Implant Guided Surgical Guide and Immediate Provisionalization

Published Date 07/24/2018
 

Case Presentation

Implant Guided Surgical Guide and Immediate Provisionalization

Guided surgical guides and premade provisionals are now considered a routine procedure because of their accuracy and predictability. This case details file merging of cone beam computed tomography (CBCT) DICOM data with iTero Element (Align Technology) STL file data to create a virtual planning platform, design and 3D print the surgical guide, and place implants.

 

Patient Presentation

The 21-year-old patient sustained facial, bone, and dental injuries (Figure 1) in an automobile accident while jogging, including the loss of teeth Nos. 7 and 8 (Figure 2). After discussing alternatives, benefits, and complications, the patient agreed to implant placement and immediate provisionalization of the missing anterior teeth.

 

cbct frontal view of dental injury intraoral anterior view of missing maxillary right and central incisors

 

Virtual Planning

We file-merged surface morphology STL data from an iTero Element digital scan (Figure 3) with the DICOM data of a NewTom VGi CBCT scan taken by Mobile Imaging Solutions. Using SIMPLANT v16 software (Dentsply Sirona Implants), we created a virtual wax-up for optimal shape and contour of the missing teeth (Figure 4).

After crown down planning, we determined each implant location to allow precise placement of the lingual access cylinder for the retention screw of the screw-retained implant restoration, as well as to ensure it was optimally located in available bone (Figure 5). Using 3Shape software, Glidewell Labs CAD designed and milled full-body polyetheretherketone (PEEK) provisionals with engaging titanium inserts (Figure 6). The titanium inserts, created to allow for screw retention, were secured with luting cement. Using the planning data, we designed a surgical guide that was 3D-printed using a Stratasys Objet 30 3D printer with FDA-approved MED 610 polymer (Figure 7).

 

itero element 2 digital scan of patient teeth merge of cbct and stl file to create 3d planning platform

simplant pro v16 software virtual implant placement peek milled provisionals with titanium insert screw stratays 3d printed guided surgical guide in med 610 polymer

 

Treatment

After administration of local anesthesia (4% Septocaine, Septodont), we inspected the tooth-supported guided surgical guide and trial-fitted in the patient’s mouth. Designed inspection windows were viewed to ensure proper adaptation (Figure 8). As flapless surgery was planned, we used a tissue-removal drill followed by a sequential series of osteotomy drills (Figure 9). Care was taken to take each drill to full depth, with the drill shoulder contacting the metal guide insert (Figure 10).

We placed Glidewell 3.7 mm x 13 mm and 4.7 mm x 13 mm implants and torqued them to 35 Ncm with the surgical guide in place (Figure 11). We placed the flat of the fixture hex parallel to the flat of the surgical guide with the implant at full depth. PEEK provisionals were placed (Figure 12). No occlusal adjustment was necessary. We removed the composite restoration on tooth No. 9 and used Spectrum TPH3 (Dentsply Sirona Restorative) to develop an improved esthetic result (Figure 13).

 

intraoral trial fit of surgical guide with view of inspection window flapless surgery with sequential drills note drills inserted full to depth, shoulder to shoulder

implant placement with guide in place to ensure positioning to full depth premade screw-retained provisionals placed into implants

anterior view with implant provisionals and composite resin repair of tooth no. 9

 

Accuracy Leads to Success

Accurate scan data produces accurate file merging, which leads to extremely accurate design and 3D printing of guided surgical guides. Accurate guided surgical guides then allow for such precise placement of implants that premade provisionals can be placed at the same time as the implants. With a 100% digital workflow, clinicians can produce predictably accurate premade provisionals in the anterior esthetic zone.

 

About the Doctor

Dr. Jones is a graduate of Virginia Commonwealth University and an adjunct faculty associate professor. He is co-founder of the American Academy of Clear Aligners. In addition, Dr. Jones is owner and CEO of Mobile Imaging Solutions, the first mobile dental imaging service in Richmond, VA, where he maintains a private dental practice.

 

Go-To Products Used in this Case

The iTero Element scanner has a compact footprint so you can fit high-precision scanning power almost anywhere. Its wand operation features built-in controls like side buttons and a touchpad for user interface control. 3D scan images appear instantly with crisp definition on a 19-inch touchscreen display.

SIMPLANT dental planning software offers clinicians a comprehensive 3D system for accurate and predictable implant planning and treatment. Clinicians can access a patient's anatomy and see exactly how it relates to the proposed restoration. SIMPLANT is compatible with more than 10,000 implants from more than 100 brands.

Spectrum TPH3 is a visible light-activated, radiopaque microhybrid composite for anterior and posterior restorations. The composite is pre-dosed in compules tips or delivered in traditional syringes. It is available in a selection of precise VITA shades, enabling nature-like esthetics and desirable results.

 

 

iTero Element Intraoral Scanner
Align Technology Inc.
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