LITERATURE REVIEW

In recent years rapid prototyping has been used to build highly accurate anatomical
models Irom medical scan data. These models have proved a valuable aid in planning
complex reconstructive surgery, particularly in head and neck reconstruction. Typically, RP
models oI skeletal structures are used to plan and rehearsal operations precisely. When
planning osseointegrated implants, the accuracy oI the RP models allows the assessment oI
bone depth and improvement oI the selection oI drilling sites beIore surgery. In many cases
using RP models has dramatically increased accuracy level and reduced theatre time.
MIMICS is the soItware which is used to simulate the CT scan images which are in
DICOM Iormat and converts into 3D CAD model. From that model, we can edit and reduce
to our required material. The main reasons why only MIMICS using Ior this technique are
Fast, easy and powerful 3D image processing and editing:
Remaining extremely intuitive and easy to learn soItware, Mimics provides very powerIul
Ieatures. A range oI segmentation tools allow you to select a region oI interest. Within a Iew
clicks this part is transIormed into a 3D model on which real time rotation, pan, zoom and
transparency Iunctions can be applied.
Easy to use:
Thanks to its intuitive user interIace, segmenting data becomes easy and
straighIorward. All relevant tools and Iunctions can be easily accessed.
Supports a wide range of image formats:
Mimics can import any 2D stack oI images and allows 3D reconstruction Irom them. Mimics
imports images like CT, TechCT, MRI and Microscopy data in a wide variety oI Iormats, Iar
beyond DICOM.
Tailored to your needs:
Mimics is a modular based system that can be tailored to meet your speciIic technical
requirements and application needs. Various modules will each export your Iile in the Iormat
you need. Some modules will also allow very specialized applications, e.g. simulation.
AIter getting the bio model,a reharsel surgery has to be done Ior the dimensions oI implants .
There are many considerations that are taken during implant Iixture, such as:
Considerations
Stabilization of an implant
It is important to achieve primary stabilization oI dental implants that will be
immediately loaded. Noninvasive devices that test the stability oI immediately
provisionalized implants placed into Iresh extraction sockets are discussed. A titanium
threaded implant was placed into a Iresh extraction socket oI a patient's nonrestorable
mandibular right canine 4]. The implant received an interim restoration immediately
Iollowing its placement. The stability oI the bone-implant complex was evaluated Irom the
day oI implant insertion through day 246 using an electronic percussive testing instrument.
During the Iirst month the bone-implant complex became progressively less stable reaching a
peak measured level oI instability at 30 days postimplantation. This was Iollowed by
progressive stabilization Iirst measured on day 46 as the implant continued to osseointegrate
6] These Iindings suggest that the bone-implant complex became less stable during the Iirst
month aIter implant placement and was Iollowed by a period oI progressive stabilization
reIlecting bone maturation around the implant. A search oI the literature Iound similar results
in a study oI single-stage implants (not immediately provisionalized) using resonance
Irequency analysis. The known sequence oI wound healing around dental implants is
reviewed to explain the Iindings oI this pilot evaluation 9]. Studies that use noninvasive
testing devices to assess implant stability at placement and during healing may provide
inIormation that can help to optimize implant treatment outcomes.
Other considerations
For dental implant procedure to work, there must be enough bone in the jaw, and the
bone has to be strong enough to hold and support the implant. II there is not enough bone,
more may need to be added with a bone graIt procedure discussed earlier. Sometimes, this
procedure is called bone augmentation. In addition, natural teeth and supporting tissues near
where the implant will be placed must be in good health.
In all cases careIul consideration must be given to the Iinal Iunctional aspects oI the
restoration, such as assessing the Iorces which will be placed on the implant. Implant loading
Irom chewing and paraIunction (abnormal grinding or clenching habits) can exceed the
biomechanics tolerance oI the implant bone interIace and/or the titanium material itselI,
causing Iailure. This can be Iailure oI the implant itselI (Iracture) or bone loss, a "melting" or
resorption oI the surrounding bone 7].
The dentist must Iirst determine what type oI prosthesis will be Iabricated. Only then
can the speciIic implant requirements including number, length, diameter, and thread pattern
be determined. In other words, the case must be reverse engineered by the restoring dentist
prior to the surgery. II bone volume or density is inadequate, a bone graIt procedure must be
considered Iirst. The restoring dentist may consult with the periodontist, endodontist, oral
surgeon, or another trained general dentist to co-treat the patient. Usually, physical models or
impressions oI the patient's jawbones and teeth are made by the restorative dentist at the
implant surgeon`s request, and are used as physical aids to treatment planning. II not
supplied, the implant surgeon makes his own one or relies upon advanced computer-assisted
tomography or a cone beam CT scan to achieve the proper treatment plan ].
Computer simulation soItware based on CT scan data allows virtual implant surgical
placement based on a barium impregnated prototype oI the Iinal prosthesis. This predicts vital
anatomy, bone quality, implant characteristics, the need Ior bone graIting, and maximizing
the implant bone surIace area Ior the treatment case creating a high level oI predictability.
Computer CAD/CAM milled or stereolithography based drill guides can be developed Ior the
implant surgeon to Iacilitate proper implant placement based on the Iinal prosthesis'
occlusion and aesthetics ].
Treatment planning soItware can also be used to demonstrate "try-ins" to the patient
on a computer screen. When options have been Iully discussed between patient and surgeon,
the same soItware can be used to produce precision drill guides. Specialized soItware
applications such as 'SimPlant' (simulated implant) or 'NobelGuide' use the digital data Irom
a patient's CBCT to build a treatment plan. A data set is then produced and sent to a lab Ior
production oI a precision in-mouth drilling guide.



Problems faced
The main problems Iaced in conventional methods are as Iollows:
Despite high success rates, implant Iixture Iailure may occur and is deIined as the
inadequacy oI the host tissue to establish or maintain osseointegration`. Lack oI
mobility is oI prime importance as loosening` is the most oIten cited reason Ior
implant Iixture removal , ].
Failure in the edentulous maxilla was approximately three times higher compared to
the edentulous mandible , ].
Peri-implantitis is considered an inIlammatory process aIIecting the tissues around an
osseointegrated implant in Iunction, resulting in loss oI supporting bone`. Signs oI a
Iailing dental implant are detected both clinically and radio graphically with the
diagnosis made in a similar way to periodontitis.
3 Surgical procedure

3 Surgical planning
Prior to commencement oI surgery, careIul and detailed planning is required to
indentiIy vital structures such as the inIerior alveolar nerve or the sinus, as well as the shape
and dimensions oI the bone to properly orientate the implants Ior the most predictable
outcome. Two dimensional radiographs, such as orthopantomographs or periapicals are oIten
taken prior to the surgery. In most instances, a CT scan will also be obtained. Specialized 3D
CAD/CAM computer programs may be used to plan the case.
Whether CT-guided or manual, a 'stent' may sometimes be required to Iacilitate the
placement oI implants. A surgical stent is an acrylic waIer that Iits either over the teeth, the
bone surIace or the mucosa (when all the teeth are missing) with pre-drilled holes to show the
position and angle oI the implants to be placed. The surgical stent may be produced using
stereolithography Iollowing computerized planning oI a case Irom the CT scan.

3 Basic procedure
In its most basic Iorm the placement oI an osseointegrated implant requires a
preparation into the bone using either hand osteotomes or precision drills with highly
regulated speed ] to prevent burning or pressure necrosis oI the bone. AIter a variable
amount oI time to allow the bone to grow on to the surIace oI the implant (osseointegration) a
tooth or teeth can be placed on the implant. The amount oI time required to place an implant
will vary depending on the experience oI the practitioner, the quality and quantity oI the bone
and the diIIiculty oI the individual situation.

33 Detailed procedure
At edentulous (without teeth) jaw sites, a pilot hole is bored into the recipient bone,
taking care to avoid the vital structures (in particular the inIerior alveolar nerve or IAN and
the mental Ioramen within the mandible). Drilling into jawbone usually occurs in several
separate steps. The pilot hole is expanded by using progressively wider drills (typically
between three and seven successive drilling steps, depending on implant width and length).
Care is taken not to damage the osteoblast or bone cells by overheating. A cooling saline or
water spray keeps the temperature oI the bone to below 47 degrees Celsius (approximately
117 degrees Fahrenheit) 8]. The implant screw can be selI-tapping, and is screwed into place
at a precise torque so as not to overload the surrounding bone (overloaded bone can die, a
condition called osteonecrosis, which may lead to Iailure oI the implant to Iully integrate or
bond with the jawbone) 7, 9]. Typically in most implant systems, the osteotomy or drilled
hole is about 1mm deeper than the implant being placed, due to the shape oI the drill tip.
Surgeons must take the added length into consideration when drilling in the vicinity oI vital
structures.
34 Surgical incisions
1Traditionally, an incision is made over the crest oI the site where the implant is to be
placed. This is reIerred to as a 'Ilap'. Some systems allow Ior 'Ilapless' surgery where a piece
oI mucosa is punched-out Irom over the implant site. Proponents oI 'Ilapless' surgery believe
that it decreases recovery time while its detractors believe it increases complication rates
because the edge oI bone cannot be visualized. Because oI these visualization problems
Ilapless surgery is oIten carried out using a surgical guide constructed Iollowing
computerized 3D planning oI a pre-operative CT scan ].
3 Healing time
The amount oI time required Ior an implant to become osseointegrated is a hotly
debated topic. Consequently the amount oI time that practitioners allow the implant to heal
beIore placing a restoration on it varies widely. In general, practitioners allow 26 months Ior
healing but preliminary studies show that early loading oI implant may not increase early or
long term complications.

II the implant is loaded too soon, it is possible that the implant may
move which results in Iailure. The subsequent time to heal, possibly graIt and eventually
place a new implant may take up to eighteen months. For this reason many are reluctant to
push the envelope Ior healing 6, 7].

36 One-stage, two-stage surgery

When an implant is placed either a healing abutment, which comes through the
mucosa, is placed or a 'cover screw' which is Ilush with the surIace oI the dental implant is
placed. When a cover screw is placed the mucosa covers the implant while it integrates then a
second surgery is completed to place the healing abutment.
Two-stage surgery is sometimes chosen when a concurrent bone graIt is placed or
surgery on the mucosa may be required Ior aesthetic reasons. Some implants are one piece so
that no healing abutment is required 4, 7, 9].
In careIully selected cases patients can be implanted and restored in a single surgery,
in a procedure labelled "Immediate Loading". In such cases a provisional prosthetic tooth or
crown is shaped to avoid the Iorce oI the bite transIerring to the implant while it integrates
with the bone.
37 Surgical timing
There are diIIerent approaches to place dental implants aIter tooth extraction. The
approaches are:
1. Immediate post-extraction implant placement.
2. Delayed immediate post-extraction implant placement (2 weeks to 3 months aIter
extraction).
3. Late implantation (3 months or more aIter tooth extraction).
According to the timing oI loading oI dental implants, the procedure oI loading could be
classiIied into:
1. Immediate loading procedure
2. Early loading (1 week to 12 weeks)
3. Delayed loading (over 3 months)

38 Immediate placement
An increasingly common strategy to preserve bone and reduce treatment times
includes the placement oI a dental implant into a recent extraction site. In addition, immediate
loading is becoming more common as success rates Ior this procedure are now acceptable.
This can cut months oII the treatment time and in some cases a prosthetic tooth can be
attached to the implants at the same time as the surgery to place the dental implants.
However, the chances oI the implant Iailing in these cases may be as high as 50 ].
Most data suggests that when placed into single rooted tooth sites with healthy bone
and mucosa around them, the success rates are comparable to that oI delayed procedures with
no additional complications. Fig 2.1 shows the teeth oI the patient beIore and aIter the
surgery is done.

Fig 2.1 Before and after surgery [4j
39 Use of CT scanning
When computed tomography, also called cone beam computed tomography or CBCT
(3D X-ray imaging) is used preoperatively to accurately pinpoint vital structures including
the inIerior alveolar canal, the mental Ioramen, and the maxillary sinus, the chances oI
complications are dramatically reduced as is chair time and number oI visits. Cone beam CT
scanning, when compared to traditional medical CT scanning, utilizes less than 2 oI the
radiation, provides more accuracy in the area oI interest, and is saIer Ior the patient. CBCT
allows the surgeon to create a surgical guide, which allows the surgeon to accurately angle
the implant into the ideal space, increasing success rates and decreasing post-operative
healing 6].
3 Placing the implants
First, implants, which look like screws or cylinders, are placed into your jaw. Then,
over the next two to six months, the implants and the bone are allowed to bond together to
Iorm anchors Ior your artiIicial teeth. During this time, a temporary teeth replacement option
can be worn over the implant sites.




Fig. 2.2 uidestent. [4j




Fig. 2.3 %eeth after surgery [5j
OIten, a second step oI the procedure is necessary to uncover the implants and attach
extensions. These small metal posts, called abutments, along with various connecting devices
that allow multiple crowns to attach to the implants, complete the Ioundation on which your
new teeth will be placed. Your gums will be allowed to heal Ior a couple oI weeks Iollowing
this procedure. Guidestent shown in Fig.2.2 helps in the placing oI implants at the desired
location 4, 6, 7].
There are some implant systems (one-stage) that do not require this second step.
These systems use an implant which already has the extension piece attached. Your
periodontist will advise you on which system is best Ior you.
Depending upon the number oI implants placed, the connecting device that will hold
your new teeth can be tightened down on the implant, or it may be a clipped to a bar or a
round ball anchor to which a denture snaps on and oII 8].
Finally, Iull bridges or Iull dentures will be created Ior you and attached to your
implants or the connecting device. AIter a short time, you will experience restored conIidence
in your smile and your ability to chew and speak. AIter the surgery the teeth are as shown in
Fig. 2.3.
4 Success rates

Dental implant success is related to operator skill, quality and quantity oI the bone
available at the site, and the patient's oral hygiene. The general consensus oI opinion is that
implants carry a success rate oI around 95. One oI the most important Iactors that
determine implant success is the achievement and maintenance oI implant stability. The
stability is presented as an ISQ (Implant Stability Quotient) value. Other contributing Iactors
to the success oI dental implant placement, as with most surgical procedures, include the
patient's overall general health and compliance with post-surgical care 9].

Failure

Failure oI a dental implant is oIten related to Iailure to osseointegrate correctly. A
dental implant is considered to be a Iailure iI it is lost, mobile or shows peri-implant (around
the implant) bone loss oI greater than 1.0 mm in the Iirst year and greater than 0.2 mm a year
aIter.
Dental implants are not susceptible to dental caries but they can develop a condition
called peri-implantitis. This is an inIlammatory condition oI the mucosa and/or bone around
the implant which may result in bone loss and eventual loss oI the implant. The condition is
usually, but not always, associated with a chronic inIection. Peri-implantitis is more likely to
occur in heavy smokers, patients with diabetes, patients with poor oral hygiene and cases
where the mucosa around the implant is thin 8].

Currently there is no universal agreement on the best treatment Ior peri-implantitis. The
condition and its causes are still poorly understood.
Risk oI Iailure is increased in smokers. For this reason implants are Irequently placed
only aIter a patient has stopped smoking as the treatment is very expensive. More rarely, an
implant may Iail because oI poor positioning at the time oI surgery, or may be overloaded
initially causing Iailure to integrate. II smoking and positioning problems exist prior to
implant surgery, clinicians oIten advise patients that a bridge or partial denture rather than an
implant may be a better solution.
Failure may also occur independently oI the causes outlined above. Implants like any
other object suIIer Irom wear and tear. II the implants in question are replacing commonly
used teeth, then these may suIIer Irom wear and tear and aIter years may crack and break up.
This is a very rare occurrence, however possible. The only way to minimize the risk oI this
happening is to visit your dentist Ior regular reviews.
In the majority oI cases where an implant Iails to integrate with the bone and is
rejected by the body the cause is unknown. This may occur in around 5 oI cases ] To
this day we still do not know why bone will integrate with titanium dental implants and why
it does not reject the material as a 'Ioreign body'. Many theories have been postulated over the
last Iive decades. A recent theory argues that rather than being an active biological tissue
response, the integration oI bone with an implant is the lack oI a negative tissue response. In
other word Ior unknown reasons the usual response oI the body to reject Ioreign objects
implanted into it does not Iunction correctly with titanium implants. It has Iurther been
postulated that an implant rejection occurs in patients whose bone tissues actually react as
they naturally should with the 'Ioreign body' and reject the implant in the same manner that
would occur with most other implanted materials.

6 Contraindications

There are Iew absolute contraindications to implant dentistry. However there are some
systemic, behavioural and anatomic considerations that should be assessed. Particularly Ior
mandible (lower jaw) implants, in the vicinity oI the mental Ioramen (MF), there must be
suIIicient alveolar bone above the mandibular canal also called the inIerior alveolar canal or
IAC (which acts as the conduit Ior the neurovascular bundle carrying the inIerior alveolar
nerve or IAN).

Failure to precisely locate the IAN and MF invites surgical insult by the drills and the
implant itselI. Such insult may cause irreparable damage to the nerve, oIten Ielt as a
paresthesia (numbness) or dysesthesia (painIul numbness) oI the gum, lip and chin. This
condition may persist Ior liIe and may be accompanied by unconscious drooling.
Uncontrolled type II diabetes is a signiIicant relative contraindication as healing
Iollowing any type oI surgical procedure is delayed due to poor peripheral blood circulation.
Anatomic considerations include the volume and height oI bone available. OIten an ancillary
procedure known as a block graIt or sinus augmentation are needed to provide enough bone
Ior successIul implant placement.
There is new inIormation about intravenous and oral bisphosphonates (taken Ior
certain Iorms oI breast cancer and osteoporosis, respectively) which may put patients at a
higher risk oI developing a delayed healing syndrome called osteonecrosis. Implants are
contraindicated Ior some patients who take intravenous bisphosphonates 7, 8, 9].

7 Advantages

A dental implant provides several advantages over other tooth replacement options. In
addition to looking and Iunctioning like a natural tooth, a dental implant replaces a single
tooth without sacriIicing the health oI neighbouring teeth. The other common treatment Ior
the loss oI a single tooth, a tooth-supported Iixed bridge, requires that adjacent teeth be
ground down to support the cemented bridge.
Because a dental implant will replace your tooth root, the bone is better preserved.
With a bridge, some oI the bone that previously surrounded the tooth begins to deteriorate.
Dental implants integrate with your jawbone, helping to keep the bone healthy and intact.
In the long term, a single implant can be more aesthetic and easier to keep clean than
a bridge. Gums can recede around a bridge, leaving a visible deIect when the metal base or
collar oI the bridge becomes exposed. Resorted bone beneath the bridge can lead to an
unattractive smile. And, the cement holding the bridge in place can wash out, allowing
bacteria to decay the teeth that anchor the bridge 6, 9].
Dental implants provide several advantages over other teeth replacement options. In
addition to looking and Iunctioning like natural teeth, implant-supported bridges replace teeth
without support Irom adjacent natural teeth. Other common treatments Ior the loss oI several
teeth, such as Iixed bridges or removable partial dentures, are dependent on support Irom
adjacent teeth.
In addition, because implant-supported bridges will replace some oI your tooth roots,
your bone is better preserved. With a Iixed bridge or removable partial denture, the bone that
previously surrounded the tooth root may begin to deteriorate. Dental implants integrate with
your jawbone, helping to keep the bone healthy and intact.
In the long term, implants are aesthetic, Iunctional and comIortable. Gums and bone
can recede around a Iixed bridge or removable partial denture, leaving a visible deIect.
Restored bone beneath bridges or removable partial dentures can lead to a collapsed,
unattractive smile. The cement holding bridges in place can wash out, allowing bacteria to
decay teeth that anchor the bridge. In addition, removable partial dentures can move around
in the mouth and reduce your ability to eat certain Ioods.

PROBLEM STATEMENT
The aim oI this project was to explore the applications oI computer-aided designing
and manuIacturing (CAD/CAM) and rapid prototyping (RP) to produce a customized
prototype Ior surgical planning. The conventional method used does not provide dentists the
exact details oI the jaw, blood vessels and nervous tissues oI the patient at the location where
the implants have to be placed which leads to ambiguity during the surgery. Hence, there is a
requirement Ior a technique that depicts the actual picture oI patient`s jaw and the shapes and
locations oI other tissues in the oral cavity oI a patient with all the necessary measurements
which can help the dentists to Iind the location oI blood vessels, nervous tissues, concavity
and convexity oI the jaw bone and orientation oI the teeth surrounding the site where the
implant can be placed. This need can be satisIied by the method proposed with my project.
The proposed technique involved the conversion oI CT scan imaged oI the jaws oI patients,
which are originally in DICOM (Digital Imaging and Communications in Medicine) Iormat,
to a three dimensional CAD model using a medical image processing soItware package and
generating a standard triangulation language (STL) Iile oI the model that can be Ied to a rapid
prototyping (RP) machine and can be edited by other soItware and pre-processing soItware
such as CATALYST, Pro/Engineer and MAGICS. Analysis and preparation are carried out in
the digital environment according to established dental principles.
For this project, we took the dental CT scan images oI Ms.Sumaya, a 25 years old
patient at Narayana Dental College, Nellore. There were three implants that needed to be
placed in her lower jaw. The second molar was missing on either side oI the lower jaw. This
new technique was implemented in this case and it was used to make a bio-model oI the jaw
oI her. This model was used by the dentist who will perIorm the implant placement surgery to
plan the surgery. This process, iI commercialized, will make diagnosis, treatment planning
and patient presentation easier Ior medical practitioners and this process would also ensure a
better end result oI the treatment with a shorter healing time a higher implant surgery success
rate.
This 3D model can be used Ior
Custom implant preparation using rp
Surgery rehearsal in simulation module
Visualization and communication
This work will demonstrate that CAD/CAM techniques can be used Ior dental
analysis, preparation, and design oI customized prototypes that can be helpIul Ior the
dentists in surgeries.