposals I typically use Biogeneric Individual in the CEREC software. You would start as you would normally for designing a restoration. Select the tooth or teeth in the Administration screen and select Biogeneric Individual (Figs. 16&17). If you have a wax up or were smart enough to either take a scan or model of the tooth before it was extracted, you can use Biogeneric Copy.

There is no right or wrong way to take a scan. At the very least you would want to get the adjacent teeth as well as a good amount of the soft tissue buccal and lingual to the edentulous space. The more scans I do, I like to get at least the whole quadrant if not the whole arch (Fig. 18). By getting the whole arch you can compare your CEREC proposal to the contralateral tooth. That way if you have problems getting a decent proposal, you can toggle the proposal off in Galileos and just look at the contralateral side (Fig. 19).

When designing a restoration in CEREC we are used to using the automatic margin finding feature. In designing a proposal to be imported in Galileos we want to turn that off and go to manual. The automatic margin finder will flop around looking for a margin and you won’t be able to get anything decent. Trace around where you want the emergence profile of the crown to be, not the eventual margin. In essence you are tracing out where the tooth socket was (Figs. 20&21).



Turn your model to the buccal and lingual and trace out the margin (Figs. 22&23). Mimic the cervical areas of the adjacent teeth in essence mimicking what a ridge lap pontic would do. If you do not do this you will end up with a small or distorted proposal. Design the crown as you would normally. I don’t spend too much time on occlusion or working out my marginal ridge heights. Just make sure that the crown looks like it fits in the arch.

In either 3.85 or in 4.0, get to the mill preview (Figs. 24&25). Inspect the crown and just make sure it can be exported. Look for any artifacts that may give you an error in the exporting process.

If you are using 3.85 you will need a dongle like the one pictured below (Fig. 26). In 4.0 there is a license manager that can be accessed by using the “top menu.” You will need an internet connection so that the license (Fig. 27) can be verified. Export the file as a .ssi file (Fig. 28). Sometimes it takes the computer awhile to pull this up, so if you don’t see the .ssi option, close the export menu and open it up again. If you have networked your CEREC, export the file to the appropriate drive and then export to the Galileos Acquisition PC (Fig. 29). If not, simply export to a USB drive. In Galileos, click the CAD/CAM menu and open the appropriate drive.

After selecting the appropriate .ssi file, a model like the one below will pop up (Fig. 30). Continue on to the next window where you will select teeth on the model (Fig. 31) and teeth on the Pan (Fig. 32). For a full arch model I look for the teeth with the least distortion, usually teeth without restorations. For me, more is better, so I may use up to 4 different points scattered throughout the mouth. For a simple quadrant I usually just select two teeth.


In the confirmation screen look at the yellow outline of the model in the Pan (Fig. 33). If it is off you will see it readily here. If it does not match up, no big deal. Just click the “back” button. Usually this does not happen, but it can. You should have a nice model that you can plan on (Fig. 34).



Author's Bio
Dr. August de Oliveira is the author of Implants Made Easy, a book geared toward starting your first implant. He just released Guided Implantology Made Easy. Dr. de Oliveira has lectured nationally on cone beam technology, dental implants and CAD/CAM technology. He has been a software beta tester for Sirona, Blue Sky Bio, Anatomage and Implant Direct. He is currently a moderator and regular contributor to Dentaltown.com’s Implantology and Mini Implants Forum. Dr. de Oliveira practices general dentistry in Encino California. To find out more about implants and Guided Surgery, go to www.implantsmadeeasy.com.
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