52
STARGET 1 I 12
StraUMaNN® CareS® GUided SUrGery
viNCeNzO MiriSOLA Di TOrreSANTO AND LUCA COrDArO
Guided surgery as a way to simplify surgical implant
treatment in complex cases
Background
Treatment plan
A 41-year-old woman with an edentulous maxilla and bilateral
The following plan was worked out to provide the patient
edentulous region (Kennedy Class I) in the mandible wanted
with the simplest and most predictable surgical treatment pos-
removable restorations for both arches (Figs. 1, 2).
sible.
Due to prosthetic constraints (reduced inter-arch distance and
Maxilla: conventional procedure
short upper lip interfering with prosthetic flanges), a fixed im-
Complex reconstruction with bilateral sinus lift and autog-
plant-supported restoration was suggested even though the
enous particulate bone harvested from the chin and multiple
edentulous maxilla and posterior mandible exhibited atrophy
bone block grafts harvested from the ramus; four months after
(Fig. 3).
insertion of six implants and loading after an additional eight
weeks with an FPD (Figs. 4 – 12).
Fig. 1
Fig. 2
Fig. 3
FiGS 4-12: MAxiLLA, CONveNTiONAL PrOCeDUre
Fig. 4
Fig. 5
Fig. 6
StraUMaNN® CareS® GUided SUrGery
STARGET 1 I 12
53
Mandible: guided surgery
The mandible exhibited severe horizontal and vertical atrophy in the lateral-posterior 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 already been used for maxillary surgery.
A guided surgical procedure was planned and proposed in order to offer the
Vincenzo Mirisola di Torresanto, DDS
patient the possibility for a less invasive surgical procedure. In addition, this
Degree in Dentistry and Dental Prosthetics. Clinical researcher
would allow for the safe insertion of smaller implants, without requiring ad-
at the Department of Periodontology and Prosthodontics at
ditional bone augmentation.
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.
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
54
STARGET 1 I 12
StraUMaNN® CareS® GUided SUrGery
Fabrication of templates and computer-assisted planning
The decision was made to insert two implants on each side in
The scan template was fabricated at the laboratory follow-
the first premolar and first molar positions. The 3D bone scan
ing the official guidelines of the Straumann Guided Surgery
showed a reduced height and width in the molar sites and
system: the initial template was fabricated with a suck-down
reduced width in the premolar sites (Fig. 15).
®
technique and then filled with radiopaque material. Next, the
templix reference plate was attached to the suck-down tem-
All implants were planned so as to maintain a distance of
plate on the Gonyx™ set with the D coordinate in the zero po-
at least 2 mm from the alveolar nerve. Insertion of a Strau-
sition before being completed for fitting in the patient’s mouth.
mann ® Tissue Level Implant RN ø 3.3 mm SLActive ® 10 mm
The DICOM data from the CT scan was processed with the
was planned for both premolar sites. However, despite the
coDiagnostix™ software. The virtual planning strategy was to
selection of a reduced diameter implant, the virtual model of
bypass the anatomical structures and make use of all avail-
the inserted implant at 4.4 showed a marginal dehiscence
able bone by using a safe and predictable procedure that
(Fig. 16). For the distal implants, a Straumann ® Tissue Level
remained simple and affordable for the patient. The proposed
Implant RN ø 4.1 mm SLActive ® 6 mm was planned for each
restoration was designed as a three-unit (44 – 46, 34 and
side. Again, the virtual model of the implant inserted on the
3.6), bilateral implant-supported FDP (Figs. 13, 14).
right side showed a minor marginal dehiscence (Fig. 17).
FiGS 13-30: GUiDeD SUrGery
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 18
StraUMaNN® CareS® GUided SUrGery
STARGET 1 I 12
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
Luca Cordaro, MD, DDS, Ph.D.
open flap procedure was chosen for the right side, while a flapless approach
Currently, Head of the Department of Periodontology
was taken for the left side. Two ø 2.8 mm sleeves were inserted in the right side
and Prosthodontics at the Eastman Dental Hospital in
of the surgical template; two ø 5.0 mm sleeves were inserted in the left side to
Italy. Private practice in Rome, Italy. Active member of
prepare for the complete preparation of the site as well for the guided insertion of
the Italian Society of Osseointegration. Fellow of the ITI
the implant (Fig. 18).
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
55
56
STARGET 1 I 12
StraUMaNN® CareS® GUided SUrGery
Surgical procedure
2.8 mm sleeve, with or without drill handle as required (Fig.
Bilateral local anesthesia was administered. The surgical tem-
24). Implant site 4.6 was prepared with a ø 3.5 mm drill,
plate was placed and carefully checked to ensure stability
drilling freehand to a depth of 6 mm. Both right-side implants
before beginning the procedure. The mucotomy on the left
were inserted with the handpiece set with a force of 35 N
side was performed by inserting a ø 4.3 mm round mucosa
and tightened manually. Similar to the dehiscences seen in
punch through the sleeves (Fig. 19).
the virtual models of the implants, a vestibular dehiscence
occurred in the case of both right side implants: a GBR pro-
Implant sites 3.4 and 3.6 were prepared according to the
cedure with a bone substitute and a resorbable collagen
drilling protocol suggested by the co-Diagnostix™ software
membrane was performed around each implant (Figs. 25,
(long and short drill sequence, (Figs. 20 – 22)), and the im-
26). The flap was opened, repositioned and sutured around
plants were inserted with the handpiece set with a force
the healing abutment.
of 35 N and tightened manually after the template was removed. On the right side, a muco-periostal flap with hori-
Prosthetic restoration
zontal incision at the top of the ridge and a distal vertical
The implants were observed two months after surgery and
incision were made (Fig. 23). Both sites were drilled with a
showed stability accompanied by no inflammation or pain.
ø 2.8 mm drill (short for 4.6 and long for 4.4) through the ø
In addition, the radiographic evaluation showed successful
Fig. 19
Fig. 20
Fig. 21
Fig. 22
Fig. 23
Fig. 24
StraUMaNN® CareS® GUided SUrGery
STARGET 1 I 12
healing of the bone, without radiolucencies. A standard pros-
tion is recommended. This case was treated with Straumann®
thetic protocol was followed.
Soft Tissue Level Implants, according to the routine protocol for
lateral-posterior rehabilitations. As a further consideration: in
Two cemented fixed dental prostheses (FDPs) were planned:
the author’s opinion selecting Straumann® Bone Level Implants
solid abutments for both mesial implants and 20° B angu-
is the best way to maximize the benefits of the system, poten-
lated abutments were selected, again based on the virtual
tiality making it easier for the clinician when it comes to soft
models (Fig. 27). Two porcelain-fused-to-metal triplicate FDPs
tissue management (especially for flapless procedures) and
were fabricated (3.4-3.5-3.6 and 4.4-4.5-4.6) and fixed in
providing a wider range of options for prosthetics.
place with temporary cement (Figs. 28, 29).
Combined with the ability to perform a predictable and
Conclusion
safe flapless procedure, one interesting indication for the
In this case, the virtual planning models and the actual out-
Straumann® Guided Surgery system is potentially the
come (Fig. 30) demonstrated that the Straumann® Guided
bypassing of anatomical structures which – in carefully
Surgery System ensures a high level of precision for the
selected cases and in the hands of experienced clinicians
purposes of implant positioning.
– can reduce or eliminate the need for bone augmentation
To achieve the most accurate results, a guided implant inser-
and the associated treatment complications.
Fig. 25
Fig. 26
Fig. 27
Fig. 28
Fig. 29
Fig. 30
57