Efficient integrated treatment workflow for single and partially edentulous patients

Efficient integrated treatment workflow Increase treatment acceptance Collaborate effectively Increase treatment efficiency Treat more patients better

Options of treatment workflow With NobelProcera surface scan, without radiographic guide Consultation Single tooth / partially edentulous Clinical diagnostics & Implant treatment acceptance: - Impression - (CB)CT scan - NobelClinician 3D Diagnosis NobelProcera Scan of dental cast / diagnostic setup NobelClinician (prosthetic-driven) planning Treatment communication to treatment partners and patient Surgery: freehand, pilot drill template or fully guided surgical template Clinical Diagnostics - Impression (CB)CT scan NobelClinician 3D diagnosis & (prosthetic-driven) planning Treatment communication to treatment partners and patient Surgery: freehand, pilot drill template or fully guided surgical template Large partially edentulous / edentulous Radiographic guide (CB)CT Double scan Surgery: freehand or fully guided surgical template Single tooth / partially edentulous / edentulous NobelClinician 3D diagnosis and planning Surgery:: freehand, only treatment plan report as reference (CB)CT scanner in-house (CB)CT scanner NOT in-house With radiographic guide Without prosthetic reference during planning, free-hand surgery

Efficient integrated treatment workflow Increasing treatment efficiency NobelConnect seamlessly links the tools the clinician needs: NobelClinician supports efficient treatment planning by linking with the NobelProcera 2G System NobelClinician Viewer or Communicator facilitates collaboration with all treatment partners and the iPad® App allows for presenting patient-specific treatment options OsseoCare Pro records and documents final implant values or any surgical information needed Switch to Guided Surgery at any point during the planning process with no need for an additional patient visit. iPad® is a trademark of Apple Inc.

Efficient integrated treatment workflow After completion of the initial planning the treatment options can already be discussed The Communicator App supports the conversation between patient and clinician After treatment acceptance the clinician can start planning the individual treatment During the first visit, the (CB)CT scan and the dental impression are done The DICOM files can immediately be uploaded to NobelClinician Supporting files like clinical pictures can be added The diagnosis and planning can start immediately

Efficient integrated treatment workflow After the first visit and the treatment acceptance by the patient, the impression is sent to the dental laboratory A gypsum model is poured and a tooth setup done The model and the tooth setup are scanned with the NobelProcera 2G System The data is transfer to the NobelClinician software via NobelConnect SmartFusion™ aligns the two data files to one files showing the (CB)CT scan and the model scan information

Efficient integrated treatment workflow Efficient and predictable treatment outcomes The NobelProcera 2G System provides accurate data of the gypsum model No additional (CB)CT scan with radiographic guide is needed minimizing the radiation dose for the patient SmartFusion™ combines the information of the (CB)CT scan and the model scan (hard and soft tissue)

Efficient integrated treatment workflow Work and communicate efficiently Effective and easy communication options using NobelClinician Communicator or Viewer Involve treatment partners in the planning process Optimize treatment outcomes leading to increased patient satisfaction

Efficient integrated treatment workflow Communicate convincingly Increase treatment acceptance by communicating in an understandable way with the patient NobelClinician Communicator iPad® App allows to present patient-specific treatment options in a clear and visual way

The efficient treatment workflow 1. Clinical diagnostics & treatment planning 3. Treatment planning 5. Production of surgical templates 2. Digitizing prosthetic information 4. Communicate treatment plan 6. Implant surgery

Treatment workflow for single unit and partially edentulous patients The treatment workflow for the partially edentulous patient allows the clinician the flexibility of taking a (CB)CT scan of the patient at any time during the initial examination of the patient. Following preliminary diagnostics and treatment planning, implant treatment can be proposed to the patient if applicable, and after the patient’s treatment acceptance the decision can be made to add clinical situation information via a surface scan of the dental cast and if applicable the diagnostic setup. With this information added in NobelClinician, the clinician can plan the implants according the patient’s anatomy and prosthetic requirements. Then he can decide on the type of surgery, either go straight to surgery or order a surgical template for either pilot drilling only or for fully guided drilling and if applicable guided implant placement.

Treatment workflow for single unit and partially edentulous patients (with NobelProcera® surface scan) Case presentation 1 Clinical diagnostics and treatment acceptance 2 Digitizing prosthetic information 3 Treatment planning with communication of plan 4 Implant placement freehand or guided 5 Prosthetic design and restoration placement

1. Clinical diagnostics and impression taking The indications for a medical procedure must be established by the responsible clinician. This decision relies on essential findings from the entire interdisciplinary treatment team. Careful initial clinical diagnostics, including systemic and dental considerations, are the basis for proper indication setting. Systemic evaluation Age Immune status including diabetes Smoking Clinical evaluation Caries activity Presence of periodontal disease Radiographic diagnostics Control of disease prior to treatment Patient cooperation including oral hygiene Dental evaluation Functional status (maximum intercuspidation, centric relation, occlusal interferences, anterior guidance) Indications for parafunctions Inter-arch relationships (prosthetic considerations) Esthetics Tissue health, attached keratinized tissue Clinical evaluation for edentulous space (visual / palpation) Diagnostic models, diagnostic wax-up

1. Clinical diagnostics and impression taking Additional considerations Assess tissue stability – important for pilot drilling and fully guided surgery All sites must be fully healed following extractions or dental grafting procedures to ensure stable surgical template support reference (extraction sites and immediate implant placement for a single tooth is supported). Assess mouth opening – important for pilot drilling and fully guided surgery A minimum mouth opening of 40 mm at implant sites is required to accommodate guided surgery tooling. Assess patient smile line Evaluate the transition zone and verify with the intended treatment (fixed or fixed-removable final prosthetic solution).

1. Clinical diagnostics and impression taking Additional considerations Evaluate soft tissue Assess the quality and quantity of soft tissue Note: Consider (mini-) flap elevation as an alternative to punching in situations with reduced or minimal attached keratinized tissue. (CB) CT scan Take a (CB) CT scan of the patient (axial slices, DICOM format, single frame uncompressed data) Separate the jaws by slightly using a wax plate or small wooden spatula taking care not to distort the facial anatomy Preliminary diagnostics and treatment planning can be done in NobelClinician, determine treatment options

1. Clinical diagnostics and impression taking Additional considerations Case selection criteria Strategically distributed teeth 6 teeth left per arch Immediate extraction is not supported, except single tooth Identical CBCT and impression Indications and contraindications for guided implant surgery remain same Extraction and immediate implant placement of a single tooth

1. Clinical diagnostics and impression taking Additional considerations Boarder line cases Front teeth missing: both canines and all incisors are missing. Molars missing on both sides: All molars (on both sides) and the second premolar (on both sides) is missing. Half arch: All molars, all premolars and the canine are missing on one side of the teeth arch.

1. Clinical diagnostics and impression taking Additional considerations Take impressions Take fully extended, definitive impressions of both jaws for dental cast and diagnostic set-up The impression quality must meet requirements of a definitive impression for the intended treatment Record an accurate bite registration using registration plates or clinical bite index Impressions are then sent to the NobelProcera lab* Diagnose the patient’s anatomy in NobelClinician Analyze the patient’s anatomy Make a preliminary implant plan Propose implant treatment to the patient * The NobelProcera 2G system using NobelProcera Software version 4.10 or higher must be used.

2. NobelProcera scan of dental cast, with diagnostic setup, if applicable Request NobelProcera lab technician to scan plaster cast, optionally diagnostic setup NobelProcera lab (not in-house): Place order request in NobelClinician Software: Enter email address from your NobelProcera lab Request the digitized scan of the dental cast and optionally diagnostic setup Send impression to lab technician NobelProcera lab (in-house): No order request needs to be submitted. * The NobelProcera 2G system using NobelProcera Software version 4.10 or higher must be used.

2. NobelProcera scan of dental cast, with diagnostic setup, if applicable Lab technician pours dental cast using Type 4 CAD stone (if CAD stone is not available, the Type 4 stone used can be sprayed using CAD spray). The dental cast must represent the same clinical situation as captured in the (CB)CT scan. Note: Trim model minimally to ensure all information will be captured in dental cast scan

2. NobelProcera scan of dental cast, with diagnostic setup, if applicable Lab technician creates removable prosthetic setup/wax-up using CAD wax Acrylic CAD acrylic Any other material using CAD spray when scanning

2. NobelProcera scan of dental cast, with diagnostic setup, if applicable Prosthetic set-up scan Add prosthetic set-up to dental cast and secure dental cast into the NobelProcera 2G scanner. Scan the prosthetic set-up according to the scan protocol Dental cast scan Remove prosthetic set-up carefully, without moving the dental cast. Scan the dental cast according to the scan protocol Note: Ensure that the model scan captures the entire model Note: Do not move the dental cast in the scanner holder. The same position must be maintained during the prosthetic set-up scan and the dental cast scan

2. NobelProcera scan of dental cast, with diagnostic setup, if applicable Provide clinician with scan of dental cast, optionally diagnostic setup NobelProcera lab (not in-house): Lab technician uploads scan to NobelConnect by selecting “Upload” in NobelProcera software NobelProcera lab (in-house): Lab technician exports the scanned file by selecting “Save to Disk” in NobelProcera software * The NobelProcera 2G system using NobelProcera Software version 4.10 or higher must be used.

3. NobelClinician (prosthetic-driven) treatment planning SmartFusion™ Download or import the scan of the dental cast, with diagnostic setup data, if applicable, into NobelClinician Align to the patient’s (CB)CT data using SmartFusion™. Check carefully that the alignment is correct.* Finalize (prosthetic-driven) treatment plan Finalize the treatment plan Select surgery type for each planned implant Create surgical template, if applicable Approve treatment plan NobelProcera 2G System (CB)CT scan SmartFusion™ in NobelClinician Software * In case of doubt, contact Nobel Biocare local technical support.

4. Communicate treatment plan to treatment partners and patient Collaborate with treatment partners Securely share NobelClinician treatment plan with other NobelClinician users over NobelConnect Communicate treatment plan to treatment partners Email treatment plan report as PDF Share NobelClinician Communicator iPad® presentation Send NobelClinician viewer Communicate treatment plan to patient Present treatment plan through NobelClinician Communicator iPad® presentation. Option to share iPad® presentation Document treatment plan and be prepared for surgery Include treatment plan report (PDF) in patient management system Print treatment plan report, regardless of chosen surgery method, as a reference during surgery Export treatment plan as OsseoCare Pro surgery, be prepared for surgery

5. Surgery Treatment plan report Regardless of chosen surgery method, have report available as a reference The details of the implant dimensions per implant site are included The guided drill depths per implant site are included, if applicable OsseoCare Pro Log in with your NobelClinician credentials. The surgery is automatically set up After completing the surgery, the surgical details are securely saved on NobelConnect The surgical report can be retrieved in NobelClinician Surgical template assisted surgery CADCAM created surgical templates Option for pilot drilling only, or fully guided implant placement

Additional considerations (CB)CT scan of patient CT Scanning Axial slices in DICOM format DICOM: Digital Imaging and Communication in Medicine, DICOM is an open and widely used standard for communicating medical images CT and CBCT scanners can export to DICOM files ! Use single frame, uncompressed DICOM files Modern CT scanning equipment Cone-beam (CB)CT scanner dedicated dental CT scanner using a cone shaped x-ray beam Multi-slice CT scanner medical CT scanner typically used in radiology departments of hospitals

Additional considerations (CB)CT scan of patient (CB)CT scanner compatibility requirements Field of view: it must contain the entire jaw bone Typical minimal field of view: diameter of 8 cm, height of 7 cm Resolution and related voxel size: maximum 0.5 mm in all directions, typically 0.3 mm Diagnostic image quality: high enough for the clinician to appropriately read the (CB)CT image data Export the axial CT slices: single-frame uncompressed data Note: Some (CB)CT scanners offer smaller volume scans only, not scanning the entire jaw bone. These scanners should not be used It is the responsibility of the clinician or the radiologist to generate (CB)CT images of optimal quality according to the standard routine and at as low radiation doses as possible. Use the “ALARA principle” (As Low As Reasonable Achievable)

Additional considerations (CB)CT scan of patient Take the patient’s (CB)CT scan Ensure the patient’s occlusal plane is positioned horizontal Slightly separate the occlusion if possible, using a wax plate or small wooden spatula Ensure quality of the scan with adequate resolution optimized settings and reduced noise Ensure that the entire dental arch is scanned including all teeth (prosthetic crowns) Note: Take into consideration patient factors such as patient movement and metallic restorations The (CB)CT data and NobelProcera scan data must include the same information

Additional considerations (CB)CT scan of patient Check for patient movement during (CB)CT scan Indicators for movement of the patient during scan include: Multi-slice CT: discontinuity of the anatomy, clearly visible in 3D CBCT: double anatomical borders, clearly visible on X-ray data, resulting in noisy 3D model If patient movement is identified, it is strongly advised to repeat the scan ! Movement artifacts introduce inaccuracies, potentially leading into incorrect diagnosis. They may also prevent the SmartFusion™ from working. Patient moved when taking a scan with a multi-slice CT scanner Patient moved when taking a scan with a CBCT scanner

Additional considerations (CB)CT scan of patient Streak artifacts Streak artifacts from radio-opaque tooth restoration material corrupt diagnostic information The SmartFusion™ is robust and has been developed to handle (CB)CT data with artifacts. However, when severe artifacts arise, this might cause issues Note: When severe artifacts are identified, contact (CB)CT manufacturer to ensure the (CB)CT settings are optimized or to calibrate the (CB)CT scanner. Export (CB) CT data Export scan data as uncompressed single-frame DICOM files