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Table of Contents

1 .      Overview   8

1.1     What is GuideMia  8

1.2     Intended Users  9

1.3     System Platform and Specifications  9

1.4     Contraindications  10

1.5     Warning  10

1.6     Procedural Precautions, Surgery  11

1.7     Caution  11

2 .      Dental Implant treatment Planning  12

2.1     Treatment Planning workflow   12

2.2     Surgical Guides  13

2.3     Basic Surgical Guide Types  14

2.4     Glossary  15

3 .      Get Started  18

3.1     System Installation And Customization  18

3.2     System At a Glance  21

3.3     File System   24

3.4     My first GuideMia case  24

4 .      GuideMia Scanning Protocols  40

4.1     Scanning Protocols Overview   40

4.2     CT scan and intra-oral scan protocol 41

4.2.1       Pateient Preparation  41

4.2.2       Patient Scanning Instructions  41

4.2.3       CT Scan Parameters and Reconstruction  41

4.2.4       CT scan Data  41

4.2.5       Intra-oral Scan  41

4.2.6       Intra-oral scan Data  42

4.3     CT scan and Optical scan of Stone Model protocol 42

4.3.1       Pateient Preparation  42

4.3.2       Patient Scanning Instructions  42

4.3.3       CT Scan Parameters and Reconstruction  42

4.3.4       CT scan Data  42

4.3.5       Optical Scan of Stone Model 43

4.3.6       Intra-oral scan Data  43

4.4     Dual scan with radiographic guide or denture  43

4.4.1       Preparation of THE Radiographic Guide  43

4.4.2       Preparation of the Radiographic Guide from A denture  44

4.4.3       Scanning Instruction  44

4.4.4       SCAN DATA   44

4.5     Dual CT Scan with Stone Model 44

4.5.1       Patient Preparation  44

4.5.2       Patient Scanning Instructions  44

4.5.3       Stone Model Scanning Instruction  45

4.5.4       SCAN DATA   45

4.6     Single Scan Protocol 45

4.6.1       Patient Preparation  45

4.6.2       Patient Scanning Instructions  45

5 .      System Functions  46

5.1     Windows layout 46

5.2     System menu  47

5.2.1       Project menu  47

5.2.2       Edit 49

5.2.3       View   50

5.2.4       Diagnosis  53

5.2.5       References  55

5.2.6       Implants  56

5.2.7       Reports  56

5.2.8       Tools  58

5.2.9       Help  58

5.3     Toolbars  59

5.4     Image window toolbars  59

5.5     Other Image Window interactions  63

5.6     Workflow   66

5.6.1       Case definition  66

5.6.2       Segmentation  68

5.6.3       Model Registration  73

5.6.4       Virtual Tissue Model 78

5.6.5       Nerve channel Definition  80

5.6.6       Tooth Extraction  83

5.6.7       Bone and Sinus Grafting  85

5.6.8       Bone Reduction  86

5.6.9       Additional References  86

5.6.10          Place Implants  87

5.6.11          Implant Library Management 93

5.6.12          Design Anchor Pins and Screw Holes  95

5.6.13          Error Simulation  96

5.6.14          Snapshot (Diagnosis Finding) Management 98

5.6.15          Planning and Design Object Navigator  99

5.6.16          Surgical Kit and Guide Options  101

5.6.17          Design Surgical Guides  103

5.6.18          Design Master Models  108

5.6.19          Generate Treatment Plans  110

5.7     Mouse Events  111

5.7.1       2D views  111

5.7.2       3D views  112

5.7.3       Arch Curve Interactions  112

5.7.4       Slice lines and Region of Interest 113

5.7.5       Placement Widget Interactions  113

5.8     Configuration and Customization  115

6 .      Treatment Planning Workflow with Dual Scan  116

6.1     Workflow   116

6.2     Clinical Cases  117

6.3     Treatment Planning Approaches  117

6.4     Variations of the Workflows  118

6.5     Workflow Steps  118

6.6     Surgical Guide Design  160

6.7     Generate Treatment Rerport 163

7 .      Surgical Guide Design  174

7.1     Guide Design for dual scan cases  174

7.2     Post Processing of Surgical Guides  182

7.3     A Special Case  191

8 .      Workflow with optical scan  196

9 .      Single scan cases and bone level guides  229

9.1     Treatment Planning for single scan cases  229

9.1.1       Applicable cases  229

9.1.2       Bone Density  230

9.2     Design bone level surgical guides  230

9.3     Bone reduction guide  234

10 .         Surgical Kit Configuration and Guide Options  250

10.1        Surgical Kit COnfiguration  250

10.2        Additional Surgical Guide Options  251

10.3        Customize Individual implant sites  253

11 .         Measurement and planning errors  254

11.1        Error Factors  254

11.2        Error Simulation  254

11.3        Dimension and angle accuracy  256

11.4        Minimize the Treatment Plan Error 256

11.4.1          Device CalIbration  256

11.4.2          Radiographic Guide Modeling  257

11.4.3          Cases with Optical Scan of Stone Models  257

11.4.4          Improve the Model Registration  257

12 .         How-to Guide  258

13 .         Miscellaneous  265

13.1        Limitations  265

 


 

1 .     Overview

GuideMia is a software system for dental implant treatment planning and surgical guide design. It uses the latest image processing technology, software development tools, as well as proprietary patent pending technologies to provide dental professionals an integrated advanced image-guided dental implant treatment planning software to evaluate patient’s oral dental anatomy, to simulate implant placement, and to design surgical guides, which can be later on made by labs and used in dental implant treatment.

GuideMia has the following functions:

  • CT image viewing and visualization. Users can view the CT scan of patient's oral-dental structure, perform measurements, and record diagnosis findings as they do with a typical DICOM image viewer.
  • Simulating the implant placement. Users can simulate implant placement by adding implant geometric models onto the patient CT scan images and corresponding 3D reconstructions. Tools are provided to view and adjust implant positions and orientations.
  • Planning additional treatments including bone reduction and grafting, sinus grafting, tooth extraction, etc. They will be documented as notes and images.
  • Designing surgical guide models based on the oral-dental structure and the treatment plan. There are two categories of surgical guides.
    • The first one is so-called bone-borne guides, which are designed to be placed onto patients' bone and/or tooth surfaces to facilitate invasive surgery. 
    • The second category is for tissue-based guides. The surgical guides are designed to fit onto patients' soft tissues (gums) and teeth so that non-invasive treatment can be performed.
  • Exporting the designed surgical guides as standard STL files, which can be sent to any lab for manufacturing.
  • Designing bone reduction guides and corresponding surgical guides, and exporting STL files for manufacturing.
  • Creating virtual models of the oral-dental structures and implants, which will serve as study models, or bases  for manually making surgical guides. Such a virtual model is called “master model” in GuideMia. Its components include bone/teeth with implant holes, soft tissues with implant holes, and duplicates of implants.
  • Exporting the master model as standard STL files, which can be sent to any labs for manufacturing. Restoration design and further traditional physical model based implant planning can be performed with such a master model. Conventional lab procedure can be also used to make a surgical guide based on such a model.
  • Generating a treatment plan, which will include many views of the oral dental structures with implants, 2D CT scan slice images, handling and drilling sequence information, etc.

A viewer version of the software is also available. It can open project, browse implants and other objects, adjust implant locations and orientation, measure dimensions and angles, but cannot create any objects, design guides nor to save projects.

The system is intended for dental professionals in dental offices, dental laboratories and treatment planning centers. The users can be categorized by their main responsibilities, but practically one single user usually runs through entire workflow of a case.

·         Dentists/oral surgeons/physicians. They will likely focus on diagnosis tools, treatment plan reviews and adjustments, surgical guide reviews, plan approval, etc.

·         Planner. They will work on data preparation, treatment planning, as well as surgical guide design.

·         Surgical guide designer. More focus on surgical guide design.

·         General. All system functions.

The users must be qualified to provide treatment planning services, and

·         must have a good understanding of the oral dental structure, and CT image concepts,

·         must be familiar with treatment planning,

·         must be knowledgeable in the case preparation procedure, such as how data is acquired, how the radiographic guide is made, how the patients are scanned, etc.

Whenever patient's pathology is concerned, the users need to be radiologist or CT professionals who are licensed to read patient's pathology.

In general, GuideMia is a desktop application. There is no user type definition in the system, therefore the system design will not differentiate the users.

The system will be eventually expected to work on Windows, Linux and Mac platforms. For the time being the development takes this into consideration, but will only support MS Windows. The supported OS include:

  • Windows 7  64bit and its successors
  • Windows 7 32bit and its successors

Recommended system specification:

Processor: Intel i7 CPU.

RAM: 4GB

Graphics card: 1G nVidia GTX260, GT450, etc

64 bit Windows 7

Lower end configuration will be for the viewer version only, which is a special version of the system that works as a limited version for doctors and patients to review their cases. We will target the middle to high end desktop/laptop configurations, which are typically for small business or video game players commonly found in Dell or HP’s website. Since the computer prices are constantly dropping, we do not list any details here.

Implants should not be placed anytime when there are general contraindications associated with elective oral surgery. Absolute and relative contraindications include, but are not limited to: cardiac and vascular disease, bleeding disorders, psychological disorders, uncontrolled diabetes mellitus, mineral, bone, or connective tissue disorders, renal disease, hepatic disease, auto-immune disorders, decreased immune function due to disease or medications, infectious disorders, and adverse conditions caused by medications. Further relative contraindications include poor oral hygiene, bruxism, malnutrition, alcoholism, tobacco usage, and history of radiation therapy.

In addition, the patient needs an adequate volume of residual bone for the placement of implants of sufficient size and number to support the anticipated functional loads to which the patient will subject these implants. Narrow implants and angled abutments are not intended for use in the posterior region of the mouth.

The software can only be used when patients have been scanned according to specific protocols and procedures, and study models have been made and scanned if necessary.

The treatment planning is based on patient's CT (or cone beam CT) scan and scan appliance (such as radiographic guide). Often time the scanning of a patient wearing a radiographic guide is necessary. Fail to properly place the radiographic guide before CT scan can cause serious errors and pose lots of risks to the surgery.

Implant treatment planning should be performed only by practitioners or lab technicians who are trained to do so. Adequate studies should be performed to examine the anatomic structures and to assess the biomechanical, functional, and esthetic requirements of each case. Radiographs or other diagnostic reviews should be performed to determine position and topography of the maxillary sinus, nasal cavities, inferior alveolar nerve, mental foramen, natural tooth positions and other anatomical features that may affect implant placement or prognosis. Consultation between the surgeon, restorative dentist, and dental laboratory is essential for success. All implants must be placed to have sufficient clearance between implants, teeth, and patients nerve structures. Risks of improper implant placement and restoration include, but are not limited to: infection, implant failure, loss of bone and soft tissue, unfavorable aesthetic result, anesthesia, dysesthesia and paresthesia in the oral and facial areas, sinus infection, dislodgement of implants and instruments in the surrounding structures, damage to adjacent teeth, non-restorable implants, fracture of implants or restorative components, and loosening of implants or restorative components.

Each implant system has unique measuring characteristics to allow full seating of the implant to the desired depth. In some instances, drill length reference lines measure longer than the stated length of the implant. It is recommended that the implant surgeon be thoroughly familiar with the specific measurement system being utilized and provide a suitable safety margin adjacent to any teeth and vital structures. Failure to recognize the difference between the actual length of the drill and radiographic measurements can result in permanent injury to the nerves or other vital structures by drilling beyond the depth intended, potentially resulting in permanent numbness to the lower lip and chin or other injuries.

Each implant system has specific design characteristics for mating implants, abutments, prosthetic components, and instrumentation including surgical kits. Combining instruments, surgical kits, and components that are not configured or dimensioned for correct mating can lead to mechanical failure of components, damage to tissue, or unsatisfactory aesthetic results.

One-hundred percent success cannot be guaranteed, no matter a treatment is planned with software or physical models. Lack of adequate quantity and/or quality of remaining bone, infection, inadequate surgical technique, poor patient oral hygiene, and generalized disease are some potential causes for failure of osseointegration, both immediately after surgery or after osseointegration is initially achieved. Pre-operative hard tissue or soft tissue deficits may yield a compromised aesthetic result or unfavorable implant angulation. With respect to children, routine treatment is not recommended until completion of alveolar growth has been verified.

The applicability of the surgical guides must be verified before the surgery. Quality assurance effort must be made to ensure the surgical guide is made according to the designed model and to the treatment plan. This includes trying the model onto diagnostic models, and on patient's anatomy. If a guide is found not fitting properly on the patient's anatomy, or cannot be properly secured, it must not be used for the treatment. The surgical guides should be visually inspected and evaluated. Any possible structure that can cause stress concentration should be identified and adjusted.

All efforts must be made to minimize damage to the host tissue. In particular, special attention must be paid to thermal and surgical trauma and to the elimination of contaminants and sources of infection. The surgical procedure requires a high degree of precision and care. Any divergence from the principle of least possible trauma at implant installation increases the risk of failure to establish osseointegration. All drilling procedures should be performed at maximum 1000-2000 RPM (or follow the manufacturer's instructions) with copious irrigation, with or without surgical guide designed by the system, with or without surgical kits provided by implant manufacturers. The use of sharp drills, sufficient irrigation, an in-and-out drilling motion, short cutting cycles, waiting for the bone to cool, and use of pilot drills in successively increasing sizes are essential. Please refer to our web site for the specific sequence of drills for each implant type and size.

An appropriate follow-up protocol should be followed.

The use of this device is restricted to, or by the order of, licensed physicians or dentists, and per prescriptions of the licensed physicians or dentists.

 

 


 

2 .     Dental Implant treatment Planning

GuideMia covers the entire workflow of treatment planning:

1)       Preparation. This includes importing the patient's CT scan and additional references. Anatomical structures are modeled from CT scan. This typically includes bone, teeth, nerve channels, etc. With GuideMia's patent pending technology, Radiographic Guides or Scan Appliances are made for accurate treatment planning. Optical scans of stone models, patient intra-oral scans, etc. are also imported into the system and aligned with anatomical structures for further planning.

2)       Image Viewing/Diagnosis. In addition to treatment planning, the GuideMia software has diagnosis tools as well. With tools to measure and archive diagnostic findings, GuideMia can help ensure safer treatment planning.

3)       Planning. Implant selection, placement, adjustment, analysis, etc. are all involved in this step.

4)       Simulation. There are always errors in the clinical output of the implant procedure regardless of the data sources and planning technology. With simulation tools in GuideMia, the users can better evaluate their treatment plans with extreme error conditions.

5)       Design. Users can design Surgical Guides as they like with their choices of surgical kits.

6)       Manufacturing. GuideMia certified dental labs can make surgical guides from the STL files exported by GuideMia with no or trivial post processing.

This workflow is illustrated by Fig. 1. The steps or components are shown as text blocks. The arrows going into blocks from the left side are the data inputs. The outputs go out of the right side. The arrows pointing to the bottom of the blocks are the "support" factors such as technology and additional inputs. The arrows to the top are the controlling factors, for example, the results of a plan simulation will be used to determine if the surgical guide design can be performed or not.

 

Figure 2.1. The overview of treatment planning workflow

 

Surgical guides are used to improve the accuracy and safety of a treatment so that implants can be placed correctly for the best possible esthetics and surgical outcome.  As illustrated in Fig. 2, a surgical guide has the following basic elements:

  • an adaption surface, which fits onto the patient's anatomy,
  • drilling holes with sleeves inserted, which comply with the treatment plan and guide the actual drills, and
  • optional form features like irrigation windows, screw holes, anchor pin holes, etc.

 

  

 

Figure 2.2. The form features of surgical guides

When a bone-borne guide is designed, the geometric model of the patient bone/teeth structure is created from the CT scan. A 3D geometric model with a thickness of about 2-3 mm is derived. This model can fit onto patient’s bone/teeth just like a denture. Then “guide drilling holes” are created on this model. Sleeves will be inserted into the holes. At the surgery time, the guide will be put onto patient’s bone/teeth, and the holes will guide the drills through.

Tissue-based guides are designed to fit onto patient's soft tissues (gums) and teeth. In order for the models to fit, the system can use any geometric models with a duplication or approximation of the tissue and tooth surfaces. This includes but is not limited to the following:

  • Prefabricated denture-like guides, often referred as radiographic guides. A digital model of this kind of guide is obtained by CT scan and surface reconstruction.
  • Stone/plaster models. The digital models are acquired through optical scans.
  • The patient's Intra-oral scans.
  • Impressions. The digital model can be from CT scan or optical scan.

Surgical guides are designed to be used with surgical kits. Implant manufacturers design and make their surgical guides according to their implant specifications, and they also have the version of kits that are specially designed for image guided surgery.  The goals of surgical kits are basically to ensure proper drilling sizes, orientations, depths, as well as the drilling sequences. Surgical guides will need to be designed according to the implants and surgical kits. When no surgical kits are available for implants used in a case, the surgical guides will be designed for pilot drills only.

The following tables show some of the possible surgical guide types. This shows you the basics how treatment plan cases can vary in terms of surgical guide design. This is NOT a complete list, and not all the combinations are possible or supported. The right column of the table marks what are supported in this release. "F" and "P" means "fully edentulous" or "partially edentulous". The surgical guide creation will also generate an object shown in the object navigator.

Surgical Guide Case

Surgical guide features

Is Supported

Tissue-based

Bone-based

Made by drilling

Made by Printing or milling

With Surgical Kit

With Tooth Extraction

Radiographic Guide CT

Stone model Optical Scan based

Impression Optical Scan based

  1.  

x

 

 

 

 

x

x

 

F, P

  1.  

x

 

 

 

 

x

x

 

F, P

  1.  

x

 

 

 

x

 

x

 

F, P

  1.  

x

 

 

 

x

 

x

 

F, P

 

 

Radiographic Guide: A denture-like model that has radiographic markers and fits onto patient's teeth and/or soft tissue.

Treatment Planning: The process to select implant type, make and model and size, and to preview the implants together with patient's oral structure, and to adjust the implant locations and orientations.

Scan Template: Same as Radiographic Guide.

Segmentation: The process or operation to separate certain structure from a CT scan data set.

Nerve Tracking: The process to follow the nerve channels on a CT dataset and to create surface models of the channels in order to simulate the nerves in patients' oral dental structure.

Surgical Guide: A model that embodies implant treatment plan with implant holes and drilling sleeves, can fit onto a patient's oral-dental anatomy, and is used to guide the drilling operations for implant surgery.

Master Model: A model that consists of a patient's bone/tooth structure, and optionally, the soft tissues, with implant holes added. It can be used for case study, further treatment planning, as well as surgical guide fabrication.

Bone Reduction Guide: A model designed to guide the bone reduction process, which has a base model fitting onto patient’s bone structure. and an opening that exposes the bone area to be removed.

Optical Scan: A process or approach to acquire geometric models of physical objects. Alternatively, this term refers to the resulted models that normally are stored as STL files.

STL File: a file format native to the stereolithography CAD software created by 3D Systems. This file format is supported by many other software packages; it is widely used for rapid prototyping and computer-aided manufacturing. STL files describe only the surface geometry of a three dimensional object without any representation of color, texture or other common CAD model attributes. The STL format specifies both ASCII and binary representations.

Rendering: the process of generating an image from a model (or models in what collectively could be called a scene file), by means of computer programs. A scene file contains objects in a strictly defined language or data structure; it would contain geometry, viewpoint, texture, lighting, and shading information as a description of the virtual scene. The data contained in the scene file is then passed to a rendering program to be processed and output to a digital image or raster graphics image file.

Volume Rendering: a set of techniques used to display a 2D projection of a 3D discretely sampled data set. A typical 3D data set is a group of 2D slice images acquired by a CT, MRI, or MicroCT scanner. Usually these are acquired in a regular pattern (e.g., one slice every millimeter) and usually have a regular number of image pixels in a regular pattern.

Surface Rendering: a set of techniques to display the geometric surface of a 3D dataset. While volume rendering displays each points of the dataset in the 3D space, surface rendering only deals with the geometric surface.

Snapshot: a tool or the results of the tool, generated from the tool in GuideMia, which capture the displayed image of a rendering window as well as the display parameters that are used to create the image, such as lighting and camera settings.

System Recovery: a process that tries to recover the project data and operation status from temporal files after system crash or any kind of abnormal termination of GuideMia session.

Axial View: one of the three cross section views of a CT scan dataset. It is parallel to XY plane of the coordinate system of the dataset. If required, it also includes cross section curves of any surface models.

Sagital View: one of the three cross section views of a CT scan dataset. It is parallel to YZ plane of the coordinate system of the dataset. If required, it also includes cross section curves of any surface models.

Coronal View: one of the three cross section views of a CT scan dataset. It is parallel to XZ plane of the coordinate system of the dataset. If required, it also includes cross section curves of any surface models.

Assembly View: one of the two 3D views in GuideMia. It displays the patient's CT scan, radiographic guide CT scan, implants, as well as any other generated or imported 3D models.

Segment View: or current object view, one of the two 3D views in GuideMia. It displays the current working object or object group, which is one of the objects or all the implants in the assembly view.

Virtual Tooth: a geometric model imported from a library of STL files, which represents a tooth and can be placed in 3D views as a reference to help treatment planning.

Virtual Tissue Model:  a geometric model generated based on CT scan dataset to simulate the actual soft tissues and tooth surfaces. Since this virtual model is similar to a stone model that typically includes soft tissue and tooth surfaces, the model is called virtual tissue model. It is also called virtual tissue model.

Tissue-borne Surgical Guide: or tissue level surgical guide, a category of surgical guides that are directly placed onto patients' soft tissues and/or tooth surfaces for the purpose of non-invasive surgery.

Bone-borne Surgical Guide: or bone level surgical guide, a category of surgical guides that are placed onto patients jaw bone and/or tooth surface for invasive surgery, in which the surgeon will peel patients' soft tissues (gum).

Arch Curve: a curve that is used to outline the overall shape of the arch of either lower jaw (mandible) or upper jaw (maxilla), and to create the panoramic view of a CT scan dataset.

Placement Widget: a GUI tool helping position geometric models in a 3D space. It typically has handles, axis, and plants.

Surgical Kit: a set of tools and instruments for drilling and implant placements in dental implant procedures.

Drilling Sequence: a sequence of drilling operations to accomplish one implant hole. The first drill is called pilot drill.

Drilling Sleeve: a metal tube inserted into surgical guides to guide the drilling operations.

Safety Zone: an area in the 3D space surrounding an implant. There should be no interference with adjacent tooth roots, implants, nerves, sinuses, etc.


 

 

3 .     Get Started

The installation is simple. GuideMia is mainly distributed through online downloading. You can download the software from our website as instructed.

The installation package is an .msi file on Windows. Double click the file will launch the installation wizard. You will need to select the language and the installation folder. Please note that you can always change GuideMia's working language by going to the menu items under "Help".

Due to Windows security reason, users will need to set GuideMia to run as Administrator. In order to do so, go to system Desktop, find GuideMia icon, right click, and select Properties from the pop up menu, then in the Property dialog as below, turn on “Run this program as an administrator”.

Figure. 3.1 Set to Run GuideMia as administrator

 

Also, latest computers may come with two graphics card. Users are advised to set GuideMia to run on the high end graphics card. Please refer to your computer’s graphics settings for more details. The following is the setting for computers with nVidia system.

Start nVidia control panel by right click on your desktop, go to manage 3D settings tab, and make sure your Preferred graphics processor is set to High-performance NVIDIA processor.

Figure. 3.2

In addition, some computers may not come with good graphics settings. If you are seeing your GuideMia displaying STL models with artifacts as in Fig. 3.3, please make change the image settings of nVidia control panel to prefer “Balance between performance and quality” or “Quality”.

 

  

(a)                                                                                                                (b)

Figure. 3.3. STL model display. (a) with artifacts due to graphics card settings (b) expected display.

 

Figure. 3.4 Graphics card settings

First time you start GuideMia, you will be asked to activate your license file or start trial. Contact us for your license file and related issues.

GuideMia will generate treatment plan reports. The reports can be customized with customer’s logo. Users will need to place a file called customerlogo.png in GuideMia installation folder so that the reports will show the logo accordingly.

The following pictures show the system layout. Fig. 3.5(a) and (b) are the normal layout for implant treatment planning, Fig. 3.1(c) is the window for surgical guide design, and Fig.3.1(d) is the system layout for GuideMia viewer.

 

(a)

 

(b)

(c)

(d)

Figure 3.5. GuideMia user interface layout. (a) Treatment planning. (b) Alternative treatment planning layout. (c) Surgical guide design. (d) View version user interface.

The user interface has the following components. Detailed descriptions will be given later.

  1. System menu bar with menus like Project, Edit, View, etc
  2. Tool bars with functions that are frequently used
  3. Task panel with the following pages as steps of a workflow:
    1. Case definition
    2. Treatment Planning
    3. Snapshot navigator
    4. Model navigator
    5. Surgical guide design
    6. Report generation
  4. Image windows for treatment planning
    1. Axial view
    2. Sagital view
    3. Coronal view
    4. 3D assembly view
    5. 3D current object view
  5. Graphics window for surgical guide design

GuideMia deals with the following file types:

1.       DICOM series, which is basically CT scan datasets. GuideMia is compliant with DICOM standards, and supports DICOM files from all vendors.

2.       IMG file, which is a GuideMia proprietary file format. An IMG file is a combined form of a DICOM series. GuideMia uses IMG to store the results of bone segmentation. This file is not for the users to manipulate.

3.       STL file, also a standard file format. GuideMia can import and export geometric models as STL files. For importing GuideMia supports both binary and ASCII format. For exporting, it outputs binary format. Depending on the license options, the exported STL files may or may not be standard STL file format.

4.       XML file, only for the implant library.

5.       SGC file, which is a GuideMia proprietary file format for surgical kit configurations.

6.       Treatment planning web page files include an HTML page and image files. There are also temporary XML files when the system is generating treatment plan web page.

 

 

In this section, a simple yet comprehensive workflow will be introduced.  After this chapter, you will be familiar with the following:

·         System user interface layout

·         Basic user interactions in 2D and 3D windows.

·         Minimum steps to plan a dual scan case with radiographic guide.

 

The example used in this chapter is available upon request. The users should be able to use their own cases to run through this workflow without issues. The following conditions are used to select a case to run this minimum workflow:

·         Patient scan should be free of large metal artifacts or scatters.

·         The radiographic guide markers are relatively clear from the bone structure or scatters. The markers themselves should not have much scatters. The size of the markers should be between 1.5mm-3mm. Spherical shapes are preferred. Long cylindrical markers should be avoided.

·         Less than 3 teeth are missing.

Figure 3.6. Sample patient scan with radiographic markers

The treatment planning steps are briefly described below. They are all illustrated in the screen shots and the accompanying notes. See other chapters for more details or more thorough procedures.

Step 1.      Create a project by opening a DICOM datasets. The DICOM files of a scan must be placed into one single directory. No other DICOM files should present in this directory.

Step 2.      Initialize the image windows and manipulate the displays. As illustrated by the pictures, perform the following operations:

a.        Zoom and Pan in all views

b.       Rotate in 3D views

c.        Threshold changes in 2D views. Look at the status bar of the application. The window/level value is shown there, as well as the thresholds. For bone structure, the thresholds will be above 300 and more depending on the patient's bone density. For radiographic markers, the lower threshold value will need to be in the 2000 range depending on the materials of the markers.

d.       Arch curve manipulation

e.       Region of interest manipulation. It is important that the region of interest will contain the radiographic markers before you go to the next step.

f.         Slice line handles

g.        Mouse wheel, or CTRL + MB1 drag and drop to change 2D slices.

Step 3.      Load DICOM files of radiographic guide scan. The DICOM files must be in a different folder than the patient scan.

Step 4.      Upon radiographic loading, the guide is automatically registered with the patient CT scan.

The information message box shows the registration error, which is an average deviation value between the markers on patient CT scan and the radiographic guide scan.

Step 5.      Segmentation. Step 5 is to create segmented models for the bone structure and the radiographic guide. In this chapter only the very essential operations are used.

a.        Essentially the segmentation of bone structure is based on the image processing techniques of connected thresholding. It includes the following steps:

                                       i.      Adjust the region of interest. Use the region box handles in the 2D views to adjust.

                                      ii.      Adjust the thresholds for the filtering. There is no definite rule to determine the bone thresholds. Depending on the patient's bone density, the lower threshold can be as low as 200 Hounsfield unit, or as high as 900. The good news is that for dual scan cases this segmentation is mostly for the purpose of viewing. Unless a bone level surgical guide is desired, there is no need to have the model better represent the actual bone structure.

                                    iii.      Specify a seed point on either of the 2D views.

b.       The segmentation of radiographic guide is a lot simpler. Users can just adjust the threshold to segment the radiographic guide.

Step 6.      Select implant for placement. In this example, we will just place one implant. See the picture for the operation details. The implant selection and library management dialog can let you select your implant, update implant selection, or manage library.

Step 7.      Place implants. Implants can be initially placed onto any of the 2D or 3D graphic views by a single mouse click. Each implant will have its placement widgets in all the five image windows. The details of placement widgets will be introduced later. Step 6 to 7 can be repeated as needed. Every operation on the placement widgets will be propagated to other windows. There are three kinds of placement widgets:

a.        2D Placement widgets. A 2D widget has an axis and two handles.

b.       3D Placement widgets. As shown in the pictures, a 3D placement widget has a circular dial, a square with X and Y  axis, Z axis with handles, etc.

c.        3D Placement widgets in cross sectional mode. As shown in the current object window, a widget if this kind is constrained on the cross section plane, or plane widget.

Step 8.      Surgical guide design. It is extremely simple for this case to design the surgical guide because it is all automatic. Just follow the instruction on the corresponding screen shots.

Step 9.      Generate report.

Step 10.  You can save the project, and exit. This concludes our very first example.

 

Note:  
It is very common that there is not enough clearance in the implant site to create the form features for drilling sleeve. The picture in the left shows a typical situation. Please refer to Chapter 7 for the procedure to design surgical guides for this case.


3. Open the DICOM series

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Step 1. Create a Project

 

 

 

 

 

Step 2. Window manipulations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Step 3. Load scan of radiographic guide, or, scan template. The DICOM files must be in a different folder than the patient scan.

 

 

Step 4. After loading radiographic guide, or scan template, registration of the guide and the patient scans are automatically performed.

 

 

 

6. Add a seed point

Step 5. Segmentation of bone structure and radiographic guide.

Step 6: implant placement - select implant

 

Step 6: implant placement - place implant

 

 

Step 7. Adjust Implants.


 

Step 8. Surgical guide design. There can be a warning or error message when entering this step. Just accept it, and proceed.

Surgical guide designed.

Step 9. Generate report.

 

Sample report.


4 .     GuideMia Scanning Protocols

The following is an overview of the supported scanning protocols. The items listed next to each of the protocols specify what kind of clinical cases the scanning protocols can be used, and what the basic requirements are. Except radiographic guides or dentures, GuideMia does not require or endorse scanning appliances or trays or help bodies of any kind. Please contact us to make sure your specially made appliances can be supported.


 

1.       Patient must remove all metal prosthesis, as well as metal jewelry that might interfere with the region to be scanned.

2.       Patient’s bite should be secure with cotton pads or other highly radio-translucent material (such as polyethylene) . Avoid using any radio-opaque material that will prevent tooth surface from being segmented in CT data processing.

3.       Upper and lower teeth should not toucheach other during the scan.

4.       Recommended space between two jaws is 5-10mm.

5.       Patient should be in a static position, and must not move or swallow during the scan acquisition.

The occlusal plane should be parallel to the plane of image slice generated, with no tilt.

The height must be set in order to center the occlusal plane in the field of view (FOV).

In case that both arches need to be treated, please provide a separate scan for each arch.

Recommended CT scan slice thickness: 0.2mm-0.5mm. Smaller thickness will require higher end hardware systems when using GuideMia Treatment Planning Software.

Please contact your CT scanner technical support for the scanning parameters and reconstruction settings.

DICOM files will be generated and made available for GuideMia.

1.       Scan the patient’s preparation area, preferably, full arch

2.       Consult your scanner’s manual for settings

3.       The scanned area  needs to have 3-5 mm margin beyond the tooth surfaces

4.       For implant site tooth setup. In case there are multiple units, and the case justifies a virtual tooth setup, use scanner or CAD software to virtually place the teeth, and save the diagnostic model as a different STL file

5.       For immediate tooth extraction cases, if possible, it is recommended to use scanner or CAD software to remove the tooth (not including the root area) that will be extracted, and save as a different STL file

6.       Step 4 and 5 can be combined

7.       The antagonist scan is recommended for both restoration and implant planning purposes

1.       It is recommended, if possible, to have you scanner software trim the scan results along the edges , but the trimmed model will need to maintain the said margin

2.       Diagnostic models can be designed with CAD software and made available for GuideMia

3.       STL file should be generated and made available for GuideMia

4.       If possible, STL models can be inspected with third party software or GuideMia for overlapping, self intersections, holes, etc.

5.       The STL model resolution depends on various factors and scanner settings. The STL file size between 5-20MB is normally acceptable.

 

1.       Patient must remove all metal prosthesis, as well as metal jewelry that might interfere with the region to be scanned.

2.       Patient’s bite should be secure with cotton pads or other highly radio-translucent material (such as polyethylene). Avoid using any radio-opaque material that will prevent tooth surface from being segmented in CT data processing

3.       Upper and lower teeth should not toucheach other during the scan.

4.       Recommended space between two jaws is 5-8mm.

5.       Patient should be in a static position, and must not move or swallow during the scan acquisition.

The occlusal plane should be parallel to the plane of image slice generated, with no tilt.

The height must be set in order to center the occlusal plane in the field of view (FOV).

In case that both arches need to be treated, please provide a separate scan for each arch.

Recommended CT scan slice thickness: 0.2mm-0.5mm

Please contact your CT scanner technical support for the scanning parameters and reconstruction settings.

DICOM files will be generated and made available for GuideMia.

1.       Scan the patient’s preparation area, preferably, full arch.

2.       Consult your scanner’s manual for settings

3.       The scanned area needs to have 3-5 mm margin beyond the tooth surfaces

4.       Scan the stone model first

5.       For implant site tooth setup. In case there are multiple units, and the case justifies a physical or virtual tooth setup, perform one of the following:

·         Add tooth on the physical model and scan it after step 4

·         Using scanner or CAD software to virtually place the teeth, and save as a different STL file

6.       For immediate tooth extraction cases, it is recommended to perform either of the following

·         Remove the tooth area from stone model, and do an extra scan of the model

·         Using scanner or CAD software to remove the tooth that will be removed, and save as a different STL file

7.       Step 5 and 6 can be combined

8.       The antagonist scan is recommended for both restoration and implant planning  purposes

1.       It is recommended to have you scanner software trim the scan results along the edges , but the trimmed model will need to maintain the said margin.

2.       Diagnostic models can be designed with CAD software and made available for GuideMia

3.       STL file should be generated and made available for GuideMia

4.       If possible, STL models can be visually inspected with third party software or GuideMia for overlapping, self intersections, holes, etc.

5.       The STL model resolution depends on various factors and scanner settings. The typical STL file sizes are 5-20MB.

 

 

A successful case begins with the creation of a properly and carefully designed Radiographic Guide.

The Radiographic Guide will communicate the desired restorative outcome to the entire treatment planning team before the surgery begins.

            

1.       Design the radiographic guide with prototype of restorations. The following is a checklist

a.        Teeth are properly chosen and placed

b.       No metal or any other radio-opaque component or material

c.        Thickness should be 2.5-4mm

d.       Buccal flanges have enough extension for radiographic markers and anchor pins

e.       Fit properly on patient’s anatomy

2.       Add radiographic markers. Gutta percha markers or radio-opaque glass beads or similar can be used.

a.        6-8 markers are recommended

b.       1.5-2.5mm size, spherical shape. Not cylindrical, no special designs with special geometries.

c.        Place half on lingual side, half on buccal side

d.       Do not evenly distribute the markers

3.       Make a bite registration

a.        Use radio-translucent material

1.       Examine the denture of your patient to decide if you can use it as a radiographic guide.

2.       The ideal denture should have:

a.        Teeth of proper size, shape and length

b.       Well established occlusion

c.        Buccal flanges wide enough for gutta-percha markers and retentive pins positioning

d.       Hard reline only

e.       Secure and close fit to soft tissue and patient cast

f.         No radio-opaque or metal materials

3.       Adding radiographic markers to the denture is same as radiographic guide

1.       The radiographic guide must be placed properly and firmly on patient mouth, and the patient needs to bite the registration properly.

2.       Take a CT scan of the patent wearing the radiographic guide.

3.       Take a CT scan of the radiographic guide only.

DICOM file sets for both scan should be made available to GuideMia

See the same section of “CT Scan and Intro-oral Scan Protocol”.

See the same section of “CT Scan and Intro-oral Scan Protocol”.

The stone model should be scanned in a position similar to its position during the patient scan.

The stone model should be supported by a highly radio-translucent material.

No supporting material should be placed onto tooth surfaces.

Recommended CT scan slice thickness: 0.2mm-0.5mm

Please contact your CT scanner technical support for the scanning parameters and reconstruction settings.

DICOM file sets for both scan should be made available to GuideMia

See the same section of “CT Scan and Intro-oral Scan Protocol”.

See the same section of “CT Scan and Intro-oral Scan Protocol”.


 

5 .     System Functions

This chapter gives all the details of the system window layout, and functional items. It serves as a general reference for system functions. Section 5.1 describes the overall windows layout of the application. Section 5.2 lists all the menu items. Almost all the menu items have their counterparts in the treatment planning workflow task panel, therefore just little details are given form the menu items. Section 4.3 listed the toolbars. Toolbar icons all correspond to system menu items. Each of the image windows has a toolbar, which is only displayed when the mouse moves into the window. 3D windows also have pop-up menus. They are introduced in section 4.4 and 4.5. Section 6 is the workflow task panel, which covers everything in a treatment planning.

The following picture is a screenshot of the system. The image window has five split areas, i.e., axial view, sagital view, coronal view, 3D assembly view, and 3D segment view (or, current object view). It has a status bar, menus and toolbars. Image views will have their own tool bars. This is the window layout for most of the time the system is running.

Axial viewStatus bar

 

Figure 5.1. System UI layout - treatment planning mode

The following is the window layout for surgical guide design.

Figure 5.2. System UI layout - guide design mode

 

The system menu has the following sections: Project, Edit, View, Diagnosis, References, Implants, Report, Tools, Windows and Help. For functions specifically available in certain image views, we will have toolbars for them.

The menu items are listed in the following table.

Menu

Description

New. This will create a new case by DICOM files, and initialize the image views. A normal file selection dialog pops out. Users can browse and select any one of the DICOM files of a patient scan.  The entire series will be loaded.

Open. This will open an existing project and initialize the image views.

Save. This will save the working project.

Save as. This will save the working project as a .pie file with a file name dialog.

Print. This will print the image views.

Export. This menu has four items:

1)       “Export DICOM series” will export working image data into DICOM series.

2)       “Export STL file” will export working object as STL file.

3)       "DICOM to IMG file" will export DICOM series as a single proprietary .img file, which encapsulates DICOM header information and all slice data.

4)       "Scan template, Implants and sleeves". This function exports a combination of the named components into one single STL file, which is for third party surgical guide design purpose.

Close. This will close the working project.

Exit. This will close project and exit GuideMia.

 

The following are a couple of screenshots showing you the user interface when a project is initialized from a DICOM set, or an existing project is loaded. 

Figure 5.3. File open dialog for Project/New

Figure 5.4. User interface upon project initialization.

Figure 5.5. Upon project open.

 

 

Menu

Description

Undo. This will undo the last operation.

Redo. This will redo the last operation.

Copy.  Not implemented at this time.

Paste. Not implemented at this time.

Update Segmentation. This will update current object by the threshold values in 2D views if the current object is segmented from CT image data, such as bone structure, tooth segmentation, etc.

 

Menu

Description

 

Panoramic View. This will turn on/off panoramic mode of image views. It has two sub menu items:

1)       2D. Show panoramic mode in sagital and coronal views.

2)       3D. Not implemented at this time.

 

Bone quality. This will turn on/off the display mode of “Bone quality” in both 2D and 3D views.

 

Stereo. This will turn on the stereo display mode. The actual effect depends on hardware configurations. Among the supported modes, red/blue mode is the basic one.

 

Clipping.  This will turn on/off one or two clipping planes and clip 3D views. Only one clipping plane is supported now.

 

Double clipping mode. This will enable two clipping planes.

 

 

Linked clipping model. Not implemented at this time.

 

Show. This is a submenu for operations to hide/show specific objects. It has the following items.

 

·         Bone.

·         Scan template, or, radiographic guide

·         Nerves

·         Implants

·         Abutments

·         Master Model - Bone

·         Master Model – Soft tissue

·         Surgical guide

·         Surgical guide base model

·         VOI box

·         Patient information

·         Slice lines

·         Dimensions  (incl. distances and angles)

·         Clipping Plane

·         POI viewer

·         Placement widget

 

 

The following are some screenshots that can help understand some basic behavior of the system.

 

Figure 5.6. Normal 2D views

Figure 5.7. Panoramic 2D views

 

Figure 5.8. Bone quality views - 2D and 3D

Figure 5.9. Stereo mode in 3D window - Red blue mode

Figure 5.10. Assembly view clipping mode

Figure 5.11. Bone model and Radiographic Guide

Menu

Description

Thresholding.  Filter CT image and create an object from the result, such as bone structure, teeth, etc. This is a generic tool other than the segmentation tools found in the task panels.

Region growing. Not implemented at this time. This is a generic tool other than the segmentation tools found in the task panels.

Distance in all 2D and 3D views. See Figure 4.13-4.14.

Angle in all 2D and 3D views. See Figure 4.13-4.14.

Neighborhood viewer. See Figure 4.15

Figure 5.12. Distance and Angle in 2D

Figure 5.13. Distance and Angle in 3D

Figure 5.14. Neighborhood viewing. Implant adjacent areas are shown in color map indicating bone quality. This window dynamically changes to show the areas with different offset to the original implant tool body.

 

Menu

Description

 

Automatic Bone Segmentation. This is an advanced tool to automatically segment bone structure with threshold values automatically determined.

Simulate Soft Tissue Peeling. See corresponding tool in task panel.

One-click Scatter Removal. See corresponding tool in task panel.

Manual Scatter Removal. See corresponding tool in task panel.

Extract Tooth. See corresponding tool in task panel.

Add Scan Template. See corresponding tool in task panel.

Add Optical Scan of Impression. See corresponding tool in task panel.

Add Optical Scan of Plaster Model. See corresponding tool in task panel.

Add Optical Scan of Scan Template (radiographic guide). See corresponding tool in task panel.

Extract Scan Template. See corresponding tool in task panel.

Register Scan Template. This will bring up the tool box in task panel.

Add Tooth Anatomy.  See corresponding tool in task panel.

Add Additional Scans. See corresponding tool in task panel.

Track Nerve Channel. See corresponding tool in task panel.

More tools to create Nerve Channel. See corresponding tool in task panel.

Bone Graft. See corresponding tool in task panel.

Bone Reduction. See corresponding tool in task panel.

Sinus Graft. See corresponding tool in task panel.

 

 

 

Menu

Description

Add Implant (Enter the task panel of adding implant, see section 6.5)

Add Anchor Pin

Add Tooth/Bone Screw

Implant Library Management

Configure Surgical Kit and Guide

 

Menu

Description

 

Generate Plan

Collision Checking

Plan Evaluation

Scan Quality Checking

Neighborhood Bone Density Checking

 

The “Plan Evaluation” function will perform a plan checking, and warn the users of any potential problems in the treatment plan. The underlying function will be also invoked when the user enters into the surgical guide design step or generating treatment plan.

The following is a screen capture of the validation result. The items included in the report are listed here.

Figure 5.15 Plan validation report

·         No nerve model has been created. This only applies to mandible cases. It needs some attention if the treatment plan does not include a nerve model.

·         The implants interfere with nerve models. When the nerve models are present, the system will perform a collision detection.

·         Some implants interfere with others.

·         The implants interfere with adjacent tooth structure.

·         One or more drilling sleeves will interfere with the patient's anatomy. You will need to adjust drilling sleeve parameters, drling prolongation, or trim the sleeves after the surgical guide is manufactured.

·         The radiographic guide has not been inspected by creating virtual tissue model and its distance map. This means that the user may not have inspected whether the radiographic guide has been properly placed at the CT scanning time.

·         The base model of surgical guide design, or the scan template, has not been registered correctly with the bone structure, or the registration results in big deviation.

·         The CT scans have slice thickness bigger than 1mm, which is not recommended.

·         You have planned treatments like bone grafting, reduction, etc, which can affect the fitness of the surgical guide.

·         The angles between two neighbor implants are bigger than 20 degrees, which can be a warning sign.

In case any of these items are reported in the dialog, the surgical guide design or plan reporting cannot continue unless the user fully understand the issue and wish to proceed.

 

Menu

Description

Options

Object Delineation. Use mouse to track a profile and extract the image data within the profile. See the tooth extraction in section 6.6.2.

Cut by Profile. Use mouse to track a profile and remove the image data within the profile.

 

 

Menu

Description

About. This is the "About GuideMia" dialog.

Activate License. This lets the user activate or update a license file.

Choose Language for Next Session.

 

There will be toolbars corresponding to system menu, and by default, they show the most commonly used menu items. Customization tool will be available too.

The following toolbars will be implemented:

Standard: common file and editing items

The items are corresponding to items with the same names in the system menu.

Tools: items from the tools menu

The items are corresponding to items with the same names in the system menu.

View: major items in the view menu

The items are corresponding to items with the same names in the system menu.

UI

Description

When there is no placement widget (no object's position is being adjusted)

When there is placement widget (one or more objects position is being adjusted)

Maximize/Normalize 2D View

Update 3D views

Color Mode

Create Snapshot

Fit View

Adjust the step length/angle for fine tuning placement widgets.

Translate (four directions) and rotate (two rotation directions) the current placement widget and underlying object.

Maximize/Normalize 3D View

Toggle Clipping Mode

 Toggle Cross section mode

Toggle between Surface Rendering and volume rendering Mode

Change 3D window opacity

Create Snapshot

Fit View

The following figures illustrate the system behavior of these functions.

Figure 5.16. 2D color mode and black/white mode

 

Figure 5.17. 2D snapshots in snapshot navigator

Figure 5.18. Cross section mode in 3D views. The axial view has a cross line corresponding to the image plane of the "working" 3D view

Figure 5.19. 3D Display mode with opacity less than 1.

 

UI

Description

 

 

Hide. Hide the object under the mouse cursor in current window.

Hide (Show) in 2D. Hide or show the cross section of the underlying object in all 2D views. "Hide" or "Show" is displayed according to the actual status of the object.

Change Color. Pop up the color selection window.

Start Positioning (or Lock Positioning). This will show (or hide) the placement widget of the underlying object and start (or lock) the positioning.

Show Fit Analysis. This only applies to surgical guide models. The function will show a surgical guide with a color map indicating the distance between the guide and patient anatomical structure.

Export STL file. Write STL file for the underlying surface model. This is only available with Guide Design license is available.

Make Current. Show the underlying object in the 3D "Object Window", and make it as current working object.

Delete. Delete underlying object.

 

The following picture is the color selection dialog. It supplements the predefined color set. Figure 4.20 shows the implant placement, and Figure 4.21 shows a surgical guide with its fitting analysis.

Figure 5.20. Color selection dialog.

(1) Implant. The placement widget can be shown and hidden

(2) Other surface model. The placement widget can be relocated by MB2 to move the two triangle handles.

Figure 5.21. Object and placement widgets

Figure 5.22. Surgical guide fit analysis.

The "Scalar bar" in the right side defines the how the "distance" is mapped to color. The "distance" is between a point on the surgical guide and the model that is used as the base for surgical guide design, such as a stone model for tissue-based guide or bone model for bone-level surgical guide.

Together with the image views is a system workflow panel, which can be resized and docked. The system functions listed in the above are organized in six panels, or six steps, of a treatment planning workflow. Some functions in this workflow panel are not found in the system main menus.

UI

Description

 

 F1.33.

 

Show and display patient information, and define a case number.

 

Figure 5.23, 5.24 are some screenshots for the registration functions.

(1)

(2)

 

(3)                                                                           (4)

Figure 5.23. Add radiographic guide. (1) Add radiographic guide dialog. (2) Radiographic guide automatically registered with patient scan. (3) Extracted scan markers on scan template. (4) Markers and some other areas with high density from patient CT scan.

   

Figure 5.24. Add stone model or intra-oral scan

 

UI

Description

 

 

 Specify seed points for bone segmentation.

Reset Volume of Interest

Adjust threshold values for bone segmentation.

Automatic scatter removal. This will initiate the operation or increase the strength of existing operation.

Manual scatter removal.

 Slice editing. Trace an area on 2D slice views and remove the pixels from the bone segmentation results.  The first time the button is pressed, system enters the function. Then users can circle an area on a slice view, and click the cut button as shown in the following toolbar to remove the circled pixels. After all the slice editing is done, users click this button again to exit the tool.

Low Density Processing.  (Not implemented for now)

Set the bone low density level. 0 means normal, no processing is needed. 4 for extremely low density cases.

 Perform the processing.

Perform surface peeling simulation.

Set the tissue thickness the simulation will use.

 Perform surface peeling. F1.29

Remove tooth areas from the bone structure by circling an area on 3D view.

 Create/Update tooth segment by changing the low threshold value.

 Delineate an area of a tooth segmentation. Use mouse button to circle tooth structure of interest in the current working object view.

 Remove an area of a tooth segmentation. Use mouse button to circle and remove an area from a tooth segmentation in the current working object view.

 Create a new tooth segmentation.

 Automatically segment radiographic guide and create surface model.

Adjust the low threshold value for segmentation of radiographic guide.

 

 

Figure 5.25. Bone segmentation

 As shown in Figure 5.25, Region box, Seed point, Thresholds are the three inputs of the bone segmentation. In Figure 5.26 the effect of soft tissue peeling simulation can be compared with the models with just thresholding. Figure 5.27-5.30 shows some additional functions.

(a)

(b)

Figure 5.26. Thresholding vs. soft tissue peeling simulation.

 

   

Figure 5.27.  Automatic scatter removal. Before and after.

    

Figure 5.28. Manual scatter removal

 

Figure 5.29 Slice editing of Bone Segmentation

    

Figure 5.30. Tooth segmentation

  

Figure 5.31. Tooth removal

UI

Description

 

 

 

Upon entering this tool page, the 3D views will be initialized for registration.

 

 Adjust and display the high threshold for markers.

 Adjust and display the low threshold for markers.

 Specify an area that is not a marker but is considered as marker for some reason.

Specify markers if not recognized. Points on a STL model can also be specified as markers.

This function has a new option “From Coronal View”. System can now specify markers from Coronal View. The helps the situation where users can hardly find a good point on the 3D rendering  due to massive scatters.

 Clear the markers and revert the registration results.

This turns off/on the function to perform registration more intelligently based on the input points. When the scatter level is high, the makers need to be more accurate and the smart mode is off.

 Perform registration and update all views.

 Fine tune the registration results.

 This button let users to load additional models, which will be placed into the views with the transformation inherited from the registered radiographic guide or stone model.

Figure 5.31 and 5.32 illustrate the procedure of model registration. See chapter 6 and 8 for more details.

 

6. Start specify markers. Very often, this step is not needed.3. Adjust thresholds for markers5. Start specify markers4. Start specify markers2. The two image windows will be setup for registration. Zoom/Rotate and other tools can be used to better orient the model so that the markers can be well viewed. The left side are the markers on the patient scan. The right side are markers on the radiographic guide scan.  1.	Enter page

(a)

(b)

2. Alignment report1.Click here to align3. Adjust thresholds for markers

(c)

(d)

Figure 5.31. Radiographic Guide registration

(1) Specify markers for registration. The markers represent areas for registration other than just points. There is no need to specify same amount of markers or have corresponding orders.

 

(2) After registration

Figure 5.32. STL model registration to bone/teeth

UI

Description

 Confirm that a virtual insertion direction is defined.

Show the radiographic guide or stone model scan or intra-oral scan.

 Generate virtual tissue surface model.

 

 

 

 

 

 

 

 

 

 Show the tissue model with color map indicating the distances between the tissue model and the bone/tooth structures.

The concept and result of virtual tissue model is shown in the following pictures. The model is the extraction of the adaption surface of a radiographic guide. In this case, since two teeth are removed the area corresponding to the teeth has a reddish color, which means the area is far from patient anatomy. The white/gray color indicates a tight fit of the radiographic guide and the patient anatomy.

 

(a)

(b)

(c)

   

(d)

Figure 5.33. Virtual tissue model. (a) Preparing model. (b) Generated result. The model is invisible by default in the assembly view. Use the model navigator to show it. (c) The uneven color distribution indicates the radiographic guide is either not properly placed when the patient was scanned, or the registration failed. (d) Virtual tissue model from optical scan. View direction shown in the left side. Result in the right side.  

 

 

 

 

 

 

 

 

UI

Description

 

 Specify the diameter of nerve model in “mm”, which will be manually drawn in 2D views.

 Draw left nerve channel.

 Draw right nerve channel.

The rest part in this toolbox is for future releases.

 

Figure 5.34 shows an example of nerve creation. The arch curve needs to be adjusted before entering the nerve modeling tool.

4132

(a)

(b)

Figure 5.34. Nerve channel drawing. (a) Process. (b) Results

Nerve channel drawing steps are listed below. Upon entering this step, the system will automatically changes to panoramic mode. Therefore, make sure the arch curve has been well defined before.

1)       Choose to define left channel

2)       Identify the entrance point by wheel to change slice, MB1 to change thresholds, etc.

3)       Place handles by MB1, change slice by mouse wheel. Keep doing this when the nerve is tracked. MB3 to finish the tracking

4)       3D nerve model shows up and changes following the 2D

5)       Repeat for another side.

 

UI

Description

 

  Tooth to extract

Add treatment notes

Finish definition of an extraction area.

 

The steps to specify tooth extraction are listed below. The tooth area can be removed first by the extraction tool found in the segmentation toolbox of the case definition panel.

1)       Enter planning page See Figure 4.36

2)       Enter first tooth number

3)       Add treatment notes

4)       Orient and zoom either 3D window so that the tooth area is well displayed

5)       Start specify tooth extraction area

6)       Draw an area by click on the window. When profile is closed, the area is defined

7)       Okay to finish specifying an area

8)       Go to Snapshot navigator to review the created notes. See Figure 4.37.

7564321

Figure 5.35. Define tooth extraction notes

Figure 5.36. Review the notes

 

UI

Description

  Define bone grafting height

 Define bone grafting range

Add bone grafting area. F1.43

 

Finish definition of a bone grafting area.

 Define sinus grafting height

 Define bone grafting range.

 Add bone grafting area.

 Finish definition of a sinus grafting area.

The user interactions are similar to "Tooth Extraction".

UI

Description

  Define bone reduction height

 Define bone reduction range

Add bone reduction area.

 

Finish definition of a bone reduction area.

The user interactions are similar to "Tooth Extraction".

UI

Description

 

Add virtual tooth models.

 

Add additional optical scans or STL files.

 

 

These tools will just prompt the user for a STL file. The specified STL file will be imported into the graphics windows, and the user can further move and rotate the STL model with placement widgets. See Figure 4.38 for a screenshot.

TIP: It is very important to have additional models like antagonist, diagnostic models, virtual teeth, etc. in order to preview the implant outcome. This is especially important for fully edentulous cases if the radiographic guides do not have enough features to help plan the cases.Figure 5.37. A virtual tooth model placed into the scene.

 

 

 

 

 

UI

Description

 

 

  Set tooth number

 Specify if there will be immediate tooth extraction at the implant site. The surgical guide design module will use this flag to design guides accordingly.

 Go to implant library.

Shows the selected implant model information.

Implant Diameters (top and bottom)

 Define implant catalog length and actual length.

 Add/Update Implant

View/inspect implant neighborhood

Check implant interference

 Turn on/off implant parallel option so that the new implants will follow the direction of the previous one

 Make all implants parallel to the first one

 Delete implant

 Go to previous implant (Set current)

 Go to next implant (set current)

Show/Hide safety zone of implants, and define the size of the safety zone

Show/Hide the drilling sleeves

Drilling sleeves for all drill sequences.

Drilling sleeves for pilot drills only.

 Abutment functions

Customize drilling sleeve height

Customize the diameters of drilling sleeves

Customize the drill prolongation

 

 

 

The procedures to place implants and adjust implant locations are shown in the following pictures. Auxiliary functions are also included in this workflow.

(a) Select Implant

(b) Add implant

 

(c) Additional functions

(d) Make implants parallel

 

(e) Fine tuning the implant  placement

(f) Implant neighborhood bone density inspection

Figure 5.38. Insert and place implants

With dual scan cases, radiographic guides are made to fit onto the plaster/stone models. The major consideration at manufacturing time is the aesthetics other than treatment planning or surgical guide design. Often times, there isn't enough materials for placing drilling sleeves.  This is shown in the Figure 4.40. In the left, the green cylinder shows the space the drilling sleeve will take. The middle one shows the cross section that green sleeve extends out of the radiographic guide.  The right one is the surgical guide created for the scenario. The green and red areas interfere with patients' soft tissue, which is not right for the tissue-based surgical guide. The material in such an area can be removed by software or a technician after manufacturing. However, this can lead to problems; for example, the sleeve can be too short for guiding the drills after been trimmed.

 

        

Figure 5.39. Adjust drilling sleeves

The tool in this section is to solve this problem by either changing the sleeve length, or changing the prolongation of the drilling operation.

   

(a)                                                                           (b)

Figure 5.40. Customize sleeve length and drilling prolongation. (a) Shorter sleeve.

(b) Bigger prolongation with original sleeve.

The dialog design is as below. It has an implant tree with header, and a couple of buttons.

 

Figure 5.41. Implant library dialog

UI

Description

 

See the full picture above this table.

  Sort implant lib by ID

 Sort by diameter

 Sort by apical diameter

 Sort by length

 And a new implant make

 Add a new implant series

 Add a new implant model

 Add implant’s STL file. The implant STL models have to be placed in a predefined coordinate system properly. Contact technical support for more details.

 Add the STL files of an implant’s compatible abuments. The STL models have to be placed in a predefined coordinate system properly. Contact technical support for more details.

 Delete selected implant or category

 Save implant lib

 Ok and close dialog

 Cancel operation

 

UI

Description

 

The user click on this button, and then the location on the radiographic guide or stone model, a preview cylinder for the anchor pin will be created with placement attached. The user can further adjust the location and orientation.

Choose the anchor pin design of either NobelBiocare or Glidewell compatible.

For customized, system will prompt for STL model specification and key dimensions. STL models will need to be placed in predefined coordinate system properly. Contact technical support for more details.

 

The anchor pin placement and adjustment operations are similar to implants.

 

 

UI

Description

 

 

Show registration algorithm error and allow adjustment for simulation purpose.

 

Show and allow to adjust segmentation errors

Specify surgical guide making error/dimension

Specify surgical guide making error/hole position

 Specify surgical guide making error/hole orientation

 Specify surgical guide making error/linear deformation

 Specify surgical guide making error/angular deformation

 Surgical guide positioning error/position

 Surgical guide positioning error/orientation

Start simulation.

Pause simulation.

End simulation

This function will generate a series of locations for an implant, and update all the image views moving the implant from one location to another. By doing this the system simulates the possible errors of the treatment plan and procedure.  The user can thus preview the extreme situations and assess the treatment plan. Figure 4.44 shows a series of implant locations in the panoramic view.

  

Figure 5.42. A series implant locations

UI

Description

 

List the snapshots, allow selection.

  The thumbnail of a snapshot.

Show and double click to edit notes/comments.

Set the snapshot to be current, meaning, restore one of the image views to the status when the snapshot was captured.

Show bigger picture of the selected snapshot

 Delete selected snapshots

 

The bigger window to show a snapshot.

 

UI

Description

Use tree list to navigate through the objects created during planning and design.

The selected object – if applicable – will have their properties shown in the table and allow editing.

 Update objects by the edited properties.

Make current the selected object.

Make selected implants parallel to the first selected.

Use selected model as the base for surgical guide design

Show/Hide selected object in 2D views

 Show/Hide the selected object in assembly view.

Delete the selected object.

Cancel object editing

 Change the color scheme for bone model.

Change the color of selected object to one of the colors in the pull down menu, or by color selection dialog. The dialog can be brought up by the last item in this combo box.

 Change the opacity of selected object.

 Change the ambient lighting of selected object.

 Change the diffuse lighting of selected object.

 Change the specular lighting of selected object.

 Change the color saturation of selected object.

 Change the color luminance of selected object.

Surgical guide options.

UI

Description

Select surgical kit.

Configure surgical kit.

 

Choose different surgical guide option

One guide per step (Not available now)

Pilot drill if surgical kit not applicable

Pilot drill only

Drills to match implant sizes instead of surgical kit

Drills to match surgical kit instead of implant size

With glue channel

Surgical kit configuration.

UI

Description

Surgical kit name.

Browse definition files.

 

Kit parameter display

This option is on, if the kit is a guided surgery kit. The surgical guides will be designed for implant placements using the drill guides, or handles. Drill guides or handles are sometimes referred as spoons, keys, or sleeve adaptors.

If the option is off, the guides will be designed according to the implant size in the list. If a certain implant diameter is not found in the table, the smaller size closest to the given diameter will be used.

Delete implant platform

New implant platform

Save configuration as a new file

 

 

Save, discard or cancel editing

Figure 4.45. Surgical kit configuration dialog

UI

Description

 

Choose surgical guide style. The opening on the top of the surgical guides can be rectangular or cylindrical.

Drilling preferred: the guide can be drilled, milled or printed. Essentially, no material can be added to the radiographic guide.

No drilling: the guide can not be a drilled guide from radiographic guide. Materials can be added to the guide as needed.

Define surgical guide type

1. Set guide type to tissue-based

2. Set guide type to bone-based guide

Set the option on/off to remove undercuts in surgical guide. Default is on.

Change the undercut angle if the option is on.

Update the guide insertion direction (in order to remove undercuts)

 Set guide thickness

Prepare data for surgical guides

Track: click points on the base model, the system will connect them by tracking the model until the profile is closed.

Circle: draw a profile in the design window to cut the base model (bone model or scan of plaster model) to create surgical guide. This is an alternative to the "Track" tool.

Cut: Use the profile to cut the base mode.

Alternative: there are cases the system actually returns the area outside of the tracking profile. When this happens, this button will switch the result to the inside part.

Reset: Undo the cutting

Reverse: reverse the normal of the trimmed surface model  in order to ensure the direction is good for making guide

Calibrate: adjust the plaster model so that it matches the tooth shapes of the CT scan.

Design surgical guides

Generate the guide model. This single button will include all the combinations of surgical kits, guide type, manufacturing method, etc.

 Circle an area on the surgical guide

Trim the guide to keep the circled area

Reset the model trimming

Add access opening to a surgical guide

Add inspection window by the profile specified by the circle tool

Add irrigation window

Add anchor pin

Add case tag

Export surgical guide as STL file

 

 

 

The tracking tool is to select a region on the base model, from which a surgical guide will be created. The operation is illustrated in the following. The stone model is used as a base, a profile/boundary is created, a surgical guide base is created by selecting area within the profile, and then the surgical guide is created for the planned implant.  The surgical guide is added into the object navigator, and can then be viewed by all the 2D and 3D views.

    

Figure 5.43.  Surgical guide styles with cylindrical cuts or rectangular.

(a) Initial base model                                                           (b) Tracking a boundary

(c) Finish defining the boundary                                       (d) Cut the base model for guide design

(e) Surgical guide designed.                                               (f) Surgical guide is planning view with distance map

(g) Define a profile for inspection window                       (h) Cut the inspection window

(i) Define an irrigation window                                            (j) Finished irrigation window

(k) Access opening                                                                (l) Defining case tag

(m) Finished case tag

Figure 5.44. Surgical guide design process. This process is for tissue-level guides based on stone model or bone level guides

UI

Description

Generate or update anatomy model (a component of the master mode)

Export STL file

Create or update master stone model

Export STL file

Create or update implant inserts model

Export STL file

Figure 4.47 gives an illustration of the master model created from radiographic guide and bone structure. Figure 4.48 is one created from optical scan of the stone model.

Figure 5.45. Master model and implant inserts for a dual scan case with radiographic guide.

 

Figure 5.46. Master model and implant inserts for a dual scan case with optical scan of a stone model.

 

UI

Description

Input operator/planner’s name and contact information that will be shown in the reports.

Add additional comments

Set to generate images for the plan using volume rendering

Set to generate images mapping bone density into colors.

Generate report and browse it in web browser

 

A treatment plan has the following sections:

1.       Customer (dental office, lab, etc) log and GuideMia logo.

2.       Title with customer address and contact

3.       Patient basic information

4.       Plan overview, including

a.       Implant list

b.       Anchor pins

c.        Drilling instructions

d.       Surgical guide

e.       Plan overview pictures (slices, cross sections, bone model, surgical guide, etc)

5.       Tooth Extraction: list screen shots and notes

6.       Bone Reduction : list screen shots and notes

7.       Bone Grafting : list screen shots and notes

8.       Sinus Grafting : list screen shots and notes

9.       Diagnosis And Planning Notes : list screen shots and notes

10.   Implants: List 16 cross section views for each implant

 

 

The following are the basic operations in all the 2D views.

 

 

 

1.       MB1: selection or input tool. For example, if an implant is showing, clicking on it will show its placement widget. If defining a distance, MB1 will specify one of the two points.

2.       MB1 press, move and release: If an object (such as a handle) is selected, this will move the object, otherwise, adjust the window/level values for thresholding. The threshold values will be shown in the status bar at the bottom of the system window.

3.       MB2 press, move and release: pan the viewport of the rendering.

4.       MB3 press, move and release: zoom in and out.

5.       MB3: stop the underlying operation, or exit from a repeatable operations. For example, if the user is defining a nerve channel by adding nodes, MB3 will finish the channel definition.

6.       MW: scroll through the image slices.

7.       CTRL_MB1: fast scroll through the slices

8.       MB1 Double click: if mouse is over an implant, the implant library dialog will popup. Otherwise, change 2D view slice lines to the clicked point and show slices accordingly.

9.       Mouse move over pixels: show pixel Hounsfield unit values

 

The following are the basic operations in 3D windows:

 

1.    MB1: selection or input tool. For example, if an implant is showing, clicking on it will show its placement widget. If defining a distance, MB1 will specify one of the two points.

2.       MB1 press, move and release: rotate the image, in other words, rotate the viewing 'camera'.

3.       MB2 press, move and release: pan the viewport. As a result, all the rendered objects are moved.

4.       MB3 press, move and release: zoom in and out.

5.       MB3: stop the underlying operation, or exit from a repeatable operations. For example, if the user is defining a nerve channel by adding nodes, MB3 will finish the channel definition.

6.       MW: MW is only used in certain operations, for example, move the cross section plane along the arch curve if in this clipping mode, update the implant neighborhood size when inspecting the neighborhoods, etc.

 

1.       Initialize arch curve by axial view

2.       Move arch curve by drag and drop

3.       Adjust arch curve by handles

4.       Update panoramic view following the arch curve

1.       Show (Initialize) slice lines and region of interest in all 2D views

2.       With Panoramic view, show slice lines in sagital and coronal views, arch curve and cross section line in axial views.

3.       With cross section mode in 3D views, show a cross section line in axial window accordingly.

4.       All slice lines in all views are associated and move together.

5.       All 2D views will have scales/rulers

6.       The changes of and region of interest boxes will trigger the update of bone segmentation

In 2D views, the following interactions will be implemented:

Figure 5.47. 2D placement widget

 

 

 

 

 

1.       MB1 drag and drop placement handles: rotate model and widget about tip or top point of an implant, or center of any other object

2.       MB1 drag and drop the center line of a placement widget: : rotate model and widget about center of the underlying object

3.       MB2 on handles: shift the shown slice to the center of the underlying object

4.       MB1 drag and drop on the model: move the widget and model

5.       MB2 drag and drop on the two triangles like handles for objects other than implants: reposition the placement widget to another location of the model.

6.       All changes of will be propagated to all image windows

 

In 3D views, the following interaction will be implemented:

            

Figure 5.48. 3D placement widget

7.       Full 3D widget mode:

o    MB1 drag and drop spherical handles: rotate implant about its center line

o    MB1 drag and drop on arrow head: rotate implant around its center

o    MB2 drag and drop on arrow head: move implant along center line

o    MB1 drag and drop the implant model: move the implant to new location

o    MB1 drag and drop the four square sides: rotate the model about X or Y axis of the placement widget

8.       Cross section mode:

o    MB1 drag and drop on arrow head: rotate implant around the axis defined by center line and view normal.

o    MB1 drag and drop the implant model: move the implant to new location on the cross section plane.

o    MB2: change the orientation of the cross section plane, and update the cross section line in 2D axial view.

o    MB1 to change the thresholding

9.       All changes of will be propagated to all image windows

 

System will work out of box without user customization. Limited user configuration can be done through an external file config.dat. This file also serves as a place to save system settings or status. It has the following data items.

This file config.dat is in C:\Users\[AccountName]\AppData\Roaming\GuideMia.  In this path "AccountName" represents your windows login.

ImageDirectory

 where the image data are stored. System will start from here in the project/new dialog.

view2DColor

view color mode or black/white mode in 2D views

view2DColorMapMode

view bone quality mode in 2D views

view2DWindow

the “window” value for 2D views

view2DLevel

the “level” value for 2D views

scanTemplateWindow

the “window” value for radiographic guide segmentation or visualization

scanTemplateLevel

the “level” value for radiographic guide segmentation or visualization

 


 

6 .     Treatment Planning Workflow with Dual Scan

This chapter will guide you through a comprehensive treatment planning workflow. The following is the quick index for the treatment planning steps. Each of them corresponds to one or two pages of screenshots along with annotations in section 6.5.

1.       New project

2.       Image window interactions

3.       Threshold adjustment

4.       Load radiographic guide

5.       Automatic registration of radiographic guide

6.       Use object navigator to browse objects

7.       Bone segmentation

8.       Undo/redo. Save project

9.       Browse project file

10.    Thresholding of radiographic guide

11.    Create tooth model

12.    Adjust tooth model by cutting

13.    Surface rendering

14.    Bone model from surface peeling simulation

15.    Simulate tooth extraction

16.    2D views: panoramic view, arch curve manipulation, slice changes

17.    2D views: color mode

18.    Manual registration of radiographic guide

19.    Specify markers

20.    Registration report

21.    Finish registration

22.    Create virtual tissue model

23.    Generated virtual tissue model

24.    Nerve drawing

25.    Finished nerves

26.    View nerve with bone structure

27.    Model navigator and model display editing

28.    More about model navigator

29.    Plan tooth extraction

30.    Review tooth extraction in snapshot navigator

31.    Plan bone grafting and sinus grafting

32.    Capture snapshots

33.    Add additional references and virtual teeth

34.    Virtual tooth manipulation with placement widgets

35.    Implant planning - select implant from library

36.    Implant planning - add implant

37.    Implant planning - adjust implant parameters and advanced operations

38.    Implant planning - more placement operations

39.    Implant planning - make implants parallel

40.    Implant planning - implant position adjustment

41.    Treatment plan error simulation

Implant treatment planning workflows in GuideMia are classified by the patient situations and the choices of treatment planning approaches.

The clinical cases can be classified as:

  1. Lower jaw fully edentulous cases
  2. Upper jaw fully edentulous cases
  3. Lower jaw partially edentulous cases
  4. Upper jaw partially edentulous cases

All the cases can come with variations in the following areas:

  1. With variations of bone modification (either grating or reduction), tooth extraction, sinus grafting, etc
  2. Without any of such treatments

Treatment planning approaches are concerned about both the inputs and the outputs. The main input data includes the following.

  1. For all the cases, the patient CT scan is a necessary input.
  2. Radiographic guides are used to classify clinical cases.
    1. Cases based on CT scan of radiographic guides
    2. Cases not based on CT scan of radiographic guides.
  3. Additional data
    1. Cases using other data sources such as digital models of patients’ oral-dental structures or plaster models.
    2. Cases not using other data sources, meaning, cases based on CT scan only.

Treatment planning can be also categorized by the outputs.

1.       Cases  generating surgical guides.

2.       Cases  generating digital models of patients' anatomy embodied with implant information, from which surgeons can further plan a treatment plan, and make surgical guides using any approved lab procedures.

In general treatment planning has four categories of clinical cases as far as the involved steps in a workflow are concerned:

·         Treatment planning with patient CT scan only. No surgical guide will be required or generated.

·         Treatment planning with patient CT scan, and additional models (either CT scan or optical scan) that can provide references for planning. No surgical guide will be required or generated.

·         Treatment planning with patient CT scan only. Surgical guide will be generated based on patient scan only.

·         Treatment planning with patient CT scan, and additional models (either CT scan or optical scan) that can not only provide references for planning, but also serve as base models for surgical guide design. Surgical guide will be designed and output.

 


1. Select “New” from toolbar or menu3. Open the DICOM series2. Browse and select any DICOM file of the patient scan

Step 1.                 New project.

 

In any view press and hold right button (MB3) and move mouse to zoom in/out. Middle button (MB2) to pan the views.3D object view showing the working object3D assembly viewArch curve Press and hold left button (MB1) and move mouse to rotate 3D views.Region of interest handleContext toolbar. Automatically show/hide by mouse entering or leaving windowHandles for region of interestSlice line handleTask panels with six pages:
Case definition
Implant Place 
Snapshots
Object navigator
Surgical guide design
Reporting

Step 2.                 Window upon case opening. There are three 2D slice windows and two 3D views. Please see the picture for some basic operations

Thresholds or HU value feedbackPress and hold Left Mouse Button (MB1), move up/down to adjust threshold level, left/right to adjust threshold window3D model following the thresholds

Step 3.                 Bone threshold adjustment.

Step 4.                 1. Click this button to add CT scan of radiographic guide, or, scan template2. Browse and select any one of the DICOM files of the radiographic guideOpen datasetLoad scan of radiographic guide, or, scan template. Same as loading patient scan, one DICOM file needs to be specified.

Step 5.                 After loading radiographic guide, or scan template, registration of the guide and the patient scans are automatically performed. The message window shows the approximate marker deviations between the two scan. The registration can also be manually done as illustrated later. The initial thresholds of the radiographic guide depend on the last session, and can be adjusted later.

 

4. Double click on "Bone" model to make it "current"2. Select any item here and double click will make the item "current"3. The selected item, or, referred as feature, will be shown in this window1. Select this page

Step 6.                 1. Click here to switch task panel page2. Click to select an objectUsing object navigator to view the radiographic markers. More operations with the navigator will be introduced later.

5. Click to place seed points in any 2D window.4. Click this to enter seed points3. Adjust thresholds for the bone structure.2. Adjust region of interest by handles1. After making bone structure current, return to this panel, and enter the "Segmentation" page6. Bone model will be updated in both 3D windows instantly

Step 7.                 2. Go to this page5. Enter Selecting seed points6. Select a seed point7. Click the button again to finish seed points 4. Further adjust thresholdsBone segmentation. It has three basic inputs: region of interest, seed points, and thresholds.

Open existing projectSave project. A file selection will pop out for project file name. Project file has an extension “.pie”Redo/Undo. Some operations’ redo/undo responds slightly slowly.

 

Step 8.                 Save Project, and some other operations.

Step 9.                 Go to menu "Project", select "Close" to close project, "Exit" to end the session, and then restart GuideMia, open project, and go to the "Segmentation" page to continue this case.

3. Change threshold of the radiographic guide. Make sure to change it back to -500 ranges to get a good model.1. If radiographic guide is not current, go to this "navigator" panel to make it current, and return to the "Segmentation page" when the bone model is created.2. Go to this task panel.

Step 10.             Change the threshold of radiographic guide, or, scan template.

 

1. Adjust tooth threshold. The tooth model will be created and show up in the object view right away.

Step 11.             Create tooth model  by thresholding

2. Select menu “Tools/Delineate object”.1. Adjust tooth threshold. The tooth model will show up in the object view right away.3. Circle the area of teeth. Click on the window to create a profile.  When profile is closed, the tooth model will be done.

Step 12.             Adjust tooth model by cutting

 

1. Make bone model "current"3. When the surface model is shown, inspect this place. There is a small hole here because there was a very loose area or dent in the bone model2. Turn to "surface" rendering mode.

 

Step 13.             Advanced bone modeling topics.  Surface rendering,

The holes disappear.3. Perform the operation. It takes about a minute. Then check the 3D views.2. Set the peeling "thickness" to 1.75, which corresponds to the rough size of the hole shown in last page.1. Go back to this panel and the segmentation page.

Step 14.             Advanced bone modeling topics.  Simulate soft tissue peeling. There is also an operation called "low density processing", which is a faster but approximate version of the "surface peeling".  For this case, if we will only use radiographic guide to create surgical guide later, we can use this faster version. However, bone-level guide needs more accurate bone model. Surface peeling is a better choice for this.

 

 
After tooth extraction
4. Click point to define profile. When profile is closed, the tooth area will be removed.3. Click this button to start.1. If bone model is not the current object, go to this page to make it current.2. Rotate and zoom the window so that the tooth area can be clearly viewed.

Step 15.             Additional bone model processing - tooth extraction. This is for the purpose to place implants and to generate surgical guide that will be used with immediate tooth extraction.

 

3. Click to view 2D panoramic mode2. Adjust arch curve and area by click and drag the circular handles  1. In any 2D view, scroll the mouse wheel to change current slice 

Step 16.             2D views: panoramic view, arch curve manipulation, slice changes

Change slices, adjust arch curve, and show panoramic mode

Enter this window, the toolbar will show up. Click this button to show 2D in color or black/white mode. Press MB1 and move mouse up and down, left and right to change 2D thresholds. This will not affect bone model any more.

Step 17.             Change 2D views.

 

4. Click to restore the status before registration.3. Adjust thresholding for the markers on the patient scan.1. Enter this page for manual registration if the results of auto registration are not good enough by visual checking.2. The two image windows will be setup for registration. Zoom/rotate and other tools can be used to better orient the mode so that the markers can be well viewed.  The left side is the markers on the radiographic guide.  The right side is markers on the patient scan.

 

Step 18.             Registration of the CT scans of patient and radiographic guide. Most of the time, users don't need to do this. The system requires same number of markers, but the order you specify them does not matter.

3. Specify markers by clicking on them. Typically it is not necessary to do so since the markers have been recognized.1.Click to start specifying markers.2. Specify markers by clicking on them.

Step 19.             Registration. The markers have been specified.

1. Click this when markers are all specified. Message about the results. It is important to know that the registration deviation can be different from the automatic registration.
Click on Ok to finish

Step 20.             Registration report.

Step 21.             Registration is completed.1. Click here to enter this page, the display will be set as registration mode with the markers displayed. The windows setting shown in the previous step will be changed into the one in this page.

5. Click to finish.3. Click on this if necessary.2. Check this box1. Go to this page4. Rotate the model to this direction so that the undercuts can be the minimum.

Step 22.             Virtual Tissue Model. This function is used to create a tissue surface model as a reference for planning and a way to define surgical guide extraction/insertion direction. This is an optional tool.


Step 23.             1.Enter this page1.Enter this page2. If the radiographic guide is not current object, use this button to show it in the 3D single object window. 4. Generate.3. Confirm that the insertion direction is well defined by the view normal. If not, go to the single object window to rotate and orient model.Virtual Tissue Model. Operation finished. Color map illustrates the gap between the radiographic guide and bone mode. Gray/White are the tooth area, while two models touch each other. Green to black means bigger distances. The orange area is due to the removed tooth. In general if you see the color distribution on the left side and right side are not even, the radiographic guide might not have been placed properly when scanned.

 

 

3D nerve model shows up and changes following the 2D 5. Place handles by MB1, change slice by mouse wheel. Keep doing this when the nerve is tracked. MB3 to finish the tracking3. Identify the entrance point by wheel to change slice, MB1 to change thresholds, etc. 4. Choose to define left channel2. Change back to black and white mode1. Go to this page 

Step 24.             Manual nerve tracking.

 

Step 25.             Manual nerve tracking. Do the same thing to the right channel. This picture shows both sides are created.

With bone quality mode, a little bit transparency shows a lot nicer volume rendering images. Keep lowering the opacity till the nerve channel is visible. The volume rendering quality decreases when the bone model has surface peeling.  Rendering without surface peeling below:  Color mapping.2. Click this button to restore volume rendering.1. Click this button. 

Step 26.             Show Bone Density/Quality

Current object window/viewTools to edit "current" object display.

Accept editing

Parameters of selected object, such as thresholds, is displayed here. In-place editing is possible.

Navigator PanelObject tree.  

Step 27.             Model navigator and model display editing

 

Show/Hide the selected objects in the 2D views

Make the selected model as the base for surgical guide design

Delete selected object

Show/Hide the selected objects in the assembly view

Make the selected implants parallel

Make the selected object current

Step 28.             More about  Model Navigator and display property editing

 

 

1. Make the bone structure current object, then enter planning page and enter the tooth number5.  Draw an area by click on the window. When profile is closed, the area is defined.3.  Orient and zoom either 3D window so that the tooth area is well displayed.2. Add treatment notes6. Okay to finish specifying an area4. Start specify tooth extraction area

Step 29.             Tooth Extraction Notes

3. Show a bigger picture in the window below.3. Delete selected note.2. Click to select a tooth extraction note. We create snapshots of all the image windows in addition to the treatment notes,1. Go to this "Snapshot" navigator 

 

Step 30.             Using Snapshot Navigator to see the defined tooth extraction, bone grafting, sinus grafting, or bone reduction.

Circle the area of planningSpecify the approximate size of the grafting 

Step 31.             Bone and Sinus grafting, Bone Reduction. Same procedure as tooth extraction.

 

6. Go back to "assembly" window, rotate model, and then click on this "Make Current" button. Notice how the 3D window is changed.5. Select the newly created snapshot, and click on the arrow to show bigger thumbnail in the window below. 2. Adjust this window till the status the information you want to capture, such as a spot with pathology finding, is shown as desired. 1. Click to turn off the display of radiographic guide, and go to the object navigator to turn on the virtual tissue model4. Click on the "Snapshot" icon to create the snapshot. 3. Enter the 3D window, click button to turn on clip mode. . Manipulate the clipping plane. MB1 on arrow to rotate, MB2 to move. MB1 on the plane handles to resize. 

 

 

Step 32.             Create Snapshot Object, which is a view status of either of the image windows. It captures an image, and let the users to write notes. This is basically a “finding card” for diagnosis or planning. This picture also includes some additional operations.

2. Click button and select STL file for the tooth. You need to have your tooth anatomy library.1. Enter from here3. After the file selection, the tooth model is added into the 3D windows with a “Placement Widget”.  If an implant od the same tooth number has been placed already, the tooth model will be placed accordingly, otherwise, an initial position is proposed with reference to the arch curve.

Step 33.             Add additional references from STL files. This is to add virtual teeth, and other reference models.

 

 

MB1 to drag, move and drop to move widget along Z-axisMB2 to drag, move and drop to rotate the Z-axisZ axis2D version of a placement widget. Manipulation is simplerPress middle button on the handle to set 2D sliceDrag, move and drop side edges to rotate about X/Y axisMaximize window

Step 34.             Manipulating Placement Widget. Each object has a placement widget in all the windows. All the placement widgets of one single object are all associative. Any changes of one of them will be propagated to the others.

3. Specify if tooth extraction is needed. This needs to be on for this case since the implant site on the radiographic guide is made with tooth remaining. It will also be on for the cases optical scans as scan templates and the teeth still exists.1. Enter from here5. Implant library browser after step 4. Select the desired implant and compatible abutments click "OK" button to finish. Not all implants have the STL files in the library.6. Adjust implant parameters with our going to implant library tool. Use with caution only when implants are not in library.4. Browse implant library if necessary

Step 35.             Place Implants (1) - Select Implant Model/Type from library.

9. Adjust implant locations by all of those handles.8. Clicking on any place on either of the image window will add the implant to that location, with placement widget and labels attached.
    The operations of the placement widgets are same as the one for virtual tooth.
7. Click button to add or update implant. If implant exists, this will update implant position. Otherwise add implant. If the virtual tooth exists, implant will be automatically added. If not, go to step 8. 

Step 36.             Place Implants (2) - Add an implant.

 

Implant labelImplant safety zone and drilling sleeve.Safety zone and drilling sleeve display, parallel implant optionsInterference detectionGo to next/last implantDelete current implantMore implant options

 

Step 37.             Place Implants (3) Adjust the implant location with either of the placement widgets in either of the image windows. See the virtual tooth page for placement widget manipulation.

White line corresponds to the cross section view in 3D windowsTurn on/off cross sectional mode. Note an implant, abutment, anchor pin or sleeve has to be the current object to turn on this modeTurn back on scan templateRotate implant about center pointRotate implant about tip pointDrag and drop implant

Step 38.             More implant placement

3.Click to add the implant here2.Click to add another implant1.Change tooth numberMake implants parallel. The "checkbox" will make implants created afterwards parallel to the previous one. The button will make all parallel to the first one.

Step 39.             Place Implants (4). After making implants parallel. There is also a button in the navigator panel, which make all selected implants parallel to the first selected.

 

Change the opacity in this view using the toolbar or the object navigator will enable the users to see through the bone model so as to check the clearance between implants and nervesThis button is to turn on/off the placement widgets.Whenever an implant has been placed, this fine tuning tools will be available.Fine tuning step length in “mm” or “degree”

Step 40.             Place implant – 4

2. Click to drop anchor pin here. ,3. Use placement widget to adjust position. Keep the center of the placement widget on or close to the model.,Opacity 

 


3. To start/pause/resume and stop error simulation. It is suggested to turn assembly view to surface rendering mode because volume rendering can be slow.3. Notice how the implant positions are changed. You can use mouse button to pan, rotate, and zoom windows while the error simulation is running. Some display changes are also possible. 1. Enter this page to start.2. Review and adjust all error sources. Some are based on our calculation, such as registration error. Some are assumptions. Users are advised to make their best guess, and accumulate some data from their experience.

 

Step 41.             Error Simulation. This operation has a high demand of GPU capability. Make sure you have a good graphics card.

 

Error Simulation. Series Implant locations.

This concludes our Implant Placement part of the workflow.

 

Please see chapter for more details for surgical guide design. In most of the cases, surgical guide design for dual scan cases is just one mouse click on the button to generate or update surgical guide.

Switch image viewsInitialized design view

Step 1.                 Enter Surgical Guide Module

 

1. Generate the guide2. Export surgical guide STL model. May not  be available with trial versions.

 

Step 2.                 Generate surgical guide model.

 

 

4.Display option for the report.1. Since we have multiple surgical guides, go to the navigator to select the one we want to generate report, and double click the tree item to make it current. In this case we select the first guide we create. Also turn on/off object display for other objects as desired.3.Type additional notes2. Enter here.

Step 1.                 Generate Treatment Plan (1)

Step 2.                 Generating Report.  Once the button "Generate report" is clicked. system will ask for an html file name.

This will generate a HTML page and a set of image files, which can be browsed and printed with web browser anytime.


 


 

Visit www.guidemia.com for a complete sample of a treatment plan report.You can place your logo here

Step 3.                 Treatment Plan - Cover Page has patient information and plan overview.

Treatment Plan - Drilling instructions and overview images. Please  note only the last surgical guide you designed will be treated as the final plan.

 


 


7 .     Surgical Guide Design

The following is a list of the operation steps to complete surgical guide design. They correspond to the screenshots with annotations in the reminder of this chapter. The components of a report are illustrated after all those steps.

1.       Enter design module, plan validation.

2.       Choose and configure surgical kit. With the supported implant library and surgical kit types, the software can automatically choose surgical kit for you, therefore this is an optional step.

3.       Specify user defined surgical kit.

4.       Configure surgical kit

5.       Basic steps to design a surgical guide for dual scan case.

 

Plan validation results. For this specific case, we need to cancel this dialog and adjust the implants, and try to enter guide design again. Complaints about the intersection between implants and tooth structure can be a “false alert” in this demo case, because tooth 19 is still there and we are placing this implant. When creating tooth segmentation we can exclude tooth 19.Ignore warnings and click OK to continue.WarningCritical itemsClick to enter

Step 1.                 Plan validation before the system gets into the guide design environment.

Switch image viewsInitialized design view

Step 2.                 Enter Surgical Guide Module

3. Surgical kit configuration toolThis will allow choosing a user/vendor configured surgical kit2. Choose predefined surgical kit1. Enter this page.Turn on bone display

Step 3.                 Choose surgical kit

This is checkbox indicates that the sleeve definitions in a surgical kit is used for implant placement (and also osteotomy). If this is off, the sleeves’ inner diameters are not bigger than implant diameters, thus the surgical guide will only for osteotomy but not implant placement.Sleeve and drilling settings of the surgical kit

Configure Surgical Kit. This tool allows the users to define implant platforms, drilling prolongation, sleeve thickness, etc. The kit configuration is not supposed for individual cases. It is to add support to kits from different vendors.

If "User Defined" is selected, the file browser will pop up, and let user to select a configuration file.

Select user’s surgical kit configuration file.

 

2. Extract the adaption surface.  This is an optional step to help avoiding interference between guide and patient anatomy.  Most of the time this Is not necessary.Guide might have problems if step 2 is skipped.  Tools to show/hide objectsTool bar for zoom, snapshot, etc3. Generate the guideExport surgical guide STL model. May not  be available with trial versions.1. Style of the top opening of the implant sites.Generated surgical guide

 

Step 4.                 Tissue-base surgical guide design (1). Most of the time, step 2 in this figure is NOT needed. See section 7.3 for more details

3. Click to Export STL file.Turn on/off radiographic guideFeatures for implants with tooth extractionFeatures for implants without tooth extraction

 

Step 5.                 Surgical guide design (2). Result.

 

 

In this chapter, we introduce the post processing of surgical guide design. We will use the example in last section. Most of the features are also available for surgical guides designed from optical scans.

 

1.       Trim surgical guide by a profile.

2.       Add inspection window

3.       Add irrigation window or access opening

4.       Add case tag

5.       View surgical guide in planning view.

6.       Enter master model tool box.

7.       Create master anatomy model.

8.       Edit implant after surgical guide design.

9.       Update surgical guide design after choosing different implant.

 

2. Draw the area that will be removed.3. Finish. The circled area will be removed.1. Click to start trimming.

 

Step 4.                 Tissue-based guide design (3) - Trim by profile

2. Create an inspection window Circle and area1. Circle an area

 

Step 5.                 Tissue-based guide design (4) - Add inspection window. Same process as "trimming".

3. Click to finish1. Click to start2. Click a point to place the box widget. MB1, MB2 to move and rotate the box.3. Irrigation window added.

 

Step 6.                 Tissue-based guide design (5) - Add irrigation window. The procedure to add access opening is same to this. The system behaves a slightly different. Once the user select a point on the surgical guide closed to an implant site, the system will automatically determine the direction of the opening, and propose a size of the tool body to create the opening.

4. Click to finish1. Click to start2. Edit tag3. Click to place and use the widget to adjust location.

Step 7.                 Tissue-based guide design (5) - Add case tag.

 

 

Step 8.                 View surgical guide in the planning view.

 

 

Turn on the bone model.Enter the panel.

Step 9.                 Master Model (1) - Enter the task

 

 

Before the implant inserts are created. The master bone modelImplant inserts.3. Generate the implant inserts (replicates)2. Generate the anatomy model.1. Go back to this panel and enter the "Master Mode" page.The master tissue model4. Hide the surgical guide.

Step 10.             Master Model (3) - Master models finished.

 

 

Step 11.             Implant editing. Change the implant #19. Reselect one with diameter of 4.3mm, which will is not in the surgical kit supported list. 

Updated surgical guide. The hole size now corresponds to a pilot drill. 

Step 12.             Surgical guide regeneration. Go back to surgical guide panel, click "Generate/Update Surgical Guide".  See the guide features are for pilot drills only. Then regenerate the master model. 

With radiographic guides as the base for surgical guide design, there are cases that the materials added for the drilling sleeves penetrate the interior surface of the surgical guide. Figure 7.1 shows an example. The green “rectangles” in Fig (a) are the drilling sleeves. Fig (b) shows the surgical guide designed according to the plan in (a). The circled area is where the material penetrates into the tissue surface. When a guide like this is made, the material has to be manually removed.

The surgical guide design process for this kind of cases is shown in Fig (c). An extra cutting step is introduced. Before generating the guide, click on the “Cut” button, the interior surface of the radiographic guide will be extracted and used to trim the surgical guide. After this, use the “Generate” button to create the surgical guide.

 

(a)

(b)

(c)

Fig. 7.1(a) Coronal view. (b) Surgical guide design without processing the sleeve penetration. (c) Option 1: trim the sleeve area., by the cut button then generate surgical guide.


 

 

8 .     Workflow with optical scan

The organization of this chapter is also workflow-based.  Instead of going through the functions and UI items, a treatment workflow is used to ensure that the functions are organized in a sensible manner. The workflow used in this section is a typical one. The patient is partially edentulous, and is scanned without any radiographic guide. Then an intra-oral scan is obtained. Alternatively, an optical scan of a plaster/stone model will serve the same purpose. This model is loaded and registered with patient scan, and used to design surgical guide after the treatment planning.


The following is the quick index to the steps. Each step of the workflow is illustrated in the pictures following this index. Some of them may not have detailed instructions if in chapter 5 and 6 already.

 

1.       New project by loading DICOM files

2.       View the DICOM files upon loaded

3.       Bone segmentation

4.       Automatic scatter removal

5.       Tooth segmentation

6.       Load intraoral scan STL model

7.       Enter model registration

8.       Specify markers for registration

9.       Finish registration

10.    View registered models

11.    Load antagonist model/scan

12.    Relocate placement widget and adjust model locations

13.    Create nerve drawing

14.    Finish nerve drawing

15.    Plan implant - select from library

16.    Plan implant - place and adjust implant

17.    Plan implant - cross section model

18.    Change cross section mode

19.    Inspect implant drill sleeves, etc.

20.    Inspect implant neighborhood

21.    Perform error simulation

22.    Create and review snapshots

23.    View objects navigator and pop up window in 3D views

24.    Enter surgical guide design

25.    Design boundary of base model - tracking and trimming

26.    Create surgical guide

27.    Review surgical guide in planning views

28.    Generate report


 

3. Open the DICOM series2. Browse and select any DICOM file of the patient scan1. Select “New” from toolbar or menu

1.       Create a project by DICOM series.

2.       View the DICOM files upon loaded. Please see chapter 5 for the manipulation of thresholds, region of interest, slice lines, color/black mode, opacity, etc.

3.       Bone segmentation. Go to the segmentation tool box, adjust the thresholds, the region of interest box, and specify a seed point on one of the 2D views. The system will instantly update the bone segmentation for you.

 

Automatic scatter removal

4.       Automatic scatter removal. Find the 'remove scatter' label and the two buttons at its right side. The majority of the scatters should be removed by this function.

5.       Tooth model created. Directly move the slider named as "Tooth (root) Segmentation" will create or update the tooth model for you.

Click here to add the scan data

6.       Select and stone model STL file or intra-oral scan.

File loaded. If you are not seeing the model on any of the views, the model is probably far away. Use the "Fit" button and the context tool bar of the view windows. Notice the toolbar will not show if the cursor is not in the window.

7.       Enter registration mode. Just click on the registration tab in the toolbox, the image windows will be reorganized for the registration purpose. The bone model is in the current object window, the intra-oral scan is in the assembly view. See how-to guide (chapter 8) if you want to specify another model as the registration base. Use the “fit” button on the toolbar of a 3D view to fit the view to the window size.

8.       Specify markers for registration. Once the models in 3D views are zoomed and placed properly you can click on "Specify Markers" icon in the tool panel, and then place markers on the 3D views. Remember: you do not need exactly same number of markers, you do not need the same orders of the markers, and you do not need to specify markers at a very accurate positions. If no marker is specified, entire model could be used for registration purpose. To rotate the models during this procedure, move cursor off the model and use MB1 to rotate as you normally do.

9.       Finish registration. After markers are specified, check the box "Template is positioned properly" and then click "Align". The resulted model deviation will be shown in a message box.

10.    View registered Models. Use fit, zoom, etc. You can also use context menu to show/hide models in 2D views. Move mouse cursor on the model you are interested in, and then press MB3.

 

11.    Load antagonist model/scan. Use “Additional Prosthesis/teeth models” button. The antagonist model is registered to the bone model automatically by inheriting the transformation from the intra-oral scan model. Right click on the model, one can see “Start Position” and “Show in 2D” buttons. Use them to further position and   view the model.

 

2D placement widget

Placement widget is moved to another location by drag and drop one of the two triangles by MB2.

 

2D and 3D manipulation of the widgets are similar to those of implants, except that in 2D views the rotation is always around the center of the widgets. Right click on the model, then select “Lock Position” to finish the positioning.

12.    Relocate placement widget and adjust model locations.

 

 

13.    Create nerve drawing. Adjust the arch curve and 2D thresholds, and enter nerve channel definition. In the "Draw Nerve" section there are two buttons,

one for left channel, one for right. Click to start a channel. Once you start, in the panoramic view MB1 to place a point, MB3 to finish, mouse wheel to scroll through slices. The nerve model is automatically updated in all the views.

14.    The both sides have been created.

Browse libraryEnter tooth number

15.    Plan implants. Enter into implant placement and select implant from the library.

16.    Place the implant and adjust implant by placement widgets. See chapter 5 for more details.

Click here to enter cross section model

17.    Enter cross section mode in the current object view, and also assembly view.

This line reflects the 3D cross section plane.

18.    Adjust the cross section mode. MB3 to adjust thresholds on the cross section plane, and mouse wheel to adjust the sectioning direction.

19.    Click on the cross section view buttons and return to normal display. Inspect implant drill sleeve. Turn on/off the "Show Safety Zone" and "Show Sleeve" to see the effects of this function on the 2D and 3D views.

20.    Inspect implant neighborhood. There are two modes to perform neighborhood inspection. The button in the place implant tool box is for the "current implant mode", the menu item "Diagnosis/Neighborhood Viewer" will perform this for all the implants. In "current implant mode" , move your mouse into the 3D current object view see how this function scroll through a neighborhood of an implant so that you can evaluate the bone density, the status message will show you a summary of the neighborhood of the current implant. The menu item for all implants will scroll through the neighborhood for all implants automatically. It is necessary to exit one mode before you enter into another.

           

           

Neighborhood viewer, individual implant. Use mouse wheel to change.

21.    Perform plan error simulation

 

       
  Click here to start/exit  

 


Click here to create a snapshot Select snapshot, and then edit notes, show big thumbnail, etc

Click here to enter the navigator 

22.    Create snapshots and view them in the navigator

23.    View object navigator and pop up window in 3D views

 

Save project

2. Update the undercut direction1.Rotate model until the undercut direction is well defined.3. Click to start tracking

 

24.    Enter surgical guide design. You may see warning/error messages coming from the plan validation. Some messages are critical, such as collisions between two implants.

Mouse cursor off the model to zoom and rotate

Press "delete" key to delete the last point. MB3 to finish.

automatically connecting the points

Add point

 

25.    Design the boundary of the base model by placing points on the intra-oral scan and tracking the boundary. Close the boundary by clicking on the first point. Do not click MB3 on the model during the process.  If it is necessary to adjust boundary, close the profile first, then drag points.

A close profile is needed. When the new point is the start point, it will close the profile.

               

Closed boundary                                                                                                  Trim the boundary model by clicking the "Cut" button, and restart by clicking on "reset"                                                                                                                                             button.

26.    Generate surgical guide, export STL file, etc. Press the "Generate/Update surgical guide" button to generate the guide model. See chapter 7 for additional operations. Use the “Base” and “Guide” buttons on one of the system toolbars to show or hide the base model or guide.

27.    Review surgical guide in planning views. Go back to planning view, right mouse click on the surgical guide model, and choose from the pop-up menu to show the surgical guide with "Fit analysis". Also inspect the cross sections in 2D views.

28.    Generate report.


 


 

9 .     Single scan cases and bone level guides

Treatment planning for single scan cases is a lot simpler than dual scan cases. The necessary steps are bone/tooth segmentation and implant placement.

Single scan process is simpler and more efficient, but not all cases are suitable. In general, one needs a very clean CT scan with good resolution.

It is not recommended for cases with X-ray scatters closed to the implant site. GuideMia does have the functions to remove scatters, but there is no guarantee that the processed bone/tooth model will actually match the anatomy within acceptable error range. Scatters typically are caused by metal artifacts such as crowns and brackets. Very often, we do not know the scatter level until a patient is actually scanned. Therefore as a guideline, any patient with restorations in their mouth should not be considered as single scan cases.

(a)     Pontic in mouth

(b)     Scatters

Figure 9.1 Cases not for bone level guides. (a) The pontic is still in the mouth when patient is scanned. (b) Scatters, even removed, can still make bone segmentation inaccurate.

In order to design bone level surgical guides, we need to have a bone surface model with good quality. Chapter 5 introduces tissue peeling simulation in bone segmentation. It is recommended that users should perform bone segmentation first and change the 3D visualization mode to surface rendering to make sure that the bone model does not have many pockets and holes. If it does, the tissue peeling simulation is suggested.

The guide design includes the following steps:

1.       Choose to design bone level surgical guide. The example from chapter 7 will be used in this chapter. Even though the case has radiographic guide, one can always choose to design bone level surgical guides.

2.       Define the area for the surgical guide.

3.       Generate bone level surgical guide.

 


If other models are still visible, turn them off. You can also turn off the clipping mode.Choose bone-based guide even if there is actually a radiographic guide. Note the “Bone reduction guide” toolbox is available now.

 

Step 1.                 Design bone-based Surgical Guide (1). With or without radiographic guide, this can always be done.

Final result 4. Define a cutting profile by clicking point on screen. The last point should be closed to the start point so that the system can close the profile. Clockwise to keep materials,, anti-clockwise to remove.6. Cut to generate an area as surgical guide base. Step 2-6 can repeat.Reset if not happy with the region definition 5. Adjust profile by manipulating nodes3. Click here to specify a region for guide design2. MB1, MB2 MB3 to zoom and orient the model 1. Define surgical guide insertion direction by the normal of the view plane. This is important for removing undercuts.7. After all trimming, if the model is dark gray, click to reverse direction. The surgical guide base created by step 6. 

Step 2.                 Design bone-based Surgical Guide (2). Data preparation. Step 2,4,5 and 6 can be repeated as many times as desired.

 

Result. 

Step 3.                 Design bone-based Surgical Guide - (3). Generate the guide. This step can take a half minute or more. It does a couple of things including generating model, smoothing, removing undercuts, etc. The post processing like trimming, inspection window, anchor pin, etc can be added as in tissue-based guide design.

 

In this section, a bone reduction guide workflow is illustrated. Even though a case for bone level guide does not require radiographic guide or optical scan, but it does need prosthesis for the treatment plan so that the implants can be well placed. A prosthesis  can be a radiographic guide, an optical scan, virtual teeth, a diagnostic model, etc.  In this workflow, radiographic guide is used. With the tooth setup on the radiographic guide, we can better preview the final implant positions.

The following is the steps for this workflow. They are illustrated with screenshots.

1.       Load scans and perform bone segmentation.

2.       Perform tissue peeling simulation to build a good surface model of the bone structure.

3.       Place implants and anchor pins.

4.       Enter surgical guide design and select Bone/Tooth level surgical guide.

5.       Enter bone reduction guide design.

6.       Clip the base model.

7.       Manipulate the cutting direction and plane, which represents the bone reduction cutting direction

8.       Define bone reduction area.

9.       Determine bone reduction depth.

10.    Preview bone reduction.

11.    Track and cut the base area for bone reduction guide.

12.    Generate bone reduction guide.

13.    Cut the reduced bone model for surgical guide design.

14.    Finish cutting the base model.

15.    Generate surgical guide that will be used after bone reduction.

 

Step 1.      Load scans and perform bone segmentation. As in the workflows introduced in previous chapters, the patient scan and the radiographic guide are loaded and registered. A bone segmentation operation is performed.

 

4. View the finished bone segmentation.3. Fill the holes by simulating  tissue peeling.2. Set an average hole size1.Turn on surface rendering to check the model quality.

 

Step 2.      Perform tissue peeling simulation to build a good surface model of the bone structure.

Step 3.      Place implants and anchor pins. Four implants and three anchor pins are placed.

2. Make sure this is set to bone /tooth level guide1.Ener here

Step 4.      Enter surgical guide design and select Bone/Tooth level surgical guide.

1.Ener here

Step 5.      Enter bone reduction guide design.

 

1.Turn on clipping mode

Step 6.      Clip the base model. This step and next will adjust the cutting plane which defines the orientation and extent of the bone reduction. It is optional to use clipping mode, but it can help visualize how the bone will be reduced.

1.Turn on clipping mode

Step 7.      Manipulate the cutting direction and plane, which represents the bone reduction cutting direction. Also rotate the model to make sure the cutting direction defined by the plane is good. The final cutting plane may or may not be this clipping plane, but direction is the same.

2.Add points to define the profile and click the first one at the last step to close profile. Then one can adjust the knots of the profile. Do not rotate the view/model here.1.Click to start define a cutting area.

Step 8.      Define bone reduction area.

Watch how this cutting plane changes when the cutting depth slider is moved.1.move the slider to designate the final cutting position.

Step 9.      Determine bone reduction depth.

1.Click to generate preview of the reduced bone.

Step 10.  Preview bone reduction.

 

 

 

3.Cut the area to verify it.2. Specify boundary points1.Start define the bondary

Step 11.  Track and cut the base area for bone reduction guide. This is same as in the workflow where surgical guides are designed from optical scans. Either the  “Track” and “Circle” tools can be used together with the “Cut” button to define the guide area.

Finalized bone reduction guide3.Update the undercut direction by the normal of the view plane.2.Rotate the model to survey the undercuts, and make sure the view direction is defined such that the undercuts are minimum and evenly distributed.1. Adjust thickness if desired.4.Start define the boundary

Step 12.  Generate bone reduction guide.

 

2. Defined profile for cutting2. Use Track+Cut or Circle+Cut  tools to define and trim the guide boundary. For bone level guides, we suggest the “Circle” tool.1. Go back to surgical guide design too1box.

Step 13.  Cut the reduced bone model for surgical guide design

Step 14.  Finish cutting the base model.

 

 Back of the guide.Finished surgical guide. The implant site will fit onto the reduced bone model.Click to generate 

Step 15.  Generate surgical guide that will be used after bone reduction.

 


10 . Surgical Kit Configuration and Guide Options

In GuideMia, surgical guides are designed according to surgical kits. The center of the design is to determine the diameters of the holes on surgical guides. The holes may be used to insert drilling sleeves, or drill guides or even drills directly. In principle, there are three levels of controls to the surgical guide design.

1.       The first level is system wide. Everything is controlled by the surgical kit configuration.

2.       The second level is project wide. All the implants in a working project are subject to same set of options. Those options determine whether and how the surgical kit configurations will be used.

3.       The third level is implant specific. Users can customize the guide design for individual implants.

Figure 10.1 illustrates a surgical kit configuration. All dimension units are millimeters. The following describes how the kit can be configured and how the holes on a surgical guide is determined.

1.       The kit has three platforms, corresponding to implant size or drill size of 3.0, 3.85 and 4.23. The software always tries to match the implant size with the drill size.

a.           When an implant size is not found in the surgical kit, there are two choices:

i.      one is to use the first row in the surgical kit configuration, which is to define a pilot drill. In this example, the size will be 3.0.

ii.     Another one is to find the closet smaller value, that is, 3.85 in this example.

b.          Next section will discuss how to choose (i) or (ii). In the reminder of this section, we use 3.85.

2.       For P2, the drill guide or handle has an outer diameter of 5, so the drilling sleeve used for this handle will have an outer diameter of 5. In order for the drill guide to be easily placed in and out, a clearance of 0.05 is defined. Therefore the actual drilling sleeve’s inner diameter is 5+0.05x2=5.1. In this example the drilling sleeve thickness is set to 0.6, so the outer diameter of the sleeve is 5.1+0.6x2=6.3.

3.       Manufacturers may offer very few sizes of the drill guides or handles. For example, Straumann has different implant/drill sizes, but a fixed 5m handle as shown in Fig 10.2.

4.       As a result the surgical guide designed for the 4.0 implant will have a hole of 6.3.

5.       If a surgical guide will NOT be used with drilling sleeve, one can set the sleeve thickness to 0, but still keep the clearance value, so the hole on the surgical guide will have a diameter of 5.1.

6.       If a surgical guide will NOT be used with the drill guides, or handles, turn off the checkbox “Surgical guides for using with drill guides/handles”. Use the same example of 4.0 implant,  the hole diameter on the surgical guide will be 3.85+0.6x2+0.05x2 = 5.15. If the user will further on eliminate the drilling sleeve (which is NOT recommended), then the hole will be just 3.85+0.05x2 = 3.95.

7.       The drilling prolongation value is defined as a distance from top of drilling sleeves to the top of implants. For example, if an implant length is 11.5, prolongation value is 9, the drill depth of the implant will be 20.5. If the surgical kit has a drill of 21mm, the doctor must set a drill stopper so that the drill will stop at 20.5.

8.       In Figure 10.1, surgical kits from manufacturers typically have their drill/implant size defined, but very often the drilling sleeves may be obtained from a third party, therefore the drilling sleeves in the kit configuration can be changed from time to time depending on the actual sleeve dimensions.

9.       The prolongation value defined in the surgical kit is for all the implants, users can customize this for individual implant as in next section.

 

Fig 10.1 Surgical Kit Configuration

Figure 10.2 Straumman’s drill guide/handle size and implant sizes

 

 

Figure 10.3 has the additional surgical guide options, which is the second level of surgical guide parameter control offering options for all implants in a working project.

Figure 10.3 Surgical guide options

1.          The option “Pilot drill if surgical kit not applicable” is the system default. This is one of the two options discussed in last section, when implant size is not found in the surgical kit definition.

2.          “Pilot drill only” is to design a pilot drill guide. The holes will be all designed for pilot drill. The size of the pilot drill is determined by the surgical kit. The first row in the surgical kit configuration will be considered the pilot drill. For example,  in Figure 10.1, 3 is considered as the size of the pilot drill, which is not a typical value. Even if “Pilot drill” is chosen, the surgical guide design is still subject to the settings of drill guides and drilling sleeves. If a new row is added to the configuration as in Figure 10.4,  the pilot drill will be 2.2, not drill guide is used, drilling sleeve will be 2.2+0.5x2+0.05x2=3.3.

3.          Drills to match implant size instead of surgical kit. This is again to overwrite the surgical kit configuration. GuideMia will ignore the surgical kit and generate holes on the surgical guide according to the sizes of implants and drilling sleeves.

a.        Users can turn on the “Uniform Drill Sleeve Option”,  and set the sleeve thickness to 0, and clearance to 0.05, then the hole size of the implant site of the surgical guide will be 4+0.05x2=4.1.

b.       If the user set the sleeve thickness to 0.5, for example, the hole size of the implant site of the surgical guide will be 4+0.5x2+0.05x2 = 5.1.

4.          Drills to match surgical kit instead of implant size. This is another choice discussed in last section when specific implant size is not found in the surgical kit configuration. The system will design surgical guides using the closest smaller size in the surgical kit. In the 4.0 implant example, 3.85 will be chosen for surgical guide design. Drill guide options and sleeves will be chosen according to the surgical kit.

5.          Uniform drilling sleeve. This is used to overwrite all the sleeve definitions in surgical kit. When users have drilling sleeves of their own, they can use this option. If they don’t want to use drilling sleeves at all because they have the drill guides, they can turn on this option, and set the sleeve thickness to 0.

 

Figure 10.4

Users can overwrite the surgical kit configuration and project settings by customizing individual implant sites. The following are the typical operations:

1.       The prolongation value defined in the surgical kit is for all the implants, users can customize this for individual implant. Take the same example, if the doctor wants to use a 21 mm drill for this 11.5 implant without using drill stop, he or she can set the prolongation value for the implant as 21-11.5 = 9.5. Figure 10.5 shows how the prolongation value can be individually adjusted.

2.       Figure 10.5 also shows how individual drilling sleeves can be customized. The customized value here can overwrite the values defined in the surgical kit configuration. If the user decided to not use drilling sleeves for individual implant, the sleeve diameter can be set to 0. For example, if a guide has two implants, one will be used with sleeve, one will not. The user can customize the second one, but leave the first one to the system default defined in the surgical kit.

Fig. 10.5 Customize drilling sleeves


 

 

11 .   Measurement and planning errors

As designed in the treatment plan error simulation module, the ultimate error of a surgical guide, or, its implants, come from the following area:

·         Image Processing Errors, including registration errors and segmentation errors. Behind the two factors is the actual accuracy of the DICOM files from the CT scanners. Because of this, we do not recommend planning cases with slice thickness bigger than 1mm. Thickness of 0.25mm or lower is preferred.

·         Surgical guide manufacturing errors, including:

o    Guide dimension errors,

o    Hole position linear errors,

o    Hole position angular errors,

o    Linear deformation of the guide, and

o    Angular deformation of the guide

·         The positioning error of surgical guide at the treatment time, or the implant placement errors with respect to the planned position and orientation.

Among the various error sources, the image processing errors will affect the design of surgical guides, and the manufacturing errors and positioning errors will affect the deployment of treatment plans.

This section gives an outline about how the error simulation is implemented. More details can be found in our corresponding US patent application [5].

The data representation of a treatment plan includes the coordinates of apex centers and the orientation vectors of all the implants. A plan is visualized in 2D and/or 3D views. Along with the bone structure, or even soft tissue models, users can visually evaluate a plan.

Error simulation is done by continuously applying different deviations to the implant parameters and updating the plan display accordingly. First, error sources are identified. A few examples are errors of stone models, manufacturing errors and deformations of radiographic guides, errors of radiographic guide placements, errors of CT image processing, etc. Secondly, each error factor is translated into the possible deviations of implant locations and orientations. Maximum deviation values are set for each of the factors. Next, a statistic distribution of the errors is assumed, and a series of deviation values are generated. For each deviation value, the display of a treatment plan is updated. With continuous update of the display, a real time visual feedback is given to the users so that they can evaluate the plan and possible error conditions. Such error simulation is coupled with techniques such as bone quality visualization to enable better treatment plan evaluation.

The software component to simulate the error conditions includes the following logical components: an interface object (the dialog) to designate the error factors and their distributions, a module to combine the error factors and generate a series of positions and orientations for each of the implants, a module to display treatment plan and update the display with the series of implant positions and orientations, and a module to control the error simulation.

Error Simulation Dialog

An error source is first translated into the deviations of implant positions and orientations, or simply, the deviations. The following figure shows an implant and its deviation. A linear error means the shifts of X, Y and Z coordinates, notated as (dx, dy, dz). An Angular error means the deviation of the implant orientation. An angular deviation can be a combination of rotations about X, Y and Z axis. Normally the rotation about Z axis does not really change implant position, hence the rotations about the X and Y axis are considered and represented by two angles: angle_x, angle_y. The deviation between two implant positions has therefore 5 components and is represented as (dx, dy, dz, angle_x, angle_y). These 5 components define a 5D space, namely, error space.

Implant Deviation

The error simulation will generate a series of model deviations before simulating the display. The module generates possible deviations according to the error source definition and statistic distributions, and applies them to the treatment plan. Each component of the deviation, for example the dx component, will have a series values: -maximum_dx, -(N-1)·maximum_dx /N, …, -maximum_dx/N, 0, maximum_dx/N, …, (N-1)· maximum_dx /N, maximum_dx.  The combinations (linear sum) of the series values of each component together make up the sampling space of the implant deviations. The “Plan Deviation” module may generate all the combinations in one run, or individually upon request.

This module then applies the deviations to a treatment plan by transforming the geometric models of the implants. For each implant and a specific deviation value (dx, dy, dz, angle_x, angle_y), it (1) stores the coordinates (x, y, z) of the implant apex, (2) translates the implant model by (-x, -y, -z) so that the apex is positioned at the origin, (3) rotates  the implant model by angle_x about X axis, (4) rotates the implant model by angle_y about Y axis, (5) and finally translates the implant model by (x+dx, y+dy, z+dz).

The display module will then receive the deviated plans from “Plan Deviation” and update the display by using transformed implant models. The minimum of the display contents include bone and implants. There are at least two kinds of display windows, ie., the 3D views and 2D views.

The measurement features, dimension and angle, are guarantee to have error smaller than 0.01mm or 0.05degree, however, all the measurements are subject to the accuracy of the input datasets. Please refer to the specs of your CT and optical scanners.

The users who make surgical guides themselves should be advised that device calibration is critical to have a satisfactory treatment plan and outcome. The devices involved include CT scanners (or CBCT scanners), CNC machines if surgical guides will be milled, or 3D printers or SLA machines if surgical guides will be made by SLA or printing technology.

As a general practice, the device operators should calibrate their equipment regularly. For the purpose of error simulation in GuideMia, users are advised to acquire the equipment’s scanning or manufacturing errors from the operators.

It is strong recommended that users use the segmentation threshold filter to create a radiographic model from its CT scan. When adjusting the threshold, measure the digital model displayed on the screen and the physical model to make sure the threshold is set such that the reconstructed model replicate the size and thickness of the physical model.

If the users prepare their cases with optical scan of stone models, or intra-oral scans, the accuracy is a very minor concern. Most of the time the surgical guide design based on an optical scan will fit on the patient anatomy very well. Therefore, optical scan is actually recommended over radiographic guide.

Since a surgical guide is designed based on the radiographic guide or stone model, the registration between such model and the patient’s scan plays a critical role for the guide accuracy.

GuideMia has the following functions to improve registration results:

·         Fine tuning tools. After registration, users can use the tool to slightly move or rotate the model so that it better match the patient anatomy. This tool can be found in SimPlant 2011.

 

·         Fit analysis. See Functional Specification F95. The idea is to calculate the deviations between the surgical guide and patient’s anatomy, and visualize them. This provides a visual tool for the users to identify problems in model registration. The "Scalar bar" in the right side defines the how the "distance" is mapped to color. The "distance" is between a point on the surgical guide and the model that is used as the base for surgical guide design, such as a stone model for tissue-based guide or bone model for bone-level surgical guide.

 

Surgical guide fit analysis.

 

12 .               How-to Guide

This chapter is a "How-to" guide, which presents some basic functions, some complex issues and solutions, some special process, and some tips. For more information and updated list, please visit our website or contact our representatives.

How to organize DICOM file folders before creating a case?

Dicom files of a scan must be placed into one folder, and there should be no other DICOM files except the series of slice data of this scan. The following file list is from an actual clinical case. Files with name "2" and "3" are "aliens" that will fail the DICOM file loading. Just remove file 1,2 and 3 to fix the problem.

Figure 8.1. A problematic folder

 

How to import a diagnostic model as a planning reference?

Use menu item "References/Add additional scans" to add the STL model of the file. If the model was in the same coordinate system as the stone model or intra-oral scan, and the later has been registered against the bone structure, the new model will inherit the registration information thus be automatically placed at the right position. Otherwise, you need to register this diagnostic model with the bone structure. In order to do this, you need to:

Step 1.      Go to the object navigator, select the new model on the object list, click on the icon "Select as Scan Template".

Step 2.      Go back to the first toolbox of the workflow panel, enter "Registration", and perform the necessary operation to register the new model.

Step 3.      Go back to the object navigator, select the actual "scan template", and click on the icon "Select as Scan Template" to set it back.

 

How to lock the position of an object?

You cannot lock the position of an implant. Use the "Placer" button on the tool bar to turn on and off the placement widgets. Once off, you cannot adjust the implant location. You can always turn them back on.

For other STL models, MB3 on the model in a 3D view, choose "Start Positioning" or "Lock Position" will turn on or off the placement widget of the model.

How to determine good threshold values for bone structure?

Unless you will design bone level guide, it is not necessary to work hard on this. If you will, the low threshold value can be in a wide range from 200 to 700 based on experience, the high threshold value should be the maximum. It is very subjective to determine the low threshold value. It is normally based on the visual assessment of the resulted model.

How to design bone level surgical guide with loose bones?

The bad news is that cases with loose bones are not good candidate for bone level guide. The good news you can use "Tissue Peeling Simulation" in GuideMia to create a good bone model for surgical guide design. See chapter 6 for tissue peeling and chapter 9 for the procedure to design the surgical guide.

Generally GuideMia does not recommend bone level guide for loose bones, or more specifically, fully edentulous cases.

How to combine GuideMia treatment planning with physical model based planning?

Use GuideMia's master model function to create study models with implant holes and additional features, and then use the master model for physical model based planning. For example, you can directly modify the master bone model in further planning.

How to inspect if a radiographic guide is properly placed and scanned?

Use the "Virtual Tissue" function (see chapter 5) to display a color map as below. If the radiographic guide was not properly placed at scanning time, the colors at the areas where guide touches the patient anatomy will be very different at the two sides.

Good fitsmall gap

Figure 8.2 Color map of the virtual tissue model

How to determine the surgical guide insertion direction so that the undercuts can be created accordingly?

By default the system will calculate the average direction of the implants as the insertion direction. If you have virtual tissue model, the direction of the model will be used. Either way, you can rotate the surgical guide design view to a good orientation and click on the "Update" button in guide design tool box.

With certain cases, there might be excessive undercuts at certain direction, it will help have a better surgical guide design if you try to identify a direction with less undercuts by visual checking.

How to improve the surgical guide design to avoid week spots?

Surgical guides can have insufficient materials in nearby areas of implants. The following picture is an example. Users can add acrylic materials to the weak spots after making the guides, or change the guide design. The techniques to do so include: using customized drilling parameters so that the top planer face can be higher, changing the boundary definition so that more materials can be included in those areas. using pilot drill only options so that the holes and sleeve areas are smaller.

Too little material. Possible strength concentration

Figure 8.3 Week spot in a guide design

How to check the fitness of a surgical guide?

After you design the surgical guide, go back to planning view by entering any other tab of the workflow panel, right click on the surgical guide model, and choose "Show Fit Analysis". Color map shown along with the images will indicate how the model fits the patient anatomy.

How to obtain best results of automatic radiographic guide registration?

Before you load the radiographic guide scan, make sure you investigate the patient scan by adjusting the thresholds. You should tell how the markers can be distinguished from the anatomy, scatters, etc. You should also adjust the region of interest to include as many markers as you can. Sometimes, the patient might have been scanned with two radiographic guides on, so you will need to make sure your region f interest does not contain the markers you don't need for the ongoing planning job.

It is important to know that even though the planning can be done with both arches, but we recommend doing one in a project.

How to specify markers for stone model registration?

Markers should be in the areas that have good and clear tooth contours, and no metal artifacts (fillings, existing implants, etc) or scatters.

How to use point of interest to associate the display of 2D views?

If you double click on any point in a 2D slice or a bone model, the point will serve as a point of interest. All 3 2D views will be set to the slices corresponding to this point.

How to browse the treatment plan reports?

A report should be brought up into a browser automatically after you create it. With some computer configurations this might not be true. You can always double click the generated HTML file from Windows Explorer to browse the reports.

How to include my logo in the plan reports?

There is a customer logo file in the GuideMia installation folder. You can simply replace that file with your logo. You are recommended not to use a logo with bigger size.

How to get better volume rendering effects?

Change the opacity to a value lower than 1 will produce better visual results. You need a graphics card as recommended to have acceptable volume rendering results.

How to determine if a system configuration is sufficient for GuideMia?

See the recommended configuration. After you load a patient scan, adjusting the thresholds, you should have instant update in the 3D views. A lagging of 3 seconds or more might indicate the system is slower than expected.

How to design surgical guides for pilot drills only?

When the size of an implant is not in the surgical kit's platforms, you will get a guide design with pilot drill only for this implant. If you want to force pilot drill only, go to the "Surgical Kits and Guide Option" tool box to turn on the corresponding option.

How to improve the system performance when changing arch curves?

Adjust the arch curve before you load any additional STL files. If you have to adjust when there are many STL files and generated surgical guides, turn off the panoramic mode (see button on toolbar), and adjust the arch curve, then go back to the panoramic mode is necessary.

How to browse and delete planning notes for bone modification, sinus grafting, etc?

Use the snapshot navigator.

How to design surgical guide if the stone model has deformed locally?

Use the "Calibration" tool. See chapter 4.

How to fix the guide so that it will not interfere with patient's anatomy?

This should only apply to cases with radiographic guide. Before you create the surgical guide, click on the "Cut" button in the guide design tool box, it will extract the adaption surface of the radiographic guide. Later on the system knows how to trim the model to avoid interference between the surgical guide and patient's anatomy.

For other cases, this is automatically handled.

How to customize the drilling sequence and sleeve for some situations where drilling sleeve cannot fit into the space?

In some situations, you don't want to use the method in the last item. You can customize the height of the drilling sleeves, and the drilling prolongation value for an individual implant.

The UI is shown in the following picture (a). The second one (b) shows the sleeve by default. Notice that it interacts with the patients' anatomy because it penetrates through the radiographic guide. The picture (c) shows a customized design.

Drilling instructions in the generated reports will reflect such customizations.

 
(b) Sleeve is moved up by changing the 'Drill prolongation'
 
(b) Sleeve interacts with anatomy
  

(a) User interface to customize sleeve

 

 

Figure 8.3 Customize drilling sleeve

How to change implant type?

In any 2D view, double click on an implant.

How to design multiple surgical guides for a case, and why is this useful?

You can design surgical guides with different options and compare them. You can also design one surgical guide for left side of an arch, and another for the right side. In case of excessive undercuts, this strategy is very useful.

It is important that the treatment planning report is always generated with the latest surgical guide.

How to inspect the difference between two surgical guides?

Go to the object navigator, make one surgical guide as the current object, then turn of the display of all objects except the second surgical guide. Now each 3D view shows one guide. You can also change the colors and compare them.

How to register multiple STL models to the patient bone structure?

See "How to import a diagnostic model as planning reference".

How to make implants parallel?

There are three ways to make implants parallel:

·         Make all implants parallel: click the "Make Parallel" button in the implant placement toolbox.

·         Make new implants parallel to previous one: check on the checkbox.

·         Make some implants parallel: go to object navigator select the one implant, and CTRL+select additional ones, then press the button "make selected implants parallel".

How to choose a model as the base for surgical guide design?

Go to object navigator, select the model, and click the button "Set Scan Template". When the users load for example multiple scans of stone models, this will give the user a chance to select a model that better serves as the base for surgical guide design for whatever reasons they decide.

How to trim or re-trim the base model for surgical guide design?

See chapter 7 for more details. There are two tools in the guide design toolbox. One is "Track", another "Circle". They will define a region by tracking the triangles on the model, or by define a closed profile as "cookie cutter".  The "Cut" button will finish the trimming. If not happy with the results, you can use "Reset". The combination of "Circle" and "Cut" can be used multiple times. If you circle the profile clockwise, "Cut" tool will give you the areas inside the profile. Otherwise, it will make a "Hole" on the model.

How to proceed if I am getting errors when creating a surgical guide?

The system uses many Boolean operations to finish surgical guide design along with other operations. For a simple case, the surgical guide model can have hundreds of thousands of triangles, which can lead to high possibility of coincident edges, manifold topologies. Also the STL file quality of the input model can contribute to the complexity of Boolean operations.  It is almost impossible to guarantee the success of Boolean operations with such models.  The system has implemented a good error handling mechanism. Many times, slightly adjusting the undercut angle or base model boundary, can fix the problems.

How to split a CT scan into two?

After loading the DICOM files, you can set the thresholds to -1024 and a value bigger than for example 10,000, adjust the region of interest, and then use menu item "Project/Export/DICOM file series".

How to set the display options in order to get a cleaner report?

This is important when you have many imported STL models or have generated many surgical guide models in the project. You may want to turn the unnecessary model off by "Show/Hide" and "Show/Hide in 2D" tools in the navigator toolbox, before you generate a report.

 


 

13 .               Miscellaneous

There can be some conditions that the system will not likely support or not be able to produce good quality results. Here are some of them:  

·         The CT scan slice thickness is more than 1mm. This can lead to inaccurate models.

·         CT scan slices are bigger than 2048x2048 pixels. In general they should be supported, but real time performance depends on hardware.

·         The CT scan has too many slices. It is well expected to process 512 slice scans without problems with recommended hardware configuration, but more slices can present difficulty for the real time rendering and contouring of image data. However, the system should still be able to process large number of slices. Dataset with more than 1024 slices will generally be supported but slowly. Use the "export DICOM series" tool to create a smaller dataset for further planning.

·         There are excessive scatters in the patient CT scan, which mainly are due to the metal crowns, fillings, existing implants, etc.

·         When a bone level surgical guide is desired, the patient has very loose jaw bones, such that it is extremely hard to create bone models from CT scan.

·         The input STL files of stone model or intra-oral scan have excessively tiny triangles, overlapped triangles, and other STL quality problems.

 

 

- END -

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