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CASE PRESENTATION: Implant Guided Surgical Guide and Immediate Provisionalization

Categories: Implant Dentistry

Author(s): PERRY E. JONES, DDS, MAGD, IADFE

Date: 08-13-2020 09:26:40 am

    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.

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).

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).

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.



GO-TO PRODUCTS USED IN THIS CASE

SPECTRUM TPH3
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.

SIMPLANT
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.

ITERO ELEMENT
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.
 
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