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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 54-57

Novel alternative use of surgical guides in full-mouth implant rehabilitation cases: A case series


1 Dental Health Care Centre, Bengaluru, Karnataka, India
2 Department of Orofacial Pain, RRDC, Bengaluru, Karnataka, India
3 Prof and HOD of Pain Clinic, RajaRajeshwari Dental College and Hospital, Bengaluru, India

Date of Submission16-Jan-2022
Date of Acceptance08-Mar-2022
Date of Web Publication16-Jun-2022

Correspondence Address:
Dr. Roshan P Thumati
296, Dental Health Care Centre, Katriguppe Main Road, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdi.jdi_1_22

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   Abstract 

Surgical guides (SGs) have been commonly used in full-mouth rehabilitation and numerous advances have been adopted in their development. However, they have been restricted to implant placement and are later rendered useless. They further add to the burden of biological waste management following their limited use. The quantum of technologies and materials used to make us ponder if they can be used further. This article establishes different ways of using SG in different stages of prosthetic phase of treatment by demonstrating the procedures clinically. It gives us an insight into how the guides can be used for implant localization and exposure during the secondary surgical phase and also during impression making, thereby enhancing the treatment outcome.

Keywords: Full-mouth rehabilitation, guided implant surgery, surgical guides


How to cite this article:
Thumati RP, Thumati P, Comandur S. Novel alternative use of surgical guides in full-mouth implant rehabilitation cases: A case series. J Dent Implant 2022;12:54-7

How to cite this URL:
Thumati RP, Thumati P, Comandur S. Novel alternative use of surgical guides in full-mouth implant rehabilitation cases: A case series. J Dent Implant [serial online] 2022 [cited 2022 Nov 30];12:54-7. Available from: https://www.jdionline.org/text.asp?2022/12/1/54/347659


   Introduction Top


Dental implants have evolved by leaps and bounds and have become a treatment option used widely for the replacement of lost teeth.[1],[2],[3],[4] Usage of guides has reduced the incidence of postsurgical complications, especially during prosthetic workflow.[3],[4],[5]

Adoption of computer-aided design (CAD)-computer-aided manufacturing has ushered an era of minimally invasive implantology which is fast, highly accurate, and reliable.[6],[7],[8],[9],[10] Hence, full-mouth rehabilitation with implants has become simplified and predictable.

Although numerous advances have been adopted in designing and fabricating surgical guides (SGs), they have been restricted to implant placement. This article probes into different ways of utilizing SG other than their primary purpose.


   Case Report Top


The purpose of this article is to present novel techniques for the use of SG in the prosthetic phase of treatment during full-mouth rehabilitation.

Case 1

A 50-year-old female patient reported to the clinic with a complaint of loose dentures and desired a new set of prosthesis. Following the examination, two treatment plans were developed.

Treatment Plan I: Replacement of the removable prosthesis with a new removable prosthesis.

Treatment Plan II: Provide implant-supported full-arch fixed prosthesis.

The patient approved the Treatment Plan II: the following protocol was set in.

Treatment Phase I: Surgical phase

The patient was sent for cone-beam computed tomography (CBCT) imaging for implant placement planning. A digital impression was made for the purpose of superimposing it in CAD software over CBCT image, for planning the implant position and designing the SG for implant placement. The upper prosthesis was designed with eight implants and the lower prosthesis with six implants [Figure 1]. The immediate transitional fixed prosthesis was planned for esthetics and limited function.
Figure 1: (a) Completely edentulous maxillary and mandibular arches planned for full-arch implants. (b) Surgical guide anchored onto the arch

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A healing period of 3 months was suggested to allow osseointegration. The patient reported after 3 months and radiographic imaging showed good healing and osseointegration around the implants.

Treatment phase II: Prosthetic phase

The prosthetic phase involved the replacement of the transitional fixed prosthesis with the final prosthesis. The temporary prosthesis had allowed the peri-implant tissue to adapt well around the abutment, thereby allowing a good emergence profile for the final prosthesis. A well-made impression was needed with details for an accurate prosthesis.

For the special tray, the SG that was previously used for implant placement was utilized. The guide was modified by removing the metallic sleeves and trimming the guide hole borders to allow open-tray impression technique [Figure 2] and [Figure 3]. They were autoclaved postsurgery and prior to impression making for maintaining asepsis. An open-tray technique was used in the upper arch and closed-tray technique in the lower arch to assess the feasibility of the tray modification [Figure 4]. An elastomeric impression material (addition polyvinylsiloxane) with single-step two-phase impression technique (heavy body and light body) was used for obtaining an accurate impression [Figure 5] and [Figure 6].
Figure 2: Removal of guide hole inserts and modification of the surgical guide

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Figure 3: (a and b) Placement of impression copings for open-tray impression technique

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Figure 4: (a and b) Placement of modified surgical guide for making an impression

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Figure 5: Intraoral impression making

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Figure 6: (a and b) Impression of both arches

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Subsequently, the laboratory analogs were fixed and laboratory steps were followed. The jig try-in was done to assess the accuracy of the impression following which the metal framework was tried for confirming the accuracy of the fit. Later, the trial prosthesis was tried to verify the position of the prosthetic components for the esthetics. The hybrid prosthesis was then fabricated and fixed to achieve the final result.

Case 2

A 62-year-old female patient reported to the clinic with a complaint of multiple missing lower anterior teeth and mobile lower teeth and desired fixed prosthesis for chewing.

Following the examination, two treatment plans were developed.

Treatment Plan I: Fabrication of a new lower removable prosthesis.

Treatment Plan II: Total extraction in lower arch followed by implant-supported single-arch and full-arch fixed prosthesis.

The patient approved the Treatment Plan II: the following protocol was set in.

Treatment phase I

The patient was sent for CBCT imaging for implant placement planning. A digital impression was made for the purpose of superimposing it in CAD software over CBCT image for planning the implant position and designing the SG for implant placement. The lower prosthesis was designed with six implants which were placed using the SG. A transitional temporary removable prosthesis was given in the lower arch.

The patient reported after healing period of 3 months and radiographic imaging showed good healing and osseointegration around the implants.

Treatment phase II: Prosthetic phase

The prosthetic phase demands accurate recording of the implant position and the associated tissues. However, due to the soft-tissue growth during the healing period, the removal of tissue overlying the implants (secondary surgical phase) with minimal damage to the surrounding tissue was necessary. For this purpose, the SG was used to locate the position of the implants. The SG was seated firmly over the arch and the tissue overlying the implants was removed with the aid of the electrocautery through the SG holes [Figure 7]. This facilitated minimal trauma through limited tissue removal in the right place while facilitating the determination of the accurate position of the implants.
Figure 7: (a) Use of surgical guide for locating the exact position of implant. (b) Ideal tissue emergence profile due to minimal tissue trauma

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For the special tray, the SG that was previously used for implant placement and determining implant location during the second phase surgery was utilized in a manner similar to the procedure in Case 1. An open-tray impression technique was used for recording the impression.

Subsequently, the laboratory steps were followed and the hybrid prosthesis was fabricated and fixed to achieve the final result.


   Discussion Top


Implant dentistry has stepped into an era of technological advances and innovations. These tools have allowed the fabrication of various components and appliances with better precision and accuracy, thereby aiding in increasing the success of the treatment and providing stable and reproducible outcomes.

The precision appliances such as implant SGs have been developed with contributions from various novel ideologies, techniques, and technologies. However, during implementation, they have been restricted to unidimensional purpose of implant placement. The magnitude of effort that is put into their development and fabrication demands that they be used more extensively. This case series has pondered alternative uses of SGs.

The primary hindrance in two-stage surgical protocol in full-arch implants is the difficulty in locating the exact positions of the implants. Locating the implant positions using the SGs minimizes the magnitude of tissue removal and trauma while facilitating faster and better healing. Furthermore, the guide holes in the SG act in a manner similar to the tray window/opening for the open-tray impression copings consequently aiding in making of an accurate impression with additional ease of locating the position of the screw for quick removal of the impression copings. The guide also acts as a well-adapted custom tray which helps in generating an accurate impression with minimal material usage.

The ability of the guides to be subjected to sterilization, as they are autoclavable, aids in maintaining asepsis which plays a critical role in implant success, especially in the initial stages of osseointegration when they are most susceptible to infection and failure. Thus, using guides for these procedures provides us an upper handover stock trays or laboratory fabricated custom trays.

While the guides have numerous advantages, they would definitely have minor marginal errors during implant position determination and implant exposure as they are not stabilized with guide pins. Firm stabilization of the guide is hence necessary for accurate localization of the implants.

A further use of the guide could be for the purpose of tissue retention in full-arch flap surgery to minimize the effects of swelling.


   Conclusion Top


With the advances in dentistry, the ability to provide predictable results successfully and repeatedly has become a reality. Using these technologies to their fullest potential is the best service that can be rendered to the patient. Using the guides for multiple purposes can increase efficiency and accuracy while minimizing laboratory procedures. Using these novel ideas and techniques, one can only enhance the outcome while minimizing trauma and provide fruitful results for the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ramasamy M, Giri, Raja R, Subramonian, Karthik, Narendrakumar R. Implant surgical guides: From the past to the present. J Pharm Bioallied Sci 013;5:S98-102.  Back to cited text no. 1
    
2.
D'Souza KM, Aras MA. Types of implant surgical guides in dentistry: A review. J Oral Implantol 2012;38:643-52.  Back to cited text no. 2
    
3.
Michelinakis G, Nikolidakis D. Using the surgical guide for impression-free digital bite registration in the edentulous maxilla – A technical note. Int J Implant Dent 2019;5:19.  Back to cited text no. 3
    
4.
Fang Y, Fang JH, Jeong SM, Choi BH. A technique for digital impression and bite registration for a single edentulous arch. J Prosthodont 2019;28:e519-23.  Back to cited text no. 4
    
5.
Solano N, Gutiérrez P, Ortega D, Ramos S. Use of surgical guides for the immediate placement of post-extraction implants. Res Rep Oral Maxillofac Surg 2020;4:036.  Back to cited text no. 5
    
6.
Tahmaseb A, Wu V, Wismeijer D, Coucke W, Evans C. The accuracy of static computer-aided implant surgery: A systematic review and meta-analysis. Clin Oral Implants Res 2018;29 Suppl 16:416-35.  Back to cited text no. 6
    
7.
Eftekhar Ashtiani R, Ghasemi Z, Nami M, Mighani F, Namdari M. Accuracy of static digital surgical guides for dental implants based on the guide system: A systematic review. J Stomatol Oral Maxillofac Surg 2021;122:600-7.  Back to cited text no. 7
    
8.
Turbush SK, Turkyilmaz I. Accuracy of three different types of stereolithographic surgical guide in implant placement: An in vitro study. J Prosthet Dent 2012;108:181-8.  Back to cited text no. 8
    
9.
Liu X, Liu J, Feng H, Pan S. Accuracy of a milled digital implant surgical guide: An in vitro study. J Prosthet Dent 2022;127;453-61.  Back to cited text no. 9
    
10.
Kim SM, Son K, Kim DY, Lee KB. Digital evaluation of the accuracy of computer-guided dental implant placement: An in vitro study. Appl Sci 2019;9:3373.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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