Digitizing Implant Workflows Improves Outcomes

Understanding the advantages and disadvantages of digitized workflows would improve the precision and efficacy of guided implant surgery, reducing problems.

The practice of implant dentistry has been transformed by digital workflows. Surgical guidelines may provide predictable outcomes for implants that have previously been cancelled due to local, patient, and/or cosmetic risks. Guided surgery enhances communication between the surgeon, dentist, and technician, as well as providing a blueprint for the final prosthesis. There are tooth-, mucosal-, and bone-borne static guide designs available today. Clinicians can also choose from a variety of professionally backed manuals. Furthermore, dynamic navigation employs cutting-edge technology to provide real-time feedback and robotic guidance during implant surgery.

Regardless of the obvious advantages of a faster workflow, surgeons must first master freehand implant placement. Intraoperative complications include guides that do not fully seat, break, or worse, resulting in inappropriate placement due to misplaced drill sleeves. Errors in imaging, planning, or printing could cause this.

FIGURE 2. Preoperative buccal view of the proposed implant sites.

GUIDED IMPLANT SURGERY ESSENTIALS

Interdisciplinary collaboration is facilitated through guided implant surgery. Because the dental team is coordinated at each phase of the process, it decreases surgical and restorative errors. Where anatomical constraints exist, digital planning makes full advantage of existing ridge dimensions to insert larger-diameter and longer implants. Difficult site development and reconstructive surgery may be avoided, saving the patient time, money, and subsequent surgery. 1 Digital workflows increase clinical outcomes significantly, especially in cases involving many implants. 2 Prior to surgery, patients can also envision the treatment plan on a computer and anticipate possible obstacles.

FIGURE 3. Cone beam computed tomography outline of the mandibular wax-up.

A recent randomised controlled clinical research found that guided implant surgery results in improved accuracy and fewer bouts of postoperative discomfort and swelling when compared to traditional implant placement. There were no significant variations in clinical indicators. 3 Any divergence at the entry, apex, angle, and final depth points of implant placement is used to determine accuracy. Because guided technology relies on numerous processes, errors are still possible. Cone beam computed tomography has been reported to have measurement errors of less than 0.5 mm in general (CBCT). 4 It can also be challenging to interpret these images; separating artefacts from metal restorations is an example.

FIGURE 4. Extractions performed in a minimally traumatic fashion, with all bony walls left intact.

As a result, patient mobility should be limited during scanning. In fully edentulous patients, a bite index is useful. Special planning software reads the resulting digital imaging and communication in medicine (DICOM) file. Implant accuracy was not statistically significant in a research that examined different common software programmes. 

FIGURE 5. Occlusal view of the printed, tooth supported guide.

Operator technique and expertise dictate final implant location once the guide is transported to the operative field. Flapless implant placement should be approached with caution, as even the most expert operators can make mistakes. 8 However, research shows that less experienced surgeons make much more positioning errors, even when using a single guide and several fixation screws, as compared to those who have placed more than 500 implants. 9 Nonetheless, clinicians should not become dependant on guides, but rather use them to help with more difficult cases.

FIGURE 1. Preoperative buccal view.

STATIC SURGICAL INSTRUCTIONS

Tooth-borne guides rely on teeth and regional anatomy for support, stability, and retention. In circumstances involving implant-supported crowns and bridges, these are employed for single or multiple implants. Patients with restricted opening may face difficulties in posterior sites, where guided drill bits are larger. 11 Instead of using the guide for early osteotomy preparation, shorter drill bits might be utilised to drill to depth without it. Drill access in confined interarch gaps is aided by an open sleeve with a buccal or lingual slot.

FIGURE 6. Occlusal view of the printed guide after being fully seated.

Only soft tissue landmarks are used in mucosal-borne guidance. Due to variations in the volume and thickness of accessible tissue, they frequently lack retention compared to their tooth-borne counterparts. In fact, implant deviation is exacerbated by increased mucosal thickness. 12 Specially supported guide designs that use mini-screws and pins with a biting index can overcome this. 13 Because of the support and stability of the surrounding teeth and tissues during site preparation, partially dentate individuals may have much better implant accuracy. 14

FIGURE 7. Printed guide used for initial osteotomy preparation according to the prescribed drilling protocol.

Stackable guides provide an immovable basis with pins or screws fixed to the bone to solve these obstacles. Other guides are then put one on top of the other to help with bone reduction, implant alignment, and insertion. When planning implants in a terminal dentition, it's best to use a tooth-borne guidance if at all possible. Extractions are scheduled such that osteotomy preparation can be done to depth, followed by alveoloplasty. This cuts down on surgery time and enhances implant precision.

FIGURE 8. Verified implant positioning and depth without the guide.

DYNAMIC NAVIGATION

FIGURE 9. Occlusal view following implant placement.

FIGURE 10. Buccal contour grafting.

FIGURE 11. Resorbable collagen membranes layered over augmented site.

REPORT ON THE CASE

The following example shows how a digital process was used to place implants in the lower anterior jaw right away. A 54-year-old woman sought implant therapy at the University of Texas Health Science Center at San Antonio School of Dentistry's graduate periodontics clinic (Figure 1 through Figure 16). She had a 7.5-pack-year smoking history and no other health problems. As part of the treatment, smoking cessation was recommended.

FIGURE 12. Postoperative occlusal view.

The patient first presented with periodontitis in isolated spots around her second molars. Where indicated, osseous resective surgery and periodontal regeneration were used to stabilise the situation. A detailed treatment plan was prepared and consents were obtained after a thorough patient examination and review of various techniques and materials. IV conscious sedation was used for surgical procedures. The treatment regimen includes the following:

A surgical guide is made using cone-beam imaging, an intraoral scan, and a digital wax-up.

Teeth #23 through #26 are extracted, followed by rapid implant placement at locations #23, 26 and 27, as well as contour bone augmentation using a printed surgical guide.

Second-stage implant surgery to expose implants in preparation for the creation of an implant-supported bridge at sites #23 through 26, as well as a single implant crown at site #27.

The patient appeared with clinically pink and healthy tissues, with probing depths less than 4 mm, one year after periodontal surgery was done (with regular recall). Her oral hygiene was still adequate, with moderate plaque and calculus deposits evident throughout. Her main concern was for teeth #23 through 26, which were hopeless and were now severely movable. Her aesthetic demand was high, and she had limited time available for treatment because she worked in a busy legal firm in a client-facing job. Because she was able to avoid extensive site development surgery to raise the native ridge dimensions of the front mandible, she was able to reduce surgical demands, time, and cost by using a tooth-supported guide.

FIGURE 13. Postoperative buccal view.

To create a surgical guidance with the final prostheses in mind, an intraoral image was combined and aligned with the CBCT. The guide was created using an in-house 3D printer, and a surgical report was used throughout the procedure to guarantee optimal implant location and placement. To avoid surgical problems, extra caution was taken to provide perfect visualisation and cautious management of the operating field.

From teeth #22 to 28, buccal and lingual sulcular flaps were produced, and a full thickness flap was reflected. Teeth #23 through 26 were extracted with as little pain as possible. For implant location, a printed surgical guide with 2.8 mm drill sleeves was employed. According to the manufacturer's instructions, two bone-level, 3.3-mm-wide, 12-mm-long implants were inserted at sites #23 and #26, and one bone-level, 4.1-mm-wide, 10-mm-long implant was placed at site #27, and main stability was attained. Mineralized freeze-dried bone allograft was manufactured and implanted 1 to 2 mm beyond the arch form within the implant-socket gaps. Collagen membranes that were resorbable were put over the enhanced areas. Non-resorbable mattress sutures and resorbable simple interrupted sutures were used to reposition and secure the flaps.

FIGURE 14. Postoperative healing at eight weeks.

The postoperative instructions were gone over again. To reduce the risk of implant failure, the patient was advised to avoid wearing her lower Essix retainer throughout the early healing period. She had composite buccal restorations applied from teeth #7 to 10 for aesthetics at her follow-up visits at two weeks and eight weeks. After three months, the implants were shown. There were no signs or symptoms of peri-implant disease in the tissues surrounding the implants, which were healthy, pink, and firm. Abutments for healing were attached. The patient returned to the clinic for final prosthetic construction and will be evaluated for annual recalls.

FIGURE 15. Postoperative healing at eight weeks, with new composite restorations from sites #7 to 10, and lower Essix retainer in place.

SUMMARY

Static guides and dynamic navigation will continue to help implant dentists overcome obstacles, but these technologies will never be able to substitute a solid grasp of hard and soft tissue care. Guided surgery enhances teamwork among dental professionals, minimising chairtime, surgical demands, and patient costs. Finally, mastering computerised workflows can improve the implant experience while reducing surgical and prosthesis mishaps.

FIGURE 16. Implant uncovery at sites #23, 26 and 27.

REFERENCES

1. Fortin T, Isidori M, Bouchet H. Placement of posterior maxillary implants in partially edentulous patients with severe bone deficiency using CAD/​CAM guidance to avoid sinus grafting: a clinical report of procedure. Int J Oral Maxillofac Implants. 2009;24:96–102.
2. Youk SY, Lee JH, Park JM, et al. A survey of the satisfaction of patients who have undergone implant surgery with and without employing a computer–guided implant plate. J Adv Prosthodont. 2014;6:395–405.
3. Vercruyssen M, Coucke W, Naert I, Jacobs R, Teughels W, Quirynen M. Depth and lateral deviations in guided implant surgery: an RCT comparing guided surgery with mental navigation or the use of a pilot‐drill template. Clin Oral Implants Res. 2015;26:1315–1320.
4. Reddy MS, Mayfield‐Donahoo T, Vanderven FJ, Jeffcoat MK. A comparison of the diagnostic advantages of panoramic radiography and computed tomography scanning for placement of root form dental implants. Clin Oral Implants Res. 1994;5:229–238.
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7. Matta RE, Bergauer B, Adler W, Wichmann M, Nickenig HJ. The impact of the fabrication method on the three‐dimensional accuracy of an implant surgery template. J Craniomaxillofac Surg. 2017;45:804–808. 
8. Van de Velde T, Glor F, De Bruyn H. A model study on flapless implant placement by clinicians with a different experience level in implant surgery. Clin Oral Implants Res. 2008;19:66–72.