The ongoing global pandemic has put healthcare professionals around the world at the frontlines against unprecedented challenges. Consequently, many in the dental field are striving to keep their practices operating safely during such crucial times, being able to assist patients with the same efficiency while maintaining the required safety measures. For implant cases, the importance of a streamlined computer-guided surgery workflow has significantly increased as a means to meet such high standards of infection control without compromising efficiency.
In this case study, we will demonstrate how adopting the latest guided surgery techniques can make complex full-mouth rehabilitation procedures safer by reducing chair time, making the entire process predictable, and condensing the entire workflow into a single surgical session.
CASE REPORT
Case Presentation and Administration
A 46-year-old female presented to the Kirkland Premier Dentistry office for a consultation, complaining of a chronic periodontic disorder; bad breath; loose, non-restorable teeth (Figure 1); and the constant frustration of having root canal treatment done on her teeth, which was both time- and money-consuming. Upon examination, it appeared that a root canal treatment had failed at site No. 10, at which an implant was placed, and it had been noted that site No. 7 was failing as well and required urgent intervention.
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| Figure 1. Preoperative CBCT panoramic image, showing chronic periodontal infection, bone loss, and an implant in site No. 10 with a radiolucency related to tooth No. 7. |
Case Planning
A CBCT scan and panoramic radiograph were taken using the office’s Planmeca ProMax 3D Classic to accurately capture the information needed to properly treatment plan this case and ensure the most ideal outcome. This was especially important since the patient discussed frustration with previous treatments that did not last very long or address primary needs or requests. For this patient, the Hahn Tapered Implant System (Glidewell) was chosen for its unchallenged high-implant stability at placement, which is a critical success factor for immediate load cases like this one.
Using the 3D implant planning software (CoDiagnostiX), the Hahn Tapered Implant System was virtually placed in key positions for the preliminary plan (Figures 2 and 3). To further develop a treatment plan, diagnostic impressions were taken, poured up, and forwarded to 3D Diagnostix (3DDX) for digitization. These models were then digitally mounted on an articulator for further analysis in order to meet the patient’s aesthetic and functional needs.
A 3D virtual treatment plan was developed and integrated with the photos and models with the assistance of 3DDX. A fine-tuning meeting with a 3DDX dentist online allowed for a comprehensive review of the digital and clinical information, creating an optimal treatment plan that would fulfill the necessary requirements for aesthetics, form, and function (Figure 4).
Next, the finished implant plan was transferred to a 3DDX prosthodontist to design the Guided Full Mouth Restorations (GFMR) components.
The full-mouth rehabilitation solution (GFMR) designed by 3DDX has a stackable sequence, and the prosthodontist proceeded to digitally design a retention pin-positioning guide, bone level guide, implant surgical guide, abutment guide, and temporary hybrid restoration.
Once everything was reviewed and agreed upon, these components were approved for production.
Implant Surgery
Now that the digital part was completed, the next appointment would be the planned surgery. The aforementioned 3DDX GFMR components were delivered a few days before the scheduled surgery date, along with a printed breakdown of the plan and surgical protocols for the case.
After taking the required precautionary presurgery measures, the patient was appropriately IV-sedated, and local anesthesia was administered. First, the pin-positioning guide was seated over existing teeth to help mark where the bone level guide should be seated. This is essential to ensuring accurate implant placement and a perfect fit for the temporary denture at the final stage. A full-arch flap was reflected, followed by the maxillary teeth being atraumatically extracted, so that the bone leveling surgical guide could be fully seated and fixed with its retention pins at the locations pre-marked with the help of the pin-positioning guide (Figures 5 to 7).
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Once the required bone leveling was accomplished with the surgical handpiece, the stackable implant surgical guide was locked in place above the bone leveling guide, and the sites for the implants were initiated with designated drills and their appropriate keys from the Hahn Tapered Implant Guided Surgical Kit (Glidewell) (Figures 8 to 10) utilizing the AEU 7000 surgical handpiece and surgical motor (Aseptico) at a speed of 1,200 rpm with copious amounts of sterile saline. Sequential osteotomy formers and keys from the Hahn Tapered Implant Guided Surgical Kit were then used to shape the final osteotomies. Once the osteotomies were completed, the rotary implant driver was used to place the implants as increased torque was necessary (Figure 11). The ratchet wrench was then used to torque the implants to final depths, reaching a torque level of about 40 to 50 Ncm. After the implants had reached their full depths, platelet-rich fibrin (Emerginova) was used to graft any exposed areas at the implant sites. Next, the implant surgical guide was replaced by the abutment guide (Figures 12 to 14), which also locks into place on top of the bone leveling guide to ensure that the multi-unit abutments are being placed as planned in the correct orientation and angulation.
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The 3DDX-prefabricated immediate provisional hybrid restoration with pre-drilled access openings was inspected before being tried in (Figures 15 to 17). The maxillary provisional restoration was tried in to verify a passive fit over the temporary abutments. After confirmation, the provided custom-made polyvinyl siloxane gasket was placed to prevent the restoration from locking on during the pickup procedure. Pickup material (CHAIRSIDE Attachment Processing Material [Zest Dental Solutions]) was injected into premade access holes in the hybrid restoration. After the material was polymerized, the immediate provisional restoration was removed, and any removal of excess material was done with the Torque Plus lab handpiece and acrylic bur (Aseptico). The restoration was then finished and finalized inside the patient’s oral cavity, enabling the patient to leave the office with a brand-new smile (Figures 18 and 19).
CONCLUSION
The ability to take a patient from start to finish with fewer appointments helps position the provider as one who can fulfill the patient’s surgical and restorative needs, especially during these crucial times. The guided surgery workflow allows you to reduce the number of visits for the patient and, most importantly, enables the dental provider to fully control the surgical and prosthetic outcome, along with reducing the risk of spreading the virus between all stakeholders. In this case, the patient was provided with a new smile after a single surgical visit at Kirkland Premier Dentistry and in collaboration with 3DDX (Figure 20). All the necessary infection control measures were taken before, during, and after the surgery, and the results are nothing short of life-altering.
Dr. Patel is a graduate of the University of North Carolina at Chapel Hill School of Dentistry and the Medical College of Georgia/American Academy of Implant Dentistry (AAID) MaxiCourse. He is a clinical instructor at the Reconstructive Dentistry Institute. Dr. Patel has placed more than 5,000 implants, published numerous articles in leading dental journals, and worked as a lecturer and clinical consultant on dental implants and prosthetics for various companies. He belongs to numerous dental organizations, including the ADA, the North Carolina Dental Society, and the AAID. He can be reached at the website implantsbyparesh.com or via email at pareshpateldds2@gmail.com.
Disclosure: Dr. Patel reports no disclosures.
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