Dr Neel Patel and Dr Vinit Gohil, both Specialists in Prosthodontics, explain the benefits of guided surgery, why they use it routinely and how anyone involved in implant dentistry can incorporate guided surgery and its benefits into their everyday practice.
The increase in predictability and accuracy that digital dentistry enables is now well-documented, and we have been taking advantage of this for some time at our practice in Oxford with the use of guided surgery and implant placement. Although until now we have been incorporating conventional impressions and study casts in the planning stages of the guided surgery workflow, the development of intraoral scanners facilitate an entirely ‘digital’ workflow. In addition to investing in an intraoral scanner for digital impressions, we hope to also incorporate a 3D printer into our practice, thus completing the entire workflow digitally.
Why guided surgery?
Although it might seem obvious, the key to successful implant-supported restorations is the correct placement of implants with respect to the supported restoration. It is well-documented that both biological and hardware complications are commonplace in implant dentistry, and unfavourable implant positioning will greatly contribute to this. Optimal plaque control and maintenance of the peri-implant tissues is critical, and the transition between the implant, abutment and restoration need to be ideal in order to facilitate this.
Where possible, we plan for screw-retained restorations and prostheses, as not only does this help facilitate maintenance of our patients’ implants and restorations, but can also help minimise complications as access to both the peri-implant tissues and abutment screws is always possible.
Optimal implant positioning also avoids the need for complex custom abutments, suprastructures and angled screw systems, thus relatively simplifying the restorative phase and can also reduce the overall cost.
The majority of our dental implants are placed with a guided surgical template where possible, even straightforward ones, as the guided surgical template ensures that the implant is placed in, or very close to, the position it was planned to be in. Many of us who have placed dental implants will be able to relate to the occasional difficulties in getting the dental implant to be placed exactly within the prepared osteotomy. Using a guided surgical template can reduce the margin of error significantly when compared to ‘freehand’ or non-guided placement.
Restoration-guided implant placement
The ideal workflow involves being able to visualise the proposed definitive tooth position, shape and form. This can be either a conventional diagnostic wax/tooth set up, that has been scanned and formatted into a surface scan (.STL file) or even a digital wax/tooth set up. Both of these can be imported into many of the available implant planning software together with the patient’s 3D CBCT images. The surface scans (.STL files) and CBCT images are aligned together through a process of segmentation (partitioning of the digital images into multiple objects) and merging (superimposing identical surfaces together). Although it may sound complicated, both these processes are easily done with a few clicks of the mouse in coDiagnostiX and other planning software.
The dental implants can be precisely planned with reference to the proposed restoration/tooth position, and the software can be easily manipulated to not only change the implant position, but also visualise potential abutment designs and relationship of proposed implant positions to vital structures.
Designing the guided surgical template is also straightforward in most cases. However, at this stage, all the information a laboratory would require to design and print it can also be transferred across to them with the press of a button.
The next step is to trial the surgical template in the patient’s mouth to make sure it fits correctly, and although uncommon (provided the planning is accurate), it can be easily adjusted and modified if required to obtain a stable and precise fit. The surgical procedure involves using the guided surgical template at every step of the osteotomy preparation sequence, followed by placing the implant through the guided surgical template.
We feel it is important to use the guided surgical template for every part of the osteotomy preparation including placement of the dental implant (where available), and not just for the pilot drill, as advocated by other guided surgery systems. As we have mentioned already, getting the dental implant to be placed exactly within the prepared osteotomy can be challenging, especially in softer bone and sites with difficult access. The guided surgical template will ensure that your implant is guided into the same place as the osteotomy and more often than not, if planned appropriately, the angulation does not need to be constantly checked (especially with adjacent implants).
We believe restoration-guided implant placement with guided surgical templates will become commonplace in implant dentistry and form an integral part of the patient treatment workflow. Nearly all implant practitioners utilise 3D CBCT imaging to help aid assessment of implant sites, adjacent anatomical vital structures and to plan proposed implant positioning. It is now even routine to incorporate the proposed restoration/tooth positon with a radiographic template and in the absence of one, even easier to import the required information through ‘segmentation’ (data separation) and ‘merging’. With all this information already present, all it takes is a couple of small steps to transfer this vital information into a guided surgical template which, when planned appropriately, will allow the implant to be placed precisely where it was planned to.
Straumann Restoration-Guided Implant Placement Course
Through our postgraduate teaching and lecturing experience, it has become apparent to us that many clinicians are nervous about taking the next step that would allow them to incorporate guided surgical templates into their practices and implant workflow. As such we have teamed up with Straumann ITI to provide a two-day course on Restoration-Guided Implant Placement including the use of coDiagnostiX planning software, guided surgical templates and the Straumann Guided Surgery system.
The course is aimed at clinicians who are competent in implant dentistry and would like to incorporate guided implant placement into their everyday practice, and those clinicians that are just getting into implant dentistry and would like to incorporate the concept of Restoration Guided Implant Placement for their patients. Most of the course will be dedicated to live demonstrations and hands-on experience of the coDiagnostiX planning and guide design software. On the second day, each participant will complete the entire coDiagnostiX planning and guided surgical template design process, prior to learning about the Straumann Guided Surgery system and using it to place implants with a guided surgical template.
We appreciate there is a learning curve in using guided surgical templates, and although they are by no means a substitute for surgical experience, we feel they can greatly enhance the overall treatment outcome. For us, one of the main advantages of restoration driven implant placement with guided surgical templates, is the ability to plan for screw-retained restorations and prostheses with optimal implant positioning. This ensures that our patients’ implant restorations and prostheses are ‘retrievable’, facilitating future maintenance and hopefully minimising the risk of subsequent complications.
We usually only have one opportunity to get it right with implant placement, and it is important we do so as it is well-documented that the implant position will influence numerous factors that will ultimately determine the success and longevity of our patients’ implant treatment in the long-term.
The Straumann ITI Restoration-guided Implant Placement course takes place on 3rd November 2017. For more information or to book your place, contact Straumann on 01293 651230 or visit http://www.cvent.com/d/ctqnvx
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BDS MFDS MClinDent MPros
Neel is a registered Specialist in Prosthodontics, and after graduating from the University of Bristol in 2002, he worked both in the Community Dental Service and General Dental Practice, and also held hospital posts in Oral & Maxillofacial Surgery. He subsequently completed 4 additional years of specialist training in Fixed and Removable Prosthodontics at the UCL Eastman Dental Institute during which he obtained the MClinDent in Fixed and Removable Prosthodontics, with Distinction, and the Membership in Prosthodontics from the Royal College of Surgeons Edinburgh.
Neel received a scholarship from the International Team for Implantology (ITI) to undertaken a 2 year full time Fellowship in Implant Dentistry at the Center for Implant Dentistry at the University of Florida, Gainesville, USA. He has gained extensive experience in all aspects of restorative, aesthetic and implant dentistry including complex treatments and managing the failing dentition. His special interests include the use of digital technology in dentistry, in particular with guided implant placement and 3D planning, and the management of complications with dental implants.
In addition to his private and referral practice limited to restorative and implant dentistry, he is also involved in post-graduate dental education and lectures both locally and nationally on topics related to implant dentistry and fixed and removable prosthodontics. Neel is a registered speaker and mentor for the UK & Ireland Section of the International Team for Implantology (ITI) and part of the Straumann Clinical Mentoring Programme for other dentists starting out in implant dentistry. He is co-director of the Oxford ITI Study Club and is part of the UK & Ireland Young ITI Committee.
BDS MFDS MClinDent MPros
Vinit is recognised as a specialist in Fixed and Removable Prosthodontics by the General Dental Council. He graduated with honours from the Guy’s, King’s & St Thomas’ Dental Institute, King’s College London. Following graduation he undertook 3 years of hospital-based further training in Oral and Maxillofacial Surgery, Paediatric and Restorative Dentistry. Vinit also gained experience in sedat