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Inside Dentistry
February 2022
Volume 18, Issue 2
Peer-Reviewed

Tooth Replacement in the Maxillary Posterior

Guided surgery facilitates restoratively driven implant placement

John R. Francis, DDS, MS

Implant dentistry has been a mainstream treatment option for many years. In many cases, implants can be placed freehand without any external assistance. However, in others, whether it is due to a narrow bony platform, the need for multiple implants, anatomic constraints, tight interproximal spacing, or other factors, guided placement can offer clinicians an added advantage for the delivery of implants into ideal, restoratively driven positions.

Whether implants are placed freehand or with a guide, the use of cone-beam computed tomography (CBCT) imaging can help to improve the accuracy of treatment. There is a significant amount of literature supporting the use of CBCT for implant diagnosis, treatment planning, and surgical guide fabrication. Furthermore, in a June 2012 position statement, the American Academy of Oral and Maxillofacial Radiology recommended that cross-sectional imaging, particularly CBCT, be used for the assessment of all dental implant sites.

Current postgraduate residents in advanced dental training are being introduced to the concept that CBCT is state-of-the-art for implant planning and placement. Although many of the postdoctoral periodontal programs in the United States are providing their residents with training regarding acquiring and interpreting CBCT images as well as training to apply implant planning software, far fewer programs use this technology to make surgical guides for the majority of their implant cases.

This case report demonstrates the favorable outcome of guided implant placement with a surgical guide fabricated using CBCT data and implant planning software. With such a guide, much of the stress of implant placement can be alleviated. Implants can be more ideally placed in restoratively driven positions, vital structures can be avoided, and any guesswork can be eliminated.

Case Report

A 72-year-old male patient with a nonsignificant medical history desired implant placement in the upper right posterior area. The restorative dentist planned for a three-unit bridge and a single implant crown. After CBCT data were obtained (3D Accuitomo 170, J. Morita), implant planning software (Invivo6, Anatomage) was used to plan three implants (Straumann® Bone Level Implant, Straumann) for the maxillary right in restoratively driven positions (Figure 1). A surgical guide was then fabricated from that 3D generated planning (Figure 2). Once the patient was anesthetized, a full mucoperiosteal flap was reflected and the guide was seated intraorally, holding the flap out of the surgical field (Figure 3). The osteotomies were performed with a series of drills and corresponding keys (Straumann® Guided Instruments, Straumann) (Figure 4), which fit into the surgical guide sleeves and provided accurate drill placement to the planned depth from the pilot drill up to the drill of the final required diameter (Figure 5). After all of the osteotomies have been prepared, the guide can be left in place for the implants to be delivered through it, or it can be removed. In this case, once the final site preparations had been completed, the guide was removed (Figure 6), and the implants were placed directly into the osteotomies (Figure 7). Cover screws were then placed, and a posttreatment radiograph was acquired to evaluate the implant placement (Figure 8). After a 4-month healing period, the implants were uncovered, and temporary restorations were placed for a 2-month provisionalization period prior to final restoration (Figures 9 and Figure 10).

About the Author

John R. Francis, DDS, MS
Clinical Assistant Professor
Department of Surgery
Midwestern University
College of Dental Medicine
Glendale, Arizona

CBCT data were obtained, and utilizing implant planning software, implant positions were chosen for an implant-supported bridge spanning site Nos. 3 through 5 and a single implant retained crown for site No. 6.

Fig. 1

An implant surgical guide commercially fabricated from the patient’s CBCT data. The guide is seated on the adjacent teeth, and the embedded metal sleeves accommodate the drill keys from the surgical guide kit.

Fig. 2

A mucoperiosteal flap was raised and held back while the surgical guide was seated intraorally.

Fig. 3

The osteotomies were performed using a series of drills in increasing diameters with corresponding keys that control their position and depth when combined and inserted into the surgical guide sleeves. There is an intimate fit of the drill into the key and then of the key into the sleeve.

Fig. 4

The osteotomies were performed using a series of drills in increasing diameters with corresponding keys that control their position and depth when combined and inserted into the surgical guide sleeves. There is an intimate fit of the drill into the key and then of the key into the sleeve.

Fig. 5

Posttreatment view of the osteotomies prepared to final diameter. Surgical guides are very helpful in cases in which multiple implants are being placed, especially when they will be used to retain a bridge for which correct spacing and parallelism are particularly important to aid in predictable restoration.

Fig. 6

In this case, the guided implant transfer piece was not used to place the implants. The surgical guide was removed, and the implants were placed directly into their prepared osteotomies.

Fig. 7

Immediate posttreatment radiograph acquired to evaluate implant placement.

Fig. 8

Bitewing radiographs following delivery of the final prostheses.

Fig. 9

Bitewing radiographs following delivery of the final prostheses.

Fig. 10

JOHN R. FRANCIS, DDS, MS

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