NobelClinician 2.

4
Instructions for use
Disclaimer of liability: This product is part of an overall concept and may only be used in conjunction with the associated original products
according to the instructions and recommendation of Nobel Biocare. Non-recommended use of products made by third parties in conjunction
with Nobel Biocare products will void any warranty or other obligation, express or implied, of Nobel Biocare. The user of Nobel Biocare
products has the duty to determine whether or not any product is suitable for the particular patient and circumstances. Nobel Biocare disclaims
any liability, express or implied, and shall have no responsibility for any direct, indirect, punitive or other damages, arising out of or in
connection with any errors in professional judgment or practice in the use of Nobel Biocare products. The user is also obliged to study the
latest developments in regard to this Nobel Biocare product and its applications regularly. In cases of doubt, the user has to contact Nobel
Biocare. Since the utilization of this product is under the control of the user, they are his/her responsibility. We assume no liability whatsoever
for damage arising thereof. Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel
Biocare sales office for current product assortment and availability.

Instruction for clinician: We strongly recommend that clinicians, new as well as experienced implant users, always go through special training
before undertaking a new treatment method. Nobel Biocare offers a wide range of courses for various levels of knowledge and experience. For
more info please visit www.nobelbiocare.com. When first beginning to use the software, working with a colleague already experienced with
the new device / treatment method, will provide further insight and understanding. Nobel Biocare has a global network of mentors available for
this purpose.

General precautions / Warnings: One hundred percent implant success can never be guaranteed. With respect to pediatric patients, routine
treatment is not recommended until the end of the jaw bone growth has been properly documented. Pre-operative hard tissue or soft tissue
deficits may yield a compromised esthetic result or unfavorable implant angulation. It is strongly recommended that NobelGuide Surgical
Templates and Duplicate Dentures are used only with appropriate Nobel Biocare implants, surgical instruments and prosthetic components, as
combining components that are not dimensioned for correct fitting can lead to mechanical and/or instrumental failure, damage to tissue or
unsatisfactory esthetic results.

In addition, it is recommended that you have active and up-to-date antivirus and anti-malware software, together with a correctly configured
firewall, on the computer on which you are using NobelClinician.

Additional Information: For additional information on the NobelGuide concept and the surgical procedures please consult the NobelGuide
Concept Manual available at www.nobelbiocare.com or request latest printed version from a Nobel Biocare representative.

Legal Manufacturer:

Nobel Biocare AB, Box 5190, 402 26

Vstra Hamgatan 1, 411 17 Gteborg, Sweden

Phone: +46 31 81 88 00. Fax: +46 31 16 31 52. www.nobelbiocare.com

Attention, see Instructions for Use

Rx only Caution: The caution text Federal (USA) law restricts the sale of this device to, or on the order of, a licensed
physician or dentist is shown on labels with Rx Only

GMT 35941. Date of issue 10-10-2014. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks used in this
document are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Product images in this
document are not necessarily to scale.

2
C on te n ts

Introduction 6
Intended use 6
Indications for use 6
Contraindications 6

User identification 7
Logging in 7
Switch users 7
Add users 7

Software overview 8
Toolbar 9
Interact with the viewers 9
Manipulate objects 10
Show or hide an object 10
Manipulate a CT slice 11
Scroll through CT images 11
Level and window 11
Level/window on 2D 11
Level/window on 3D 11

Start 12
Open a planning scenario 12
Save a planning scenario 12
Rename or delete a planning scenario 12
Close a planning 12
Close a patient file 12

Prepare 13
Create a 3D patient model 13
Visualization of the patient model 13
What is a transfer function? 13
How to clean up the visualization of the patient model 13
Patient mask 13
Erase bone artifacts 14
Disable mask 14
Reset Patient Mask 14
Keep the largest part 15
Diagnostic setup 15
Dental cast 15
Order a scan of the dental cast 15
 Add the dental cast to the patient model 16
SmartFusion 17
Initialization of SmartFusion 17
Initialization procedure 17
How to start the initialization wizard 17
How to define corresponding points in the wizard 18
Radiographic guide model 20
Edit the shape of the reslice curve 20
Manipulate the existing control points 20
Use tooth control points 20
Adjust the size of the cross-sectional reslice 21

Diagnose 22
Nerves 22
Teeth 22
Remove teeth from the model 22
Subtract all teeth simultaneously 23
Extract a single tooth 23
Measurements 23

Plan Implants 25
Work with third-party implants 25
Add an implant to a planning 25
What does the yellow zone mean? 26
Tooth position 26
Tooth chart 26
Manipulate an implant 26
Change the implant orientation 26
Move an implant 27
Make implants parallel 27
Place a parallel implant 27
Place all implants in parallel 27
Abutments 27
Set the surgery type 28
Different surgery types 29
Pilot sleeve offset 29
Pilot sleeve rotation 29
Anchor pins 30
Add an anchor pin to the planning 30
Correct angulation and depth of anchor pins 30

Finalize 31
Create a surgical template 31
Inspect the surgical template 31

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 Edit the virtual surgical template 31
Approve a planning 32

Orders 33
Product orders 33
Create a product order 33
Send a product order 33
Scan orders 33
Create a scan order 33
Generate a scan order form 34

Work with the NobelClinician Assistant 35

NobelClinician Warning System 36

Planning warnings 37
Production warnings 37
Usage warnings 37
Configurable warnings 39
Technical constraints 39
Minimal distance between guided sleeves 39
Minimal distance between sleeves and implants / sleeves and anchor pins 40
Collision between implants, anchor pins, or implants and anchor pins 40
Relationship between guided sleeve and radiographic guide / dental cast 40
Guided abutments 42
Radiographic guide was created without calibrated isovalue. 42

Scanner Calibration 43
Create a new calibration set 43

Index 45

5
In tr od u c ti on

In te n d e d u s e
The NobelClinician Software is a software interface for the transfer and visualization of imaging information from
equipment such as a CT scanner for the purpose of diagnosis and treatment planning in the dental and cranio-
maxillofacial regions. The NobelClinician Software can be used to design a surgical template for the purposes of
aiding placement of dental implants.

With the NobelGuide treatment concept, the physician uses NobelClinician to plan dental implant treatment by
utilizing the digitized patient data (medical or cone beam CT data of the patient, and optionally the scanned
radiographic guide, dental cast and/or wax-up, representing the diagnostic tooth setup). He reviews and orders the
surgical template if guided surgery is intended.

NobelClinician users can choose to subscribe to regular training and education sessions to master the planning
software and to get the best out of it. For more information, please revert to the Nobel Biocare website at
www.nobelbiocare.com and look for the courses section.

Please note that the information mentioned in this document is basic and concise to get you up and running in no
time. For more detailed information turn to the help files comprised within the NobelClinician Software.

Warning
It is important to acknowledge that the planning program does not automatically check all
technical constraints! Even in the event that no technical constraints are automatically
shown in the software, it might be that the surgical template cannot be produced.

Before using the NobelClinician Software, please read this Instructions for Use document thoroughly and
retain it for future reference.

In d ic a ti on s f or u s e
NobelClinician Software is indicated for:

1. Supporting diagnostics and treatment planning for dental, cranio-maxillofacial and related treatments.

2. Supporting the NobelGuide concept: prosthetically-driven implant planning based on (1) the digitized patient
data (medical or Cone Beam CT data) and (2) the scanned radiographic guide representing the ideal
diagnostic tooth setup, or alternatively for smaller partially edentulous cases the surface scan of the intra-oral
situation optionally combined with a surface scan of the tooth setup; preview and order the surgical
template if guided surgery is intended. See the NobelGuide concept for more details.

C on tr a in d ic a ti on s
Not applicable for the NobelClinician Software.
U s e r id e n tifi c a ti on
Multiple users might have access to the computer with the NobelClinician Software. To ensure that only authorized
users may enter and utilize NobelClinician, proper user identification is needed. The program will then apply the
correct user settings and patient privacy rules.

L og g i n g in
1. Open the software

2. Select the user

3. Enter the corresponding password

4. Click on Login.

Note
When logging in for the first time, enter the password received in the registration e-mail. Then change the
password, as is requested. Your password should be as secure and strong as possible and not consist of evident
wording.

S w itc h u s e r s
In NobelClinician, switch users via the Switch Account option in the NobelClinician menu in the My Office module.

Add users
To add new users, contact your local Nobel Biocare Customer Service or Support desk.

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S oftw a r e o v e r vie w
The main graphical user interface components are indicated in the image below.

1 Toolbar with action groups specific to

the selected module
2 Assistant
3 Workspace
4 Module bar
5 Upload Center

Click on the icons to navigate through the different modules NobelClinician is comprised of:

My Office to manage your patients and calibration sets.

Patient info to store patient information and manage clinical pictures in the Patient Library.

Planning to import DICOM files, create patient and guide models, diagnose and plan.

Order to easily order scans of the dental cast or wax-up, or the surgical template and duplicate
denture together with standardized components.

Communication to facilitate the communication about a treatment plan with colleagues and
patients - by means of viewer files, reports and/or Communicator presentations - and to link up
NobelClinician and OsseoCare Pro by the creation of OsseoCare Pro surgeries.

Double-click on a patient in My Office to go to a specific section related to this patient. Click on 3D planning to
diagnose and plan a treatment.

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T o olb a r

At the top of the workspace, a context specific toolbar shows you the tools needed for certain tasks. In the Planning
module dedicated tabs appear when selecting specific objects (e.g. cross-sectional reslice, implants, ). These
dedicated tabs also called contextual tabs - offer an alternative access to actions which are also available on the
pop-up menus when you right-click an object.

In te r a c t w ith th e vie w e r s
Interaction modes are in fact the types of interaction in the 2D and 3D viewers. Switch between them via clicking the
icons in the Interaction toolbar, via an Interaction right click menu, and via a combination of shortcut keys.

Interaction Mode Select an object or identify an object for an action simply by pressing the left
mouse button.

Rotation Mode Rotate the 3D scene (only 3D) by dragging the mouse.

Pan Mode Pan the scene by dragging the mouse.

Zoom Mode Zooming in on or out of the model by dragging the mouse.

Zoom Box Mode Zoom to focus on a specific area of the model by drawing a rectangular area (only
in 2D).

Quickly change between the different Interaction modes by means of the shortcuts:

Ctrl (Cmd) or middle mouse Switch to Pan mode when you are in any other mode. As long as the button is
button pressed down, Pan mode is maintained. Release the button to return to the
original mode.

Alt Switch to Rotation mode when you are in any other mode. As long as the button
is pressed down, Rotation mode is maintained. Release the button to return to
the original mode.

Shift Switch to Zoom mode when you are in any other mode. As long as the button is
pressed down, Zoom mode is maintained. Release the button to return to the
original mode.

Tab key Toggle between Interaction mode and Rotation mode.

Switch to Interaction mode when in any other mode.

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A number of standard views are available in the 3D viewer

Select the skull icons to jump to the corresponding standard views of the model.

Front - Standard frontal view. [5]

Left - Standard left lateral view. [1]

Right - Standard right lateral view. [3]

Top to bottom - Standard cranio-caudal view. [9]

Bottom to top - Standard caudo-cranial view. [7]

M a n ip u la te ob je c ts
1. To select an object, get in Interaction mode and click on the object. In a 3D viewer, a white contour line
indicates that the object is selected. In a 2D viewer, the outline of the selected object is colored.

Note
The patient model is the exception in this case. No contour line is shown when the patient model is selected.

2. Select the cross-sectional reslice, an implant or an anchor pin and access related actions via the dedicated
toolbar tab.

3. Right-click on any object to see the pop-up menu with possible actions related to that object.

S h ow or h id e a n ob je c t
To efficiently plan a patients treatment, it is important to see only the objects of interest during the planning stage.

A single object can be hidden through the right-click menu or shortcut key H.

With the Visibility Editor, the visibility of the standard objects can be toggled with a single mouse click.

Different visibility icons are available for group objects:

1 When the black Visibility icon is displayed in front of the group, all
objects belonging to the group are on display.

2 When the gray Visibility icon is shown in front of the group, one or
more objects in the group are hidden, while others are still shown.

3 When no icon is displayed in front of the group, all objects

belonging to the group are hidden.

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M a n ip u la te a C T s lic e
Scroll through CT images
NobelClinician is equipped with a number of tools to easily browse through the slices: with the mouse scroll wheel,
the slider or the slice input field.

L e ve l a n d w in d ow
The level/window tool is a tool to be used on both 2D and 3D viewers to change the level and window of the values
used to convert the data into an image or model. Depending on the type of image (2D or 3D) the result will differ.

Level/window on 2D
The contrast of CT slices as well as panoramic views is defined by the window and level values. With the
level/window setting, it is defined which gray values are displayed on the screen. A selection, centered around the
level value, and with a width of the window value (equally divided at both sides of the level), is displayed. By operating
these settings, the contrast of the CT slices is modified.

The level is modified by dragging the mouse up and down. The window is updated by dragging the mouse left
(narrowing) and right (widening).

Level/window on 3D
When working in 3D view, the level/window tool is used to control the scaling or the center of the transfer function.
By this the amount of noise in the patient model is reduced or the color settings are adjusted in order to get a better
visualization of the patient model.

Move the center of the transfer function without affecting the width of the range by dragging the mouse up- or
downward. Drag left or right over the patient model to respectively widen or narrow down the range of values used to
generate the patient model.

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S ta r t
A treatment includes all planning scenarios concerning a patient. A new treatment can be started when creating a
new patient or when working with an existing patient.

A planning scenario contains the basic patient model, dental cast, wax-up and/or radiographic guide as well as all the
planning products in the current scene configuration of a specific patient.

O p e n a p la n n in g s c e n a r io
To open a planning scenario for a specific patient, click on the NobelClinician tab in the toolbar and then click on the
Open option . When the Planning Overview window appears, select the planning scenario and click on Open
Scenario.

S a ve a p la n n in g s c e n a r io
To save a planning scenario, use the Save option [CTRL + S] on the NobelClinician tab. The planning is saved.

R e n a m e or d e le te a p la n n in g s c e n a r i o
To rename or delete a planning scenario, use the Manage option in the NobelClinician tab. This is only possible when
specific conditions are complied with.

C l os e a p la n n in g
To close a planning, click on the NobelClinician tab in the toolbar and click on the Close Planning option . The
planning is closed and the Planning Overview dialog appears.

C l os e a p a ti e n t file
To close a patient file, click on the NobelClinician tab in the toolbar, choose Close Patient in the menu and, when the
'Medical Record' dialog appears, click on Close Patient.

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P re p a r e

C r e a te a 3D p a tie n t m od e l
To create a good 3D patient model it is important to select the correct DICOM files, to set the most appropriate
volume of interest, to indicate the optimal isovalue and select the correct jaw type. The system will guide you through
these steps in the Create Patient wizard.

1. Enter the Create Patient wizard (via New Treatment option or the Patient icon ).

2. Indicate the folder containing the correct DICOM data.

3. Select the appropriate set from the list of loaded DICOM sets and click Next.

4. Set the Volume of Interest (VOI) on the Set the volume of interest and isovalue page

5. Set an appropriate isovalue by means of the Isovalue slider and click Next.

6. Adjust the scanner orientation and set the occlusal plane by means of the sliders.

7. Select the jaw type you want to treat for the patient.

8. Click Finish.

V is u a liz a ti on of th e p a tie n t m od e l
Warning
It is prerequisite that the clinician is familiar with the interpretation of CT data and the way CT
data are visualized by means of volume rendering.

What is a transfer function?

When a patient model is created, each grey value is converted into a specific color with certain opacity to give the
patient model a typical look. Therefore a transfer function is applied, which assigns RGB values and opacity to every
voxel in the volume. By applying the transfer function the 3D volume is visualized.

Transfer functions can be managed and applied to the patient model by means of the transfer function gallery. This
gallery holds the thumbnails representing the different available transfer functions as well as a number of actions that
can be performed on these transfer functions. A distinction is made between built-in transfer function templates,
custom templates and 'This Patient' transfer functions for the current patient.

H ow t o c l e a n up th e vis u a li z a ti on of th e
p a tie n t m od e l
When in planning mode, cleaning up artifacts and cluttering particles is done in a simple and straightforward way via
the Patient Mask or the Erase Bone Artifacts actions.

Patient mask

1. Click on the Patient Mask icon .

2. In the Patient Mask action, click one of the following buttons:

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 Click on the Cut icon to start indicating the part of the volume to be removed from the model.
Everything within the drawn polygon will be hidden.

Click on the Isolate icon to start indicating the part of the volume you would like to show.
Everything outside the drawn polygon will be hidden.

To start re-adding part of the volume that has been cut away, click on the Add icon.

3. Now start drawing the polygon:

Click a point with the left mouse button.

Move the mouse and click a second point. The two clicked positions are linked with a green
dotted line.

Click a third point. The linking green dotted line will change into a polygon.

Continue marking points until you have enclosed in a polygon the part of the model that you
want to cut away.

Right-click or push Enter to apply.

Erase bone artifacts

1. Click on the Erase Bone Artifacts button in the Patient Editor group on the Prepare tab. The Erase Bone
Artifacts action starts.

2. Click on the Magic eraser button or the Eraser button in the Erase Bone Artifacts action.

3. Now click on the CT data or keep the mouse button pressed down to mark the parts to be removed from the

patient model. With the Magic eraser , the masking is removed in a small, medium or larger region

around the clicked position, depending on the brush settings. With the Eraser , all masking is removed
in a sphere around the clicked position. The size of the sphere also depends on the brush settings.

Brush settings can be changed to work properly in specific cases.

Note
The Erase Bone Artifacts action does not affect the original CT data. When artifacts have been removed and the
patient model is edited afterwards via the Edit Patient action, the artifacts will be part of the model again.
Therefore, if you need to perform both actions to obtain a better result, the preferred procedure is to edit the
patient model first and then to erase possible noise and artifacts afterwards.

Disable mask

Use the Disable Mask button to toggle between the complete patient model and the specified selection.

Reset Patient Mask

Use the Reset Patient Mask button to show the complete patient model again as it was generated.

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Kee p the la rgest part
When fine-tuning the model by means of the Patient Mask action, instead of cutting away all the smaller particles
cluttering the view, it is possible to keep only the largest 'bony' part of the model, since this is - in practice - quite
probably the part you are most interested in.

To do so, click on the Keep largest part action in the Patient Mask or Erase Bone Artifacts actions. The smaller
particles and parts with a density different from the bone density will be removed. The largest bony part remains
visible.

D ia g n os t ic s e tu p
When using NobelClinician, two types of scan protocols can be followed to model the virtual diagnostic setup,
depending on the clinical indications:

For small partial edentulous patient cases (preferably at least 6 teeth remaining), the protocol
without radiographic guide can be followed (using a dental cast).

For edentulous patient cases and for large partial edentulous patient cases (very few teeth
remaining), the protocol with radiographic guide needs to be followed.

To decide which protocol to use, the decision table in the NobelGuide concept manual can be used.

D e n ta l c a s t
The dental cast is made from an impression and represents the patients intraoral situation. A prosthetic restoration
can be constructed on the cast using a prosthetic set-up or wax-up. The surface of this model can be accurately
scanned (digitized) with a NobelProcera 2G System by your dental laboratory. This surface scan can be imported into
the NobelClinician Software to be aligned with the patients 3D model from DICOM information.

After having made the impression, open the NobelClinician Software, open the patient file and order a scan of the
dental cast from your NobelProcera laboratory. Once the laboratory has uploaded the scanned file to NobelConnect
you can download the scan and align it with the DICOM data from the patient model via SmartFusion.

Order a scan of the dental cast

1. Open a patient file, go to the Order module and click on the Scan icon .

2. Enter the e-mail address of the lab that will process the order.

3. Indicate the jaw type (upper jaw or lower jaw) and whether you also want to order a scan of the prosthetic
set-up / wax-up (recommended for prosthetic driven planning).

4. Select the intended delivery date for receiving the surface scan back and enter special instructions in a note
to the dental laboratory if necessary. Then, click on Next.

5. Fill out the shipping details. These are comprised of patient details, clinician name and address, and whether
or not additional items were sent to the lab.

6. Then click on Finish. Now the scan order is sent to the lab, provided that the 'Send order after finishing'

option was marked. Otherwise, click on the Send icon .

15
Add the dental cast to the patient model
When the scan of the dental cast is uploaded by the dental lab, the surface scan can be aligned with the patient
model.

1. Open the treatment.

2. Click on the Dental Cast icon in the Create group on the Prepare tab.

3. Select the Ready for download scan order from the list and click on Next. The download is automatically
started, followed by SmartFusion to align the surface scan of the dental cast with the patient model.

4. On the Check Alignment page of the wizard, check whether the patient model and the dental cast are
correctly aligned. If everything is ok, click on Finish.

5. Carefully verify if the automatic alignment is correct. The outline of the aligned dental cast (by default
displayed in pink color) must accurately correspond to the occlusal information of the teeth within the
(CB)CT scan. It is the clinicians responsibility to assure that this step is correct. If it is incorrect, try
SmartFusion initialization (see below). If you cannot align the two models accurately, please contact
customer support.

1 Incorrect alignment
2 Correct alignment

Warning
A wrong alignment will result in a wrong surgical template and may not be used for surgery!

6. If the alignment is correct in every aspect, click on Finish.

7. The dental scan is now added to the scene. If the prosthetic set-up / wax-up scan was included in the order,
it is added automatically as well.

16
S m ar tF u s i on
Initialization of SmartFusion
When the SmartFusion of the dental cast and patient model fails, or is not sufficiently accurate, you need to adjust the
initial position of the dental cast and restart the SmartFusion calculation. This is called SmartFusion Initialization.

Note
It is likely that SmartFusion will be less accurate when the patient has less than six remaining teeth.

Initialization proce dure

To inilialize the SmartFusion, you will need to define at least three pairs of corresponding points, shown on the teeth
of the patient model and dental cast respectively. If the points are placed inaccurately, you can remove them and
indicate them again. Should you need to remove all corresponding points, you can do so with a single click.

For more information on how to define the corresponding points, turn to the How to define corresponding points
section below, or to the Explaining the Corresponding Points wizard section in the NobelClinician help files.

How to start the initializa tion wi zard

When SmartFusion is running, but you want to adjust the initial position of the dental cast in
relation to the patient model straight away, enter the SmartFusion wizard by clicking the
'Initialize SmartFusion' link.

When SmartFusion is running, but the process fails, a warning message is displayed. Click
Initialize Position and you will open the Initialization wizard. This allows you to initialize the
position of the dental cast and restart the SmartFusion.

When SmartFusion is running after an initialization attempt, but the process fails again, a
warning message is displayed and you will be guided to the Check Alignment page. On this
page enter the Initialization wizard by clicking on the Indicate corresponding points action (see
image below).

When SmartFusion is running and succeeds, but the dental cast and patient model are not
correctly aligned, enter the Initialization wizard by clicking on the Indicate corresponding points
action on the Check Alignment page of the wizard.

17


How to define corresponding points in the wiza rd

Insert a point

1. When entering the wizard, the 'Insert points' action is activated.

2. Click a specific position in the left pane on the teeth of the patient model.

3. Click the corresponding position in the right pane on the dental cast.

Repeat steps 2 and 3 until you have defined three pairs of corresponding points.

4. Check whether there are any warnings in the warnings section of the wizard.

5. When a message states that the requested number of pairs is reached, click on Finish to close the wizard.
Make sure all warnings are addressed before closing the wizard. Otherwise you will not be able to finish.

Tip
Make sure the points you are adding are well-distributed over the complete dental arch. Avoid clustering. The
larger the area covered, the more likely the alignment will be executed correctly. Place points in at least two out of
four quadrants as shown in the image below.

18
Remove selected points
Note
If the options to remove points are disabled, right-click to finish the Insert points action. Now the other actions are
enabled.

To remove selected points, do the following:

1. Select a point in one of the viewers.

2. Click the 'Remove selected points 'action .

3. The selected point and its corresponding point are removed.

Remove all points

Should you wish to remove all indicated points, click on the 'Remove all points' action . Now all defined virtual
points are removed.

Warnings used in SmartFusion initialization

Dental cast manually aligned. When users choose to apply the manual alignment instead of the
SmartFusion of the dental cast and the patient model, the system
This option might introduce small
will warn them to double check extremely meticulously to avoid
inaccuracies. Check the dental cast
possible inaccuracies.
alignment carefully. If incorrect, make sure
the corresponding points are positioned
correctly.

One or more pairs of points are not The system measures the distance between the points placed on
corresponding the patient model and the corresponding points indicated on the
dental cast. If the distance is too different, the system warns the
user. The user is requested to adjust the pairs of points.

The defined points are insufficiently
distributed over the dental cast.
When the system detects that the defined points are not placed in
at least 2 out of 4 of the quadrants, a warning is generated. The
user is requested to adjust the corresponding points, or to add a
pair of corresponding points, taking into account good distribution
over the quadrants of the dental arch. Clustering should be
avoided.

Indicate at least three corresponding points. Not enough pairs of points have been defined to be able to finish
the wizard. Place additional pairs of points until the minimum
number of point pairs to be placed is reached.

19
R a d i og r a p h i c g u id e m od e l
Based on the clinical patient diagnostics, a radiographic guide will be constructed from a clinically validated tooth
setup, containing markers for the double scan procedure. The virtual model is constructed when the patient model is
created.

This is the procedure to create the radiographic guide model:

1. Enter the Create Guide Wizard via the Guide button .

2. Select the correct DICOM data and click Next.

3. Set the Volume of Interest (VOI).

4. Using the suitable calibration set, the Calibrated Isovalue is loaded. Click Next.

5. Check the radiographic guide model.

6. Patient model and radiographic guide are automatically aligned.

7. Check the alignment result and click Finish.

E d it th e s h a p e of th e r es lic e c u r ve
For the optimal reslice curve, the cross-sectional reslice should always be positioned perpendicular to the occlusal
plane. When creating a new patient model, a default reslice curve is calculated based on the set jaw type, volume of
interest and occlusal plane. The shape of this curve can be edited, as well as the size of the cross-sectional reslice.

To adjust the shape of the reslice curve, take the following steps:

1. Select the Reslice curve button in the CT Editor group on the Prepare tab.

2. The Adjust Reslice Curve action is started.

3. Now you can either fine-tune the calculated curve by manipulating the existing control points or you can
generate a whole new curve by placing tooth control points.

Manipulate the existing control points

1. Click and drag the control points to manipulate the shape of the reslice curve.

2. Insert a point, add an end point or select and remove a point.

3. Choose Finish when the curve is looking satisfactory.

Use tooth control points

1. Click the Re-indicate curve action .

2. Follow the instructions in the tooltips to place the tooth control points appropriately:

Click the axial viewer to indicate the position of the right third molar (wisdom tooth).

Then click the axial viewer to indicate the position of the next tooth, the right canine.

Click the axial viewer to indicate the position of the canine on the left side.

Finally click the axial viewer to indicate the position of the fourth tooth, the left third molar
(wisdom tooth).

20
 Note
The dental numbers indicated in the tooltips differ depending on the used dental notation
system. This notation can be changed in the preferences.

If the tooth marker points are to be positioned where dentition is physically no longer present,
position them where they would/should be located.

3. Now these four points - the 2 third molars and the 2 canines - together with 5 automatically generated
control points form the basis for the reslice curve.

4. Check the curve and fine-tune, if necessary.

5. Choose Finish when the curve is looking satisfactory.

Adjust the si ze of the cross -sectional reslice

Adjust the size of the perpendicular view to see the appropriate image in the cross-sectional reslice:

1. Click on the Reslice curve icon to open the Adjust Reslice Curve action.

2. Drag the boundaries of the shown region in the Perpendicular view up and/or down or sideways.

Note
It is possible to drag the upper or lower boundaries independently. When dragging the left or right boundary, the
opposite one will move in the opposite direction and with the same distance to assure the central position of the
reslice image.

21
D ia g n os e

N e r ve s
To delineate a nerve, click on the Nerve button on the Diagnose tab and a wizard opens.

1. Adjust the Nerve Reslice if necessary.

2. Click to indicate the construction points of the nerve.

3. Right-click to stop adding points and click Finish.

The spheres are now connected with a tube-like line, indicating the nerve.

To add another nerve, choose the Add New Nerve action in the Nerve Actions group. Now start indicating the
points of the new nerve.

Tip
When it is difficult to visualize the nerve canal, adjust the Nerve Reslice. This U-shape is not linked with or related
to the shape of the Reslice curve.

T e e th
To annotate a tooth, click on the Tooth button on the Diagnose tab and a wizard opens.

1. Select the tooth in the chart at the top to be annotated.

Note
Default the FDI notation will be used here. If necessary, change the dental chart notation via the general
preferences.

2. Fine-tune the position of the selected tooth to adjust its central axis.

3. Now click on the Magic mark fill button or the Mark brush button .

4. Scroll through the CT slices and click or drag to mark the tooth bit by bit. All data in a specific area around
the clicked position is colored and will be added to the tooth.

5. Now click on Update 3D . The tooth is now shown in a 3D preview and it is added to the patient model in
the 3D viewer.

6. If necessary, select a new tooth in the chart to be annotated.

7. When all teeth are annotated, click Finish.

R e m ove te e th fr om th e m od e l
When teeth are annotated, it is possible to subtract them from the patient model, one by one or all teeth at the same
time.

22
Subtract all teeth simultaneously

1. Click the Subtract Teeth button on the Prepare tab. This button is only enabled when teeth have been
annotated.

2. If necessary, correct the patient model afterwards with the Patient Mask or Erase Bone Artifacts actions.

Note
When new tooth annotations are added or when teeth are edited after a subtraction took place, execute the
Subtract action again if you want to apply it to the newly added or edited teeth as well. It will not be executed
automatically. Or use the Extract Tooth action.

Extract a single tooth

1. Click on the annotated tooth to select it.

2. Click the Extract Tooth icon in the Diagnose group on the Diagnose toolbar.

Note
This Extract Tooth icon will only be enabled when teeth have been annotated.

3. The extracted tooth is colored red.

M e a s u r em en ts
Measurements allow for easy diagnosing the patients anatomy. By means of the annotations you can obtain an
optimal treatment plan.

Tip
If it is difficult to read the measurement text because the objects in the scene are hiding it, select it or its text to
display the measurement result in the status bar.

Distance between 2 points

1. Click the Distance button on the Diagnose tab.

2. Click to indicate the first point and click again on a second position.
The measurement is now displayed.

Angle
1. Click the Angle button on the Diagnose tab.

2. Indicate the three points a, b, and c.

3. The angle is visualized by means of an angle arch and the

measurement value is shown.

Grey value / HU
1. Click the HU Value button on the Diagnose tab.

2. Indicate a point to measure the HU value there.

23
Angle between implants or
abutments 1. Select an implant and click the Implant Angle button on the
Diagnose tab.

2. Select the second implant. An arched yellow line visualizes the

measurement together with the value.

24
P la n I m p la n ts

Disclaimer
Prior to planning any extra-oral surgical procedure, the user of Nobel Biocare implants is responsible for
determining whether or not an implant is intended and cleared for extra-oral use. Not all implants are
regulatory cleared to be used for extra-oral use.

W or k w ith th ir d - p ar ty i m p la n ts
Not only Nobel Biocare products are available in the NobelClinician Software, but the software is also open to third-
party implants including other major implant systems. Only a few mouse clicks on the Implant Products tab of the
Preferences dialog are needed to indicate which implant systems you want to include in NobelClinician.

Note
An Internet connection is needed to download third-party implants to the NobelClinician Software.

Adding or removing implant systems from the NobelClinician Software can only be done when all planning scenarios
are closed. Therefore, close all patient files and turn to the Preferences dialog:

1. Click on the NobelClinician tab.

2. Select General Preferences.

3. Now click on Installed Products.

4. Indicate which implant systems are to be added to or removed from the software.

5. Click OK to finish.

Note
When products are used which are not available on the computer, they will be replaced in the planning with
cylinder-shaped dummy products. The original product information, however, is stored and when the products do
become available, the dummies in the planning are replaced with a more detailed representation of the products.

A d d a n im p la n t t o a p la n n in g
This section explains how to virtually plan an implant. It is, however, recommended that you know and are aware of
the quantitative and qualitative constraints related to planning oral implants.

To add an implant to the planning, follow these steps:

1. Click the Implant button on the Plan tab.

2. Click the patient model to indicate the implant shoulder point.

3. Then click the model to indicate the apex of the implant.

4. Select the proper manufacturer from the Manufacturer section on the Product Selection window.

5. Select an implant. Optionally, indicate also the surgery type, a compatible abutment and check the tooth
position.

6. Then click the Select Product button to confirm your choice.

25
 Caution
Products which are unavailable are displayed with a red warning in the Product Selection
window and shown in blue in the 3D view. Ordering these products is not possible.

What does the yellow zone mean ?

The typical tolerance of the NobelGuide concept is within 1.5 mm. The semi-transparent yellow zone helps the user to
be conscious of this aspect in relation to vital structures. The zone is a cylinder that exceeds the radius of the actual
implants by 1.5 mm combined with a cone with a height of 3 mm.

It warns the surgeon of potential risks when the yellow zone becomes visible through the outer bone surface.

Note
Drills may extend 1 mm longer than planned implant(s). This yellow warning zone also takes
into account this variance.

It is advised to keep at least 3 mm of vital bone in between two implant-bone interfaces and a
minimal distance of 1.5 mm between a tooth and an implant to allow a cellular re-colonization
with proper blood supply.

The NobelGuide concept includes several clinical steps, which the clinician has to take into
consideration for each individual case. Therefore, the total accuracy in each individual case has
to take in account the influence of these procedures.

Tooth posi tion

Implants get assigned to a specific tooth number. This tooth number pops up on several locations in the software,
such as on the 'Property Panel' of an implant, the dedicated implant tab, the right-click menu of an implant and in the
status bar when the implant is selected.

Tooth cha rt
The Tooth Chart offers the possibility to check and, if necessary, adjust the estimated tooth position an implant is
assigned to. The tooth numbering convention used on this tooth chart corresponds with the setting in the general
preferences.

The 'question mark position' is used for tooth positions which are unknown or unclear. For example when an implant
is planned between two positions where already other implants are planned.

M a n ip u la te a n im p la n t
To plan the optimal position of the implant, the NobelClinician Software provides the best manipulation possibilities.

Change the implant orientation

The orientation of an implant can be adjusted by dragging the spheres.

4. Select the implant. The spheres turn red.

26
 5. Then do one or more of the following:

Click the upper sphere on the implant and drag to rotate, while using the apical point as a
rotation point.

Click the lower sphere on the implant and drag to rotate, while the shoulder point of the implant
is used as a rotation point.

Move an implant
To physically translate the implant, do the following:

1. Select an implant. The gray tube on the implant turns green.

2. Click the green tube and drag the implant to the desired position. The implant will retain its original
orientation.

Depth and rotation can also be changed via icons on the dedicated implant toolbar.

Make implants parallel

Place a parallel implant
To place a single new implant in parallel with a selected implant, do as follows:

1. Select the implant you want to use as a base.

2. Click the Parallel Implant button .

3. Click in the 3D or 2D viewer to indicate the shoulder point of the implant.

4. The new implant is placed parallel to the indicated implant.

Place all implants in parallel

To place all implants available in the planning in parallel, follow these steps:

1. Select the implant you want to use as a base.

2. Click the Parallelize All button .

3. All implants are placed in parallel with the initially selected implant.

Note
After the Parallelize All command, carefully inspect all implant positions. If the result is clinically unacceptable, use
the Undo function.

A b u tm e n ts
To select an appropriate abutment for an implant, do the following:

1. Select the implant in the scene.

2. Click the Abutment button on the Implant tab or right-click the selected implant and choose the Add
Abutment option from the shortcut menu.

3. The Product Selection window is opened, with an immediate focus on the compatible abutments.

27
 4. By default, No Abutment is selected. Select an abutment, taking into account the correct dimensions.

5. Then click on Select Product.

Note

These options are only available if the selected implant does not have an abutment yet. If an abutment is already

present, you need to click on the Change Product menu item or toolbar button to display the Product
Selection window.

S e t th e s u r ge r y t yp e
The surgical template generated from a dental cast scan supports different surgical options (freehand, pilot drilling
only or fully guided). The surgery type can be set individually for each implant in the planning.

1. Select the implant.

2. Click on the Surgery Type icon on the dedicated tab on the toolbar. This icon differs in shape depending on
the different surgery types.

3. Select the appropriate surgery type from the list. The available options will differ depending on the selected
implant type.

Note
When placing a new implant, the surgery type can easily be set via the Surgery Type tab on the
'Product Selection' window.

The surgery type can be adjusted easily on the 'Check Surgery Setup' window when creating a
surgical template.

28
Different surgery types
Depending on the selected products in the planning, a different surgical approach is possible. The following surgery
types are available.

Freehand: no surgical template (no guided sleeve) will be used to place this implant.

Fully-guided: a surgical template with a fully-guided sleeve (enabling guided drilling and guided
implant insertion) will be used to transfer this planned implants position into the patients mouth.

Pilot drilling (for NobelGuide 1.5 and 2.0 mm twist drills only): a surgical template with a pilot sleeve
(guided pilot drilling only) will be used to transfer the planned implant positions into the patients
mouth. After using this initial pilot drill, the surgical template is removed, the guided drilled depth is
recorded by direction indicator or freehand twist drill in relation to an anatomic landmark (e.g. bone
crest) and the freehand drilling procedure is initiated, followed by freehand implant insertion (all depths
of freehand tools according to defined anatomical landmark after template removal). Depending on the
implant diameter, a different pilot sleeve diameter can be selected.

Pilot sleeveless: a hole is provided in the template that must be used in conjunction with a pilot drill
guide (1.5 or 2.0 mm diameter). For NobelActive 3.0 this enables the use of a 1.5 mm pilot drill for soft
bone situations (1.5 mm is the final drill for this bone quality) or continue with the same surgical
template to drill also a 2mm pilot drill, if bone quality is medium or hard.

Pilot sleeve offset

This feature is designed for pilot drilling only. In certain clinical indications, the default distance between planned
implant (implant shoulder) and sleeve is not sufficient (e.g. implant needs to be placed deeper, knife edge ridge which
is going to be removed after implant placement, interference of sleeve with neighboring teeth, ). In these indications
the sleeve at default position collides with the surface model of the dental cast and a warning is triggered for pilot
sleeves. In order to create a surgical template without sleeve collisions and to keep the implant at planned clinical
position, the sleeve can be moved upwards. The default relation of guided sleeves and planned implant is reflected in
the depth marks of all NobelGuide guided drills for all drill protocols. The additional distance is called sleeve offset
and is automatically recorded and added to the NobelGuide Surgical Instructions page which is shipped with the
surgical template.

1. Select an implant.

2. Make sure the surgery type for the selected implant is pilot drilling.

3. Click on the Sleeve Offset button which is located next to the Surgery Type button on the dedicated Implant
tab. Or right-click the implant and select Sleeve Offset from the pop-up menu.

4. Now drag the slider to reposition the sleeve in height or enter the offset height directly in the slider box.

Pilot sleeve rotation

If the sleeves are not in the correct rotational position, it is possible to adjust the rotation using sleeve rotation.

1. Right-click on an implant.

4. In the pop-up menu click on the Sleeve Rotation option.

5. Now drag the slider to rotate the sleeve until the correct rotational position is set.

29
A n c h or p in s
To establish an appropriate fixation during the start of the surgical procedure, guided anchor pins anchor the surgical
template. When planning guided anchor pins, the angulation and depth are important. Typically 3-4 anchor pins are
placed in an edentulous jaw. The anchor pins must be placed in areas with adequate cortical bone. To minimize the
risk of tissue damage, bi-cortical anchorage of anchor pins must be avoided.

Note
The position and orientation should allow easy installation (consider lip retraction and mouth
opening) as well as avoid critical structures like blood vessels.

The surgical index should allow for access of drilling and placement of the Anchor Pins.

Add an anchor pin to the planning

You can position an anchor pin in a similar way to placing an implant.

1. Click the Anchor Pin button .

2. Click to indicate the anchor pin.

3. Click to indicate the apex of the anchor pin.

4. The anchor pin is placed.

Tip
It is more convenient to define the shoulder and apex points on an appropriate 2D reslice.

Correct angulation and depth of anchor pins

To stabilize the surgical template for implant insertion, anchor pins can be placed at strategic positions. Their
angulation and depth are crucial.

The anchor pins can also serve as lip retractors during surgery. Anchor pins spread too widely within the arch could
negatively affect mouth opening. A short-shaft version of the anchor pin is available to mitigate this potentially
negative effect. Nevertheless, the anchor pins should be planned so as to offer good access and should not interfere
with the implant sites.

The sleeves should be placed close to the mucosa, represented by the digitized surface model of the intraoral situation
(about 0.5 to 1mm distance from the mucosa) but should not interfere or collide with the aforementioned model when
using a smart fused surface scan.

When using a radiographic guide, the sleeve must be connected to the radiographic guide but must not protrude the
intaglio surface.

For edentulous situations a minimum of four anchor pins is recommended. The anchor pin sleeves are positioned in
the vestibulum entering from extra-orally, or, in selected situations, from the opposite direction (palatally or lingually),
to lock the surgical template in place from two sides.

30
F in a liz e

C r e a te a s u r g ic a l te m p la te
The surgical template helps you to perform surgery exactly as planned. When finalizing your planning, you can create
a virtual surgical template, which is a preview of what you will be receiving after ordering.

To create a surgical template according to your planning, do the following:

1. Click the Create Template button on the Finalize tab. A window pops up to verify the implant positions
with the selected sleeves (surgery types). If needed you can modify the surgery type you decided upon.

2. Press Next if correct. The virtual surgical template is generated.

Inspect the surgical template

When finalizing a planning it is of major importance to look out for a number of issues which might prevent the
surgical template from being created correctly.

1. Check the position of the anchor pins.

2. Check the angulations between implants and when in doubt - discuss among the team whether the
angulation could negatively impact the prosthetic treatment.

3. Check the guided sleeves in relation to neighboring teeth.

Make sure the sleeve does not touch the neighboring teeth.

Check the 3D scene to see whether the surgical template touches the neighboring teeth, or not.
This is to know whether the template needs grinding, modification, or not.

4. Check each implant in the perpendicular reslice as well as in the 3D scene to verify the plan.

5. Make sure there are no breaches or holes in the support structures of the surgical template that surrounds
the sleeves of the implants or anchor pins.

Communicate the planning to the team to check all aspects.

Edit the virtual surgical template

When you notice that the virtual template is not correctly distributed over the dental arch (extending evenly over the
labial/buccal and lingual surfaces), you can edit its shape. Change the shape of the blue line in the Edit Template
wizard to make the curve coincide with the dental arch.

1. Click on Edit Template in the Finalize tab.

2. Click and drag the dots on the curve to change the position.

3. When the position of the blue line coincides better with the dental arch, click Finish.

4. The virtual surgical template is now regenerated.

If the fitting is still not optimal, repeat these steps until it is.

31
A p p r ove a p la n n in g
When a planning is completely finalized, lock it by approving it. Please read the text in the Approve dialog carefully
and agree with it to continue the approval.

Its approved status appears in the Planning Status bar.

An approved planning cannot be changed. To disapprove, thus allowing to making changes again, click on the
Disapprove Planning button.

32
O r d er s
Orders are divided into scan orders and product orders.

P r od u c t or d e r s
Create a product order
To create a product order, take the following steps:

1. Click the Order button on the Finalize tab of the Planning toolbar or in the Order module toolbar.

2. The list is displayed of the planning files available for the current patient. In the right window pane consult
the details of the selected planning file, choose the appropriate planning file and click Next.

Note

Make sure the planning file to be ordered is an approved one . Only an approved planning can be converted
into an order. A warning is displayed in the case of a not yet approved planning file.

3. After some calculations, the Product List is displayed. Uncheck the items on the list that do not require
ordering or adjust the quantity of the products to be ordered and click Next.

4. Fill out the details of the order and check the products to be ordered.

5. Click Finish. The order is created and displayed in the list of created orders.

Send a product order

To send a created product order, take the following steps:

1. Select the created order in the list.

2. Click on the Send button in the toolbar.

S c a n or d e r s
In order to receive a surface scan of the dental cast and/or a diagnostic set-up or wax-up, you need to send a scan
order to your NobelProcera dental laboratory.

Create a scan order

1. In the Order module click the Scan button in the Create group on the Order tab.

2. Enter all the necessary details, any special instructions required, and click Next.

3. Fill out the shipping details and click Finish.

4. Now the scan order is sent to the lab, provided that the 'Send order after finishing' option was marked. The
scan order is added to the order list and shown with the order number retrieved from the server.

33
Generate a scan order form
It is possible to create the scan order form and print it and ship it together with the impression (or casted model if
already available) to the NobelProcera dental laboratory.

1. Select the scan order and click on the Export button in the toolbar.

2. The scan order form is generated and the Export order Report dialog is opened.

3. Click on Save.

4. Now the pdf is stored in the indicated location and the document is opened. You can print it like any other
pdf document.

34
W or k w ith th e N ob e lC li n ic ia n A s s i s ta n t
To open the NobelClinician Assistant, click on the Assistant button in the top right corner of the NobelClinician screen.

Then the NobelClinician Assistant window is displayed. In general, the NobelClinician Assistant is comprised of
different tabs:

Tasks : An overview of planning and additional tasks guides you through the planning
procedure.

Warnings : Warning messages make you aware of possible technical issues.

Planning overview : An overview is given of the implants, abutments and/or anchor pins
used in the planning. Whether or not radiographic guide and surgical template have been
created is indicated too. The position of the planned implants is clearly indicated on the tooth
chart.

Help Files : The full NobelClinician help file is available for consultation. Click through the
different topics or check the index for access to specific information.

35
N ob e lC li n ic i a n W ar n in g S ys te m
NobelClinician generates warnings when technical planning issues are detected. Check them in the Warnings section
in the Planning Assistant.

Open the Planning Assistant and select the Warnings icon , or click on the
Warnings button below the Assistant button

The Planning Assistant now shows the warnings.

If the same warning is violated more than once, then the number of occurrences is added to the warning in the Count
column.

Production warnings are marked with a red triangular icon .

Warnings that are configurable are marked with the Preferences icon .

In case a configurable warning was disabled in the preferences, a caution warning is displayed, informing the user
that some of the possible issues might not be detected.

When a planning created in a previous version of the software, is opened in the new version of the software, but
without opening the Planning module, a caution note will be displayed in the warning sections of the software
(assistant, reports, etc.), informing the user that the warnings incorporated in the newer version will not be taken into
account. For example, when opening a planning and turning immediately to the Communication module, a note is
displayed in the warning sections. To make sure all possible warning issues can be detected, open the planning in the
Planning module and save it. The warnings in the newer version are then recalculated and checked.

36
P la n n in g w a r n in g s
NobelClinician automatically detects the possible violation of some of the technical constraints.

Warning
It is important to acknowledge that the planning program does not automatically
check all technical constraints! Even in the event that no technical constraints are
automatically shown in the software, it might be that the surgical template cannot be
produced.

Planning warnings indicate that the surgical template resulting from the planning cannot be produced or that
problems might arise when using the customized template in surgery. These problems, whether they are technical or
clinical, might jeopardize the patients health.

Within the planning warnings we distinguish between production warnings and usage warnings. If a warning
exists, the affected planned object is displayed in a different color in the 2D and 3D viewers:

Red warnings Production warnings. The surgical template cannot be produced.

Orange warnings Usage warnings. Some aspects related to the usage of the surgical templates needs
to be checked additionally.

Production warnings
During a planning, specific technical constraints have to be considered to ensure the correct production of the
surgical template and the successful usage of the produced template during surgery. If some technical constraints are
violated, a warning message will appear.

Warning Explanation

The sleeves are positioned too close to each other. Two sleeves are positioned very close to each other or are even
colliding.

Dental cast has been aligned without SmartFusion. Dental cast has been aligned without SmartFusion.

Pilot sleeve is colliding with dental cast. Pilot sleeve and dental cast are positioned very close to each
other or are even colliding.

Usage warnings
Some of the usage warnings are configurable, i.e. they can be enabled or disabled and/or the values used to trigger
the warnings can be defined by the user via the General Preferences. In the table below the configurable warnings
have a tick in the Config. column.

Warning
The values that trigger warnings must be set meticulously according to the clinical expertise
and experience of the user.

37
 Con
Warning Explanation
fig.

No anchor pins are planned. No anchor pins are planned.

Implant and sleeve are colliding. An implant and sleeve are positioned very close to each
other or are even colliding.

Anchor pin and sleeve are colliding. An anchor pin and sleeve are positioned very close to
each other or are even colliding.

Implants are colliding. Two implants are positioned very close to each other or
are even colliding.

Implant and anchor pin are colliding. An implant and anchor pin are positioned very close to
each other or are even colliding.

Anchor pins are colliding. Two anchor pins are positioned very close to each other
or are even colliding.

Patient model and sleeve are colliding. The bone surface (which includes the teeth) and sleeve
are positioned very close to each other or are even
colliding. *

Radiographic guide was created without No custom-made calibration set is used to create the
calibrated isovalue. radiographic guide obtained from the (CB)CT scanner.

An implant is positioned too close to an According to your settings, an implant is positioned too
annotated nerve. close to an annotated nerve surface.

Annotated tooth and sleeve are colliding. An annotated tooth and sleeve are positioned very close
to each other or are even colliding.

An implant is positioned too close to an According to your settings an implant is positioned too
annotated tooth. close to an annotated tooth surface.

A sleeve is positioned too close to the dental Sleeve and dental cast are positioned too close to each
cast. other or are even colliding.

Low-quality visualization is used for the 3D Low-quality visualization is used for the 3D patient
patient model. model.

Not installed products are planned. The planning contains products which are not available
on the system.

Dental cast alignment has been adjusted Dental cast alignment has been adjusted manually.
manually.

* The bone surface model might contain remaining teeth and artifacts.

38
Configura ble wa rnings
The configurable warnings are based on a volume around the implant, the so-called warning volume. When this
volume collides with an annotated anatomical structure, the warning is triggered.

The warning volume is defined based on a distance. By default, this distance is set
to 1.5 mm, the minimal distance. With this minimal distance, the warning volume
coincides with the yellow zone (representing a 1.5 mm distance around the implant
and a 2 x 1.5 mm (3.0 mm) distance at the apex). The warning volume can be
increased. As you can see in the picture (for a distance of e.g. 4.0 mm) the warning
volume is scaled accordingly.

Warning between implants and nerves

When an implant is placed too close to an annotated nerve, i.e. when the warning volume collides with the
visualization of the annotated nerve, a warning is triggered, the affected implant is shown (if it was not visible yet) and
turns orange.

Warning between implants and tooth roots

When an implant is placed too close to a tooth root, i.e. when the warning volume collides with the annotated tooth, a
warning is triggered. The implant is shown and turns orange.

Note
The default minimum distance of the warning volume should be carefully set by each user via Treatment >
Preferences in the My Office module. These distance settings are user settings and stored as such. Therefore a
user will always work with the distances as stored in his account.

T e c h n ic a l con s tr a in ts
A number of technical constraints which are crucial to the correct creation of the surgical template are explained.
When these constraints are not taken into account, it is not guaranteed that the surgical template can be produced or
that it can be used correctly.

Minimal distance between guide d slee ves

For the surgical template, a minimal distance between guided sleeves needs to be respected. When the distance is
too small, the surgical template cannot be produced.

When the minimal space between the guided sleeves is violated, the guided sleeves
will become visible automatically. The red sleeves are too close to each other or are
colliding. In this configuration, the surgical template cannot be produced.

To solve this situation, move or tilt the implants in such a way that the space
between the sleeves increases. When the distance is large enough, the guided
sleeves will automatically return to their normal color.

39
Minimal distance between slee ves and implants / sleeves and anchor pins
When sleeves and implants or sleeves and anchor pins are positioned very close or are even
colliding, they will become visible automatically and turn orange. Too small a distance might
be difficult during surgery

To solve this situation, move or tilt the implants or anchor pins in such a way that the space
between them and the sleeve increases. When the distance is large enough, they will
automatically return to their normal color.

Collision between implants, an chor pins, or implants and anchor pins

When the implants, anchor pins, or implants and anchor pins are colliding, they
automatically become visible and turn orange. The collision of these objects might raise
problems during surgery.

To solve this situation, move or tilt the implants or anchor pins in such a way that they are
not colliding. Then, they will automatically return to their normal color.

Note
In some cases, the implant site is utilized for an anchor pin first. Before the implant is inserted, the anchor pin
must be removed first.

Relationship between guided sleeve and radiogra phic guide / den tal cast
During planning, besides all clinical considerations, it is important to consider the technical constraints for the position
of the guided sleeves in relationship to the radiographic guide and/or the dental cast: the position of the guided
sleeves needs to be verified with the radiographic guide and/or the dental cast shown.

Radiographic guide
Position

The majority of each guided sleeve should be positioned within the radiographic guide to ensure that there is
sufficient material in the surgical template to support the guided sleeve.

1 Correctly positioned
2 Wrongly positioned: the sleeve is placed too distant and is
not connected to the radiographic guide

40
Depth

Note that it is necessary to verify the depth of the guided sleeve in relationship to the radiographic guide. The guided
sleeve should not penetrate the surface facing the gingiva (intaglio surface) in order to secure the correct position of
the surgical template. In order to verify the depth of the guided sleeve, please view the position of the guided sleeve

and fine-tune the implant depth by means of the Depth icon in the dedicated toolbar.

1 Correctly positioned
2 Wrongly positioned: the sleeve is placed too deep

Dental cast
Verify sleeve positions after implant planning. The following situations must be resolved:

Lateral collisions

Lateral collisions are collisions with neighboring teeth or potentially soft tissue (surface scan of the intraoral situation).
If a collision occurs, verify whether you can change the position of the implant so that the collision warning is not
triggered. If this is not possible, try to narrow the sleeve diameter or choose the pilot drilling only option. Advanced
users can also consider skipping parts of the guided drilling procedure and finalize the drill protocol with the freehand
protocol after removal of the surgical template. The implant is then placed freehand.

1 Wrongly positioned: too close to or colliding with neighboring teeth or soft tissue
2 Correctly positioned: changed diameter
3 Correctly positioned: changed to pilot sleeve

Vertical collisions

Vertical collisions are collisions with potentially soft tissue (surface scan of the intraoral situation). If a vertical collision
occurs and you have chosen a pilot drilling option, consider adjusting the sleeve offset.

41
 1 Correctly positioned: sleeve offset adjusted
2 Wrongly positioned

Guide d abu tments

Relation between the Guided Sleeve and Bone

During planning, it is important to consider the technical constraints for the position of the guided sleeves in
relationship to the bone surface which might include teeth. When the guided sleeve collides with the bone surface, or
the remaining teeth being part of the bone model, it might not be possible to correctly seat the surgical template
during surgery.

However, in some cases this error can be acceptable. For example, if the sleeve collides with a tooth that will be
extracted before surgery or when a sleeve collides with an artifact.

When guided abutments are planned to be used, make sure that the angle between the most angulated implants
does not exceed 30 degrees.

Radiog raphic gui de was create d withou t calibrated isovalue.

It is recommended to use the calibrated isovalue when creating a radiographic guide model if a surgical template is
exported to production. If the calibration set is not used, a calibration warning is produced (The radiographic guide
model was created without a calibrated isovalue) to highlight the importance of this unique, safe and convenient
automated step.

42
S c a n n e r C a lib r a ti on
Note
This scanner calibration procedure is only needed for the creation of a radiographic guide, not when you are using
a dental cast.

To correctly and accurately transfer the treatment plan from the computer to the patient for surgery, it is very
important to generate a surgical template which fits as good as the radiographic guide on surrounding soft and hard
tissue. This needs an accurate 1:1 copy involving digitization by a (Cone Beam) CT scanner and creation of a virtual
radiographic guide model in the software using the scanner dependent appropriate settings. The identification of this
value, the isovalue, can be done either manually, by meticulous manual interaction or can be determined
automatically using a calibration scan from the unique NobelGuide calibration object acquired by the scanner used
with the suitable settings. The NobelGuide calibration object is an object with the same radiolucent properties as the
radiographic guide (PMMA) and has an accurately defined shape known to software. Examining the reference scan
(calibration scan) automatically and comparing it to the known original shape, NobelClinician is able to automatically
determine and afterwards apply the most appropriate isovalue (the Calibrated Isovalue) for extracting (segmenting)
the correct dimensions and shape from the radiographic guide scan. The software stores all scanner specific
calibration sets. For each scan of a radiographic guide, it automatically looks up a suitable calibration set out of the
known scanners. If such a scanner is detected, the corresponding Calibrated Isovalue is suggested and applied
automatically. The isovalue editor in the radiographic guide wizard provides information about the used calibration set,
the type of scanner that is used and the calibrated isovalue.

It is recommended to use the calibrated isovalue when creating a radiographic guide model if a surgical template is
exported to production. If the calibration set is not used, a calibration warning is produced (The radiographic guide
model was created without a calibrated isovalue) to highlight the importance of this unique, safe and convenient
automated step.

When calibration is used, the isovalue editor shows Calibrated Isovalue instead of Isovalue. When using a system
generated calibration set, suggested isovalue is displayed.

C r e a te a n ew c a lib r a ti on s e t
The first time image data from a specific (CB)CT scanner and particular protocol are used, a new calibration set needs
to be created. Once this calibration set has been developed it may be used for all patients scanned with this imaging
unit. It is recommended to create a new calibration set at least every six months or when the imaging unit has been
updated, upgraded or had maintenance performed.

To create a new calibration set, click the New button in the Calibration set group on the Scanner tab of the My
Office module. The Create Calibration Wizard is started.

43
The calibration wizard leads you through the calibration procedure in three steps:

1. Load the calibration DICOM files

2. Calculate Calibration Settings

3. Fill out the Details and Save the Calibration Set

44
In d e x
A E
abutment ....................................................................... 27
add ........................................................................... 27
add ................................................................................ 14
alt 9
anchor pin ......................................................... 30, 31, 40
add ........................................................................... 30
angulation................................................................. 30
depth ........................................................................ 30
angulation ............................................................... 30, 31
approve ......................................................................... 32
assistant .......................................................................... 8
button ....................................................................... 35
B guided sleeve .................................................... 31, 39, 40
button
assistant ................................................................... 35
C
calibration set
create ....................................................................... 43
cast ............................................................................... 15
cmd ................................................................................. 9
collision ......................................................................... 40
control point .................................................................. 20
corresponding points .................................................... 18
distribution ............................................................... 18
insert ........................................................................ 18
remove ..................................................................... 19
remove all ................................................................. 19
create
guide ........................................................................ 20
create calibration set ..................................................... 43
create order ................................................................... 33
cross-sectional reslice
size ........................................................................... 21
CT slice .......................................................................... 11
Ctrl .................................................................................. 9
cut ........................................................................... 14, 19
D order ........................................................................... 8
dedicated tab................................................................... 9
dental cast ..................................................................... 15
add to model ............................................................ 16
order ......................................................................... 15
erase
artifacts ..................................................................... 14
bone artifacts ............................................................ 14
magic eraser ............................................................. 14
extra-oral use ................................................................. 25
F
finalize ........................................................................... 31
freehand ........................................................................ 29
fully-guided .................................................................... 29
G
guide ............................................................................. 20
depth ........................................................................ 41
position ..................................................................... 40
relation sleeve and bone ........................................... 42
H
help files ........................................................................ 35
I
icons
add abutment ........................................................... 27
add anchor pin .......................................................... 30
add implant ............................................................... 25
add new nerve .......................................................... 22
angle ......................................................................... 23
change product......................................................... 28
close ......................................................................... 12
communication ........................................................... 8
create order .............................................................. 33
distance .................................................................... 23
extract tooth ............................................................. 23
HU value ................................................................... 23
implant angle ............................................................ 24
interaction ................................................................... 9
my office ..................................................................... 8
open ......................................................................... 12
pan ............................................................................. 9
parallel implant ......................................................... 27
parallelize all.............................................................. 27
patient....................................................................... 13
patient info.................................................................. 8
 planning...................................................................... 8
preferences............................................................... 36
red triangle ............................................................... 36
rotation ....................................................................... 9
subtract teeth ........................................................... 23
zoom .......................................................................... 9
zoom box.................................................................... 9
identification .................................................................... 7
implant .................................................................... 31, 40
add ........................................................................... 25
change orientation .................................................... 26
extra-oral use ............................................................ 25
make parallel ............................................................ 27
manipulate................................................................ 26
move ........................................................................ 27
orientation ................................................................ 26
parallelize all ............................................................. 27
place parallel implant ................................................ 27
third-party ................................................................. 25
interaction ....................................................................... 9
isolate ............................................................................ 14
L
level ............................................................................... 11
level/window ................................................................. 11
2D 11
3D 11
log in ............................................................................... 7
M
magic eraser .................................................................. 14
manipulate .................................................................... 10
measurements............................................................... 23
minimal distance ..................................................... 39, 40
module
communication........................................................... 8
order ........................................................................... 8
patient info ................................................................. 8
planning...................................................................... 8
module
my office .................................................................... 8
module bar ...................................................................... 8
N S
nerve ............................................................................. 22
O
object
hide .......................................................................... 10
46
manipulate ................................................................ 10
order
create........................................................................ 33
overview ........................................................................ 35
P
pan .................................................................................. 9
parallel implants............................................................. 27
patient
close ......................................................................... 12
patient mask .................................................................. 13
add ........................................................................... 14
cut ...................................................................... 14, 19
disable ...................................................................... 14
isolate ....................................................................... 14
keep largest part ....................................................... 15
reset.......................................................................... 14
patient model................................................................. 11
3D 13
clean up .................................................................... 13
create patient wizard................................................. 13
pilot drill ......................................................................... 29
planning
approve..................................................................... 32
planning overview ......................................................... 35
planning scenario .......................................................... 12
close ......................................................................... 12
delete ........................................................................ 12
open ......................................................................... 12
rename ..................................................................... 12
save .......................................................................... 12
polygon ......................................................................... 14
product selection ........................................................... 25
R
radiographic guide ......................................................... 20
remove teeth
all teeth ..................................................................... 22
single tooth ............................................................... 22
reslice curve .................................................................. 20
control point ............................................................. 20
rotation ............................................................................ 9
scan order...................................................................... 15
scanner .......................................................................... 43
scanner calibration ........................................................ 43
scroll .............................................................................. 11
shift ................................................................................. 9
sleeve ............................................................................ 40
guided ...................................................................... 40
offset ........................................................................ 29
rotation ..................................................................... 29
SmartFusion
corresponding points................................................ 18
initialize..................................................................... 17
start .......................................................................... 17
warning .................................................................... 19
sphere ........................................................................... 26
subtract teeth ................................................................ 23
surgery
type .......................................................................... 28
surgery type .................................................................. 28
surgical template ..................................................... 31, 37
inspect ...................................................................... 31
T
tab ................................................................................... 9
technical constraints
anchor pins ............................................................... 30
teeth .............................................................................. 22
remove ..................................................................... 22
subtract .................................................................... 23
template ........................................................................ 13
tolerance margin ........................................................... 26
toolbar ......................................................................... 8, 9
tooth chart ..................................................................... 26
tooth position ................................................................ 26
transfer function ............................................................ 11
template ................................................................... 13
treatment....................................................................... 12
tube ............................................................................... 27
47
U
user
add ............................................................................. 7
switch ......................................................................... 7
V
view
bottom ...................................................................... 10
front .......................................................................... 10
lateral ........................................................................ 10
standard.................................................................... 10
top ............................................................................ 10
viewer
2D 9
3D 9
virtual pilot drill .............................................................. 29
W
warning
configure .................................................................. 39
orange ...................................................................... 40
planning .................................................................... 37
production ................................................................ 36
technical warning ..................................................... 37
warnings ........................................................................ 35
window.......................................................................... 11
workspace ....................................................................... 8
Y
yellow zone.................................................................... 26
Z
zoom................................................................................ 9
zoom box ......................................................................... 9