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This article describes a prototype application for The PISA project investigates and develops the
Dental implants interactive planning of dental implants, developed planning process and transfer to the patient as a
can be planned on the EasyVision clinical workstation, and whole, including many aspects of all the steps from
interactively on integrated with the existing software environment planning to the manufacture of a tool for the
the EasyVision of EasyVision. The application features a task- transfer of planning results to the patient.
workstation. oriented workflow which takes the clinical user
step by step through the process of (virtually) The tools developed within the PISA project
positioning dental implants, ending with the can lead to a significant improvement of the
design of a surgical aid (drill guide) for transfer of planning for implant placement, by optimizing
the planning results to the patient. The design of implant shapes and positions. Further
the shape of the drill guide is put completely in improvement can be expected with respect to
the hands of the clinical user, as shape design or the quality of the surgical intervention itself.
modification by the manufacturer is, in principle, Due to the use of surgical aids such as drill guides,
no longer necessary. The drill guide shape can the intervention will be better controlled,
be exported to a manufacturer in CAD/CAM as the guidance of surgical instruments will allow
compatible format. the surgeon to perform the operation exactly
according to the plan. It is expected that the
The work was carried out as part of the EC-funded time until replacement of the implant will be
PISA project, aimed at the development of tools increased considerably, and that fewer
for the design and manufacture of personalized replacements will be required. Additionally,
implants and surgical aids. the duration of the surgical intervention itself
will also be reduced.
The PISA project The work of Philips Medical Systems within the
PISA project focused on the clinical pre-operative
PISA (Personalized Implants and Surgical Aids) is planning for placement of dental implants, and on
The user is led a project aimed at developing tools and techniques the design of surgical aids in the form of drill
step by step to for improving the design and manufacture of guides to transfer the planning to the patient.
the design of personalized implants and surgical aids. Within the Interactive manipulation of computer-generated
a customized context of the PISA project, dental implants, hip implant models is used to simulate the placement
drill guide. or knee prostheses, pedicle screws, cranial plates of implants, and an automatic procedure has been
etc. are regarded as p ersonalized when they are developed to generate a surgical aid. We have also
optimally adapted and positioned to a specific developed an interface between the medical
patient. A perfect fit and positioning of implants workstation and the CAD/CAM oriented
is of high importance. Sub-optimal implant environment, which produces the actual implants
positioning causes sub-optimal load transfer and surgical tools. The results of Philips Medical
between implant and bone, and is a major cause Systems work in the PISA project are described in
of implant failure and (too) early replacement. an internal report [1].
Figure 2.
Selection of relevant
segmentation results
using EasyVisions 3D
segmentation tools.
Figure 3.
Panoramic view plus
cross sections along
the user-defined
curve through the
mandibula.
in the direction of automatic evaluation and Drill guide generation and interface with the
restriction of the distance between implant models manufacturer
and nerve canal.
The drill guide is generated automatically, based
The optimal position for implants is determined on the planned positions and sizes of the implants The drill guide
interactively by placing and repositioning and an area of contact between bone and drill is generated
geometric models of implants with respect to the guide. The contact area indicates where the drill automatically.
segmented bone and, if applicable, the nerve canal. guide is allowed to touch the bone. A proposed
The required implant can be selected from a list of contact area is generated automatically, after which
available implant sizes and lengths, which can be it can be modified interactively in 3D by the user,
customized to represent, for example, the range of if required (Figure 5).
implants which is available from a preferred
supplier, or the set of implants which is commonly The building of a suitable drill guide from
used in a particular institution. implants and contact area is a complicated process
involving manipulation of the surface of the
The implant models can be virtually placed jawbone as well as geometrical primitives
within the patient image data by a single mouse representing implants and supporting cylinders.
click in the base plane through mandibula or We developed an automatic solution for this,
maxilla. The implant is then positioned at the which uses representations of bone, contact area,
indicated location and perpendicular to the base implants, and drill guide in the form of a
plane. Cross sections or 3D renderings of the triangulated surface.
implant are visualized in all other viewports as
well. The segmented bone in the 3D visualization The whole procedure of drill guide generation is
can be rendered as transparent if desired. After very user friendly and fast, and results in a
placement of an implant model, the position and description of a complete drill guide, which can be
orientation of the model can be modified exported in STL format to any manufacturer.
interactively in any of the viewports until the Knowledge of the application by the manufacturer
position and orientation are considered to is not required, as production from this description
be optimal. is straightforward and will result in a drill guide
which will be exactly as planned by the clinical possibility to export bone segmentations to a third
The design of expert who performed the planning. This puts the party for design of a drill guide.
the drill guide is design of the drill guide shape completely in the
in the hands of hands of the clinical user, as shape design or First evaluation
the clinical user. modification by the manufacturer is, in principle,
no longer necessary. In our opinion, only the We have performed a first evaluation of the
clinical expert can be responsible for the final shape described method by planning the placement of
of the drill guide. implants in data acquired from an edentulous
patient, and evaluating the fit of the resulting
Export to and import from a manufacturer is drill guide on a model of the mandibula for
possible in the form of triangulated surface which it was designed. Three implants were
descriptions in STL format. This format is a positioned in the mandibula and, based on this,
commonly used standard in CAD/CAM a drill guide was designed and manufactured
environments. The EasyVision visualization by Materialise, which is a partner in the
software was extended with functionality to render PISA project.
such triangulated surfaces in combination with
voxel-based segmentation results. In addition to the planning data, the CT data
were also sent to Materialise in order to produce a
Conversion of voxel-based segmentations to model of the mandibula itself (Figure 6). The fit
triangulated surface descriptions was also included between drill guide and the mandibula model
in the tools we developed. This provides the appeared to be perfect.
References
[1] Lobregt S, Vuurberg E, Schillings JJ. Dental Implant An Image-Guided Planning System for Endosseous
Planning in EasyVision, Technical End Report PISA Oral Implants. IEEE Transactions on Medical
Project, Philips Publication XPR 072-010024.00, Imaging 1998; 17: 842852.
March 2001.
[3] Materialise Rapid Prototyping & Manufacturing,
[2] Verstreken K, Van Cleynenbreugel J, Martens K, Leuven. SurgiCase: Drilling Templates for Dental
Marchal G, Van Steenberghe D, Suetens P. Implantology.