See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/343840267

Guided Surgery with 3D Printed Device: A Case Report

Article in Journal of Oral Implantology · August 2020

DOI: 10.1563/aaid-joi-D-19-00278

CITATION READS

1 55

6 authors, including:

Tamara Kerber Tedesco Sergio Allegrini

University of São Paulo Universidade Ibirapuera
170 PUBLICATIONS 1,525 CITATIONS 39 PUBLICATIONS 667 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Tamara Kerber Tedesco on 05 January 2023.

The user has requested enhancement of the downloaded file.

CASE REPORT

Guided Surgery with 3D Printed Device: A Case Report

Michelle Carvalho de Sales, DDS1
Rafael Maluza Florez, DDS, MSc2
Julianny da Silva Guimaraes, DDS3
Gustavo Vargas da Silva Salomão, DDS, MSc4
Tamara Kerber Tedesco, DDS, MSc, PhD5
Sergio Allegrini Junior, DDS, MSc, PhD5*

Downloaded from http://meridian.allenpress.com/joi/article-pdf/47/4/325/2893456/i1548-1336-47-4-325.pdf by Universidade de Sao Paulo user on 08 September 2021

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.

Key Words: surgical guide, flapless surgery, dental implant

INTRODUCTION DICOM files obtained by CT scanning, providing a preoperative

overview of anatomic structures.4 For partially edentulous

F
requent improvements and changes in dental proce-
dures have enhanced their predictability and accuracy, patients, an existing, metal-free, removable denture can be
improving patient comfort and increasing the likeli- included in the scan, providing a supplementary image that
hood of success of clinical treatment. With the advent shows the alignment between the positions of the teeth and
of osseointegration, many surgical options and techniques the morphology of bone structures. These 2 sets of information
have emerged, resulting in high success rates over the long can be correlated by the software and used to make decisions
term.1 An accurate preoperative plan defining implant place- on the ideal positions for implants. This information is then
ment and denture manufacture is essential for successful oral transferred to the patient with a high level of accuracy by
rehabilitation of patients using osseointegrated implants.2 A means of a virtually planned and 3-dimensional (3D)-printed
careful preoperative study and detailed planning of restorations surgical guide.3
will facilitate preservation of vital intraoral structures during Prior planning with virtual images results in quicker, more
rehabilitation of the esthetics and functionality of the predictable, and less traumatic surgical interventions. Ideal
stomatognathic system.1 implant placement also facilitates and simplifies prosthetic
Dental surgeons are adopting imaging examinations such
restorations.4
as computed tomography (CT) to obtain more detailed
The surgical guide is a key element in the system, because
visualization of facial anatomic structures.1,2 Software programs
it enables the ideal positions of the restorations, predefined
exist that can convert CT images to physical prototypes of the
region to be treated surgically and can also be used to during virtual planning, to be transferred to the oral cavity
manufacture surgical guides3 to ensure ideal placement of oral during surgery to insert the implants into the bone. The
implants. These software programs combine 3D images from 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
1
Private Practice, Department of Prosthodontics, Ibirapuera University,
locations in the virtually planned procedure and act as guides
São Paulo, SP, Brazil.
2
Departments of Oral Surgery and Prosthodontics, Santa Cecilia during surgery. The information transferred using the surgical
University, Santos, SP, Brazil. guide enhances safety and predictability of oral rehabilitation
3
Program of Scientific Dentistry, Ibirapuera University, São Paulo, SP, and reduces postoperative complications, resulting in less
Brazil.
4
Department of Prosthodontics, Ibirapuera University, São Paulo, SP, morbidity and greater patient comfort, reducing edema and
Brazil. painful symptoms.3
5
Division of Master and Doctorate in Dentistry, Program of Scientific The aim of this report is to describe use of a surgical guide
Dentistry, Ibirapuera University, São Paulo, SP, Brazil.
* Corresponding author, e-mail: [email protected] for placement of osseointegrated implants and the outcomes
https://doi.org/10.1563/aaid-joi-D-19-00278 obtained, assessing the differences between the virtual plan

Journal of Oral Implantology 325

Guided Virtual Planning

and the outcomes actually achieved after placement of the with the patient wearing the marked denture, in occlusion, to
titanium implants. 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 deter-
REVIEW OF THE LITERATURE mined. The gutta-percha markers are therefore used as
reference points during virtual planning.2,4,16
Guided surgery contributes to the success of oral implants
Because the markings are visible in both sets of scan
because it is based on 3D planned rehabilitation using
images, these points can be realigned to combine the denture
minimally invasive procedures in the maxilla and/or mandible
within the maxillofacial structure. Once the structures have
with surgical guides.4
been accurately aligned, planning can be conducted and
The ideal treatment protocol for a dental implant is one
controlled to produce an integrated model. The combination of

Downloaded from http://meridian.allenpress.com/joi/article-pdf/47/4/325/2893456/i1548-1336-47-4-325.pdf by Universidade de Sao Paulo user on 08 September 2021

that both achieves osseointegration and provides the most
the 2 scans provides a 3D model of the bone tissue including
favorable implant position for optimal functional and esthetic
the positions of the teeth, showing the dental surgeon the best
prosthodontic restoration.6
surgical and prosthetic alignment for implant placement.14
Successful rehabilitation with implants is dependent on
Conversion of CT scan images using specific software
diagnosis and accurate planning.2,7 Inadequate planning can
programs enables the exact 3D position of the planned implant
produce undesirable outcomes. Incorrectly placed implants
to be predetermined in advance and then transferred to the
result in nonaxial distribution of forces, causing inadequate
loading, and increased stress and can sometimes cause loss of surgical site, so the surgical procedure is planned virtually.15
osseointegration.8,9 Tomographic images are stored in a digital format that
Surgical guides for partially dentate patients can be complies with the DICOM (Digital Imaging and Communica-
manufactured in the laboratory on cast models (conventional tions in Medicine) international standard. These images are
guides). When virtual planning is used, cone-beam computed obtained from axial slices. These slices can be artificially joined
tomography (CBCT) in combination with specific software together by computer programs to produce 3D reconstructions
programs (ImplantViewer), can be used to create surgical of the object scanned, so it can be displayed in different planes
guides that are designed in virtual models after scanning the (axial, sagittal, and coronal).11,13
patient’s mouth, reliably reproducing tissues in 3D images.10 There are software programs specifically designed for
By planning surgical guides virtually, placement of implants dental implant planning that use CT images. These programs
can be based on the most favorable angles and ideal positions can be used to determine the amount of bone available for
of restorations and their relationships with teeth, determined in implant placement at specific sites.16 They process the DICOM
advance.11 This is only possible because virtual planning image data, providing a preoperative view of the patient’s
enables visualization of the relationships between surgical anatomic structures.4
positioning of the implant to be fitted and the position of the In addition to the DICOM file, a stereolithography (SLT) file
prosthetic restoration that will be manufactured.4 is also needed. This is obtained by digitization of a plaster cast
To achieve successful treatment, it is important to follow a model and from intraoral scans of the patient.13 When
prosthesis-driven implant plan,12 considering 3 aspects that are combined, these 2 files facilitate virtual planning and optimi-
essential for better 3D positioning of the implant: the most zation of implant placement.16
favorable bone morphology for osseointegration, biomechan- A high-precision scanner (for example, Cerec by Sirona,
ics, and esthetics.7,13 Itero by CADENT, or Lava by 3M) can capture images of the cast
Prosthetic preparation seeks to establish the ideal condi- model and of the patient’s dental arches, transferring them to
tions for rehabilitation using provisional dentures with ade- the computer screen. These images are stored and interpreted
quate functionality and esthetics. This provides a basis for by planning software, and a virtual 3D model is created. The
determination of the vertical dimension of occlusion and the combination of models and digital images obtained from CBCT
relationships between the future restorations and the sur- scanners can be of great help in diagnosis and planning.2,16
rounding soft tissues, including the relationship between the They enable the implants to be located in areas with adequate
mucosal area and the pink segment of the denture, if quantities of bone, favorable inclination, and ideal positioning.7
needed.4,13–15 The image files are imported to a dedicated program (eg,
Use of techniques for 3D reconstruction of both the maxilla ImplantViewer), which reads the data and converts them into
and mandible enables these anatomic structures to be an interactive 3D model. The software is used to align the 2 CT
imported into the planning software, in virtual form, together image files, accurately superimposing the images. The surgical
with CT images of the patient. By superimposing these virtual guide can be designed in the planned position and then
images, the positions of the implant in the remaining alveolar exported for manufacture by prototyping.8
bone and of the restoration that will be mounted on it can then Rapid prototyping techniques fabricate parts by building
be planned accurately, facilitating flapless surgical procedures.3 up the materials layer by layer. The most commonly used
Production of virtual guides entails scanning the patient processes include SLA and fused deposition modeling (FDM),
twice. For patients who already wear complete or partial that is, 3D printing. Together, these techniques can be used to
dentures, these will be individually identified with radiopaque view images of the virtually planned implants on the computer
markers (gutta-percha inserted into the sides of the dentures), screen and then manufacture guides to transfer the planned
enabling superimposition of images of the patient scanned positioning to the oral cavity during the surgical procedure.9
with and without the dentures.4 The first scan is performed Surgical guides should possess certain essential features,

326 Vol. XLVII / No. Four / 2021

 de Sales et al

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

Downloaded from http://meridian.allenpress.com/joi/article-pdf/47/4/325/2893456/i1548-1336-47-4-325.pdf by Universidade de Sao Paulo user on 08 September 2021

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

CASE REPORT
FIGURES 1 AND 2. Three-dimensional computed tomography images
This is a case report using study methodology that was of bone region (FIGURE 1) and superimposition of bone scan and
reviewed by an independent statistician. A patient with teeth images of the cast model (FIGURE 2).
missing from the maxilla was selected at random for the study.
Two criteria were stipulated for selection of the surgical case: During the surgical procedure, after local infiltration
use of virtual planning and low maxillary posterior bone height. anesthesia, the guide was fitted onto the patient’s teeth, and
Meeting these criteria, a 45-year-old male patient with 5 teeth the milling protocol (Straumann) was implemented, following
missing from his maxilla (14, 15, 16, 24, and 26) sought the the measurements of the 4 planned implants. In the region of
outpatient implantology clinic for oral rehabilitation. Guided
tooth 26, the initial milling plan had to be shortened because of
surgery was suggested after history taking, clinical examination,
the position of the maxillary sinus. At this site, the surgical socket
supplementary tests, and analysis of CT scans and intermaxillary
was initially widened using the installation guide but short of the
relationships. The patient was given and signed an informed
planned length. An atraumatic maxillary sinus lift was then
consent form (compliant with the Helsinki Declaration ethical
performed using Summers instruments. Drill handles were not
principles).
used in this sinus lift surgical procedure. Therefore, the guide and
Initially, a cast study model was sent to a radiology clinic for
the newly formed surgical socket served to guide and direct the
CBCT scanning and digitization in SLT format. Another set of CT
Summers instruments, used to break through the floor of the
images were obtained by scanning the patient’s maxilla (Figure
sinus cavity. The other sockets were milled using the guide and
1). The CT images of the cast model were then superimposed
drill handle, according to plan. All implants were placed with the
on the images of the maxilla (Figure 2), and 5 Straumann BLT
aid of the surgical guide and appropriate wrenches, preventing
implants were planned using ImplantViewer software (Figures 3
and 4). The planned prosthetic restoration and the patient’s deviation from the planned position. After implant placement,
bone status were taken into consideration to obtain the best only cover screws were fitted, and the prosthodontic restoration
functional positioning for the implants (Figures 5 and 6). was dealt with in a subsequent phase of treatment. Sutures were
Once the positions of the planned implants had been not needed because of the small size of the surgical access. A
defined in the virtual model, a teeth-supported surgical guide provisional removable denture that occluded the holes was used
was designed for 3D printing (Figures 7 and 8), using the same for containment, esthetics, and control of bleeding.
software. The remaining natural teeth were used to support the The patient reported no intraoperative discomfort and was
guide, eliminating the need for stabilization screws. The virtual quite satisfied with the shorter duration of treatment. There
guide data were imported to UP Studio software so that they was no local sensitivity and no apparent edema in the
could be sent to a UP Mini 2 3D printer. The guide was printed postoperative period. A follow-up CT scan was requested 2
in polylactic acid (PLA) plastic (Figures 9 and 10) and fitted onto weeks after surgery (Figures 11 through 14) to assess the
the cast model to check stability and precision (Figure 10). positions of the new implants, and the outcome was very
Metal sleeves, supplied by Straumann, were fitted into holes in similar to the virtual plan.
the printed guide to allow use of a milling guide and specific The images obtained from the virtual planning procedure
milling cutters, also provided as part of the Straumann guided were superimposed onto images of the implants after
surgery kit. The manufactured guide was then chemically placement in axial slices showing the cervical and apical
sterilized with peracetic acid. ImplantViewer provided the portions of the implants (Figures 15 through 18). Assessments
depth measurements for each implant to the bases of the were only performed at these 2 points because the software
sleeves, defined by virtual planning. Milling depths were did not allow analysis of possible differences in angulation
calculated for each implant based on these data. using coronal slices (Figure 17).

Journal of Oral Implantology 327

Guided Virtual Planning

Downloaded from http://meridian.allenpress.com/joi/article-pdf/47/4/325/2893456/i1548-1336-47-4-325.pdf by Universidade de Sao Paulo user on 08 September 2021

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.

A statistical analysis was performed to verify the accuracy of from the measurements of the different teeth were then
the 3D printed device. Reference points defined in bone and compared against this reference (Table 1). The data for clinical
dental regions in both sets of CT images were aligned and success in percentage were subjected to the v2 test with
superimposed. Discrepancies (in mm) identified between the Bonferroni adjustment and are illustrated in Figure 19. The level
implant positions defined virtually, and their actual positions of significance was set at 5% (SPSS v.25 Inc). Dental implant 26
after physical placement were calculated for each implant site exhibited larger deviations, which were the result of the change
(Table 1). The unit of statistical analysis was the implant. Thus, 5 in the surgical approach because of the presence of the
implants were each assessed at 2 different points: 1 cervical and maxillary sinus roof.
1 apical. Each implant was labeled according to its position in
the dental arch (ie, the number of the missing tooth it TABLE 1
replaced), and these positions were defined as the independent
Discrepancies (mm) in the cervical and apical regions of
variables. These variables did not influence the main measure. each implant*
The dependent variables were defined as the difference
Dental Position
between the virtual position and the position achieved after
the implant had actually been fitted. These data were 14 15 16 24 26
important to determine the effectiveness of the technique Cervical region 0.28b 0.48a,b 0.82c 0.01a 0.91d
using virtual planning. These measures were transformed into Apical region 0.71b 0.74b,c 0.86c 0.46a 1.86d
frequencies, defining a discrepancy of 0.01 mm as the *Superscript letters indicate statistically significant differences between
maximum tolerance for clinical success. The values obtained the columns. Letter a indicates the best outcome.

328 Vol. XLVII / No. Four / 2021

 de Sales et al

Downloaded from http://meridian.allenpress.com/joi/article-pdf/47/4/325/2893456/i1548-1336-47-4-325.pdf by Universidade de Sao Paulo user on 08 September 2021

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).

DISCUSSION devised plan using an appropriate analytical software program,

accurate fabrication of the surgical guide, and careful surgical
Virtually guided surgery has been adopted in oral implantol-
procedures. Nevertheless, small deviations between the virtual
ogy.2–4,10–13,15,16,18 The present study reported the case of a
plan and the newly placed implants were observed.
patient with missing maxillary teeth who underwent virtual
Surgical guides allow for a less invasive intraoral surgical
analysis based on preoperative CT scans of his existing
procedure because there are no gingival detachments or flaps,
prosthesis and planning of implant placement with virtual
comparison of both scans (of the patient and of his prosthesis). reducing chair time and ensuring a less painful postoperative
After defining the planned positions of the implants virtually, a recovery.3,4,8,12,17 Moreover, complications associated with the
surgical guide was manufactured using 3D printing and used postoperative quality of soft tissues, infection, suture dehis-
during physical placement of implants. The patient reported an cence, and necrosis of peri-implant tissues are less frequent in
uneventful postoperative period and minor use of painkillers. A guided surgeries.8,17,18,21 A longitudinal study21 demonstrated
postoperative CT scan was performed, showing the physical a mean implant survival rate of 97.3% (n ¼ 1941) in guided
positions of implants, which were compared with their virtually surgeries compared with 93%–98% success rates for the
planned positions, revealing the effectiveness of implant conventional approach.
placement. The analysis comparing the implants as inserted Preoperative and postoperative images were compared,
in the maxilla with the virtual plan is partially limited, because it with close observation of implant sites where virtual planning
was not possible to determine angular misalignment, because was used. Some deviation between virtual planning and the
the software used only offers analysis of deviations in lateral final clinical outcome is inevitable because of certain technical
position and depth. A different radiologic software package details20 such as the quality of tomographic images (panoramic,
that enables assessment of all 3 types of deviation (lateral transverse, and axial), unfaithful 3D reconstruction reproduc-
position, depth, and angle)19 would have been more useful in tion, quality of the prototype model, and stability and accuracy
this situation, allowing more accurate analysis of the positions of the surgical guide.11
of each implant after placement. Four types of measurements are often used to assess the
Advances in implantology and the need for less traumatic discrepancies between virtual planning and the clinical position
surgical procedures have encouraged dentists to use guided of the implant after surgery (depth, global, lateral, and angular
surgery. Breakthroughs in radiology and computer science play deviations).22,23 In our case report, after surgically guided
a crucial role.2,3,8,11,20,21 Using CT scans and virtual planning, the placement of implants with a tooth-supported guide, devia-
spatial view of the anatomic structures was more accurate, and tions were evaluated at the cervical and apical regions of the
surgical planning was safer and more efficient. Accurate implants (Table 1), showing significant differences between the
transfer of virtual planning data to the recipient in vivo20 is virtually planned positions and those of the titanium implants
closely related to good-quality imaging combined with a well- actually placed in the maxilla. Greater deviation was observed

Journal of Oral Implantology 329

Guided Virtual Planning

Downloaded from http://meridian.allenpress.com/joi/article-pdf/47/4/325/2893456/i1548-1336-47-4-325.pdf by Universidade de Sao Paulo user on 08 September 2021

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.

in the implant placed in position 26, where a maxillary sinus It is important to note that limitations affecting the present
elevation procedure was performed with an atraumatic study could be the cause of conflicting results compared with
technique. Although installation was aided by the surgical other studies.24–27 Because this is a clinical case report with a
guide, the final milling depth had to be changed because of single patient, it is not possible to compare the postoperative
local conditions, resulting in a greater proportion of deviation results or to claim that the guided surgery technique involves
compared with the adjacent implants. Anatomic/surgical much less discomfort than ‘‘freehand’’ surgery.28,29 The number of
limitations found in some clinical cases prompt professionals
to carry out more detailed and thorough surgical planning to TABLE 2
anticipate possible intraoperative surgical complications and to
Mean deviations (mm) at the cervical and apical levels of
obtain a more accurate and efficient final result. the implants*
Leaving aside the results obtained for tooth position 26,
Mean Deviation Mean Deviation
where there were variations between planned and actual Study at the Cervical Level at the Apical Level
placement, the mean deviations of the other dental elements
Present case report 0.36 0.7
(14, 15, 16, and 24) were 0.36 for the cervical region and 0.7 for
Geng et al24 0.17 0.37
the apical region. These values are higher than those obtained Van Assche et al25 0.73 0.98
by Geng et al24 but lower than others described in the Cassetta et al26 1.55 2.05
literature,25–27 in which deviations at the cervical level ranged Schneider et al27 1.16 1.96
from 0.17 to 1.55, and deviations at the apical level ranged from *Results observed in the current study and comparisons with those
0.37 to 2.05 (Table 2). observed in the scientific literature.

330 Vol. XLVII / No. Four / 2021

 de Sales et al

Downloaded from http://meridian.allenpress.com/joi/article-pdf/47/4/325/2893456/i1548-1336-47-4-325.pdf by Universidade de Sao Paulo user on 08 September 2021

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.

implants installed was also a limiting factor in terms of results, ments using atraumatic sinus elevation procedures is very rare.
possibly introducing a bias in the statistical results presented. To During selection of cases that were appropriate for virtual
accurately determine the similarity between the positions planned planning, only 1 clinical case was found involving this type of
virtually and the positions actually achieved, statistical tests to atraumatic surgical technique.
estimate the ideal number of samples would be necessary. Additional studies evaluating possible deviations caused by
Superimposition of virtual images on those acquired unforeseen changes to the plan during surgery could provide
after implant placement showed that the final anatomic
important information for dental surgeons who are starting to
positions were similar. The virtual surgical planning method
learn this operating technique. The present study is a case in
used in the case reported here was successful, allowing
point because there was a need to perform a maxillary sinus
accurate implant placement because of the surgical guide
printed via DICON. elevation procedure. Another possibility would be a need to
Superimposition of the STL file on the data from the DICOM reduce instrumentation of the surgical alveolus because of a
file enabled very precise planning for most of the implants, patient’s bone quality. This kind of information is extremely
ensuring safety during surgery. As for the region of tooth important because it forewarns implantodontists of possible
number 26, where the decision was made to use an atraumatic complications that could emerge at the time of surgery.
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 CONCLUSION
postoperative surgical analysis demonstrated that the tech-
nique using guides offers safety and a high degree of It can be concluded that virtually guided surgery enabled
predictability for treatment with dental implants. better surgical/prosthetic planning of placement of implants.
Several studies have been published showing deviations The technique described here achieved a surgical procedure
using the guided surgery technique,24–27 where it can be seen involving mild trauma, minor discrepancies in the positioning
that small path changes exist but are considered minimal in of newly placed implants, better predictability, shorter operat-
most cases. The combination of virtual planning with treat- ing time, and minimal patient discomfort.

Journal of Oral Implantology 331

Guided Virtual Planning

ABBREVIATIONS 12. Meloni SM, Tallarico M, De Riu G, et al. Guided implant surgery after
free-flap reconstruction: four-year results from a prospective clinical trial. J
CBCT: cone-beam computed tomography Cranio-Maxillo-Facial Surg. 2015;43:1348–1355.
CT: computed tomography 13. Albiero AM, Benato R. Computer-assisted surgery and intraoral
welding technique for immediate implant-supported rehabilitation of the
FDM: fused deposition modeling
edentulous maxilla: case report and technical description. Int J Med Robotics
SLT: stereolithography Comput Assist Surg. 2016;12:453–460.
14. Heammerle CHF, Cordaro L, van Assche N, et al. Digital
technologies to support planning, treatment, and fabrication processes
and outcome assessments in implant dentistry. Summary and consensus
ACKNOWLEDGMENTS
statements. The 4th EAO consensus conference. Clin Oral Impl Res. 2015;
The authors thank Tamara Kerber Tedesco, PhD, for valuable 26(Suppl 11):97–101.
15. Coachman C, Calamita MA, Coachman FG, Coachaman RG, Sesma
contributions to the statistical analyses performed in this study.

Downloaded from http://meridian.allenpress.com/joi/article-pdf/47/4/325/2893456/i1548-1336-47-4-325.pdf by Universidade de Sao Paulo user on 08 September 2021

N. Facially generated and cephalometric guided 3D digital design for
complete mouth implant rehabilitation: a clinical report. J Prosthetic Dent.
2015;5:1–9.
16. Assche NV, Steenberghe DV, Guerrero M, et al. Accuracy of implant
NOTE
placement based on pre-surgical planning of images: a pilot study. J Clin
The authors declare no conflicts of interest. Periodontol. 2007;34:816–821.
17. Mascarenhas VI, Molon RS, Tavares LJ, et al. The use of computer
guided implant surgery in oral rehabilitation: a literature review. World J
Dent. 2014;5:60–63.
REFERENCES 18. Ochia M, Kanazawaa MN, Satob D, et al. Factors affecting accuracy
of implant placement with mucosa-supported stereolithographic surgical
1. Greenstein G, Carpentieri JR, Cavallaro J. Dental cone-beam scans: guides in edentulous mandibles. Comput Biol Med. 2013;43:1653–1660.
important anatomic views for the contemporary implant surgeon. Compend 19. Smitkarn P, Subbalekha K, Mattheos N, Pimkhaokham A. The
Contin Educ Dent. 2015;36:735–741. accuracy of single-tooth implants placed using fully digital-guided surgery
2. De Vico G, Spinelli D, Bonino M, et al. Computer-assisted virtual and free hand implant surgery. J Clin Periodontol. 2019;46:949–957.
treatment planning combined with flapless surgery and immediate loading 20. Stübinger S, Buitrago-Tellez C, Cantelmi G. Deviations between
in the rehabilitation of partial edentulies. Oral Implantol (Rome). 2012;5:3–10. placed and planned implant positions: an accuracy pilot study of skeletally
3. Amorfini L, Migliorati M, Drago S, et al. Immediately loaded supported stereolithographic surgical templates. Clin Implant Dent Relat Res.
implants in rehabilitation of the maxilla: a two-year randomized clinical trial 2014;16:540–551.
of guided surgery versus standard procedure. Clin Implant Dent Relat Res. 21. Bornstein MM, Al-Nawas B, Kuchler U, et al. Consensus statements
2017;19:280–295. and recommended clinical procedures regarding contemporary surgical and
4. Cai H, Liang X, Sun DY, Chen JY. Long term clinical performance of radiographic techniques in implant dentistry. Int J Oral Maxillofac Implants.
flapless implant surgery compared to the conventionalapproach with flap 2014;29(Suppl):78–82.
elevation: a systematic review and meta-analysis. World J Clin Cases. 2020;8: 22. Valente F, Schiroli G, Sbrenna A. Accuracy of computer-aided oral
1087–1103. implant surgery: a clinical and radiographic study. Int J Oral Maxillofac
5. Sigcho López DA, Garcı́a I, Da Silva Salomao G, Cruz Laganá D. Implants. 2009;24:234–242.
Potential deviation factors affecting stereolithographic surgical guides: a 23. Pettersson A, Komiyama A, Hultin M, et al. Accuracy of virtually
systematic review. Implant Dent. 2019;28:68–73. planned and template guided implant surgery on edentate patients. Clin
6. Kopp KC, Koslow AH, Abdo OS. Predictable implant placement with Implant Dent Relat Res. 2010;14:527–537.
a diagnostic/surgical template and advanced radiographic imaging. J 24. Geng W, Liu C, Su Y, et al. Accuracy of different types of computer-
Prosthet Dent. 2003;89:611–615. aided design/computer-aided manufacturing surgical guides for dental
7. Lin CC, Wu CZ, Huang MS, Huang CF, Cheng HC, Wang DP. Fully implant placement. Int J Clin Exp Med. 2015;8:8442–8449.
digital workflow for planning static guided implant surgery: a prospective 25. Van Assche N, Vercruyssen M, Coucke W, et al. Accuracy of
accuracy study. J Clin Med. 2020;9:980. computer-aided implant placement. Clin Oral Implants Res. 2012;23(Suppl 6):
8. D’haese J, Velde TV, Komiyama AI, et al. Accuracy and complica- 112–123.
tions using computer-designed stereolithographic surgical guides for oral 26. Cassetta M, Giansanti M, Di Mambro A, et al. Accuracy of two
rehabilitation by means of dental implants: a review of the literature. Clin stereolithographic surgical templates: a retrospective study. Clin Implant
Implant Dent Relat Res. 2012;14:321–335. Dent Relat Res. 2013;15:448–459.
9. Casseta M, Manbro DI, Stefanelli LV, et al. How does an error in 27. Schneider D, Marquardt P, Zwahlen M, et al. A systematic review on
positioning the template affect the accuracy of implants inserted using a the accuracy and the clinical outcome of computer-guided template-based
single fixed mucosa-supported stereolithographic surgical guide? Int J Oral implant dentistry. Clin Oral Implants Res. 2009;20(Suppl 4):73–86.
Maxilofac Surg. 2014;43:85–92. 28. Arisan V, Karabuda CZ, Ozdemir T. Implant surgery using bone and
10. Ma L, Jiang W, Zhang B, et al. Augmented reality surgical navigation mucosa supported stereolithographic guides in totally edentulous jaws:
with accurate CBCT-patient registration for dental implant placement. Med surgical and post-operative outcomes of computer-aided vs. standard
Biol Eng Comput. 2019;57:47–57. techniques. Clin Oral Implants Res. 2010;21:980–988.
11. Testori T, Robiony M, Parenti A, et al. Evaluation of accuracy and 29. Hultin M, Svensson KG, Trulsson M. Clinical advantages of
precision of a new guided surgery system: a multicenter clinical study. Int J computer-guided implant placement: a systematic review. Clin Oral Implants
Periodontics Restorative Dent. 2014;34(Suppl 3):s59–s69. Res. 2012;23(Suppl 6):24–35.

332 Vol. XLVII / No. Four / 2021

View publication stats