Guided Surgery for

I m p l a n t Th e r a p y
a,b, c
Gary Orentlicher, DMD *, Marcus Abboud, DMD

KEYWORDS
 Guided surgery  Dental implant  Flapless surgery
 CT/CBCT scans

With the recent introduction of new three-dimensional (3D) diagnostic and treatment
planning technologies in implant dentistry, a team approach to the planning and place-
ment of dental implants, according to a restoratively driven treatment plan, has
become the norm in quality patient care. The team can now start with the end result,
the planned tooth, and then place an implant into the correct position according to the
restorative plan. The accurate and predictable placement of implants according to
a computer-generated virtual treatment plan is now a reality, taking the virtual plan
from the computer to the patient clinically. Recent advances in 3D imaging in dentistry,
in combination with the introduction of third-party proprietary implant planning soft-
ware and associated surgical instrumentation, have revolutionized dental implant
diagnosis and treatment and created an interdisciplinary environment in which
communication leads to better patient care and outcomes.

HISTORICAL OVERVIEW

Since the introduction of the first dental radiographs, dentists have become comfort-
able with evaluating and diagnosing patients using two-dimensional (2D) images (ie,
periapical, bitewing, panoramic, and cephalometric radiographs, and so forth). The
obvious limitations of these technologies in evaluating 3D problems required clinician
acceptance because few options were available. Because of their hospital-based
training, oral and maxillofacial surgeons have long used computed tomography (CT)
scans for the 3D evaluation of facial trauma and pathologic lesions. These CT evalu-
ations typically were viewed in 2D as axial or reformatted frontal or coronal slices

This article was previously published in the May 2011 issue of Oral and Maxillofacial Surgery
Clinics of North America.
a
Private Practice, New York Oral, Maxillofacial, and Implant Surgery, 495 Central Park Avenue,
Suite 201, Scarsdale, NY 10583, USA
b
Oral and Maxillofacial Surgery, White Plains Hospital, White Plains, NY, USA
c
Department of Prosthodontics and Digital Technology, Stony Brook University School of
Dental Medicine, 160 Rockland Hall, Stony Brook, NY 11794-8700 , USA
* Corresponding author. Private Practice, New York Oral, Maxillofacial, and Implant Surgery,
495 Central Park Avenue, Suite 201, NY 10583.
E-mail address: [email protected]

Dent Clin N Am 55 (2011) 715–744

doi:10.1016/j.cden.2011.07.008 dental.theclinics.com
0011-8532/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
716 Orentlicher & Abboud

through the area of interest of a patient’s anatomy, printed on plain films, or viewed as
such on a computer screen. The remainder of the dental community had little, if any,
exposure to 3D image evaluation.
The first medical-grade helical CT scanners were all single-slice, slower machines
that were based in hospitals or private radiology facilities. Typical medical multislice
CT scanners of today are capable of performing a scan of the upper and/or lower
jaw in a few seconds, but the size and cost of the machines, the radiation exposure,
the lack of familiarity and training amongst dentists, and the perceived cost/benefit
ratio in patient care made them inappropriate for a dental office setting. With the devel-
opment and introduction of the New Tom 9000 (Quantitative Radiology, Verona, Italy)
in 1998, cone beam volumetric tomography (CBVT/cone beam computed tomography
[CBCT]) was introduced to the dental community.1 Although the first machines were
larger than those available today, the advantages were that they produced good 3D
images at lower radiation doses,2–4 and the footprint of the machines were small
enough to fit into a dental office. The disadvantages were that, although the radiation
was less than medical-grade CT, it was more than conventional dental radiographs
and, because of the reduced radiation, the images produced had less definition
than medical CT. Since the first CBCT was introduced, machines with multiple
different features have been developed and introduced by various manufacturers.
The gold standard for accurate 3D diagnosis continues to be medical-grade CT.5,6
The recent introduction of adaptive statistical iterative reconstruction (ASIR) software
has been reported to allow up to a 50% radiation dose reduction in medical CT scans,
without diminishing image quality.7–10 There are different average deviations and
percentage error measurements for all CBCT scanners.11,12
In the late 1980s, articles began to appear in the literature discussing the use of Den-
taScans to evaluate the bone of the maxilla and mandible in preparation for placement
of dental implants.13–16 Columbia Scientific (CSI) introduced the 3D Dental software in
1988. This software converted CT axial slices into reformatted cross-sectional images
of the alveolar ridges for diagnosis and evaluation. In 1991, a combination software
was introduced, ImageMaster-101, which allowed the additional feature of placing
graphic dental implants on the cross-sectional images. The first version of Sim/Plant
was introduced by CSI in 1993, allowing the placement of virtual implants of exact
dimensions, on CT images, in cross-sectional, axial, and panoramic views. In 1999,
Simplant 6.0 was introduced, adding the creation of 3D reformatted image surface
rendering to the software.17 Materialise (Leuven, Belgium) purchased CSI in 2001,
introducing the technology for drilling osteotomies to exact depth and direction
through a surgical guide in 2002. NobelBiocare (Zurich, Switzerland) introduced the
NobelProcera/NobelGuide technology in 2005. The NobelGuide technology was intro-
duced as a complete implant planning and placement system, for both straight-walled
and tapered NobelBiocare implants. Appropriate instrumentation was developed to
create osteotomies of accurate depth and direction, as well as the ability to place
implants flapless, to accurate depth, through a guide. The system was designed for
conventional postimplant insertion treatment (cover screws or healing abutments),
immediate loading of implants, and the fabrication of partial or full arch restorations
before implant placement. A completely redesigned upgrade of the NobelGuide soft-
ware, NobelClinician, has been introduced in 2011. Software from other manufac-
turers, such as EasyGuide (Keystone Dental, Burlington, MA, USA), Straumann
coDiagnostiX (Straumann, Basel, Switzerland), VIP Software (BioHorizons, Birming-
ham, AL, USA), Implant Master (IDent, Foster City, CA, USA), and others, are now
available as well. Other implant manufacturers have developed instrument trays for
the guided placement of their implants using the Simplant software for implant
 Guided Surgery for Implant Therapy 717

planning (ie, Facilitate, AstraTech Dental, Molndal, Sweden; Navigator, Biomet 3i,
Palm Beach Gardens, FL, USA; ExpertEase, Dentsply Friadent, Mannheim, Germany.)

GENERAL TECHNOLOGY CONCEPTS

CT/CBCT scanners allow the dentist and surgeon to visualize a patient’s anatomy in 3
dimensions. Visualization of the height and width of available bone for implant place-
ment, soft tissue thicknesses, proximity and root anatomy of adjacent teeth, the exact
location of the maxillary sinuses, and other pertinent vital structures such as the
mandibular canal, mental foramen, and incisive canal are possible.18–20 Once images
are imported into proprietary software programs (eg, Simplant, NobelClinician) the
clinician can then virtually treatment plan the placement of implants for an individual
patient’s anatomy and case plan. The type and size of the planned implant, its position
within the bone, its relationship to the planned restoration and adjacent teeth and/or
implants, and its proximity to vital structures can be determined before performing
surgery.18–22 Computer-generated surgical drilling guides can then be fabricated
from the virtual treatment plan. These surgical guides are used by the doctor to place
the planned implants in the patient’s mouth in the same positions as in the virtual treat-
ment plan, allowing more accurate and predictable implant placement23–27 and
reduced patient morbidity.28–31
All of the current systems have similar restorative and surgical protocols. Upper and
lower arch impressions are made and a bite registration is obtained. Models are
poured and mounted on an articulator. Guided surgery requires reverse planning.
The prosthodontist or restorative dentist first creates an ideal restorative treatment
plan, determining the planned tooth position by creating a diagnostic wax-up that indi-
cates the exact anatomy and position of the teeth to be replaced. An acrylic prosthesis
is then fabricated that reproduces the planned restorations in the acrylic appliance.
Depending on the system to be used, this scan prosthesis can be a partial or full
denture (Figs. 1–3). Most systems, other than NobelGuide, require that the planned
restorations contain a 20% to 30% barium sulfate mixture in the acrylic to allow for
radiopacity of the planned restorations in the CT/CBCT images. NobelGuide uses
a double-scan technique with a hard acrylic scan prosthesis and gutta percha marker
reference points, with no barium sulfate. The CT/CBCT scan is then taken with the
patient wearing the scan prosthesis according to the individual system protocols.

Fig. 1. NobelGuide radiographic guide, fully edentulous.

718 Orentlicher & Abboud

Fig. 2. Simplant radiographic barium stent, partially edentulous.

The CT scan (Digital Imaging and Communication in Medicine [DICOM]) images are
then imported into the various proprietary software programs (eg, Simplant, Nobel-
Guide, EasyGuide). The software programs are then used to virtually place implants
into their ideal positions related to the planned restoration and the underlying bony

Fig. 3. EZ Guide radiographic appliance, partially edentulous.

 Guided Surgery for Implant Therapy 719

anatomy (Figs. 4–6). The digital treatment plan is then uploaded to the manufacturer
for fabrication of a surgical guide (Figs. 7–9). The surgical guide is used, with implant-
specific drilling instrumentation, to precisely place the implants in the same positions,
depths, and angulations as was planned virtually.
Many CT-guided implant planning technologies require radiopaque fiducial refer-
ence markers to be placed in the scan prosthesis that the patient wears during the
CT/CBCT scan. These reference markers are then used by the software to virtually
position the scanning appliance and, with it, the parameters of the planned restora-
tion(s) as related to the patient’s jaw. Some CBCT scanners have difficulty in accu-
rately assessing these geometric markers. This problem has the potential to add
error into a precise planning system. This error can lead to inaccurately fitting surgical
guides and error in implant placement. It is advisable to make every effort to investi-
gate and use CBCT scanners that have high levels of accuracy or medical CT scan-
ners when using these technologies.32

INDICATIONS FOR USE

Because of its precision and accuracy in implant placement, an argument could be

made for the use of CT-guided implant surgery in almost all cases. As with anything
in medicine, a cost/time/benefit determination must be made by the clinician based
on the circumstances of an individual case. The increased patient and treatment plan-
ning time, the additional expense, and the additional patient radiation exposure may
outweigh the clinical benefits in certain cases. We have found that these technologies
are most beneficial to the patient and the doctor in the following clinical situations:
Three or more implants in a row
Proximity to vital anatomic structures
Problems related to the proximity of adjacent teeth
Questionable bone volume
Implant position that is critical to the planned restoration
Flapless implant placement
Multiple unit or full arch immediate restorations, with or without extractions and
immediate placement

Fig. 4. NobelGuide virtual treatment plan, fully edentulous.

720 Orentlicher & Abboud

Fig. 5. Simplant virtual treatment plan, partially edentulous.

Fig. 6. EZ Guide virtual treatment plan, partially edentulous. “A” and “B” on image are
associated with software measurement tool.

Fig. 7. NobelBiocare NobelGuide fabricated from treatment plan, Figs. 1 and 4.

 Guided Surgery for Implant Therapy 721

Fig. 8. Simplant SurgiGuide fabricated from treatment plan, Figs. 2 and 5.

Significant alteration of the soft tissue or bony anatomy by prior surgery or trauma
Patients with physical, medical, and psychiatric comorbidities.

Conventional surgical stents to aid in implant positioning have been used in implant
dentistry for many years. Guides of these types can be simple (ie, vacuform shells with
the buccal or palatal/lingual facings of the planned restorations) or more complex (ie,
stents with 2-mm drill holes or metal tubes). The problem is that there is no correlation
in these appliances between the planned restoration and the underlying bony
anatomy. With the use of computer-guided implant surgical guides, this anatomic rela-
tionship can be predictably established and considered before surgery.
The fabrication of a surgical guide, used in implant treatment, is determined by the
patient’s anatomy and local references, such as the numbers and locations of teeth in
the arch to be treated or in the opposing arch. With increasing length of the edentulous
area, fewer anatomic references are present for the predictable accurate placement of
implants. In a fully edentulous case, other than the soft tissue ridge and palate, all local
references are lost. Bone and soft tissue loss from periodontal disease and atrophy,
long-term denture wear, and sinus pneumatization can make it difficult to predictably
use a traditional surgical guide.

Fig. 9. EZ Guide fabricated from treatment plan, Figs. 3 and 6.

722 Orentlicher & Abboud

In cases in which 3 or more implants in a row are planned, concepts of implant

spacing and angulations, implant parallelism in all dimensions, proximity of implants
to anatomic structures, and relationships between implant positions and the planned
restorations are significant considerations for the clinician. CT/CBCT-guided surgery
allows for the ideal placement of multiple dental implants according to the planned
restoration, the relationships of implants to surrounding anatomy, and principles of
ideal implant positioning and spacing (Figs. 10–13).
Differences in radiograph machines and radiographic techniques commonly lead to
distortion of anatomic structures on conventional 2D images, such as elongation,
shortening, stretching, and contraction. Accurate 3D evaluations and measurements
of the relationship between a planned implant and the position of the mental nerve,
inferior alveolar nerve (Figs. 14 and 15), nasopalatine/incisive nerve (Fig. 16), maxillary
sinuses, and nasal floor (Fig. 17) are best visualized, evaluated, and measured by
using CT-generated images. In cases in which there are questions of nerve or sinus
proximity related to the patient’s available bone, implants are most accurately placed
using computer-generated surgical guides. These technologies minimize potential
patient morbidities.
All proprietary implant planning softwares have the functionality to isolate the roots
of teeth in the edentulous areas to aid in the accurate placement of implants between
and adjacent to tooth roots in the planned sites. Some softwares use virtual dots or
lines to outline tooth roots (Fig. 18), whereas others have the ability to alter the soft-
ware’s sensitivity to Hounsfield units or isovalues to virtually remove bone from around
tooth roots (called segmentation) (Fig. 19). These technologies are most beneficial
when tooth roots are in extremely divergent or convergent relationships or when
implants must be placed in tight spaces because of close root proximities.
Surgical dilemmas that require implant placement in only 1 location, and/or at only 1
implant depth, are common. Difficult clinical scenarios frequently require the place-
ment of implants into tight spaces with minimal bony leeway either mesial-distally,
buccal-lingually, or both (see Fig. 16; Fig. 20). Adjacent tooth root proximity can
make implant placement feel to the clinician like threading a needle. This is a common
problem with congenitally missing teeth. Scenarios of limited bone volume often leave
situations in which the patient’s anatomy dictates where the implant can be placed.
Essentially, there is only 1 location in which an implant can be placed.
Some of the most complex restorative and surgical cases treated in implant
dentistry involve single and multiple implants in the esthetic zone. Thicknesses of
crestal and buccal soft tissues and buccal and palatal cortical plates, buccal-lingual

Fig. 10. Lower right mandible, 3 implants in a row, virtual treatment plan.
 Guided Surgery for Implant Therapy 723

Fig. 11. Three implants in a row, NobelGuide in place. Note implant mounts with attached
implants placed to depth.

Fig. 12. Final periapical radiograph. Note implant parallelism, different diameters and
lengths, and spacing corresponding to the implant site and the planned restorations.

Fig. 13. Final individual restorations, 3 implants in a row.

724 Orentlicher & Abboud

Fig. 14. Severe atrophy posterior mandible, implant placement planned lingual to the infe-
rior alveolar nerve.

ridge dimensions, proximity to adjacent teeth, implant-to-root relationships, gingival

and papilla support and contours, gingival exposure, smile lines, and implant angula-
tions and emergence are just a few of the many complex considerations. In addition,
knowledge of the appropriate implant position based on the type of restoration

Fig. 15. 3D reformation of Fig. 14. Note appearance of proximity between implant and infe-
rior alveolar nerve in lateral view.
 Guided Surgery for Implant Therapy 725

Fig. 16. Implant placement planned in close proximity to enlarged nasopalatine canal.

planned (ie, cement or screw retained) is an important prosthetic-based consider-

ation. Very small variations in implant positions can lead to difficult restorative
dilemmas in these cases. Proper implant position can be critical to the esthetic and
functional success of the planned restoration. CT/CBCT-guided implant planning
and placement allows for the evaluation and visualization of the ideal restoration for

Fig. 17. Severe maxillary atrophy. Implant planned in the anterior nasal spine, in close prox-
imity to the nasal floor.
726 Orentlicher & Abboud

Fig. 18. Outlining of tooth roots with virtual treatment planning.

a site based on the surrounding bony and soft tissue anatomy, then the virtual place-
ment of implants based on the planned restoration related to the underlying bone.
Surgical guides then position the implants accurately and predictably into the optimal
position for the planned restoration (Figs. 21–24).
Implant technologies and surface characteristics in use today have dramatically
reduced the time required from implant placement to loading. Immediate placement
and immediate loading of implants is now commonly performed. In some cases, teeth
can be extracted, implants can be placed immediately, and temporary crowns can be
placed at the time of implant insertion. Concepts of cross-arch stabilization and
loading of multiple implants have changed the way treatment is planned. Depending
on the clinical circumstances and the experience and comfort level of the dental

Fig. 19. Segmentation of images with virtual treatment planning.

 Guided Surgery for Implant Therapy 727

Fig. 20. Implant virtually placed in location with limited buccal-palatal width.

Fig. 21. Figs. 21–24: 17 year old female, over-retained maxillary right primary canine and
lateral incisors and congenitally missing right canine and bilateral lateral incisors and second
premolars. Preoperative grafting procedures were necessary to prepare each site for dental
implants. A 17-year-old girl before surgery.
728 Orentlicher & Abboud

Fig. 22. Virtual treatment plan.

team, these technologies can be used to place single units, multiple units, or full
arches of implants. Implants can be placed as a 2-stage, a single-stage with healing
abutments, or as an immediate-placement/immediate-load case. Implants can be
placed accurately with a tissue incision or flapless. Patients experience less surgical
trauma, pain, and swelling. Recovery time is reduced and the return to their normal
lives is expedited.22–29
Taking CT-guided technology to the next step involves accurate fabrication of
a provisional restoration before implant insertion, with immediate insertion at the
time of surgery. After the virtual treatment plan is created by the clinician (Figs. 26
and 33), computer-generated stereolithographic surgical guides are fabricated by

Fig. 23. Virtual treatment plan, occlusal view. Note implant planned in the right canine site
for 2 unit cantilever bridge anteriorly.
 Guided Surgery for Implant Therapy 729

Fig. 24. The 17-year-old female from Fig. 21, final restorations.

Fig. 25. Figs. 25–31: A 20-year-old man bilateral maxillary central incisors avulsed traumat-
ically. Treatment using AstraTech Dental Facilitate technology. A 20-year-old man before
surgery.

Fig. 26. Facilitate virtual treatment plan.

730 Orentlicher & Abboud

Fig. 27. Presurgical laboratory placement of implant analogs into the Facilitate surgical
guide, before pouring stone into the guide for fabrication of a master model.

Fig. 28. Presurgical fabrication of provisional restorations on the poured master model.

Fig. 29. Guided osteotomy preparation using the Facilitate instrumentation.

 Guided Surgery for Implant Therapy 731

Fig. 30. Implants inserted, temporary restoration placed at the time of surgery.

Fig. 31. Final restorations in place, 5 months later.

Fig. 32. Figs. 32–40: A 60-year-old man, fully edentulous mandible. The patient desired
immediate fixed restorations and, ultimately, as many fixed individual crowns as possible.
Preoperative mandibular ridge. Note areas where temporary implants have been removed.
732 Orentlicher & Abboud

Fig. 33. Virtual treatment plan, mandible. Tenimplants planned.

the manufacturer from the virtual treatment plan (Figs. 27 and 34). A dental laboratory
then uses the fabricated surgical guide, along with mounted patient models, to fabri-
cate temporary, and in some cases final, restorations, before implant placement
surgery (see Figs. 27, 28, 35, 36). The surgical guide can then be used to place
implants flapless, only removing a core of tissue in the planned implant sites. Typically,
once the surgical guide is accurately secured, implants can be placed through the
surgical guide without removing it until all implants are inserted to proper depth and
direction (Figs. 29 and 38). Abutments can then be immediately placed on the
implants, and temporary or, in some cases, final restorations inserted (see Figs. 25–
31 and 32–40).
In most circumstances, placing the implants where the bone is has become an
outdated concept. Current techniques allow the surgeon to perform soft tissue and
bone augmentation procedures to prepare the planned implant site before placing
implants. Large and small soft tissue and connective tissue grafts, as well as sinus
floor grafts, block grafts, alveolar ridge splits, and alveolar distraction procedures,
are a few of the procedures routinely performed to prepare the recipient jaw before
placing implants.

Fig. 34. NobelGuide fabricated from the virtual treatment plan.

 Guided Surgery for Implant Therapy 733

Fig. 35. Presurgical master model fabricated from the NobelGuide. Note implant analogs
with temporary abutments in place.

Previous surgical procedures, including prior placement of different types of dental

implants (ie, blade and subperiosteal implants), can leave patients with challenging
reconstructive bony defects (Figs. 41 and 42). Loss of bone, teeth, and soft tissue,
with resultant defects of varying sizes, can result from traumatic injuries or benign
and malignant abnormalities of the jaws. Reconstructive procedures to treat these
defects can leave areas of abnormal bony anatomy and scarred soft tissue. After heal-
ing, graft maturation, and settling of graft materials, resultant bone and soft tissue
volumes can be unpredictable. Lateral block-onlay grafts can resorb a portion of their
bone volume during healing and maturation.33–35 CT/CBCT-guided technologies allow
the surgeon to predict the volume of sinus graft material necessary to augment an area
of the maxilla to a desired height of bone.36 Newer technologies are being investigated
and developed in which customized block bone grafts can be created after evaluating
bony defects from CT/CBCT data.
Using these technologies allows for the visualization and evaluation of distorted
anatomy without making an incision.37 Implants can be placed accurately and

Fig. 36. Presurgical fabrication of temporary restoration.

734 Orentlicher & Abboud

Fig. 37. Accurate surgical positioning of the NobelGuide using a surgical index (a bite regis-
tration, made on mounted models, which relates the position of the surgical guide to the
opposing arch) before guide pin/screw stabilization.

Fig. 38. Surgical guide in place with 10 implants placed to correct depth using appropriate
guided instrumentation.

Fig. 39. Surgical guide removed, temporary abutments placed on inserted implants.
 Guided Surgery for Implant Therapy 735

Fig. 40. Temporary full arch mandibular restoration immediately inserted at the time of
surgery.

predictably with a clear knowledge of available bony anatomy, without flapping and
removing periosteal blood supply (Figs. 43–46).

COMPROMISED PATIENTS

Pre- and postoperative radiation therapy potentially alters healing capacities in

patients who have head and neck cancers. The literature advocates pre- and postop-
erative courses of hyperbaric oxygen therapy (HBO) to increase bone vascularity
before implant placement in these patients.38–41 Placing implants with minimal flap
elevation and hard and soft tissue trauma is indicated in these patients to minimize
the likelihood of the development of osteoradionecrosis.38,42 Bleeding, swelling, and
alteration of the blood supply are limited by using these technologies.43

Fig. 41. A 68-year-old woman who had a prior full arch maxillary subperiosteal implant.
Note severe atrophy and distorted anatomy.
736 Orentlicher & Abboud

Fig. 42. Virtual treatment plan, for the case shown in Fig. 41, 4 implants planned for over-
denture restoration.

Patients with associated medical problems, such as bleeding dyscrasias, anticoa-

gulation issues, or significant cardiovascular disease, may require specific medication
protocols that cannot be altered before surgery. Minimizing bleeding by limiting
surgical trauma to the soft and hard tissues is indicated in patients with difficult

Fig. 43. A 32-year-old man, severe atrophy anterior maxilla from a sports injury. Preopera-
tive cross-sectional image in area of right lateral incisor, Simplant. Note measurements
revealing deficiencies of bone in all dimensions.
 Guided Surgery for Implant Therapy 737

Fig. 44. Postgrafting cross-sectional image of the case shown in Fig. 43, area of right lateral
incisor, after maxillary anterior distraction osteogenesis and lateral block grafts, NobelClini-
cian. Note measurements of 13.0 mm (height) and 8.0 mm (width).

medical management issues. 3D implant evaluation and planning, with CT-guided

implant placement, allows for flapless, minimally traumatic, accurate implant place-
ment, an indication for use in patients with these challenging medical management
problems.
Patient’s historical experiences in dental offices vary greatly. Procedures that
require long periods in a dental chair can prevent some patients from seeking treat-
ment because of extreme levels of anxiety, stress, and phobias. Orthopedic and spinal
disorders may limit the amount of time a patient can sit in a dental chair. Wheelchair-
bound patients pose another set of logistical treatment problems. These types of
patients can require extensive planning and preparation before treatment. Treatment
must be performed quickly and efficiently, without compromising quality. Computer-
generated implant planning allows for the preoperative visualization of most of the
potential planning and anatomic issues that may be encountered during surgery, all
before the patient sits in the dental chair. By using surgical guides, implants can be
placed quickly and predictably, thus minimizing patient stress, pain, and time in the
dental chair.

DISCUSSION

Three types of computer-generated surgical guides are currently available: tooth sup-
ported, mucosa supported, and bone supported. Tooth-supported guides are used in
partially edentulous cases. The surgical guide is designed to rest on other teeth in the
arch for accuracy of guide fit. Mucosal-supported guides are used primarily in fully
edentulous cases and are designed to rest on the mucosa. Accurate interarch bite
registrations are of utmost importance when using these guides to assure accurate
738 Orentlicher & Abboud

Fig. 45. Cross-sectional view, after sinus lift graft. Note bone graft placement primarily later-
ally, virtual implant placed.

surgical guide positioning and placement of securing screws or pins before the place-
ment of implants (see Fig. 37). Bone-supported guides can be used in partially or fully
edentulous cases, but are used primarily in fully edentulous cases in which significant
ridge atrophy is present and good seating of a mucosa-supported guide is question-
able. These guides require elevation of an extensive full-thickness flap to expose the
bone in the planned implant sites and in the adjacent areas for full, stable seating of the
guide over the bony ridge. At this time, only Simplant (Materialise) manufactures bone-
supported surgical guides.

Fig. 46. 3D reconstruction of left mandible after ameloblastoma resection and iliac crest
reconstruction. Virtual treatment plan, 4 implants.
 Guided Surgery for Implant Therapy 739

Dental implant placement using CT-guided surgery with drill guides is known to
enhance safety compared with using a freehand technique.44–46 According to the
NobelGuide protocol, when using the Guided Abutment to secure the immediate
restoration, the accuracy should be sufficient for inserting a prefabricated final resto-
ration at the time of implant surgery. However, no available CT-guided drill guide tech-
nology exists today with absolute precision. All articles on stereolithographic guides
show error in all dimensions between virtual planning and obtained implant posi-
tions.47 According to the literature, implants placed by bone-supported guides have
the highest mean deviations, whereas implants placed by mucosa-supported guides
have lower deviations.48 Tooth-supported guides have the lowest measured devia-
tion.49 A single guide, using metal guide sleeves and rigid screw or pin fixation with
specific drilling instrumentation, further minimizes error. Most systems use these fixa-
tion techniques to stabilize mucosal-supported guides.
The main advantage of inserting a final restoration immediately after implant place-
ment is reduced treatment time. More commonly, clinicians who are using these tech-
nologies are placing temporary restorations after implant placement for many reasons.
Regardless of whether a case is done flapless or not, there is no way to accurately
predict the contours and anatomy of the healed gingiva, a significant issue for a labo-
ratory technician fabricating a final restoration. Patients’ esthetic demands can some-
times be great. Observation of the tissue response to the temporary restoration gives
the restorative dentist invaluable information as to the gingival contours and esthetics
required in preparation for the final restoration. In addition, regardless of whether an
implant is placed guided or nonguided, a small number of implant failures occur. Typi-
cally, most surgery-related implant failures occur within the first 3 to 4 months after
placement. Management of an implant failure, both surgically and restoratively, is
best done before insertion of the final restoration. According to Abrahamsson and
colleagues,50 changing from a healing abutment to a permanent abutment did not
result in a change in the dimension and quality of the transmucosal attachment that
developed, and did not differ from the mucosal barrier that formed to a permanent
abutment placed after surgery. In addition, an acrylic occlusal surface or a composite
restoration has been found to have better shock absorbing behavior and reduces the
force of occlusal effect compared with ceramic materials.51 These are all valid reasons
to place immediate acrylic temporary restorations, not immediate final porcelain
restorations.
NobelGuide/NobelClinician (NobelBiocare) and Simplant (Materialise) are the 2
major systems currently in use. Clinically, the NobelGuide system is a more compre-
hensive system, with a full set of specific instrumentation for fully guided placement of
NobelBiocare implants. NobelGuide is the only system currently available with the
instrumentation for placement of tapered implants. The NobelGuide technology and
instrumentation can be used for performing osteotomies for a straight-walled implant
from any implant manufacturer. However, in these cases, the system can only be used
for depth and direction of osteotomies. Because NobelGuide Implant Mounts are
designed only for NobelBiocare implants, implants from other implant manufacturers
cannot be accurately placed fully guided, through the guide. In these cases, the depth
of implant placement should be evaluated with the guide off, usually after tissue flap
elevation.
Simplant is designed as an open system for all implant systems. Although this
feature increases its functionality, it is also a limitation because it is not perfectly adap-
ted to 1 implant system in a comprehensive manner. Some clinicians believe that the
Simplant software currently is more intuitive and easier to learn. Several implant manu-
facturers have recently developed and marketed instrumentation specific for the
740 Orentlicher & Abboud

placement of straight-walled implants, flapless and fully guided, using the Simplant
software (eg, Facilitate, AstraTech Dental; ExpertEase, Dentsply Friadent; Navigator,
3i/Biomet). Other manufacturers have developed nonstereolithographic model tech-
nologies for the fabrication of surgical guides (eg, IDent, Foster City, CA, USA; EZ
Guide, Keystone Dental, Burlington, MA, USA; Straumann coDiagnostiX, Straumann,
Basil, Switzerland) In these technologies, the surgical guide is created by scanning the
patient while they are wearing a barium radiographic appliance, planning the implant
placement virtually, then creating the surgical guide by milling the radiographic appli-
ance according to the digital CT-based treatment plan. Guide sleeves are then added
to the guide to aid in the depth and direction of osteotomies before implant placement.
The rationale for using minimally invasive procedures is to maximize patient comfort
by minimizing traumatic injury to the tissues. Flapless insertion of dental implants has
been found to have implant success rates comparable with conventional implant
placement, also minimizing potential complications from soft tissue elevation such
as infection, dehiscence, and soft and hard tissue necrosis.30,52,53 Surgical guidance
for drill depth and angulation, in combination with a flapless technique, minimizes the
potential injury to underlying anatomic structures during the implant osteotomy prep-
aration. Because fully guided instrumentation for implant insertion is not available in
most Simplant cases, fully flapless surgery is not advised. Depth and angulation guid-
ance of all osteotomies is possible, but accurate implant platform placement requires
direct visualization of the bone, necessitating elevation of a flap. If using Navigator,
ExpertEase, Facilitate, or Simplant fabricated NobelGuide compatible surgical guides,
fully guided and flapless placement of implants is possible using available
instrumentation.
CT-based technologies available today have limitations and questions that require
further investigation as to their effect on guided surgery outcomes. The resolution and
accuracy of specific CBCT machines compared with the gold standard of medical-
grade CT scanners has been questioned.54 NobelBiocare markets a calibration object
that calibrates an individual CBCT/CT machine to an acrylic object of a known contour
and density specifically for the NobelGuide protocol. Although theoretically the
concept of a calibration object of this type makes sense, its efficacy is yet to be proved
in the scientific literature.
The manufacture of a stereolithographic surgical guide or model involves reproduc-
ing the digitally planned dimensions of the surgical guide or model by using a laser
beam to selectively solidify an ultraviolet-sensitive liquid resin. Stereolithographic
materials have inherent potential problems that can lead to light sensitivity and expan-
sion and/or shrinkage of the material. Leaving them exposed to light for extended
periods of time, as well as sterilization in high-temperature autoclaves, distorts stereo-
lithographic materials. The literature concludes that implant site preparation using
surgical drill guides generates more heat than classic implant site preparation, regard-
less of the irrigation system used.55

SUMMARY

New technologies, based on 3D evaluation of patients for dental implants, has opened
new avenues to clinicians for accurate and predictable diagnosis, planning, and treat-
ment in a multidisciplinary patient-based approach. Communication between clini-
cians and understanding of these technologies are key components to improved
case results and clinical outcomes. Analyzing, understanding, and adopting these
technologies will open new doors for the dental team and benefit patients with more
predictable outcomes.
 Guided Surgery for Implant Therapy 741

The use of CT-guided implant planning and placement does not remove the need for
the surgical and restorative team to diligently adhere to the basic principles of implant
surgery and prosthetic dentistry. Well-established concepts of implant spacing, depth
and angulation, case planning and engineering, minimally traumatic manipulation of
soft and hard tissues, soft tissue and bone grafting, osseointegration healing time,
soft and hard tissue healing, heat generation, dental materials, ideal occlusion, and
many others must be maintained and adhered to. CT-guided implant surgery facili-
tates the placement of dental implants into an ideal position according to a restora-
tively driven treatment plan. The final tooth position is determined first. The ideal
implant position is then planned, and the implant is then placed into that position
with precision. Treatment plans should be created according to the requirements of
an individual case and the comfort level of the surgical and restorative team. Cases
can be treated with implants staged, with healing abutments, or immediately loaded
with temporary, or in some circumstances, final restorations. Proper case selection
and patient awareness, education, and compliance are all critical factors for success.
There is often a steep learning curve before there is successful incorporation of CT-
guided surgery into a dental implant practice. Clinicians interested in these technolo-
gies are strongly encouraged to pursue continuing education. CT-guided implant
surgery is not conventional implant surgery. Knowledge of CT scans, proprietary treat-
ment planning software, the complete treatment protocols, and guided surgery instru-
mentation and surgical techniques, are all instrumental to a successful outcome. In
addition, clinicians should take into consideration the inherent additional costs
involved in the use of proprietary software and CAD/CAM processing technologies.
Of primary importance is good patient selection, in addition to appropriate diag-
nosis, planning and treatment. These requirements are best facilitated by a knowledge
of CT-based technologies that enables the clinician to adhere to surgical, prosthetic,
and biologic principles that will optimize patient care.

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