December 10, 2019
by Mark Antal, DMD, MSc, PhD; George Freedman, DDS, Dipl. ABAD, FAACD, FIADFE
The tremendous proliferation of implant services worldwide has created a need for simplified and more predictable treatment guidance modalities. There are currently a number of surgical guide platforms available, but most systems are strictly limited to specific implant catalogues, typically the products sold by the surgical guide sponsor. Other surgical guides are “open systems” and allow the practitioner to use any selected dental implant. The practitioner has the options of freehand, partially guided, and fully guided implant placement surgery. Guided surgery results in more accurate results than freehand surgery. Computerized treatment planning and guided surgery provides improved accuracy, predictability and patient care.
Given the wide selection of high-quality implants that can be utilized by the dental practitioner, the implants’ very large variation in cost to the dentist, and the regional disparity in product access, it makes more sense to develop a treatment plan based on the patient’s needs and anatomic suitability rather than on a specific implant manufacturer’s product lines. Thus, the ideal guidance system can be adapted to a variety of implant brands and types, offering recommendations that are patient-centered rather than product-centered.
The SMART Guide Technology System (dicomLAB Dental Ltd., Szeged, Hungary) provides complete case analysis and preparation shortly after imaging, enabling immediate treatment planning for any type of implant placement; it is possible to set the implant length with 0.5 mm increments and the diameter with 0.1 mm accuracy. The surgical protocol of the system is entirely dependent on the properties of the implant which is selected by the practitioner. The shape of the implant is also at the discretion of the dentist: conical or parallel shapes can be selected.
The following presentation is a detailed, step-by-step presentation of a case where planning and surgery were both accomplished with the assistance of the SMART Guide system. The female patient (age 39) presented with a broken left upper first bicuspid (tooth 24). The tooth had previously had endodontic treatment; a subsequent vertical fracture of the root and unrestorable coronal structures made the case for an implant treatment the best choice (Figs. 1-3).
Virtual model of #24 fractured.
Virtual model of #24 fractured with SMART Guide visualization.
The remaining dental structures of tooth 24 were extracted. In order to avoid any complications due to residual bacteria or possible periapical or periradicular infection, a two-month healing time was mandated. After the initial healing step, a CBCT was taken, and an intraoral impression of the patient was made with a custom-made plastic impression tray and C-silicone. This is the SMART Guide “Simple CBCT Protocol”. This approach does have some limitations as the superimposition of the CBCT to the silicone impression requires the presence of a minimum of eight sound teeth to be present as reference points on the dental arch to be treated. The silicone impression must be scanned with an extraoral scanner for the digital superimposition of the CBCT to the impression. Another option is to use an intraoral scanner. The same limitations regarding sound teeth apply, however. The reference teeth must be sound or restored with metal-free restorations; any metal restorative components, such as amalgam fillings, PFM crowns or bridges and/or metal posts interfere with the CBCT data acquisition.
After the CBCT of the patient and the scanned impression were completed, both data sets were uploaded, without patient identifying information, to the SMART Cloud. Then the SMART Guide center checked the quality of the pictures.
In cases where the patient is completely edentulous or where there are not enough metal-free, sound or restored teeth to provide the required minimum 8 reference points, the “Double CBCT” technique can be employed. This procedure consists of an initial impression of the patient. Then, radio-opaque gutta percha markers are positioned on the tray. The patient then wears this tray intraorally during the second CBCT. Thus, there are two separate CBCTs, one of the gutta percha marked tray extraorally and one of the marked trays intraorally – hence “Double CBCT”. This process ensures a precise fit in those cases where the number of sound tooth reference points are limited.
Once the dicomLAB Dental SMART Guide center has prepared the case, the operator receives a notification e-mail or text. This is typically within approximately four hours after successful data upload. The practitioner then downloads the patient data to the practice computer on which the Smart Guide software has previously been installed. It is now possible to plan the optimal positioning (location, angulation, depth, and diameter) of the implant, considering the implant properties (length, diameter, and shape) as indicated above (Figs. 4-8).
Planned implant in Occlusal Vertical (OV) view.
Planned implant in OV and MD view.
Panoramic view of the planned implant in the SMART Guide.
Zoomed in view of the planned implant in SMART Guide software.
. Zoomed in view of the planned implant in SMART Guide software.
In the current example, the replacement of the earlier extracted left upper first premolar with an implant and an implant-borne crown are demonstrated. The software makes it possible to visualize the bone, the soft tissue, and the intraoral impression taken of the patient. The software then suggests a crown shape, which assists with the planning of the implant angulation and the ideal emergence profile of the restorative crown. The recommended shape considers the anatomical properties of the adjacent and opposing teeth and the soft tissue condition. In cases where screw-retained crowns are planned, this process is essential in ensuring the proper location for optimal angulation and access of the retention screw (Figs. 9-12).
Digital tooth setup visualization in the SMART Guide Software.
Implant for fractured #24 planned.
Planned implant in 3D visualization in the SMART Guide Software.
SMART Impression tray visualization in the SMART Guide Software.
Once the planning phase is completed, it is possible to ask for a treatment plan review by a contracted expert implant specialist within the SMART Guide System who is able to mentor the practitioner. This approach offers confirmation of treatment approach and direction prior to beginning any surgical steps. For those who are less experienced in treatment planning, this is an invaluable and highly protective service. A comprehensive “Preplan Service” (that begins immediately after data uploading) is also available.
In all cases, however, the final decisions are always in the operator’s hands. Further planning and modifications are always possible before the SMART Surgical Guide is ordered.
A short time after it is ordered, the printed surgical guide arrives at the practice. It is a good idea to sterilize it in an autoclave. Along with the printed surgical guide, the operator is provided with a specific surgical protocol which matches the planned implant (Figs. 13-19).
First preview picture of the case in SMART Cloud.
Second preview pictureof the case in SMART Cloud.
SMART Guide Surgical Protocol.
Abutment in the model.
The surgical guide after arrival.
The surgical guide after sterilization.
The surgical guide in the patient’s mouth.
During the actual implant placement surgery, the sequence that is suggested on the attached drilling protocol chart should be followed. The Surgical Kit of the SMART Guide System consists of 20 mm, 24 mm and 28 mm long burs, each with a diameter of 2.0; 2.5; 3.0; and 3.5 mm (Figs. 20-27).
START long drill.
The first drill goes in with the spoon to stabilize the drill.
The first drill with its spoon.
Inserting the first drill through the surgical guide after the START drill.
The second drill with its spoon.
Inserting the second drill.
The third drill with the corresponding spoon.
The final drilling step is done with the final core drill of the selected implant system, at the proper depth and diameter to ensure perfect implant placement.
The final implant drill can also be used without the surgical guide, since the direction and depth of the bone preparation are already pre-established with the SMART guide. The bony housing is already prepared to a size which almost matches that of the intended implant (Figs. 28-43).
After the preparation, use the implant drills up to the last drills needed.
Implant insertion (2).
Implant insertion (3).
Implant insertion (4)
Implant insertion (5).
Checking vertical position through the surgical guidewith depth control.
Healing cap insertion.
Post-OP Panoramic radiograph.
Implant is exposed.
Before the final step.
The missing tooth #24 replaced using SMART Guide
The SMART Guide Technology offers a versatile implant placement guidance system that can be adapted to most implant brands and types, making implant surgery patient-centered (rather than product-centered), more predictable, and more efficient.
Oral Health welcomes this original article.
About the Authors
Dr. Mark Antal, senior lecturer in Dentistry, University of Szeged, Hungary, specialized in operative dentistry and oral surgery at Halle-Wittenberg, Martin-Luther University, Boston University, and NYU. Member, FDI Education Committee, Hungarian Academy for Esthetic Dentistry, Hungarian Implantology Association and the IADS.
Dr. George Freedman, past-president of AACD, co-founder of CAED, the IADFE, and a Diplomate and Chair of American Board of Aesthetic Dentistry; Adjunct Professor, Western University, Pomona, California and Professor-Program Director, BPP University, London; author/co-author of 14 textooks, including “Contemporary Esthetic Dentistry (Elsevier).
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