Guided dental implant surgery

Guided dental implant surgery is a method of surgically placing a dental implant in the most ideal position. It utilizes the best technology to create a guide that aids the doctor in implant placement.

What is guided dental implant surgery?

It consists of a surgical guide that fits on the patient in a precise position and therefore allows precise placement of dental implants.

How do we accomplish guided dental implant surgery?

We need a CBCT 3 dimensional x-ray of the jaw, a digital impression or model of the teeth and or gums, software to plan the dental implants, and a 3D printer. Next, we take the data from those things and stitch the digital information together in the software to design the guide. Finally, we print the surgical on a 3D printer and insert metal sleeves later.

There are 2 methods to fabricate a surgical guide for guided dental implant surgery.

We can make a guide from a model, known as model based, or from a CBCT based. There is few reasons to do a model guide in this day and age. Other options for the surgical guide include tooth, bone, or tissue born options.

Model based method 1 2

1. Stone cast on surveyor and use 2mm drill press to place hole at desired angle 5-10mm deep
2. Place 2x10mm drill blank (McMaster-Carr Co) into hole
3. Next, place 2mm bushing over blank
4. Place appropriate guide sleeve over bushing
5. Inject any light polymerizing gel (Triad Gel) around guide pins
6. Need inserts for different sizes

Cast should be marked as shown

CBCT based 1

1. Inital cast has teeth set in ideal location and barium sulfate flipper or denture that the patient wears.
2. CBCT with flipper in place
3. Implants placed on software

How to make a CBCT guide on edentulous patient.

Cory Glen video using BSB.

Guide surgery case example

Another view of surgical guide in the mouth

Drilling through the surgical guide

Drilling through surgical guide

Immediately after denatl implants placed. Since this was done flapless there is very little pain after.

What are the options and techniques for a 3D printed dental implant surgical guide?

What are the options for surgical guides if don’t print own?

$35 to scan stone model and print surgical guide. 3-5 day turn around Digi 3D

Dominion Milling Center will print a surgical guide for you for $35. Need scan of teeth no model printing.

Top companies for 3D guided dental implant surgery

1. Nsequence is one of the biggest names because they work with Pikos.
2. Bonadent is another one that looks slick I saw on dt.

What are the 3D printing in office surgical guide options?

Never absolute precision in CBCT. Most systems have 20-30% barium sulphate acrylic scan prosthesis (not Nobel that uses gp). If partially edentulous may not need at all, use teeth as reference.

Types – with any of these types it helps to have holes in guide or drill holes self to ensure fully seating. Post 35

1. Tooth born=most accurate
2. Tissue born
3. Bone born

Companies

1. SimPlant – Facilitate (bone guide available)
2. NobelGuide/NobelClinician
3. 3D Diagnostix (bone guide available)
4. Sicat – Sirona
5. VIP3 – Biohorizons (no pilot)
6. Blue Sky Plan (bone guide available)
7. CoDiagnostix
8. Cybermed – OnDemand (bone guide available)
9. iGuide by iDent
10. EasyGuide by Keystone dental (pilot only)
11. gonyX by Straumann
12. Guided Surgery Solutions
13. Anatomage – InVivo5 (bone guide available)
14. 360 Imaging
15. Canada Bay
16. Implant Concierge
17. Jurim Dental Studio
18. Nemotec
19. nSequence Great bone guide system
20. Ottawa Dental Lab
21. Swiss Meda/SMOP
22. GuideSMILE V2R Biomedical Great pin referenced provisional in use Tischler article in dentalcetoday

Indications

1. 3 or more implants in a row
2. Proximity to vital structures, adjacent teeth
3. Questionable bone volume (significant soft or hard tissue defects)
4. Implant position critical to restorative success
5. Flapless plan
6. Multiple unit or complete arch immediate restorations planned

94% patients have some form of nonodontogenic pathology!! List is here

Large volume CBCT has 2.7-25 times radiation pano, kind of useless since we use limited image.
CBCT is about 20% conventional CT in radiation
Thyroid collar can reduce exposure by 40%
CAS (carotid artery stenosis) found in pano is about 2-5%. Duplex ultrasound is gold standard to confirm

Place cotton roll under upper lip before CBCT to prevent shadowing.

Guide surgery vs free hand dental implant surgery

There are some advantages and disadvantages to both. I personally feel guided can cause more problems than it solves in a single site implant as seen in this video. Bernard 2019 JPD found no difference in success of implants with a pilot guide.

Issues with guided surgery.

Potential problems with guided surgery fall into several categories. A lot of the initial issues deal with the old adage of garbage in, garbage out.

• The initial impression and or CT data will have very minor flaws. This is unlikely to be the source of any real issue though, unless there is some critical anatomy that the CT resolution is too low to pick up.
• Stitching the data together will definitely have some errors and some people and software are better at this than others.
• Guide design and materiel selection will have an impact. Some will flex more than others, which you do not want. Shorter guide sleeves will be less accurate on average as well. The farther the bottom of the guide is to the apex, the more deviation the apex can have. Bill discusses these in post 12.
• Seating the guide can be problematic. It may not seat properly due to inaccurate impression or less than ideal guide design.
• Waggle or wag is an issue. Waggle is the wiggle room that the drills have in the guide. The longer the drill the more deviation at the apex the implant can have. The longer the guide tube is the less waggle there is. The more tolerance or space between the guide tube inner wall and the implant drill diameter the more deviation. Keyless systems have less waggle since there is one less component. Osteotomy site can influence waggle as well. Immediate dental implants that attempt to deviate from the extraction site will have drills that want to fall into the extraction site. A similar issue will occur when attempting to drill into any area where bone densities vary from one side to the other. The drill will always want to go towards the less dense area.