In this Clinical Tip, Dr. Bradley Bockhorst explains the benefits of using a surgical guide when transferring a virtual implant plan to the clinical setting. See a guided drill try-in for evaluating vertical opening prior to guided surgery and an educational animation of a soft tissue surgical guide in use.
Bradley C. Bockhorst, DMD Director of Clinical Technologies,
Glidewell Laboratories
Newport Beach, Calif.
800-521-0576 inclusivemagazine@glidewelldental.com
After receiving his dental degree from Washington University School of Dental Medicine, Dr. Bradley Bockhorst served as a Navy Dental Officer. Dr. Bockhorst is Director of Clinical Technologies at Glidewell Laboratories, where he oversees Inclusive® Digital Implant Treatment Planning Services and is editor-in-chief and clinical editor of Inclusive magazine. A member of the CDA, ADA, Academy of Osseointegration, International Congress of Oral Implantologists and American Academy of Implant Dentistry, Dr. Bockhorst lectures internationally on an array of dental implant topics. He maintains a private practice focused on implant prosthetics in Mission Viejo, Calif.
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Guided surgery can be utilized to precisely place implants based on a digital treatment plan. The Surgical Template contains a metal sleeve based on the diameter of the implant. Drill guides slide into the sleeve and precisely guide each diameter drill, providing directional control. Drill stops provide depth control.
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The primary purpose of the surgical guide (aka Surgical Template, SurgiGuide®, etc.) is to transfer the virtual implant plan to the clinical setting. A few of the benefits include:
Implants are placed in a more ideal position based on a restorative-driven treatment plan.
Allows flapless procedures, if indicated, to be performed in a more precise manner.
Implant placement can be performed with a higher degree of safety, as vital structures have been identified pre-surgically.
However, the surgeon must be aware that guided drills are longer than standard drills, as they will be going through the surgical guide and soft tissue into the bone. This can be an issue if the patient has limited vertical opening, particularly for posterior implants.
The total drill length for Materialise SurgiGuides (cases planned with SimPlant® software) varies and is based on the addition of three numbers: the length of the planned implant, the height of the guidance sleeve and the "prolongation" length (Fig. 1). The prolongation length is the distance from the top of the implant to the bottom of the sleeve. If a Mucosa Level SurgiGuide is ordered, the prolongation length will be slightly greater than the thickness of the soft tissue. A Bone Level SurgiGuide would obviously have a shorter prolongation length than a Mucosa Level SurgiGude. The prolongation length may also be affected if the sleeve collides with an adjacent crown. A Drill Guideline listing the total drill length for each osteotomy (Fig. 2) is supplied with the SurgiGuide.
Other guided systems, such as NobelGuide™ (Nobel Biocare; Zurich, Switzerland), have a fixed distance from the top of the implant to the top of the sleeve in the Surgical Template. In Figure 3, the distance is 9 mm. The drill guides that fit into the sleeve have a 1 mm flange. Therefore, the total depth is the length of the implant plus 10 mm. The parallel-walled NobelGuide Twist Drills are 10 mm longer than the company's standard drills (Fig. 4). The overall length of the NobelGuide Tapered Drills is approximately 6 mm more than the standard drills. NobelGuide Tapered Drills have built-in depth stops (Fig. 5).
Evaluating Vertical Opening at the Consultation Appointment If you are considering guided surgery, the vertical opening can easily be accessed at the consultation appointment. A quick visualization can be made by placing a guided drill in the handpiece, asking the patient to open wide and determining whether you can fit the drill over the intended implant site (Fig. 6a, Fig. 6b).
Dealing with Limited Vertical Opening During the Procedure First do the obvious: If the patient has a removable prosthesis on the opposing arch, it should be removed after the anchor pins/horizontal fixation screws have been placed. If the drill is too long, you may want to start with a shorter drill (Fig. 7a), then place the longer drill through the surgical guide into the osteotomy. Next, attach the handpiece to the drill and continue to the desired depth (Fig. 7b).
A key to success with guided surgery is becoming familiar with the components and understanding their uses and limitations. Evaluating the patient's vertical opening at the start can eliminate surprises and help the case go smoothly.
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