52 STARGET 1 I 12
viNCeNzO MiriSOLA Di TOrreSANTO AND LUCA COrDArO
Guided surgery as a way to simpli fy surgical implant t reatment in complex cases
Background
A 41-year-old woman with an edentulous maxilla and bilateral
edentulous region (Kennedy Class I) in the mandible wanted
removable restorations for both arches (Figs. 1, 2).
Due to prosthetic constraints (reduced inter-arch distance and
short upper lip interfering with prosthetic flanges), a fixed im-
plant-supported restoration was suggested even though the
edentulous maxilla and posterior mandible exhibited atrophy
(Fig. 3).
Treatment plan
The following plan was worked out to provide the patient
with the simplest and most predictable surgical treatment pos-
sible.
Maxilla: conventional procedure
Complex reconstruction with bilateral sinus lift and autog-
enous particulate bone harvested from the chin and multiple
bone block grafts harvested from the ramus; four months after
insertion of six implants and loading after an additional eight
weeks with an FPD (Figs. 4 – 12).
Fig. 5Fig. 4 Fig. 6
Fig. 1
FiGS 4-12: MAxiLLA, CONveNTiONAL PrOCeDUre
Fig. 2 Fig. 3
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53STARGET 1 I 12
Vincenzo Mirisola di Torresanto, DDS
Degree in Dentistry and Dental Prosthetics. Clinical researcher
at the Department of Periodontology and Prosthodontics at
Eastman Dental Hospital in Rome, Italy. Awarded the H.M.
Goldman Prize by the Italian Society of Periodontology for his
clinical research in 2007. various national and international
publications and lectures. ITI member and co-director of the
ITI Study Club of Rome. Private practice in Rome.
Mandible: guided surgery
The mandible exhibited severe horizontal and vertical atrophy in the lateral-pos-
terior region and remaining frontal dentition (from canine to canine), which, even
if compromised, was considered maintainable after a periodontal non-surgical
phase. After all, bone-harvesting sites in the chin and retro-molar region had al-
ready been used for maxillary surgery.
A guided surgical procedure was planned and proposed in order to offer the
patient the possibility for a less invasive surgical procedure. In addition, this
would allow for the safe insertion of smaller implants, without requiring ad-
ditional bone augmentation.
Fig. 11 Fig. 12Fig. 10
Fig. 7 Fig. 8 Fig. 9
S t r a U M a N N ® C a r e S ® G U i d e d S U r G e r y
54 STARGET 1 I 12
Fabrication of templates and computer-assisted planning
The scan template was fabricated at the laboratory follow-
ing the official guidelines of the Straumann® Guided Surgery
system: the initial template was fabricated with a suck-down
technique and then filled with radiopaque material. Next, the
templix reference plate was attached to the suck-down tem-
plate on the Gonyx™ set with the D coordinate in the zero po-
sition before being completed for fitting in the patient’s mouth.
The DICOM data from the CT scan was processed with the
coDiagnostix™ software. The virtual planning strategy was to
bypass the anatomical structures and make use of all avail-
able bone by using a safe and predictable procedure that
remained simple and affordable for the patient. The proposed
restoration was designed as a three-unit (44 – 46, 34 and
3.6), bilateral implant-supported FDP (Figs. 13, 14).
The decision was made to insert two implants on each side in
the first premolar and first molar positions. The 3D bone scan
showed a reduced height and width in the molar sites and
reduced width in the premolar sites (Fig. 15).
All implants were planned so as to maintain a distance of
at least 2 mm from the alveolar nerve. Insertion of a Strau-
mann® Tissue Level Implant RN ø 3.3 mm SLActive® 10 mm
was planned for both premolar sites. However, despite the
selection of a reduced diameter implant, the virtual model of
the inserted implant at 4.4 showed a marginal dehiscence
(Fig. 16). For the distal implants, a Straumann® Tissue Level
Implant RN ø 4.1 mm SLActive® 6 mm was planned for each
side. Again, the virtual model of the implant inserted on the
right side showed a minor marginal dehiscence (Fig. 17).
Fig. 16Fig. 16 Fig. 17Fig. 17 Fig. 18Fig. 18
Fig. 13Fig. 13 Fig. 14Fig. 14 Fig. 15Fig. 15
FiGS 13-30: GUiDeD SUrGery
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55STARGET 1 I 12
Luca Cordaro, MD, DDS, Ph.D.
Currently, Head of the Department of Periodontology
and Prosthodontics at the Eastman Dental Hospital in
Italy. Private practice in Rome, Italy. Active member of
the Italian Society of Osseointegration. Fellow of the ITI
and Chairman for the Italy chapter of the ITI, Chairman
of the Study Club Committee and member of the Board
of Directors. Author and co-author of scientific papers
and literature, international lecturer. Dr. Cordaro’s
professional interests are periodontology, implantology
and oral surgery, with a special focus on reconstructive
treatments for alveolar atrophies.
gonyx™: Device for surgical template fabrication
S t r a U M a N N ® C a r e S ® G U i d e d S U r G e r y
The planning for the axial inclination of the implant was anatomically-driven rather
than prosthetically-driven.
Using coDiagnostix™, it was determined that a 20° angulated abutment for the
distal implants would make it possible to achieve the required parallelism with
the mesial implants.
Because of the dehiscences of the implants planned for 4.4 and 4.6, a traditional
open flap procedure was chosen for the right side, while a flapless approach
was taken for the left side. Two ø 2.8 mm sleeves were inserted in the right side
of the surgical template; two ø 5.0 mm sleeves were inserted in the left side to
prepare for the complete preparation of the site as well for the guided insertion of
the implant (Fig. 18).
56 STARGET 1 I 12
Fig. 19Fig. 19 Fig. 20Fig. 20
Surgical procedure
Bilateral local anesthesia was administered. The surgical tem-
plate was placed and carefully checked to ensure stability
before beginning the procedure. The mucotomy on the left
side was performed by inserting a ø 4.3 mm round mucosa
punch through the sleeves (Fig. 19).
Implant sites 3.4 and 3.6 were prepared according to the
drilling protocol suggested by the co-Diagnostix™ software
(long and short drill sequence, (Figs. 20 – 22)), and the im-
plants were inserted with the handpiece set with a force
of 35 N and tightened manually after the template was re-
moved. On the right side, a muco-periostal flap with hori-
zontal incision at the top of the ridge and a distal vertical
incision were made (Fig. 23). Both sites were drilled with a
ø 2.8 mm drill (short for 4.6 and long for 4.4) through the ø
Fig. 23Fig. 23 Fig. 24Fig. 24
2.8 mm sleeve, with or without drill handle as required (Fig.
24). Implant site 4.6 was prepared with a ø 3.5 mm drill,
drilling freehand to a depth of 6 mm. Both right-side implants
were inserted with the handpiece set with a force of 35 N
and tightened manually. Similar to the dehiscences seen in
the virtual models of the implants, a vestibular dehiscence
occurred in the case of both right side implants: a GBR pro-
cedure with a bone substitute and a resorbable collagen
membrane was performed around each implant (Figs. 25,
26). The flap was opened, repositioned and sutured around
the healing abutment.
Prosthetic restoration
The implants were observed two months after surgery and
showed stability accompanied by no inflammation or pain.
In addition, the radiographic evaluation showed successful
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Fig. 22Fig. 22
Fig. 21Fig. 21
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healing of the bone, without radiolucencies. A standard pros-
thetic protocol was followed.
Two cemented fixed dental prostheses (FDPs) were planned:
solid abutments for both mesial implants and 20° B angu-
lated abutments were selected, again based on the virtual
models (Fig. 27). Two porcelain-fused-to-metal triplicate FDPs
were fabricated (3.4-3.5-3.6 and 4.4-4.5-4.6) and fixed in
place with temporary cement (Figs. 28, 29).
Conclusion
In this case, the virtual planning models and the actual out-
come (Fig. 30) demonstrated that the Straumann® Guided
Surgery System ensures a high level of precision for the
purposes of implant positioning.
To achieve the most accurate results, a guided implant inser-
tion is recommended. This case was treated with Straumann®
Soft Tissue Level Implants, according to the routine protocol for
lateral-posterior rehabilitations. As a further consideration: in
the author’s opinion selecting Straumann® Bone Level Implants
is the best way to maximize the benefits of the system, poten-
tiality making it easier for the clinician when it comes to soft
tissue management (especially for flapless procedures) and
providing a wider range of options for prosthetics.
Combined with the ability to perform a predictable and
safe flapless procedure, one interesting indication for the
Straumann® Guided Surgery system is potentially the
bypassing of anatomical structures which – in carefully
selected cases and in the hands of experienced clinicians
– can reduce or eliminate the need for bone augmentation
and the associated treatment complications.
Fig. 30Fig. 30Fig. 29Fig. 29Fig. 28Fig. 28
Fig. 25Fig. 25 Fig. 26Fig. 26 Fig. 27Fig. 27