Case Presentation: Designing an Implant Surgical Guide Using 3D Technology

Published Date 02/25/2019
Prosthetically driven digital implant planning is revolutionizing implant dentistry, resulting in improved surgical and prosthetic outcomes. Likewise, utilizing a full digital workflow with in-house 3D printing and milling improves the efficiency of implant cases, resulting in better patient experiences.

One of my passions is to teach digital implant dentistry to other clinicians, especially to experienced implant surgeons. This case provided a unique opportunity for me to help one of my mentors, Dr. Robert Gellin, with his first digital implant planning case. A combination of challenging esthetics, emergence, intraosseous residual endodontic material, and malocclusion motivated Dr. Gellin to digitally plan this single-unit anterior case as a guided surgery from start to finish.

The patient presented with an intact edentulous ridge at site No. 10 with a possible retained root fragment and residual endodontic material, but with adequate ridge dimensions for implant placement.

Digital Implant Planning and Treatment
A CBCT image was captured using the Planmeca ProMax 3D Max, and a scan of the intraoral tissues was merged in the Planmeca Romexis implant planning software. A digital waxup was created in the Romexis CAD/CAM module with considerations of occlusion, gingival margin, incisal edge position, emergence profi le, and prosthetic connection. This data were observed in tandem when virtually positioning the implant, with careful attention to place the implant in an ideal relationship to the labial plate of bone, adjacent anatomy, and to allow proper positioning of the implant platform for prosthetic success and future health. A virtual temporary abutment was placed and all of the planned elements were exported from Romexis to Meshmixer (Autodesk) to create the screw access hole through the planned restoration.

The prosthesis was milled from CERASMART (GC America) on a Planmeca PlanMill 30 S, then cemented to the abutment to create an immediate temporary restoration. A surgical guide was designed with the Romexis guide design module, and the guide was 3D printed. A metal Steco guide sleeve was luted into the guide’s sleeve holder, and the guide was processed in preparation for clinical use. On the day of surgery, fully guided Astra twist drills (Dentsply Sirona) were used to prepare the osteotomy via flapless approach and an Astra Tech OsseoSpeed EV 3.6 × 9-mm implant (Dentsply Sirona) was inserted with torque exceeding 45 Ncm. The temporary was seated with minimal adjustment, confirming occlusion. Postoperative healing was uneventful and the implant is now fully integrated.

The treatment plan is evolving for this patient. She is now interested in restoration of the maxillary anterior teeth to improve function and esthetics. We can be confi dent that because of the careful planning and accurate implant position, the potential restorative outcome will be successful. Dr. Gellin felt that this case was an enlightening experience compared to how he’d been handling implants previously. Digital implant planning, he said, is a method that allows the clinician to come as close as possible to a perfect result.
Figure 1—Preoperative anterior view
Figure 2—View of the CBCT image merged with the digital waxup and the planned implant in position
Figure 3—Volume rendering of the waxed tooth and predicted implant emergence path, and the custom-designed implant surgical guide
Figure 4—View of the guide seated during osteotomy preparation
Figure 5—Merged images of the virtual planned implant and CBCT image with the postoperative periapical radiograph
Figure 6—Anterior view showing temporary restoration seated on the day of implant placement
The new Planmeca Creo C5 brings speed and precision to chairside 3D printing. Custom-engineered for dental professionals to facilitate high-speed printing of surgical guides, dental models, and provisional crowns, this easy-to-use 3D printer has a compact, streamlined design that fits perfectly on a countertop or desk. LCD printing technology eliminates the need for calibration so that you can simply plug it in and start printing, while LCD Photomask Technology projects a uniform light source that eliminates imperfections. Planmeca Creo C5 creates dental appliances that have high resolution and extraordinary precision.

Estimated 3D printing times for same-day appliances:
• Surgical guide or dental model in 8–9 minutes
• 50–60 temporary crowns in less than 10 minutes
• Up to 5 full arch dental models in 8–10 minutes
Dr. Evans earned his DMD, PhD, and completed his residency in periodontics at the Medical University of South Carolina. He spent time in private practice and has since transitioned full time to the university’s periodontics faculty, where he is actively engaged in digital implant dentistry training and research.
Dr. Gellin attended dental school in Kentucky and earned his DMD in 1980. He went on to complete his periodontics residency and MHS in 1985 at the Medical University of South Carolina, where he serves on the faculty and mentors dental residents in periodontics and implant surgery.
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