Guided Surgery for Implant Placement to Increase Dramatically?

I am a lab owner who because of my involvement with Nobel Guide in the early stages have a great deal of exposure to treatment planning using guided surgery. That being said I do not pretend to have the proper training to make decisions concerning the final placement of dental implants. What I do bring to the table is a working knowledge of the software. I offer this disclaimer so as not to be attacked for over stepping my boundaries in entering this discussion. When I was first introduced to Nobel Guide, and later when I got involved in Keystone's Easy Guide, I did so as a laboratory trying to stay on top of emerging technologies. Nobel Guide's teeth in an hour required a working knowledge of the software, as does Easy Guide, so that we in the lab can bring the "parts and pieces" together. We also found as we were involved in presenting cases that were done using guided surgery that more and more surgeons would seek out advice about treatment planning using the softwares on difficult cases. The comment we heard the most was that they like the idea of guides but just didn't think they would use it enough to stay comfortable with the functions of the software. When we were approached about buying software packages and offering them as a service through our lab I had real reservations but we agreed to a trail. We now offer to assist in treatment planning using Easy Guide and have found that it is being used more than we projected. Those cases that were considered questionable are sometimes very treatable with a guide and those case where aesthetics are crucial are now being looked at as possible guided cases because we can project the outcome and have known treatments because of exact placement of the implants. I project that with 12-18 months we will be designing custom abutments off of the same softwares and placing them at the time of surgery. And that gets me to an answer to your question. If we can do all these things, how then do we not make guided surgery a regular part of implant placement? The world is changing so fast it's hard for us old timers to keep up. But we gotta keep trying.

Guided surgery is certainly a very useful tool. Impossible cases by clinical judgement become possible. Also the minimally invasive nature of the procedure makes it very easy for the patient. More users will also bring down the cost of the procedure. We have been using Nobleguide and are very happy with the result and so are our patients.

There are some disadvantages of computer-guided implant placement that should be put into consideration. Above all are the complexity of the whole system and the cost of tools needed including the software program, CAD/CAM cast fabrications and surgical templates, and last but not the least, the potential thermal injury due to reduced access for external irrigation during drilling. CT scans and recent diagnostic software provide practitiones with an excellent vision of bony structures. Such software applications provide a very fine evaluation of the bone quantity and quality. The primary problem with this technology is in translating the simulated plan to the patient at the time of surgery. The use of CT-derived templates fabricated to incorporate simulated virtual implant placement is supposed to give the oral and maxillofacial surgeon an efficient, accurate mechanism for preparing osteotomies within a high degree of correlation to the original plan, diminishing surgical time and preserving soft tissues. In this way, it is possible to diminish the possible jeopardizing of critical anatomic structures and improve the esthetic and functional advantages of implant surgery.Unfortunately, everthing does not go that smoothly all the time, especially when the study casts and digital data should travel to another country in another continent. Sometimes when the results are back, you will see that you cannot trust or rely on Dr. James or Dr. Jones.

Does anyone have experience with Med3D implant planning system.

I second Dr Mehdi's views. How do you keep the external irrigation running when the template is obstructing the flow? Especially when some implant systems are only externally cooled? Not all implant system drills are internally irrigated like for e.g. Xive from Friadent Dentsply. That would imply that if the doctor has an external cooling system he would have to start using an internally irrigated system. Though I haven't laid my hand's on those templates I wonder how you can keep your pilot drill centered in a tube which will be very broad designed for a broad drill and you can probaly still get your angulations wrong because your drills long axis may not be parellel to the long axis of the guiding tube ( unless they have a very convincing idea how it can't happen for e.g. you have a separate template for every drill which would be very costly). Even the risk of shaving off the guided tubes from inside and carrying the shavings into bone. Often the ridge isn't as voluminous and promising as it may seem on a CBCT, the basis to make the templates for guided surgery. Remember CT scan images are "COMPUTER GENERATED" where as regular x-ray images are true shadows. To create an illusion of abundent bone takes just the smallest error to creep in, which may be in the way the patient's head is placed while scanning and error of margin inherent in the computing software. We all know from first hand experience that even during non guided surgery if one were to put an implant of even 0.4 mm wider diameter one can end up perforating the buccal cortical plate. Lastly it is a flapless technic, often, so you never ever get to see the ridge first hand and draw conclusion about length and breadth from that. Can any one here tell me whether my fears are imaginery?

The pilot drills are narrower than the subsequent drills, to avoid a wobble there are special drill guides that ensure an accurate fit into the surgical template. Also though the initial cost is high as the inventory is elaborate the end reuslt is good both for the patient and the operator. More number of users will help cut down costs. The degree of accuracy is very high and as rightly pointed out by several users even a small deviation will result in an inaccurate fit. It needs practice to sort out errors and difficulties that may occur at the time of surgery. We have used tooth supported, soft tissue supported as well as the bone supported surgical guides both for partial replacement and for full mouth rehabilitation.

While the guide may be useful, there is too much hype. Firstly, I have been using flapless surgery since 1998 and use it in 1 of every 10 or more implants. The other 9 implants are better placed with a minimal access approach to reposition the keratinised tissue. Flapless surgery is for experience clinicians rather than one needing guides as it is technically more difficult as you lose visual access and tactile feel. Secondly if you use the guide, then use it sparingly. Templates should only serve as guides and you can use it to guide your initial point of insertion and to verify your progress. Drilling directly through the guide throughout will hamper your visual access and irrigation. Thirdly CT images are superior to CBCT images in most instances albeit the higher radiation. Finally while I embrace the use of any technology which helps, do not be over-reliant on it. It should be as the name implies a guide only rather than to depend totally on it.

Good surgical guides are a must. Computer enhanced info can be a great help. I still like to see the amount and quality of bone I am placing implants in. If long term prognosis proves to be as good as advertised, some of us will begin to look at more immediate placement and restoration, (i.e. teeth in an hour types). I think we are several years away from accurate long term data.

Having been involved with implants for over 26 years, it appeared that we have always been on the cusp of technological breakthroughs which would dramatically change the way we practice. CT and CBCT, and interactive diagnostic, treatment planning software, in my opinion has been the most important and significant innovation since osseointegration. What may be missing from previous comments is the concept that the templates used for guided surgery are only as good as the plan.... therefore, we need to discuss apples and apples. Guided surgery is not an automatic or robotic preparation of an osteotomy. It needs to start out with a precise understanding of the CT/CBCT data, so that potential receptor sites can be assessed, and proper decisions made. Only then will the template be fabricated, if required. The ultimate decision is still made by the clinician, but in a virtual environment, with all of the three-dimensional data on hand. Whether you then wish to use a template is another decision - if the most accurate assessment of the patient's anatomy is understood, at least three dimensional imaging should be part of the planning process. Having been a proponent of this technology for the past 20 years, I have heard every possible argument for not using CT/CBCT. The ability to accurately assess existing bone anatomy, vital structures, and bone defects with CT/CBCT imaging and interactive treatment planning software far exceeds what even the most experienced clinician can determine with two dimensional imaging, or by exposing the bone and making decisions at the time of surgery. I believe that there is a great need for clinicians to be educated on the benefits and risks of this technology if Millennium Research report's predictions will be realized.

I have used computer aided guides for implant placement a few times. It is convenient and quick. Even though the systems tout flapless surgery, I have always had the guide fashioned so that it rests on bone. I feel much more comfortable viewing the width of the available bone during the preparation process. Between all the variables involved in this process there is no substitute for two good eyes. i will continue to emply CT scans and computer manufactured guides in my practice because the information gained is worthwhile and helpful. The "teeth in an hour" thing with porcelain and metal restorations is too much for me.

Using the excuse that utilizing any and all proper tools for treatment and evaluation is too expensive won't stand up to the argument that their patients complain about the high cost of implants. This is what they are paying for, and Doctors that know how to use these tools.

I have used computer aided guides during my residency as it was a must for first 10 cases. Then I started to use less as years went by. Thus I think the report by Millennium needs a little clarification. I see that a lot of dentists that are new in implants would use it, then as they think about the cost/time/necessity/type of case/etc. etc.... usage will drop again. I think it comes down to personal preference.

When performing flapless surgery with help of computer generated guides there are some caveats to consider: 1. the (in)accuracy of the CT scan. 2. the "bone" on the CT view is computer generated. 3. the soft tissue resilience on which the guides rest. So, apart from the cooling problem I think flapless surgery, even with help of computerguides, is not recommended. Especially in knife edge cases and for the beginning implantologist. Who has not found a knife edeg ridge with lots of osseofibrous tissues on the labial side, making it appear a very broad alveolar ridge? Yes, a CT would reveal this. But considering the above caveats would you trust on the guides to put an implant in these cases without "direct visual control"? It is this what concerns me mostly: Some producers of computerguides promote these as being simple and safe. They make it appear as if implantology can be done by monkeys when using there "protocol". I therefore fully agree with some of the earlier comments. Computer generated guides are "helpfull" but not to be used by inexperienced implantologists as a "safetyline".

Marvick, you brought up good points! I believe that the patients will be best served, if we all could deliver a multimodal treatment.

I fully endorse view of Dr.Willium Chong.Technology cannot and will never replace experience,skill and knowledge.With advent of computer guided implantology one shall not start thinking that there is no need for conventional technics.The Guide shall be only a Guide and not the final and The Guide for surgical excellence.Flapless surgery is The thing in implantology but it requires lot of experience with open flap surgery.One must prepare one self fully before attempting flapless surgery and use guides only as an aid and not to rely fully on it.

Dear Dr. SDJ and Dr. Mehdi, I'm sorry you haven't looked far enough into CTscan technology to find what those of us who are using it are enjoying. I use I-Dent 3D software and therefore have the advantage of I-Guides which answer several of your concerns. First of all, the basic sleeve which is embedded in the surgical guide is harder than the drill surfaces which does not allow 'shavings' to spiral into the osteotomy site. Second, my Monte Blanc handpiece allows both internal and external water cooling. The I-Dent system provides you with a small drill sleeve which fits inside of the broader embedded sleeve of the surgical guide which then allows me to use a 1.1mm pilot drill to start. Using a pumping action allows plenty of water coolant to spriral into the osteotomy site. I then use a 2.0 drill (on up to 3.5, 4.3 or 5.1mm) with an internal irrigating center hole to keep the bone cool. Further, the CTscan views, both axial and sagittal can be studied easily to determine the flaws in the bone surrounding the virtual implant which allows the planner to avoid undesirable bone. And I mean completely see the voids and weak areas. Lately I have had 2 noteable oral surgeons tell me they don't pay much attention to H.U.'s or Hounsfied Units which is a bone density measurement. A very popular periodontist told me a year ago that he had never even heard of H.U.'s and it plain to see that his good looks and great personality were the main source of referrals and patient acceptance. All 3D softwares allow very simple assessment of bone density, landmarks and other negatives. I don't know how anyone but Superman with x-ray vision can say they merely need to reflect the mucoperiosteal flap to 'see' and quantify' boney defects or hounsfield units beyond the outer surface of the cortical plate. Narrow ridges that come to a peak at the crest are the biggest problems when not reflecting a flap. This is why I always refer to specialists (who use CTscan technology) when I discover weak bone, sharp peaked ridges, maxillas needing sinus lifts and other problems which should be in the hands of oral surgeons and periodontists. knowing when to refer is probably the pinnacle of any General Dentist's career. I fully respect all of our specialist in dentistry but am partial to those who use CBCT and 3D software. I feel my patients are much safer. mgs