 Computer guided treatment planning will be the standard of care

within the next few years.

Definition :

 Selection of implant sites and placement of dental implants

employing surgical templates developed with CBCT scans and
software programs.
Free hand drilling(previous method):

 Free hand drilling uses the template to identify the position of the
implants.

 The clinician decided the depth and angulation of the osteotomy

preparation
Disadvantages of free hand implant
placement
 Catastrophic mistakes made in position and angulation
Disadvantages of free hand implant
placement
 Catastrophic mistakes made in position and angulation
Disadvantages of free hand implant
placement
 Catastrophic mistakes made in position and angulation
Disadvantages of free hand implant
placement
 Catastrophic mistakes made in position and angulation

Implant positioned interproximally

Disadvantages of free hand implant
placement

penetration of the drill in the nasal cavity access to the maxillary sinus
Disadvantages of free hand implant
placement

Perforation of the sinus floor implant dislocation in the sinus cavity

Disadvantages of free hand implant
placement

perforation of the sublingual lodge

Disadvantages of free hand implant
placement

The anatomical structures on the oral floor have been damaged

Disadvantages of free hand implant
placement

The drill can damage the submental artery

Disadvantages of free hand implant
placement

Dental implant emergence at the mental foramen

Computer guided application for Bone
Grafting

simulation of bone grafts necessary to treat deficient receptor sites

Computer guided application for Bone
Grafting

The sinus graft

volume can be
simulated to predict
how much bone
should be used
Computer guided application for Bone
Grafting
The volume of an onlay graft (a) and sinus graft (b) can be
simulated and calculated using planning software.

(a) (b)
Computer guided application for Bone Grafting

 Graft simulation on bone models (3D Replay, Rome,

Italy): (a) maxillary bone, (b) mandible

(a) (b)
SURGICAL GUIDES FOR HARVESTS AND GRAFTS

• Simulation on
stereolithographic model of a
series of onlay grafts.

• On the STL model, the extent of

the defect is assessed and
reconstruction is planned.
SURGICAL GUIDES FOR HARVESTS AND GRAFTS
HarvestGuide*

Guide for harvests from mental symphysis and mandibular body ramus
SURGICAL GUIDES FOR HARVESTS AND GRAFTS
LocalizationGuide*
SURGICAL GUIDES FOR HARVESTS AND GRAFTS
SinusLiftGuide*
Schneider’s membrane elevation
Stereolithographic surgical guides

a) Mucosal-Supported Guides

 used for completely edentulous arches (flapless)

Stereolithographic surgical guides

b) Tooth-Supported Guides

 correct position and stabilization of the guide.

 flapless surgery, or minimal flap designs
Stereolithographic surgical guides

c) Bone-Supported Guides

indications :
 visually check the preparation of implant sites.
 Narrow safety margins
 advanced atrophy.
 Reliability .
 Need to make corrections to the implant site.
fit-check
Advantage of computer guided
treatment planning and surgery
 Visualize potential implant sites in 3 D in relation to the proposed
prosthesis
Advantage of computer guided
treatment planning and surgery
 Enables flapless surgery
_ less postsurgical morbidity ( pain, swelling ect.)
Advantages of flapless guided surgery

D haese J 2012
Disadvantages of flapless guided surgery

D haese J 2012
Advantage of computer guided
treatment planning and surgery
 Better implant distribution pattern for more favorable biomechanics
Advantage of computer guided
treatment planning and surgery
 Select an implant of proper length and diameter
Advantage of computer guided
treatment planning and surgery
 Precise implant placement
- implants can be precisely placed in tooth
positions as opposed to interproximal positions
Advantage of computer guided
treatment planning and surgery
 Less risk of compromising adjacent vital structures
- inferior alveolar nerve
- branches of the lingual artery
Advantage of computer guided
treatment planning and surgery
 Less risk of compromising adjacent vital structures
- maxillary sinus.
- Anterior palatine foramina.
Advantage of computer guided
treatment planning and surgery
 Prefabrication of the abutments, prostheses.
Computer guided implant
placement
 Two types
- Fully guided surgery: implies that the surgical templates with their drill
sleeves ( bushings) control the position, angulation, diameter as well as
the depth of the implant osteotomy sites.
Computer guided implant
placement
 Indication of fully guided approach
- Edentulous patients
Computer guided implant
placement
 Fully guided approach
- used less frequently in partially edentulous patients
. Lack of mesial distal space.
. Lack of interocclusal space.
Computer guided implant
placement
 Fully guided approach
- Used less frequently in partially edentulous patients
. Disadvantageous when bone or soft tissue grafting is necessary.
. Verification and alteration of apical coronal position is difficult
Disadvantages

 Lack of flexibility during surgery

- Soft tissue and bone grafting is more difficult.
- Coronal-apical position is difficult to visualize and control
Computer guided implant
placement
 Two types
Semi-guided surgery : employ the same treatment planning software
programs as fully guided surgery, but the drill sleeves ( brushings )
incorporated within the surgical templates are designed to
accommodate the 2-3 mm twist drill and as a result, control only the
position, and angulation of the initial osteotomy.
Computer guided implant
placement
 Indications- Semi-guided approach
- Partially edentulous patients
posterior quadrants with limited interocclusal space
- The esthetic zone
apical-coronal positioning and angulation is critical
permits bone and soft tissue grafting
Semi-guided implant placement

 When soft tissue procedures or bone grafting are anticipated during

surgery
- Patients with thin periodontal biotype frequently require soft tissue
supplementation and bone grafting.
Semi-guided implant placement

 When flexibility is required during surgery

- The esthetic zone
apical coronal positioning
Grafting
Combined fully guided and semi-
guided implant placement
Combined fully guided and semi-
guided implant placement
 Posterior implants placed with fully guided approach
 Anterior implants placed with a semi-guided approach
Combined fully guided and semi-
guided implant placement
 The tilted implants were placed using fully guided technique
 The anterior implants were placed with a semi-guided technique
WORKFLOW

 CT Scan

 Implant planning

 Surgical guide fabrication

 Guided surgery & prosthesis

RESEARCH AND REVIEWS
er
PAIN EXPERIENCED

Good score were

reported on patient
comfort and pain
after surgery and
patient satisfaction
with oral functions
after 3-12 months

(Steenberghe et al.
2005;
- Statistically significant reduction in immediate
postoperative pain, use of analgesics, swelling, edema,
hematoma, hemorrhage, and trismus when flapless
guided surgery was performed.

- Arisan et al, (2010) also compared guided flapless

surgery with guided open flap surgery and
demonstrated consist rated consistently better outcome
measures for the flapless guide technique
For Resorbed Ridges

 The study was based on patients previously treated with

extensive onlay bone grafting of severely resorbed maxilla.

 They reported 98% implant survival rate and 100% prosthesis

survival rate after more than 4 years.

Barier S. (2010) Computer-aided implant placement in the reconstruction of a severely restored maxilla- a5-
year clinical study.
Duration of treatment and cost-
effectiveness.
 Arisan et al (2010) found the flapless guided surgery
technique to be significantly faster (24min) compared to
both open flap guided surgery (61 min) and
conventional surgery (69 min).
 No study has reported on cost-effectiveness
measurements
Complications

 The most common complication was fracture of the

surgical guide.
 Implant survival after 1 year ranged between 89 and
100% (mean 97%) and the corresponding prosthesis
survival between 62 and 100% ( study mean 95%).
 No obvious difference in implant survival rate was
observed between studies using an immediate or
delayed loading protocol.

Hultin M. et al. Clinical advantages of computer-guided implant placement: a systemic review. 2012
Experienced Vs Inexperienced
surgeons
Types of
Guides
GUIDED VS. UNGUIDED

 The mean deviation at the entry point in vivo was

0.87 mm when the implant placement was guided
vs. 1.34 mm when unguided.

 Deviation parameters ( entry, apical and angle )

were significantly lower for implants, which were
guided during the insertion.

Assche N. et al. Accuracy of computer-aided implant placement.(2012)

Implant placed in anterior or
posterior regions:
 Di Giacomo et al. (2011) found a significant
lower angular deviation for anterior implants.
 Same result by Vasak et al. (2011).
 D haese et al. (2009) found no difference.

Assche N. et al. Accuracy of computer-aided implant placement.(2012)

THANK YOU