Surgical planning and prosthesis construction using computer technology and medical imaging for immediate loading of implants in the pterygomaxillary region

This report describes a protocol that uses computerized tomography (CT), computer-aided design/computer-assisted manufacture (CAD/CAM) technology, and the Internet to plan placement of anterior and posterior dental implants and construct a precise surgical template and definitive prosthesis, which is connected at the time of implant placement. This procedure drastically reduces surgical treatment time and the recovery period. Patients with an edentulous arch had a denture with radiopaque markers constructed for CT scans of the appropriate jaw. The CT images, with acquisition slices of 0.5 mm, were transferred into a three-dimensional image-based program for planning and strategic placement of dental implants. After implants were virtually placed on the computer, the surgical treatment plan was sent to a manufacturing facility for construction of a surgical template and the prosthesis, Special surgical guide components were also manufactured for placement of implants in the pterygomaxillary region. The manufactured surgical components, surgical template, and definitive prosthesis were then delivered to the clinical site. Implant placement surgery was performed using the surgical template, without a flap, and the prosthesis was delivered, achieving immediate functional loading. Minor occlusal adjustments were made. The total surgical treatment time required was less than 60 minutes. Postoperative symptoms, such as pain, swelling, and inflammation, were minimal. Identification of the bone in relationship to the tooth position via three-dimensional CT prior to surgery allows precise placement of implants. CAD/CAM technology using the three-dimensional images allows for fabrication of the surgical guide and final prosthesis. This is a significant advancement in implant dentistry and prosthodontics.     

Computer-aided dental implant planning

Computer-aided dental implant planning increases the predictability of replacing missing teeth in partially and fully edentulous cases. This article describes how Nobel Biocare's Procera surgical planning software converts a patient's double CT scan data into a virtual three-dimensional model of the alveolar bone and overlying prosthesis. Using these images, the practitioner virtually places implants in the bone in precise relation to their position in the final prosthesis. Procera uses this virtual plan to fabricate a customized surgical template that guides the placement of the implants safely, precisely, and accurately. Then the dental laboratory can construct the master cast and provisional restoration before surgery, allowing the restoration to be inserted immediately after placement of the implants. Furthermore, computer-based guided implant surgery is minimally invasive and requires a shorter chair time and fewer appointments than traditional methods.     

CAD/CAM-guided implant surgery and fabrication of an immediately loaded prosthesis for a partially edentulous patient

The treatment planning, placement, and restoration of dental implants for the partially edentulous patient can be challenging. Anatomical limitations can make implant location difficult to determine. The use of CT scans and surgical planning software to produce a CAD/CAM surgical template, as well as the use of a flapless surgical technique, can make implant placement more predictable, safer, and easier for patients. The article describes a computer-guided surgical technique for the partially edentulous patient, with a restoration fabricated prior to implant placement, for immediate loading.     

Restoration of immediately placed implants in 3 appointments: from surgical placement to definitive prostheses

This article describes a comprehensive approach that enables the clinician to place dental implants, and fabricate a provisional prosthesis and a definitive metal-acrylic resin or metal-ceramic fixed complete denture in 3 appointments. This technique allows the practitioner to immediately load the implants with a provisional fixed complete denture at the time of implant placement, to record the relative positions of the implants and soft tissues, the occlusal vertical dimension, maxillomandibular relationship, and tooth position at the second appointment by using the information provided by the provisional fixed denture, and to insert the definitive prosthesis at the third appointment. This technique reduces chair time for both the patient and the clinician, and could ultimately reduce the cost of implant treatment and potentially increase treatment acceptance.     

Surgical technique for achieving implant parallelism and measurement of the discrepancy in panoramic radiograph.

PURPOSE: This article describes a surgical technique for achieving implant placement parallelism and presents an equation concept to predict the bone depth available for implant placement by measuring the discrepancy of the panoramic radiograph compared with a clinical situation in cases in which a wide edentulous area is present. MATERIALS AND METHODS: A surgical template with tube technique in combination with measurement of the vertical dimension of the mandible bone available for implant placement was used to treat 2 patients in whom 7 and 3 implants, respectively, were inserted in the lower and upper jaws. RESULTS: All implants were successfully implanted into their reliable positions. In regard to the position of an important area such as the inferior alveolar nerve and maxillary sinus, this predictive equation can provide an extra margin of security. CONCLUSION: A partial denture surgical template technique with tube technique using a Coen's drill guide in combination with a mathematical equation to find the clinical-radiographic discrepancy can be used as an alternative method in placement guidance of dental implant insertions and its fixed prosthetic treatment planning in a wide edentulous area.     

Oral rehabilitation of a patient with bruxism and cluster implant failures in the edentulous maxilla: a clinical report

For most patients with failed dental implants, the placement of new implants is the only option that allows for retreatment with a fixed dental prosthesis. This clinical report describes the rehabilitation of a patient with a history of bruxism and cluster implant failures in the edentulous maxilla 10 years after the insertion of a milled bar overdenture. Seven failed implants were removed and simultaneous bone grafting was performed. After an 8-month healing period, 8 dental implants with new surfaces were placed. These supported a metal ceramic fixed complete denture with a metal occlusal surface. The prosthesis was retained with 3 sections of milled bars and 3 set screws. This clinical report describes the details of the treatment with an emphasis on prosthetics.     

Immediate loading with mini dental implants in the fully edentulous mandible

The use of immediate loaded prostheses is not recommended for at least 2 weeks to prevent implants from premature loading. In addition, immediate removable prostheses are negated for at least 4 weeks at the site of guided bone regeneration or bone graft. However, patients are often not pleased with limited diets and the unaesthetic appearance during the healing period without a denture between implant placement and final prosthesis. Mini dental implants provide stable and esthetic temporary prostheses immediately after implant placement and bone grafts. The use of mini dental implants is simple and cost effective because the patient's old denture is used as a provisional prosthesis. This article shows the success of 27 mini dental implants that were placed for 11 mandibular fully edentulous patients.     

Prosthetically driven, computer-guided implant planning for the edentulous maxilla: a model study

Objectives: To analyze computer‐assisted diagnostics and virtual implant planning and to evaluate the indication for template‐guided flapless surgery and immediate loading in the rehabilitation of the edentulous maxilla. Materials and Methods: Forty patients with an edentulous maxilla were selected for this study. The three‐dimensional analysis and virtual implant planning was performed with the NobelGuide? software program (Nobel Biocare, Göteborg, Sweden). Prior to the computer tomography aesthetics and functional aspects were checked clinically. Either a well‐fitting denture or an optimized prosthetic setup was used and then converted to a radiographic template. This allowed for a computer‐guided analysis of the jaw together with the prosthesis. Accordingly, the best implant position was determined in relation to the bone structure and prospective tooth position. For all jaws, the hypothetical indication for (1) four implants with a bar overdenture and (2) six implants with a simple fixed prosthesis were planned. The planning of the optimized implant position was then analyzed as follows: the number of implants was calculated that could be placed in sufficient quantity of bone. Additional surgical procedures (guided bone regeneration, sinus floor elevation) that would be necessary due the reduced bone quality and quantity were identified. The indication of template‐guided, flapless surgery or an immediate loaded protocol was evaluated. Results: Model (a) – bar overdentures: for 28 patients (70%), all four implants could be placed in sufficient bone (total 112 implants). Thus, a full, flapless procedure could be suggested. For six patients (15%), sufficient bone was not available for any of their planned implants. The remaining six patients had exhibited a combination of sufficient or insufficient bone. Model (b) – simple fixed prosthesis: for 12 patients (30%), all six implants could be placed in sufficient bone (total 72 implants). Thus, a full, flapless procedure could be suggested. For seven patients (17%), sufficient bone was not available for any of their planned implants. The remaining 21 patients had exhibited a combination of sufficient or insufficient bone. Discussion: In the maxilla, advanced atrophy is often observed, and implant placement becomes difficult or impossible. Thus, flapless surgery or an immediate loading protocol can be performed just in a selected number of patients. Nevertheless, the use of a computer program for prosthetically driven implant planning is highly efficient and safe. The three‐dimensional view of the maxilla allows the determination of the best implant position, the optimization of the implant axis, and the definition of the best surgical and prosthetic solution for the patient. Thus, a protocol that combines a computer‐guided technique with conventional surgical procedures becomes a promising option, which needs to be further evaluated and improved.     

Simultaneous Le Fort I osteotomy and zygomatic implant placement

The aim of this retrospective study was to evaluate the outcomes of simultaneous LeFort I osteotomy and zygomatic/dental implant placement for oral rehabilitation of patients with extremely atrophic/dysmorphic edentulous maxilla.Simultaneous LeFort I osteotomy and zygomatic/dental implant placement was performed with patient-specific anatomical models and surgical guides produced through three-dimensional virtual planning methods. All patients received their final prosthesis, with immediate loading, on the day after surgery. The primary outcome variables were the implant survival rate, and the incidence of intra/postoperative complications. In total, 15 zygomatic implants and 33 conventional dental implants were inserted in eight patients. The mean follow-up of the patients was 38.5 months. The implant survival rate was 93.3% for zygomatic implants and 100% for dental implants. No intra/postoperative complications were observed.Simultaneous LeFort I osteotomy associated with zygomatic/dental implant surgery can be considered as a valuable treatment option for rehabilitation of patients with extremely atrophic edentulous maxilla and esthetic issues of the face.     

Possibilities and limitations of implant placement by virtual planning data and surgical guide templates

The use of computer-aided surgical systems for dental implant bed preparation and implant placement results in an average precision within 1 mm of implant position and within 5 degrees of deviation for implant inclination. The accuracy of axis and implant position is significantly more precise with the three-dimensional surgical guide than with the free-hand method. The three-dimensional assessment of the restorative goal (radiopaque simulation of prosthesis with scanning template) allows virtual planning of implants, which enables optimized positioning of implants with surgical guide templates in oral surgery. If there is a clear indication for three-dimensional diagnostics, it should always be checked whether the data can be used as planning data for a surgical guide template, otherwise the chance for guided surgery remains unused. Since uncertainties still exist despite the use of a drilling template, it is recommended that the minimum safety distance from adjacent structures be maintained. The successful use of surgical guide templates requires comprehensive knowledge of and experience in using three-dimensional information for the virtual planning of implant position.     

Removable partial denture design involving teeth and implants as an alternative to unsuccessful fixed implant therapy: a case report

Various dental implants have been used, and high success rates have been reported. However, as their uses increase, implant failures have been reported. There are partially edentulous patients with an initial treatment plan of an implant-supported fixed partial denture. At times, one or more strategic implants fail to osseointegrate. In situations where financial, systemic, or local conditions preclude the use of a fixed partial denture, a well constructed removable partial denture can be an excellent treatment alternative. It has been reported that prosthesis support can be improved with the use of osseointegrated dental implants, with improved preservation and maintenance of existing hard and soft tissues around dental implants. This article describes the prosthodontic rehabilitation of a partially edentulous patient by the use of a removable partial denture design involving teeth and implants as an alternative to unsuccessful fixed implant therapy. This treatment option solved a difficult clinical problem derived from the failure of two strategic implants and provided the patient with an esthetic and functional prosthesis.     

Rescue implant concept: the expanded use of the zygoma implant in the graftless solutions

The use of "anteriorly or posteriorly" tilted implants in a graftless approach for immediate loading the edentulous maxillae has been well documented in the literature. This treatment concept allows for rehabilitation of the edentulous maxillae with a fixed prosthesis. The purpose of this article is to describe criteria for the use of the zygomatic implant, including the expanded use of the zygoma implant in cases where failure of one of the anterior or posterior tilted implants has occurred in the All-on-Four treatment concept. Zygomatic implant placement becomes a "rescue procedure", which allows for continuity of care without resorting to a removable denture.     

Rescue implant concept: the expanded use of the zygoma implant in the graftless solutions

The use of "anteriorly or posteriorly" tilted implants in a graftless approach for immediate loading the edentulous maxillae has been well documented in the literature. This treatment concept allows for rehabilitation of the edentulous maxillae with a fixed prosthesis. The purpose of this article is to describe criteria for the use of the zygomatic implant, including the expanded use of the zygoma implant in cases where failure of one of the anterior or posterior tilted implants has occurred in the All-on-Four treatment concept. Zygomatic implant placement becomes a "rescue procedure", which allows for continuity of care without resorting to a removable denture.     

Prosthetically directed implant placement using computer software to ensure precise placement and predictable prosthetic outcomes. Part 1: diagnostics, imaging, and collaborative accountability

The need for an accurate diagnosis and treatment plan remains essential for predictable treatment outcomes with dental implants. Advances in computerized tomography (CT) technology now enable the execution of a surgical outcome based on presurgical planning. Precise implant placement no longer relies on socalled mental navigation but rather can be computer guided, based on a three-dimensional, prosthetically directed plan. Current CT technology enables all implant team members to embrace the concept of collaborative accountability, which can ensure consistent outcomes. Clinicians can fabricate an implant-supported prosthesis presurgically using patients' CT scan data. The purpose of this paper is to discuss the use of scanning appliances to transfer clinically relevant prosthetic outcome information to a CT data set. With SimPlant software, this information can be used to provide a pretreatment outcome analysis, which can be used for fabrication of stereolithographic models and surgical drilling guides used during osteotomy preparation.     

Transforming an existing fixed provisional prosthesis into an implant-supported fixed provisional prosthesis with the use of healing abutments

Maintaining a fixed provisional prosthesis through all phases of complex implant prosthodontic therapy for a soon-to-be completely edentulous arch is a difficult task. This article focuses on the treatment phase in which teeth and/or transitional implants supporting a provisional fixed partial denture are removed. The described technique makes use of healing abutments to support a modified provisional fixed partial denture. This protocol ensures patient comfort and allows proper soft tissue healing before definitive implant abutment selection. It also eliminates the placement of interim implant abutments.     

A newly designed template device for use with the insertion of immediately loaded implants

This article describes a newly designed surgical template that was used to facilitate dental implant placement. The implants were planned to function by loading them immediately. A case report describing the device and the benefits of its use for a patient with an edentulous mandible is presented. Four implants were placed in the anterior region of the mandible to support an immediately fixed prosthesis. Clinical and radiographic analyses were conducted postoperatively to evaluate bone loss and peri-implant soft-tissue healing. The salutary results demonstrated the positive value of this therapeutic approach and presented the advantages of shorter treatment times, fewer patient visits, lower costs, and elimination of secondary surgical procedures.     

Stabilization of a Computer‐Aided Implant Surgical Guide Using Existing Dental Implants with Conversion of an Overdenture to a Fixed Prosthesis

This clinical report describes a technique to stabilize a computer‐aided dental implant surgical guide to existing implants. A patient requested conversion of her existing mandibular implant‐assisted overdenture into a fixed complete denture. The surgical procedure was planned virtually, and the two existing dental implants were integrated into the surgical plan as a means to fixate the surgical guide. The implants were placed, and the patient's prosthesis was converted into an interim fixed complete denture.     

Computer-assisted implant placement. A case report: treatment of the mandible

The authors present a case of immediate loading of mandibular implants using a 5-step procedure. The first step consists of building a scannographic template, the second step consists of taking a computerized tomographic (CT) scan, and the third step consists of implant planning using SurgiCase software. The final 2 steps consist of implant placement using a drill guide created by stereolithography and placement of the prosthesis. Using a CT scan-based planning system, the surgeon is able to select the optimal locations for implant placement. By incorporating the prosthetic planning using a scannographic template, the treatment is optimized from a prosthetic point of view. Furthermore, the use of a stereolithographic drill guide allows a physical transfer of the implant planning to the patient's mouth. The scannographic template is designed so that it can be transformed into a temporary fixed prosthesis for immediate loading, and the definitive restoration is placed 3 months later.     

Utilization of 3D/Dental software for precise implant site selection: clinical reports.

Preoperative planning is an essential aspect of endosteal implant placement. Three-dimensional imaging allows the surgeon and restorative dentist to accurately visualize potential implant receptor sites relative to adjacent vital structures. This information is correlated with the planned occlusion, and transferred to the patient by means of a surgical prosthetic guide, which is developed on the diagnostic cast. The steps involved in planning and placing implants in an atrophic mandible in the first case illustrates the value of three-dimensional scanning in treating patients with limited bone volume. The second case presented with a mandibular bilateral distal extension partial denture, which was ultimately replaced with two implant-supported fixed prostheses. The use of three-dimensional imaging showed the location of the inferior alveolar neurovascular bundle which allowed utilization of all of the bone above it without encroaching on the nerve. The third case illustrates an edentulous maxilla where visualization of the osseous contour allowed for implant placement at an optimal angulation to provide support for the planned prosthesis.     

Development of gingival esthetics in the edentulous patient prior to dental implant placement using a flangeless removable prosthesis: a case report

Development of gingival contours found in healthy natural dentitions enhances the esthetic results achieved with implant-supported fixed prostheses. However, this endeavor is frequently difficult to achieve, especially in the completely edentulous patient. Edentulous patients with optimal hard and soft tissue can be treated with a specially designed removable prosthesis that will develop gingival contours prior to implant placement. By means of a transitional complete removable prosthesis with ovate pontics and no labial flange, a natural-looking soft tissue profile can be developed prior to dental implant placement. A minimally invasive tissue punch surgical technique is used to place the implants, which are immediately restored with a 1-piece, cross-arch, provisional fixed prosthesis. This article presents the prosthodontic and surgical protocols utilized to improve the appearance of the definitive implant rehabilitation.