Advanced Digital Implant Dentistry a Peer-Reviewed Publication Written by Scotty L

Earn 2 CE credits This course was written for dentists, dental hygienists, and assistants.

Advanced Digital Implant Dentistry A Peer-Reviewed Publication Written by Scotty L. Bolding DDS, MS

Abstract Learning Objectives: Author Profile The Dental Implant industry has seen significant advances Scotty L. Bolding, DDS, MS was born in Arkansas where he attended the University of Arkansas 1. Develop an understanding of digital and received a Bachelor of Science Degree in Medical Sciences. He then attended Baylor College in the past three decades, however there are still millions impression scanners of Dentistry in Dallas, TX, where he earned his DDS degree in 1989. Dr. Bolding completed a of people across the globe with missing teeth that have not 2. Learn the procedures involved with Masters Degree in Craniofacial Biology at Baylor University in Waco, TX in 1992 and completed his enjoyed the benefits of replacing their teeth with dental taking a digital implant impression Oral and Maxillofacial Surgery training at Baylor University Medical Center in Dallas, TX in 1993. implants. There are many factors that prevent patients from Post-graduation, Dr. Bolding has remained very active in research and education. Throughout 3. Develop an understanding of digital his career he has continued to strive for advancing the art and science of Oral and Maxillofacial choosing implants such as fear, cost, and lack of knowledge. implant treatment planning Surgery. He has written multiple publications and is a sought after and active speaker in Oral However, even in developed countries there are still many and Maxillofacial Surgery. In addition to being a diplomate of the American Board of Oral and 4. Develop an understanding of how Maxillofacial Surgeons, he also served as a Board Examiner for six years. dentists who do not offer implants to their patients because CAD/CAM is utilized in implant of the perceived complexity and associated costs. Dr. Bolding is very active in developing technologies that advance the science of surgically dentistry facilitated orthodontics, dental implant therapy, and Temporomandibular Joint Management. He New digital technologies are beginning to streamline the is a leader in the evolution of digital implant dentistry, digital orthognathic surgery, and digital dental implant workflow simplifying the delivery for the records management. In addition, Dr. Bolding is the President and Founder of MaxSurge Healthcare Solutions. dental implant team. Through advanced digital engineer- MaxSurge is a healthcare consulting and business resource firm that is working to enhance the ing, dentists are now able to offer precise guided planning, delivery of healthcare to the public by improving business processes for the provider, patient digital impressions, CAD/CAM models, and restorations. and the employer. These techniques are providing the revolutionary Dr. Bolding enjoys spending time with his family, flying, traveling, boating and golfing. opportunity for the dental team to collaborate and plan Author Disclosure dental implant cases virtually with more predictable cost The author of this course has no commercial ties with the sponsors or the providers of the and more predictable outcomes. unrestricted educational grant for this course.

Publication date: June 2012 Go Green, Go Online to take your course Expiration date: May 2015 PennWell designates this activity for 2 Continuing Educational Credits This course has been made possible through an unrestricted educational grant.

Supplement to PennWell Publications CE Planner Disclosure: Michelle Fox, CE Coordinator does not have a leadership or commercial interest with Align This course was written for dentists, dental hygienists and assistants, from novice to skilled. Technologies, the commercial supporter, or with products or services discussed in this educational activity. Educational Methods: This course is a self-instructional journal and web activity. Educational Disclaimer: Completing a single continuing education course does not provide enough information Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any to result in the participant being an expert in the field related to the course topic. It is a combination of many products or services discussed or shared in this educational activity nor with the commercial supporter. educational courses and clinical experience that allows the participant to develop skills and expertise. No manufacturer or third party has had any input into the development of course content. Registration: The cost of this CE course is $49.00 for 2 CE credits. Requirements for Successful Completion: To obtain 2 CE credits for this educational activity you must pay Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. full refund by contacting PennWell in writing. Educational Objectives While dental implants have seen significant advance- 1. Develop an understanding of digital impression scanners ments, these precision designed and engineered fixtures 2. Learn the procedures involved with taking a digital have relied on traditional non-precision manual surgical implant impression placement, traditional restorative methods, and traditional 3. Develop an understanding of digital implant treatment laboratory techniques for the delivery and replacement of planning the missing tooth. This lack of engineering in the delivery 4. Develop an understanding of how CAD/CAM is utilized of the dental implant has paved the way for the new frontier in implant dentistry for dental implants. Dental implant companies are now taking advantage of the new digital solutions in dentistry to Introduction improve dental implant ease of use, and provide more preci- The art and science of dentistry has provided significant ad- sion and cost effective delivery.1 Precision surgical guided vancements in our abilities to treat patients with both simple placement using restorative driven three-dimensional imag- and complex dental problems. Over the past twenty five years ing and planning allows for more predictable surgical place- we have biologically improved and developed techniques to ment. High surface digital impression scanning and CAD/ prevent and treat caries and periodontal disease, replace CAM milling allows for precision design and modeling for missing teeth, reposition teeth, and change overall facial improved fit and accuracy of both the abutment and restora- structures. Additionally, we have developed wear resistant tions. Combining these digital technologies allows the den- esthetic materials that have allowed us to replace the miss- tist to plan and treat the patient in a more efficient manner ing teeth with very natural, biologically friendly, beautiful with more predictable results. The digital implant dentistry replacements. The past twenty five to fifty years have allowed workflow is now redefining and paving a new standard of dentistry to advance significantly from a professional stand- delivery for the replacement of missing teeth, giving the point, offering patients predictable clinical results. dental team more confidence when treating their patients. While the biological sciences and material sciences have allowed for these advancements, we are now seeing evidence Intraoral scanning and cad/cam in dentistry of a new wave of digital solutions that are offering even more One of the critical components of the digital implant den- predictable treatment outcomes. Over the past five years tistry workflow involves the digital capture of the patient’s we have seen the introduction of digital radiology solutions, dentition for planning, placement, and restoration. Intraoral three-dimensional cone beam tomography, digital impres- scanning in its simplest form is a way for the dental team to sions, digital models, and CAD/CAM (computer-aided take an impression without traditional impression material design and computer-aided manufacturing) restorations that and create an accurate virtual model of the patient’s denti- are now making their way into the mainstream dental prac- tion.2 (Fig 1 and 2) Once the virtual model has been created tice. These advancements are providing advanced engineering technology to the practice of dentistry that will add to the Figure 1. The iTero®Intra-oral Scanner by Align Technology, Inc. art and science of dentistry and make it even more predictable and more precise. I call this the Digital Age of Dentistry.

History of digital implant dentistry Dental Implants are one of the most significant advancements in dentistry in the past two decades. Today, the dental implant is becoming the standard of care to replace missing teeth. The advancements in the science and engineering of dental implants adds a whole new dimension to the replacement of the missing tooth. Not only can dental implants replace a missing tooth, they can absorb load and have the biological capa- bilities to integrate into the patient’s bone, providing in many cases a lifetime restoration. Dental implant systems have improved their interface attachments at the mucosal surface level of the implant which reduces abutment loosening and enhances overall esthetics. However, while dental implant technology has significantly advanced in the past twenty five years from both a surgical and restorative standpoint, there have been some limitations. These limitations in many ways have limited the number of dentists that offer dental implants to their patients.

2 www.ineedce.com Figure 2. iTero® Intra-oral Scanner Virtual Dental Models Figure 4. Triangulation Image Capture Laser

CCD/PSD - Sensor

through various CAD/CAM technologies, then an accurate physical model can be created of the patient’s dentition.3 Lense (Figure 3) The first digital intraoral scanner for restorative dentistry was introduced in the early 1980’s by Dr. Werner Mörmann, a Swiss dentist, and Marco Brandestinian, an 4 Italian electrical engineer. DZ Object Figure 3. Milled Models on an iTero® articulator

The triangulation technique (Figure 4) utilizes a timed laser light that is directed at the tooth structure that is then reflected back to the camera and the data is captured to register the image. The triangulation format allows one angled cone of light to capture a single image at 15,000 microns. These dental scanning systems require that a reflective powder be applied to the teeth prior to scanning to assure accurate capturing of the image. The triangulation scanning technique was first introduced into dentistry in 1987 through CEREC® by Sirona Dental Systems LLC. Additionally, the active wave-front sampling technique (Figure 5) also requires a powder, but instead of using the laser light to capture the tooth data, these scanning systems The intraoral scanning devices utilize a sophisticated use a lens with a rotating aperture that allows the capturing optical surface scanning technology that works similarly of three-dimensional data in a video sequence and models to a camera, but instead of simply capturing lights and the data in real time (approximately 20 3-D datasets per colors, the sensors measure light reflection times from second). The Lava C.O.S. intraoral scanner by 3M ESPE various surfaces through processes to capture the object utilizes this technology. three-dimensionally. This information is then captured by the three-dimensional software that utilizes specific align- Figure 5. Active Wave-Front Sampling Technique ment algorithms to allow for registration of the object. In dentistry today there are several commercially available approaches to scanning and capturing detailed intraoral Camera Object surfaces. Three of the common scanning principles used center today by intraoral dental scanners on the market in the Rotating Rotating United States are triangulation, active wave-front sam- o -axis image Image pling, and parallel confocal laser scanning. Each of these aperture Lens point plane techniques utilize a combination of these various imaging capturing methodologies to collect the surface data of the The confocal laser scanning methodology (Figure 6) teeth and mucosa so that the information can be registered projects a laser beam onto the surface of the tooth without and “stitched” together through an alignment process in a powder and then the immediate reflection along the same order to create the virtual three-dimensional model. ray-path are put through a conoscopic crystal and projected www.ineedce.com 3 onto the camera. The result is a diffraction pattern, that ally, dental implant impression techniques utilize impres- can be frequency analyzed to determine the distance to the sion copings that are inserted into the implant at the time measured surface. The confocal approach allows for the of impression. Traditional impression materials such as scanner to captures 100,000 points of laser light in perfect polyvinyl siloxane or polyether are used to capture the rep- focus at 300 focal depths of the tooth structure. These focal resentative teeth and mucosa in the impression tray. Once depth images are spaced approximately 50 microns apart the impression is taken, the implant analogs are attached to allowing for very detailed capturing of the surface data the impression copings and a stone model is created with both inside and outside the tooth, thus allowing for col- the analogs representing the positioning of the implant lecting extremely accurate representative structured data. in the model. While this technique has been used in im- One of the commercially available scanners that utilize plant dentistry for several years, there are several layers this methodology is the iTero® Intraoral scanner by Align of potential inaccuracies associated with the various steps Technology, Inc. involved.5 In order to minimize these steps and streamline the Figure 6. Comparison of Confocal Intraoral Scanner (No Powder workflow of the implant impression, a digital scan body was Scan) F2/F4 vs. Triangulation and Active Wave-Front Sampling Scanners (Powder) F1/F3 created. (Figure 7) The scan body replaces the traditional impression coping and allows the implant fixture to be captured with an intraoral digital scanning device. The scan bodies fit precisely into the dental implant fixture in the mouth to allow for accurate capture of the associated teeth and mucosa in reference to the position of the implant fixture, just as a traditional implant impression coping does.6 However, the scan body has a precise geometrical shape on the surface to allow for optical capture of the fixture. Once the scan body image is captured and registered the CAD software, through alignment algorithms, can accurately position the implant into the virtual model. (Figure 8) This gives the dental team an accurate impression and a virtual three-dimensional model of the implant, the associated teeth, and mucosa.

Once the tooth is scanned and the structured data is Figure 7. Straumann® Scanbody in patient’s mouth and the iTero® captured, software is then used to process each data point to Image of Virtual Model create a geometrical virtual three-dimensional model. This virtual model now can be used by the dentist or lab technician in a variety of applications. The viewing software can allow the dental team to virtually share the models digitally for treatment planning and discussion. Additionally, the dental team can utilize the models to process virtual abutments, copings, crowns, removable prosthesis and other or- thotic devices without a physical model through computer aided design (CAD) software applications. Once the CAD software applications have created the virtual geometric three-dimensional model, computer aided manufacturing (CAM) techniques use various printing and milling machines to create an exact replica of the virtual model in a physical form. It is through this process that the dental team can utilize the scanning technology to create more accurate models, abutments, and restorations for the dental implant patient.

Digital dental implant scanning Obtaining an accurate impression to isolate the position of the implant in the patient’s mouth is critical to providing the precision needed for the dental restoration. Tradition-

4 www.ineedce.com Figure 8. Straumann® Scanbodies and iTero® Intra-oral Scan Digital implant treatment planning Virtual capture of the dental implant placement has provided needed precision and increased efficiency for the implant team, but proper surgical placement of the dental implant is still paramount for predictable restorations. Traditional surgical placement of dental implants relies on the surgeon’s surgical skill and judgement to place the implant into the alveolus in a proper position for an ideal restoration. Tra- ditional surgical guides were fabricated from stone models based on the prediction of where the implant position should Figure 9. Image of Virtual Straumann® CARES® Ceramic Abutment be in relation to the restoration. While these guides provided the restorative dentist and the surgeon the ideal position of the restoration, they did not take into account the availability of bone for the dental implant fixture. This often led to either failing implants due to inadequate bone around the implant, or the surgeon would have to reposition the implant into a less desirable position. Through the development of Computerized Axial To- mography (CAT Scan) and Cone Beam Computed Tomog- raphy (CBCT) a three-dimensional view of the patient’s jaw bone is now available for implant dentistry. Through the utilization of these technologies the dental surgeon and restorative dentist can now accurately guide dental implant Figure 10. The digital file is sent to the computer milling station where placement with more accuracy. an AvaDent is milled from a proprietary bio-hygienic base material. In the digital implant workflow, the dentist will obtain an intraoral digital scan of the patient’s arches to create a virtual dental model. Today the virtual model is milled to create a physical model and the missing teeth are replaced with radiopaque teeth and attached to a radiographic template guide that has radiopaque reference markers that can be captured by the scan. (Figure 11 and 12) The guide is placed into the patient’s mouth and the CAT or CBCT scan captures the underlying bone structures and radiopaque material in the

Figure 11. Straumann® Radiographic template with Markers

Figures 7-10, photos were provided by Dr. Frank Higginbottom, Dallas, Texas Once the virtual model is created with the dental implant in position, virtual digital creation of abutments and restorations can be designed through the CAD software. (Figure 9) Additionally, new developments for digital impression processing allow for the digital creation of a physical dental model with a removable repositionable implant analog. (Figure 10) This development provides the dental team with an extremely accurate model and implant analog so the laboratory technician can utilize the digital model in a traditional fashion for restoration fabrication. The abil- ity to utilize the intraoral scanner and virtually create an accurate physical model significantly improves efficiencies for the dental team, thus streamlining the workflow.7 This improved workflow has valuable benefits for the dentist, the laboratory technician, and the patient. www.ineedce.com 5 Figure 12. Attach the radiographic template to the Straumann® guide. The image file from the scan is then uploaded into the gonyX table using the templiX pins CAD planning software so that the reference markers can be identified to allow for software alignment and accurate predictable planning. (Figure 13) Through the software, the dental team then can identify underlying bone quality, proper implant size selection, and placement. Once the virtual implant is positioned properly in the bony image, the software then provides detailed alignment values for the laboratory technician to properly place the surgical guide sleeves into the intraoral surgical guide to be used for the patient’s implant surgery. (Figure 14) The surgeon utilizes the guide during the implant surgery to place the dental implants into the pre-planned sites, thus providing more accurate and predictable placement. (Figure 15) Now that more predictable placement is achievable through guided surgical planning, the digital implant workflow is enhanced. Just as the surgeon is capable of predictably placing the dental implant into the patient’s mouth, the laboratory technician can utilize the same surgical guide on the physical implant model and place an implant analog into the model. Once the implant analog is placed in the model, then a customized provisional can be fabricated on a temporary abutment to allow for delivery at the time of surgical implant placement if so desired. This allows for ideal sculpting of associated tissues and leaves the patient with a provisional restoration at the time of surgery. Modelless fabrication of surgical guides and provisionals will be possible in the future as CAD/CAM planning software and milling or printing technologies continue to advance, thus further enhancing the overall digital dental implant workflow.

Figure 13. Straumann® coDiagnostiX software planning Straumann Implant in the Bone and iTero® scan imported into coDiagnostiX

6 www.ineedce.com Figure 14. Convert the radiographic template to a surgical surgeon’s understanding of the final restorative plan and can template using a Surgical Guide with Straumann® sleeve lead to not only unfavorable results, but also an increased cost of supplies and parts for both the restorative dentist and surgeon. Unless the surgeon and restorative dentist have constant communication or meetings which are dif- ficult to do with busy practitioners, it creates a breakdown in collaboration and confidence as a team. This is a primary reason that many practitioners do not offer dental implants to their patients. Through the digital implant process, however, the implant surgeon, the restorative dentist, and the lab technician are connected digitally and can review and plan the case virtually throughout the treatment process. The restorative dentist will have more confidence in recommending dental implant options because the digital workflow will allow the restoration to be more predictable Figure 15. Straumann® Surgical Guidein the patient’s mouth with fewer hassles, lower cost, and more profitable. The digital dentistry workflow begins with the evaluation. When the patient presents with a missing tooth the implant option should be in most cases today the recom- mended option. The restorative dentist or surgeon will digitally scan the patient’s arch with an intraoral scanner and create a virtual model for treatment planning. Once the restorative option is selected, a radiographic guide is created for the patient from the digitally processed models. The patient then receives a CBCT or CAT scan with the radiographic guide. The images are then transferred to the implant planning software. The appropriate implant size is chosen and positioned into the underlying bone image. If there is inadequate bone, the restorative plan may need Figures 11-15, photos were provided by Dr. William L. Wiley, College Station, Texas to be altered, or bone grafting may be necessary either at the time of implant placement or before an implant can Digital implant dentistry in practice be placed. After the digital implant planning is complete, There are over 100 million teeth replaced annually world- the information from the software is transferred to the wide today. Unfortunately, only 15% of the patients that laboratory technician. The radiographic guide can then be receive replacement are benefiting from dental implant converted into a surgical guide by placing the appropriate technology. However, the latest advancements in digital surgical guide sleeves to facilitate proper implant place- implant dentistry will continue to streamline the dental ment. The surgeon will then utilize the surgical guide at implant workflow and should provide the dental team the time of surgery to place the dental implant in the ideal with a more predictable methodology for restoring the position. After the implant is placed into the patients arch, missing tooth. a scanbody can be used either at the time of surgery or after While digital implant dentistry will continue to become integration to allow for an intraoral impression scan to cap- more predictable and efficient for the dentist, many dentists ture the implant placement in the dental arch either by the and patients will continue to offer dental implants through surgical team or restorative team. Generally the intraoral a referral team approach. The conventional relationship impression is performed after integration to assure final between the dental implant surgeon, restorative dentist tissue position and a cleaner field for scanning. The digital and lab will continue to exist. Through the technological impression is then transferred to the laboratory technician advancements in digital implant dentistry the workflow will with the restorative prescription attached. The laboratory streamline and enhance the overall collaboration between technician confirms the transfer and digitally plans a virtual the dental implant team making the workflow more predict- abutment and restoration. The crown can be created virtu- able, cost effective, and convenient. ally and milled, or the crown can be created conventionally Conventionally, the implant surgeon and the restorative from of the digitally milled physical models and abutment. dentist work separately, with the surgeon rarely involved The restorative prosthesis is returned to the dentist and in the restorative and laboratory process. Many times, this the abutments are inserted along with the final restoration. lack of involvement in the restorative process inhibits the Additionally today, removable dentures are beginning to www.ineedce.com 7 be processed digitally (AvaDent™ Digital Denture is a of the Council on Scientific Affairs. Vol 6, Issue 2, Spring/ Trademark of Global Dental Science. All Rights Reserved. April 2011. © Global Dental Science LLC 2012) (Figure 16) and will 6. Lee SJ, Gallucci GO. Digital vs. conventional implant impressions: efﬁciency outcomes. Clin. Oral Impl. Res. 00, 2012. ultimately play a role in the removable and fully fixed dental 7. Hack, G., Barnes, D., DePaola, In vitro Evaluation of the Itero implant patient in the future. Digital Impression System: A Cooperative Alliance between the Dental School, University of Maryland, Baltimore and the Figure 16. This screenshot shows a computer designed AvaDent ADA Product Professional Review. ADA Professional Product with implant housing pockets. Review. A Publication of the Council on Scientific Affairs. Vol 6, Issue 2, Spring/April 2011.

Author Profile Scotty L. Bolding, DDS, MS was born in Arkansas where he attended the University of Arkansas and received a Bachelor of Science Degree in Medical Sciences. He then attended Baylor College of Dentistry in Dallas, TX, where he earned his DDS degree in 1989. Dr. Bolding completed a Masters Degree in Craniofacial Biol- Straumann® and / or other trademarks and logos from Straumann® that are men- ogy at Baylor University in Waco, tioned herein are the trademarks or registered trademarks of Straumann Holding AG TX in 1992 and completed his Oral and/ or its affiliates. All rights reserved and Maxillofacial Surgery training at 3M™, ESPE™, Lava™ are trademarks of 3M or 3M ESPE AG. Used under license in Canada. Baylor University Medical Center in Dallas, TX in 1993. Post-graduation, Dr. Bolding has remained very active Conclusion in research and education. Throughout his career he has Digital Implant Dentistry will have an enormous impact on continued to strive for advancing the art and science of Oral the dental implant market in the near future because of the and Maxillofacial Surgery. He has written multiple publica- predictable results, more predictable cost, and improved tions and is a sought after and active speaker in Oral and efficiencies with the workflow. These increased efficiencies Maxillofacial Surgery. In addition to being a diplomate of through digital implant dentistry workflow will help con- the American Board of Oral and Maxillofacial Surgeons, trol cost and save time for both the patient and the dental he also served as a Board Examiner for six years. team. Digital planning and processing will also make the Dr. Bolding is very active in developing technologies dental implant treatment option much less burdensome and that advance the science of surgically facilitated ortho- easier to deliver for the dental implant team and patient, dontics, dental implant therapy, and Temporomandibular thus improving acceptability and utilization globally. It is Joint Management. He is a leader in the evolution of digital predictable that dental implants will become the most com- implant dentistry, digital orthognathic surgery, and digital mon replacement option for the missing tooth as we evolve records management. further into the digital dental age. In addition, Dr. Bolding is the President and Founder of MaxSurge Healthcare Solutions. MaxSurge is a healthcare References consulting and business resource firm that is working to en- 1. Patel, N. Integrating Three-Dimensional Digital Technologies hance the delivery of healthcare to the public by improving for Comprehensive Implant Dentistry. JADA, vol. 141, no. business processes for the provider, patient and the employer. suppl 220S-24S, June, 2010. 2. Birnbaum NS, Aaronson HB, Stevens C, Cohen B: 3D Digital Dr. Bolding enjoys spending time with his family, fly- Scanners: A High-Tech Approach to More Accurate Dental ing, traveling, boating and golfing. Impressions. Inside Dentistry; 5: 70-74, 2009. 3. R. DeLong, M. Heinzen, J.S. Hodges, C.-C. Ko, and W.H. Disclaimer Douglas, Accuracy of a System for Creating 3D Computer The author of this course has no commercial ties with the Models of Dental Arches. J Dent Res 82(6):438-442, 2003. 4. S. Logozzo, G. Franceschini, A. Kilpelä, M. Caponi, L. sponsors or the providers of the unrestricted educational Governi, L. Blois: A Comparative Analysis Of Intraoral 3d grant for this course. Digital Scanners For Restorative Dentistry. The Internet Journal of Medical Technology. Volume 5 Number 1, 2011. Reader Feedback 5. Geissberger, M. et al. Clinical Evaluation: A Time Study (In We encourage your comments on this or any PennWell Vivo). Evaluation of the Digital Impression Technique using the Cadent Itero Scanner versus the Conventional Impression course. For your convenience, an online feedback form is Technique. ADA Professional Product Review. A Publication available at www.ineedce.com. Online Completion Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions

1. What is the name of the digital implant 9. Confocal Laser scanning allows the 17. Once the data points are captured from impression coping? scanner to capture how many points of an intraoral scanner the image points are a. Analog laser light in perfect focus? manipulated together through the follow- b. Pick-up Impression Coping a. 50,000 ing process to visualize the final image. c. Transfer Impression Coping b. 1,000,000 a. Stiched d. Scanbody c. 250,000 b. Blended 2. What is the definition of CAD/CAM d. 100,000 c. Morphed d. Carried a. Computed Aided Development/ Computed- 10. Which Scanner utilizes the Parallel Aided Mechanical Confocal Scanning Technique? 18. The parallel confocal scanner captures b. Computer Aided Design/Computer Aided- a. Itero laser light points at 300 focal depths of the Manufacturing b. CERAC tooth structure and spaces them how far c. Comprehensive Aided Design/Comprehensive- c. LAVA C.O.S. apart to insure extreme accuracy? Aided Milling d. Impress a. 100 microns d. Computer Aided Development/ Computer-Aided 11. Once a Scanner captures a tooth image b. 50 microns c. 2 mm Milling three-dimensionally, then the image d. 500 microns 3. Guided Surgical Implant Placement can be transferred to a physical model allows for more predictable placement through the following process. 19. How does the scanner capture the by utilizing three-dimensional planning a. Precise Milling scanbody information from the digital software and the associated b. Stone Modeling impression? a. Periapical Radiograph c. Virtual Modeling a. Through Reference Pins b. It cannot capture the scanbody b. Impression d. Wax-Up c. Reference Geometrical Shape c. Stone Model 12. How is the digital surgical guide refer- d. Dow Pins d. Computerized Tomography enced to the three dimensional software 20. The scanbody best allows for digital 4. Who created the first intraoral digital for planning? capture of the following. scanner? a. The dentist must align the teeth edges from the radiograph a. Dental Implant Position a. Dr. Werner Mormann and Marco Brandestinian b. Tooth Position b. There are Radiographic markers mounted to the b. Dr. Harvey Smith and Scott Bell c. Occlusion guide c. Dr. Michael Carter and Henry Matthews d. Inter-arch distance d. Dr. Albert Hanby and Dwight Duckworth c. The software automatically can determine tooth position 21. Digital Scanning of dental implants 5. Intraoral Scanner technology works d. The digital surgical guide does not require allows for the dentist to best do the through sophisticated optical surfacing radiograph following. scanning techniques that measure? 13. The digital surgical guide allows the sur- a. Have a final model with analog for crown fabrica- a. Red Lights tion geon to place an implant more precisely b. Colors b. Have a reference model only c. x-ray beams and more predictably do the following. c. Have a computer image of implant only d. Light Reflection Times a. Place Custom screw retained provisional d. Digital impressions of implants are not possible b. Place more implants at the time of surgery 6. What type of intraoral scanner utilizes c. There are no advantages 22. Digital scanning of dental implants can a time laser light that is directed at the d. Place a Healing Abutment provide for virtual development of all of tooth and requires a powder that is then the following except? 14. Globally in 2011 what are the percentage a. Models reflected back to the camera to capture of implants utilized to replace missing the image? b. Crowns teeth? c. Abutments a. Confocal Laser a. 70 % d. Screws b. Parallel Laser b. 38% c. Triangulation c. 4% 23. Digital Scanning of dental implants d. Active Wave Front Sampling d. 15% compared to conventional impressions is 7. What type of intraoral scanner reflects the following 15. The Active Wave Front Scanning a. Equal to or More Accurate a laser beam from the surface of a tooth technique utilizes uses a rotating lens b. Less Accurate without a powder and projected through a and captures the three-dimensional data c. Equal to or Less Accurate crystal to capture the image? through the following. d. Digital Scanning is not possible of dental implants a. Confocal Laser a. Triangulation 24. Digital Scanning of dental implants b. Parallel Laser b. Video Sequencing a. Decreases workflow time for the dental tea c. Triangulation c. Parallel Imaging b. Increases workflow time for the dental team d. Active Wave Front Sampling d. Reflective Lighting c. Eliminates the need for laboratory technician 8. What was the first intraoral scanners 16. An example of an Active Wave Front d. Increases cost for the patient were introduced commercially in to Scanner on the Market today is the 25. Digital Implant Treatment Planning dentistry? following? a. Eliminates the need for surgery a. Impress a. CERAC b. Allows for easier workflow and virtual b. CERAC b. Itero communication c. Itero c. Lava C.O.S. c. Increases time required by the patient d. LAVA C.O.S. d. Glidewell d. Eliminates abutment requirements www.ineedce.com 9 ANSWER SHEET Advanced Digital Implant Dentistry

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

If not taking online, mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, 1. Develop an understanding of digital impression scanners A Division of PennWell Corp. 2. Learn the procedures involved with taking a digital implant impression P.O. Box 116, Chesterland, OH 44026 3. Develop an understanding of digital implant treatment planning or fax to: (440) 845-3447 4. Develop an understanding of how CAD/CAM is utilized in implant dentistry For immediate results, go to www.ineedce.com to take tests online. C ourse Evaluation Answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No Objective #2: Yes No Objective #4: Yes No Payment of $49.00 is enclosed. (Checks and credit cards are accepted.) Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. If paying by credit card, please complete the 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 following: MC Visa AmEx Discover 3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Acct. Number: ______4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 Exp. Date: ______Charges on your statement will show up as PennWell 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 7. Was the overall administration of the course effective? 5 4 3 2 1 0 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 10. Do you feel that the references were adequate? Yes No 11. Would you participate in a similar program on a different topic? Yes No 12. If any of the continuing education questions were unclear or ambiguous, please list them. ______13. Was there any subject matter you found confusing? Please describe. ______14. H ow long did it take you to complete this course? ______15. What additional continuing dental education topics would you like to see? ______AGD Code 149 ______

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

COURSE EVALUATION and PARTICIPANT FEEDBACK Provider Information RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CEROP is a service of the American Dental association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please with the course. Please e-mail all questions to: [email protected]. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Participants will Completing a single continuing education course does not provide enough information to give the receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada. participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of mailed within two weeks after taking an examination. org/cotocerp/ many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST The PennWell Corporation is designated as an Approved PACE Program Provider CANCELLATION/REFUND POLICY All participants scoring at least 70% on the examination will receive a verification form verifying 2 CE by the Academy of General Dentistry. The formal continuing dental education Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ programs of this program provider are accepted by the AGD for Fellowship, Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact Mastership and membership maintenance credit. Approval does not imply © 2012 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell their state dental boards for continuing education requirements. PennWell is a California Provider. The acceptance by a state or provincial board of dentistry or AGD endorsement. The California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00. current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# 320452 ADIGIMP612DE