Dental surgeons need in-depth knowledge of the bone tissue status and gingival morphology of atrophic maxillae. The aim of this study is to describe preoperative virtual planning of placement of 5 implants and to compare the plan with the actual surgical results. Three-dimensional (3D) planning of rehabilitation using software programs enables surgical guides to be specially designed for the implant site and manufactured using 3D printing. A patient with 5 teeth missing was selected for this study. The patient's maxillary region was scanned with cone-beam computed tomography (CBCT), and a cast model was produced. After virtual planning using ImplantViewer, 5 implants were placed using a printed surgical guide. Two weeks after the surgical procedure, the patient underwent another CBCT scan of the maxilla. Statistically significant differences were detected between the virtually planned positions and the actual positions of the implants, with a mean deviation of 0.36 mm in the cervical region and 0.7 mm in the apical region. The surgical technique used enables more accurate procedures compared with the conventional technique. Implants can be better positioned, with a high level of predictability, reducing both operating time and patient discomfort.

surgical guide, flapless surgery, dental implant

Frequent improvements and changes in dental procedures have enhanced their predictability and accuracy, improving patient comfort and increasing the likelihood of success of clinical treatment. With the advent of osseointegration, many surgical options and techniques have emerged, resulting in high success rates over the long term.1  An accurate preoperative plan defining implant placement and denture manufacture is essential for successful oral rehabilitation of patients using osseointegrated implants.2  A careful preoperative study and detailed planning of restorations will facilitate preservation of vital intraoral structures during rehabilitation of the esthetics and functionality of the stomatognathic system.1 

Dental surgeons are adopting imaging examinations such as computed tomography (CT) to obtain more detailed visualization of facial anatomic structures.1,2  Software programs exist that can convert CT images to physical prototypes of the region to be treated surgically and can also be used to manufacture surgical guides3  to ensure ideal placement of oral implants. These software programs combine 3D images from DICOM files obtained by CT scanning, providing a preoperative overview of anatomic structures.4  For partially edentulous patients, an existing, metal-free, removable denture can be included in the scan, providing a supplementary image that shows the alignment between the positions of the teeth and the morphology of bone structures. These 2 sets of information can be correlated by the software and used to make decisions on the ideal positions for implants. This information is then transferred to the patient with a high level of accuracy by means of a virtually planned and 3-dimensional (3D)-printed surgical guide.3 

Prior planning with virtual images results in quicker, more predictable, and less traumatic surgical interventions. Ideal implant placement also facilitates and simplifies prosthetic restorations.4 

The surgical guide is a key element in the system, because it enables the ideal positions of the restorations, predefined during virtual planning, to be transferred to the oral cavity during surgery to insert the implants into the bone. The surgical guide contains information on positioning and alignment of implants and on the final prosthetic structure.5  The guide is fitted with metal cylinders that indicate the drilling locations in the virtually planned procedure and act as guides during surgery. The information transferred using the surgical guide enhances safety and predictability of oral rehabilitation and reduces postoperative complications, resulting in less morbidity and greater patient comfort, reducing edema and painful symptoms.3 

The aim of this report is to describe use of a surgical guide for placement of osseointegrated implants and the outcomes obtained, assessing the differences between the virtual plan and the outcomes actually achieved after placement of the titanium implants.

Guided surgery contributes to the success of oral implants because it is based on 3D planned rehabilitation using minimally invasive procedures in the maxilla and/or mandible with surgical guides.4 

The ideal treatment protocol for a dental implant is one that both achieves osseointegration and provides the most favorable implant position for optimal functional and esthetic prosthodontic restoration.6 

Successful rehabilitation with implants is dependent on diagnosis and accurate planning.2,7  Inadequate planning can produce undesirable outcomes. Incorrectly placed implants result in nonaxial distribution of forces, causing inadequate loading, and increased stress and can sometimes cause loss of osseointegration.8,9 

Surgical guides for partially dentate patients can be manufactured in the laboratory on cast models (conventional guides). When virtual planning is used, cone-beam computed tomography (CBCT) in combination with specific software programs (ImplantViewer), can be used to create surgical guides that are designed in virtual models after scanning the patient's mouth, reliably reproducing tissues in 3D images.10 

By planning surgical guides virtually, placement of implants can be based on the most favorable angles and ideal positions of restorations and their relationships with teeth, determined in advance.11  This is only possible because virtual planning enables visualization of the relationships between surgical positioning of the implant to be fitted and the position of the prosthetic restoration that will be manufactured.4 

To achieve successful treatment, it is important to follow a prosthesis-driven implant plan,12  considering 3 aspects that are essential for better 3D positioning of the implant: the most favorable bone morphology for osseointegration, biomechanics, and esthetics.7,13 

Prosthetic preparation seeks to establish the ideal conditions for rehabilitation using provisional dentures with adequate functionality and esthetics. This provides a basis for determination of the vertical dimension of occlusion and the relationships between the future restorations and the surrounding soft tissues, including the relationship between the mucosal area and the pink segment of the denture, if needed.4,13–15 

Use of techniques for 3D reconstruction of both the maxilla and mandible enables these anatomic structures to be imported into the planning software, in virtual form, together with CT images of the patient. By superimposing these virtual images, the positions of the implant in the remaining alveolar bone and of the restoration that will be mounted on it can then be planned accurately, facilitating flapless surgical procedures.3 

Production of virtual guides entails scanning the patient twice. For patients who already wear complete or partial dentures, these will be individually identified with radiopaque markers (gutta-percha inserted into the sides of the dentures), enabling superimposition of images of the patient scanned with and without the dentures.4  The first scan is performed with the patient wearing the marked denture, in occlusion, to obtain a bite record. The denture will then be scanned separately, outside of the patient's mouth, so that the relationships with images showing the bone can be determined. The gutta-percha markers are therefore used as reference points during virtual planning.2,4,16 

Because the markings are visible in both sets of scan images, these points can be realigned to combine the denture within the maxillofacial structure. Once the structures have been accurately aligned, planning can be conducted and controlled to produce an integrated model. The combination of the 2 scans provides a 3D model of the bone tissue including the positions of the teeth, showing the dental surgeon the best surgical and prosthetic alignment for implant placement.14 

Conversion of CT scan images using specific software programs enables the exact 3D position of the planned implant to be predetermined in advance and then transferred to the surgical site, so the surgical procedure is planned virtually.15 

Tomographic images are stored in a digital format that complies with the DICOM (Digital Imaging and Communications in Medicine) international standard. These images are obtained from axial slices. These slices can be artificially joined together by computer programs to produce 3D reconstructions of the object scanned, so it can be displayed in different planes (axial, sagittal, and coronal).11,13 

There are software programs specifically designed for dental implant planning that use CT images. These programs can be used to determine the amount of bone available for implant placement at specific sites.16  They process the DICOM image data, providing a preoperative view of the patient's anatomic structures.4 

In addition to the DICOM file, a stereolithography (SLT) file is also needed. This is obtained by digitization of a plaster cast model and from intraoral scans of the patient.13  When combined, these 2 files facilitate virtual planning and optimization of implant placement.16 

A high-precision scanner (for example, Cerec by Sirona, Itero by CADENT, or Lava by 3M) can capture images of the cast model and of the patient's dental arches, transferring them to the computer screen. These images are stored and interpreted by planning software, and a virtual 3D model is created. The combination of models and digital images obtained from CBCT scanners can be of great help in diagnosis and planning.2,16  They enable the implants to be located in areas with adequate quantities of bone, favorable inclination, and ideal positioning.7 

The image files are imported to a dedicated program (eg, ImplantViewer), which reads the data and converts them into an interactive 3D model. The software is used to align the 2 CT image files, accurately superimposing the images. The surgical guide can be designed in the planned position and then exported for manufacture by prototyping.8 

Rapid prototyping techniques fabricate parts by building up the materials layer by layer. The most commonly used processes include SLA and fused deposition modeling (FDM), that is, 3D printing. Together, these techniques can be used to view images of the virtually planned implants on the computer screen and then manufacture guides to transfer the planned positioning to the oral cavity during the surgical procedure.9 

Surgical guides should possess certain essential features, such as stability and stiffness, and they must remain stable in the completely or partially edentulous arch.17  These structures are virtually designed in CAD to precisely reproduce the position and angulation of implants, providing the operator with the necessary information at the time of surgery.7 

Indications for guided surgery may include minimally invasive flapless surgery, when enough bone volume is available, anxious patients, and planning optimization (ie, achieving the ideal position of dental implants and their relationship with the prosthetic restoration).7–9  The method can also be used for immediately loaded restorations for completely edentulous patients, with placement of multiple implants.6  The accuracy achieved with guided surgery protocols increases the likelihood of an ideal prosthetic reconstruction outcome.3 

Surgical guides increase the safety of placement of implants, expediting the procedure in flapless surgery and improving the predictability of prosthetic rehabilitation.3,4 

This is a case report using study methodology that was reviewed by an independent statistician. A patient with teeth missing from the maxilla was selected at random for the study. Two criteria were stipulated for selection of the surgical case: use of virtual planning and low maxillary posterior bone height. Meeting these criteria, a 45-year-old male patient with 5 teeth missing from his maxilla (14, 15, 16, 24, and 26) sought the outpatient implantology clinic for oral rehabilitation. Guided surgery was suggested after history taking, clinical examination, supplementary tests, and analysis of CT scans and intermaxillary relationships. The patient was given and signed an informed consent form (compliant with the Helsinki Declaration ethical principles).

Initially, a cast study model was sent to a radiology clinic for CBCT scanning and digitization in SLT format. Another set of CT images were obtained by scanning the patient's maxilla (Figure 1). The CT images of the cast model were then superimposed on the images of the maxilla (Figure 2), and 5 Straumann BLT implants were planned using ImplantViewer software (Figures 3 and 4). The planned prosthetic restoration and the patient's bone status were taken into consideration to obtain the best functional positioning for the implants (Figures 5 and 6).

Figures 1. and 2.
Three-dimensional computed tomography images of bone region (Figure 1) and superimposition of bone scan and images of the cast model (Figure 2).
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Three-dimensional computed tomography images of bone region (Figure 1) and superimposition of bone scan and images of the cast model (Figure 2).

Figures 1. and 2.
Three-dimensional computed tomography images of bone region (Figure 1) and superimposition of bone scan and images of the cast model (Figure 2).
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Three-dimensional computed tomography images of bone region (Figure 1) and superimposition of bone scan and images of the cast model (Figure 2).

Close modal
Figures 3–6.
Panoramic computed tomography images (Figure 3) and images obtained from the occlusal (Figure 4) and parasagittal planes (Figures 5–6), showing virtually positioned implants.
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Panoramic computed tomography images (Figure 3) and images obtained from the occlusal (Figure 4) and parasagittal planes (Figures 5–6), showing virtually positioned implants.

Figures 3–6.
Panoramic computed tomography images (Figure 3) and images obtained from the occlusal (Figure 4) and parasagittal planes (Figures 5–6), showing virtually positioned implants.
View largeDownload slide

Panoramic computed tomography images (Figure 3) and images obtained from the occlusal (Figure 4) and parasagittal planes (Figures 5–6), showing virtually positioned implants.

Close modal

Once the positions of the planned implants had been defined in the virtual model, a teeth-supported surgical guide was designed for 3D printing (Figures 7 and 8), using the same software. The remaining natural teeth were used to support the guide, eliminating the need for stabilization screws. The virtual guide data were imported to UP Studio software so that they could be sent to a UP Mini 2 3D printer. The guide was printed in polylactic acid (PLA) plastic (Figures 9 and 10) and fitted onto the cast model to check stability and precision (Figure 10). Metal sleeves, supplied by Straumann, were fitted into holes in the printed guide to allow use of a milling guide and specific milling cutters, also provided as part of the Straumann guided surgery kit. The manufactured guide was then chemically sterilized with peracetic acid. ImplantViewer provided the depth measurements for each implant to the bases of the sleeves, defined by virtual planning. Milling depths were calculated for each implant based on these data.

Figures 7–10.
Three-dimensional images obtained with ImplantViewer, in which the implants were virtually placed (Figure 7) and the position of the virtual surgical guide based on the position of the implants (Figure 9). Image of printed surgical guide (Figure 8) and its position in the cast model (Figure 10).
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Three-dimensional images obtained with ImplantViewer, in which the implants were virtually placed (Figure 7) and the position of the virtual surgical guide based on the position of the implants (Figure 9). Image of printed surgical guide (Figure 8) and its position in the cast model (Figure 10).

Figures 7–10.
Three-dimensional images obtained with ImplantViewer, in which the implants were virtually placed (Figure 7) and the position of the virtual surgical guide based on the position of the implants (Figure 9). Image of printed surgical guide (Figure 8) and its position in the cast model (Figure 10).
View largeDownload slide

Three-dimensional images obtained with ImplantViewer, in which the implants were virtually placed (Figure 7) and the position of the virtual surgical guide based on the position of the implants (Figure 9). Image of printed surgical guide (Figure 8) and its position in the cast model (Figure 10).

Close modal

During the surgical procedure, after local infiltration anesthesia, the guide was fitted onto the patient's teeth, and the milling protocol (Straumann) was implemented, following the measurements of the 4 planned implants. In the region of tooth 26, the initial milling plan had to be shortened because of the position of the maxillary sinus. At this site, the surgical socket was initially widened using the installation guide but short of the planned length. An atraumatic maxillary sinus lift was then performed using Summers instruments. Drill handles were not used in this sinus lift surgical procedure. Therefore, the guide and the newly formed surgical socket served to guide and direct the Summers instruments, used to break through the floor of the sinus cavity. The other sockets were milled using the guide and drill handle, according to plan. All implants were placed with the aid of the surgical guide and appropriate wrenches, preventing deviation from the planned position. After implant placement, only cover screws were fitted, and the prosthodontic restoration was dealt with in a subsequent phase of treatment. Sutures were not needed because of the small size of the surgical access. A provisional removable denture that occluded the holes was used for containment, esthetics, and control of bleeding.

The patient reported no intraoperative discomfort and was quite satisfied with the shorter duration of treatment. There was no local sensitivity and no apparent edema in the postoperative period. A follow-up CT scan was requested 2 weeks after surgery (Figures 11 through 14) to assess the positions of the new implants, and the outcome was very similar to the virtual plan.

Figures 11–14.
Panoramic computed tomography slices (Figure 11) and slices in the occlusal plane (Figure 12) of the maxilla after implant placement. The parasagittal images (Figures 13 and 14) show alignment of the implants placed between the bone plates.
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Panoramic computed tomography slices (Figure 11) and slices in the occlusal plane (Figure 12) of the maxilla after implant placement. The parasagittal images (Figures 13 and 14) show alignment of the implants placed between the bone plates.

Figures 11–14.
Panoramic computed tomography slices (Figure 11) and slices in the occlusal plane (Figure 12) of the maxilla after implant placement. The parasagittal images (Figures 13 and 14) show alignment of the implants placed between the bone plates.
View largeDownload slide

Panoramic computed tomography slices (Figure 11) and slices in the occlusal plane (Figure 12) of the maxilla after implant placement. The parasagittal images (Figures 13 and 14) show alignment of the implants placed between the bone plates.

Close modal

The images obtained from the virtual planning procedure were superimposed onto images of the implants after placement in axial slices showing the cervical and apical portions of the implants (Figures 15 through 18). Assessments were only performed at these 2 points because the software did not allow analysis of possible differences in angulation using coronal slices (Figure 17).

Figures 15–19.
Occlusal tomographic slice (Figure 15) indicating the virtual position (magenta) and physical position (yellow). Figures 16–18 show discrepancies of 0.28 in the cervical region and 0.71 in the apical region on axial sections. Figure 17 shows a coronal slice, comparing the virtual position (magenta) to the physical position achieved after the surgical procedure. Figure 19 Percentage success of implant positioning in relation to the reference tolerance.
View largeDownload slide

Occlusal tomographic slice (Figure 15) indicating the virtual position (magenta) and physical position (yellow). Figures 16–18 show discrepancies of 0.28 in the cervical region and 0.71 in the apical region on axial sections. Figure 17 shows a coronal slice, comparing the virtual position (magenta) to the physical position achieved after the surgical procedure. Figure 19 Percentage success of implant positioning in relation to the reference tolerance.

Figures 15–19.
Occlusal tomographic slice (Figure 15) indicating the virtual position (magenta) and physical position (yellow). Figures 16–18 show discrepancies of 0.28 in the cervical region and 0.71 in the apical region on axial sections. Figure 17 shows a coronal slice, comparing the virtual position (magenta) to the physical position achieved after the surgical procedure. Figure 19 Percentage success of implant positioning in relation to the reference tolerance.
View largeDownload slide

Occlusal tomographic slice (Figure 15) indicating the virtual position (magenta) and physical position (yellow). Figures 16–18 show discrepancies of 0.28 in the cervical region and 0.71 in the apical region on axial sections. Figure 17 shows a coronal slice, comparing the virtual position (magenta) to the physical position achieved after the surgical procedure. Figure 19 Percentage success of implant positioning in relation to the reference tolerance.

Close modal

A statistical analysis was performed to verify the accuracy of the 3D printed device. Reference points defined in bone and dental regions in both sets of CT images were aligned and superimposed. Discrepancies (in mm) identified between the implant positions defined virtually, and their actual positions after physical placement were calculated for each implant site (Table 1). The unit of statistical analysis was the implant. Thus, 5 implants were each assessed at 2 different points: 1 cervical and 1 apical. Each implant was labeled according to its position in the dental arch (ie, the number of the missing tooth it replaced), and these positions were defined as the independent variables. These variables did not influence the main measure. The dependent variables were defined as the difference between the virtual position and the position achieved after the implant had actually been fitted. These data were important to determine the effectiveness of the technique using virtual planning. These measures were transformed into frequencies, defining a discrepancy of 0.01 mm as the maximum tolerance for clinical success. The values obtained from the measurements of the different teeth were then compared against this reference (Table 1). The data for clinical success in percentage were subjected to the χ2 test with Bonferroni adjustment and are illustrated in Figure 19. The level of significance was set at 5% (SPSS v.25 Inc). Dental implant 26 exhibited larger deviations, which were the result of the change in the surgical approach because of the presence of the maxillary sinus roof.

Table 1

Discrepancies (mm) in the cervical and apical regions of each implant*

Discrepancies (mm) in the cervical and apical regions of each implant*
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Discrepancies (mm) in the cervical and apical regions of each implant*
View Large

Virtually guided surgery has been adopted in oral implantology.2–4,10–13,15,16,18  The present study reported the case of a patient with missing maxillary teeth who underwent virtual analysis based on preoperative CT scans of his existing prosthesis and planning of implant placement with virtual comparison of both scans (of the patient and of his prosthesis). After defining the planned positions of the implants virtually, a surgical guide was manufactured using 3D printing and used during physical placement of implants. The patient reported an uneventful postoperative period and minor use of painkillers. A postoperative CT scan was performed, showing the physical positions of implants, which were compared with their virtually planned positions, revealing the effectiveness of implant placement. The analysis comparing the implants as inserted in the maxilla with the virtual plan is partially limited, because it was not possible to determine angular misalignment, because the software used only offers analysis of deviations in lateral position and depth. A different radiologic software package that enables assessment of all 3 types of deviation (lateral position, depth, and angle)19  would have been more useful in this situation, allowing more accurate analysis of the positions of each implant after placement.

Advances in implantology and the need for less traumatic surgical procedures have encouraged dentists to use guided surgery. Breakthroughs in radiology and computer science play a crucial role.2,3,8,11,20,21  Using CT scans and virtual planning, the spatial view of the anatomic structures was more accurate, and surgical planning was safer and more efficient. Accurate transfer of virtual planning data to the recipient in vivo20  is closely related to good-quality imaging combined with a well-devised plan using an appropriate analytical software program, accurate fabrication of the surgical guide, and careful surgical procedures. Nevertheless, small deviations between the virtual plan and the newly placed implants were observed.

Surgical guides allow for a less invasive intraoral surgical procedure because there are no gingival detachments or flaps, reducing chair time and ensuring a less painful postoperative recovery.3,4,8,12,17  Moreover, complications associated with the postoperative quality of soft tissues, infection, suture dehiscence, and necrosis of peri-implant tissues are less frequent in guided surgeries.8,17,18,21  A longitudinal study21  demonstrated a mean implant survival rate of 97.3% (n = 1941) in guided surgeries compared with 93%–98% success rates for the conventional approach.

Preoperative and postoperative images were compared, with close observation of implant sites where virtual planning was used. Some deviation between virtual planning and the final clinical outcome is inevitable because of certain technical details20  such as the quality of tomographic images (panoramic, transverse, and axial), unfaithful 3D reconstruction reproduction, quality of the prototype model, and stability and accuracy of the surgical guide.11 

Four types of measurements are often used to assess the discrepancies between virtual planning and the clinical position of the implant after surgery (depth, global, lateral, and angular deviations).22,23  In our case report, after surgically guided placement of implants with a tooth-supported guide, deviations were evaluated at the cervical and apical regions of the implants (Table 1), showing significant differences between the virtually planned positions and those of the titanium implants actually placed in the maxilla. Greater deviation was observed in the implant placed in position 26, where a maxillary sinus elevation procedure was performed with an atraumatic technique. Although installation was aided by the surgical guide, the final milling depth had to be changed because of local conditions, resulting in a greater proportion of deviation compared with the adjacent implants. Anatomic/surgical limitations found in some clinical cases prompt professionals to carry out more detailed and thorough surgical planning to anticipate possible intraoperative surgical complications and to obtain a more accurate and efficient final result.

Leaving aside the results obtained for tooth position 26, where there were variations between planned and actual placement, the mean deviations of the other dental elements (14, 15, 16, and 24) were 0.36 for the cervical region and 0.7 for the apical region. These values are higher than those obtained by Geng et al24  but lower than others described in the literature,25–27  in which deviations at the cervical level ranged from 0.17 to 1.55, and deviations at the apical level ranged from 0.37 to 2.05 (Table 2).

Table 2

Mean deviations (mm) at the cervical and apical levels of the implants*

Mean deviations (mm) at the cervical and apical levels of the implants*
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Mean deviations (mm) at the cervical and apical levels of the implants*
View Large

It is important to note that limitations affecting the present study could be the cause of conflicting results compared with other studies.24–27  Because this is a clinical case report with a single patient, it is not possible to compare the postoperative results or to claim that the guided surgery technique involves much less discomfort than “freehand” surgery.28,29  The number of implants installed was also a limiting factor in terms of results, possibly introducing a bias in the statistical results presented. To accurately determine the similarity between the positions planned virtually and the positions actually achieved, statistical tests to estimate the ideal number of samples would be necessary.

Superimposition of virtual images on those acquired after implant placement showed that the final anatomic positions were similar. The virtual surgical planning method used in the case reported here was successful, allowing accurate implant placement because of the surgical guide printed via DICON.

Superimposition of the STL file on the data from the DICOM file enabled very precise planning for most of the implants, ensuring safety during surgery. As for the region of tooth number 26, where the decision was made to use an atraumatic technique, the implant was inserted in a similar position to that planned, facilitated and guided by the use of the surgical template. The result initially achieved according to virtual and postoperative surgical analysis demonstrated that the technique using guides offers safety and a high degree of predictability for treatment with dental implants.

Several studies have been published showing deviations using the guided surgery technique,24–27  where it can be seen that small path changes exist but are considered minimal in most cases. The combination of virtual planning with treatments using atraumatic sinus elevation procedures is very rare. During selection of cases that were appropriate for virtual planning, only 1 clinical case was found involving this type of atraumatic surgical technique.

Additional studies evaluating possible deviations caused by unforeseen changes to the plan during surgery could provide important information for dental surgeons who are starting to learn this operating technique. The present study is a case in point because there was a need to perform a maxillary sinus elevation procedure. Another possibility would be a need to reduce instrumentation of the surgical alveolus because of a patient's bone quality. This kind of information is extremely important because it forewarns implantodontists of possible complications that could emerge at the time of surgery.

It can be concluded that virtually guided surgery enabled better surgical/prosthetic planning of placement of implants. The technique described here achieved a surgical procedure involving mild trauma, minor discrepancies in the positioning of newly placed implants, better predictability, shorter operating time, and minimal patient discomfort.

Abbreviations

Abbreviations
CBCT:

cone-beam computed tomography

CT:

computed tomography

FDM:

fused deposition modeling

SLT:

stereolithography

The authors thank Tamara Kerber Tedesco, PhD, for valuable contributions to the statistical analyses performed in this study.

The authors declare no conflicts of interest.

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