ACCURACY OF COMPUTER-

AIDED IMPLANT PLACEMENT

N. Van Assche, M. Vercruyssen, W. Coucke,

W. Teughels, R. Jacobs and M. QuirynenClin. Oral Implants Res. 23 (Suppl. 6), 2012, 112–123

AAMIR ZAHID GODIL

FIRST YEAR P.G.

DEPARTMENT OF PROSTHODONTICS

M.A.R.D.C.

OUTLINE• INTRODUCTION

• GUIDED IMPLANT SURGERY– STEREOLITHOGRAPHIC SURGICAL GUIDES

• STEPS IN COMPUTER- AIDED IMPLANT PLACEMENT

• ADVANTAGES AND DISADVANTAGES OF FLAPLESS GUIDED SURGERY

• CLINICAL CASE

• RESEARCHES AND REVIEWS

• CONCLUSION

• CRITIQUE

INTRODUCTION

GUIDED IMPLANT SURGERY• During the last decade, special attention was given to a “prosthesis

driven” implant placement, to optimize the aesthetic outcome of

the final restoration with optimal loading conditions and good

access for cleaning.

• Three-dimensional imaging (showing the alveolar bone in relation to

the ideal tooth position), obtainable with relative low radiation

dosages especially when CBCT are used (Loubele et al. 2009;

Pauwels et al. 2012) in combination with planning software opened

the possibility for preoperative planning and proper

communication among the patient, the surgeon and the

prosthodontist.

STEREOLITHOGRAPHIC

SURGICAL GUIDES

Tooth-supportedRecommended for single

tooth and partially

edentulous cases when

minimally invasive surgery

is preferred

Bone-

supportedFor partially or fully

edentulous cases when

increased visibility is

needed

Mucosa-

supportedFor fully edentulous cases

when minimally invasive

surgery is preferred.

STEPS IN COMPUTER- AIDED IMPLANT

PLACEMENTPre-operative CBCT of patient + CBCT scan of

stone cast or denture

Computer software program for virtual placement of implants

Fabrication of stereolithographic surgical guide and implant placement using this guide

Post-operative CBCT to evaluate differences in planned and placed implants

PRE-OPERATIVE SCANS

PLANNING

POST-OPERATIVE

EVALUATION

A. Illustrating the measurement deviation calculation at the level of the hex, apex, and angular deviation.

B. B. Represents the measurement deviation calculation of the depth between the virtually planned implant and implant placed

after surgery (aa = apex actual; ap = apex planned, ha = hex actual; hp = hex planned).

ADVANTAGES OF FLAPLESS

GUIDED SURGERY

Facilitated surgical

procedure

Reduced surgical

intervention time

Reduced postoperative complications

Treatment of medically

compromised

Avoiding bone grafting

procedures

Facilitated immediate

loading protocol

D'haese J, Van De Velde T, Komiyama AI, Hultin M, De Bruyn H. Accuracy and Complications

Using Computer‐Designed Stereolithographic Surgical Guides for Oral Rehabilitation by Means of

Dental Implants: A Review of the Literature. Clinical implant dentistry and related research. 2012

Jun 1;14(3):321-35.

DISADVANTAGES OF FLAPLESS

GUIDED SURGERYLack of visibility

and tactile control during surgical

procedure

Insufficient mouth opening

jeopardizes surgical procedure

Risk of damaging vital anatomical

structures

D'haese J, Van De Velde T, Komiyama AI, Hultin M, De Bruyn H. Accuracy and Complications

Using Computer‐Designed Stereolithographic Surgical Guides for Oral Rehabilitation by Means of

Dental Implants: A Review of the Literature. Clinical implant dentistry and related research. 2012

Jun 1;14(3):321-35.

CLINICAL CASE

RESEARCHES AND

REVIEWSPAIN EXPERIENCED AND SURGICAL TRAUMA

FOR RESORBED RIDGES

DURATION OF TREATMENT AND COST-EFFECTIVENESS

COMPLICATIONS

ALL ON FOUR AND ALL ON SIX

EXPERIENCED V/S INEXPERIENCED SURGEONS

TYPES OF GUIDES

SYSTEMATIC REVIEW

FROM THE CHOSEN ARTICLE

PAIN EXPERIENCED

Good scores were

reported on patient

comfort and pain

after surgery and

patient satisfaction

with oral functions

after 3–12 months

(Steenberghe et al. 2005;

Nikzad & Azari 2010;

Abad-Gallegos et al.

2011)Hultin M, Svensson KG, Trulsson M.

Clinical advantages of computer‐guided

implant placement: a systematic review.

Clinical oral implants research. 2012 Oct

1;23(s6):124-35.

Fortin et al. 2006; Nkenke et al.

2007; Arisan et al. 2010• Statistically significant reduction in immediate

postoperative pain, use of analgesics, swelling, edema, hematoma, hemorrhage, and trismuswhen flapless guided surgery was performed.

• Arisan et al. (2010) also compared guided flapless surgery with guided open flap surgery and demonstrated consistently better outcome measures for the flapless guided technique

FOR RESORBED RIDGES

• The study by Barter (2010) was based on patients previously treated with extensive onlay bone grafting of severely resorbed maxillas.

• They reported 98% implant survival rate and 100% prosthesis survival rate after more than 4 years.

Barter, S. (2010) Computer-aided implant placement in the reconstruction of a severely resorbed maxilla-a 5-year clinical study. The International Journal of Periodontics & Restorative Dentistry 30: 627–637.

DURATION OF TREATMENT AND COST-EFFECTIVENESS

• Arisan et al (2010) found the flapless guided surgery technique to be significantly faster (24 min) compared to both open flap guided surgery (61 min) and conventional surgery (69 min).

• No study has reported on cost-effectiveness measurements.

Arisan et al. (2010). “Accuracy of two stereolithographic guide systems for computer-aided implant placement:

Hultin M, Svensson KG, Trulsson M. Clinical advantages of computer‐guided implant placement: a

systematic review. Clinical oral implants research. 2012 Oct 1;23(s6):124-35.

COMPLICATIONS

• The most common surgical complication was fracture of the surgical guide

• Implant survival after 1 year ranged between 89 and 100% (study 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

ALL-O

N-F

OU

R A

ND

AL

L-O

N-S

IX

Van de Wiele G, Teughels W, Vercruyssen M, Coucke W, Temmerman A, Quirynen M. The accuracy of guided surgery via mucosa-

supported stereolithographic surgical templates in the hands of surgeons with little experience. Clin. Oral Impl. Res. 00, 2014, 1–6

EXPERIENCED V/S INEXPERIENCED

SURGEONS

TYPES OF

GUIDES

Schneider D, Marquardt P, Zwahlen M, Jung RE. A systematic review on the accuracy and the clinical outcome of computer-guided

template-based implant dentistry. Clin. Oral Impl. Res. 20 (Suppl. 4), 2009; 73–86.

GUIDED V/S UNGUIDED• The mean deviation at the entry point in vivo was

0.87 mm (SE 0.11, max 3) when the implant placement was guided, vs., 1.34 mm (SE 0.06, max 6.5) when unguided.

• Deviation parameters (entry, apical and angle) were significantly lower for implants, which were guided during the insertion.

Assche N, Vercruyssen M, Coucke W, Teughels W, Jacobs R, Quirynen M. Accuracy of computer‐aided implant

placement. Clinical oral implants research. 2012 Oct 1;23(s6):112-23.

INCONSISTENCY IN

OBSERVATIONS• When comparing the data of the maxilla with

the mandible:– Some publications reported no differences (Ersoy

et al. 2008; Arisan et al. 2010)

– Pettersson and co-workers (2010) and Vasak et al. (2011) observed significant difference between both jaws (in favour of the mandible)

– Di Giacomo et al. (2011) observed significant higher deviations in the maxilla

Assche N, Vercruyssen M, Coucke W, Teughels W, Jacobs R, Quirynen M. Accuracy of computer‐aided implant

placement. Clinical oral implants research. 2012 Oct 1;23(s6):112-23.

• When comparing the data of implants placed in anterior and posterior regions:

– Di Giacomo et al. (2011) found a significant lower angular deviation for anterior implants

– A study by Vasak et al. (2011) found significant lower deviations for anterior implantscompared to posterior ones

– D’haese et al. (2009) found no differenceAssche N, Vercruyssen M, Coucke W, Teughels W, Jacobs R, Quirynen M. Accuracy of computer‐aided implant

placement. Clinical oral implants research. 2012 Oct 1;23(s6):112-23.

CONCLUSION• Irrespective of the study design the mean deviation of implants

inserted using guided surgery techniques was: 1.09mm at entry, a mean deviation of 1.28 mm at the apex and 3.9° in angulation.

• The importance of this value becomes more understandable when compared to the accuracy of mental navigation (with or without a surgical template)

• However, to find the best guiding system and most important parameters for optimal accuracy, more RCTs are necessary.

Assche N, Vercruyssen M, Coucke W, Teughels W, Jacobs R, Quirynen M. Accuracy of computer‐aided implant

placement. Clinical oral implants research. 2012 Oct 1;23(s6):112-23.

CRITIQUE

• The current systematic review highlights

all necessary evidence based updates and

is an excellent article for reference

Thank You