A guide to guided surgery – David Veige

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  Posted by: probe-admin      14th August 2019

As products, techniques and technologies evolve, some of the barriers once preventing dental practitioners from offering guided dental implant surgery are falling away. Perhaps most significantly, the expense involved with this technique has reduced greatly in recent years – what once would have cost the practice and consequently the patient £600, is now available for as little as £20. While a substantial investment of time is still required from clinicians, those who want to take their dental implantology skills to new standards have more opportunity to do so with guided surgery today.

Maximising opportunities

There are several benefits afforded by the technique. Firstly, everything is planned before surgery commences, so the procedure is much quicker. The clinician is effectively able to perform surgery on the computer before commencing treatment on the patient, for improved predictability. By saving time, treatment becomes more comfortable for the patient and more profitable for the practice.

It can also be less invasive when employing a flapless approach, as well as being more precise than conventional dental implant placement. All the planning is derived from where the final tooth needs to be, so the correct position of the dental implant is identified and the lab has sufficient information to deliver an effective and predictable restoration.

Avoiding common pitfalls

For the best results, it’s important for practitioners to understand the digital workflow and scanning protocols involved. We need to obtain certain information for safe case selection and accurate planning. The patient therefore needs to be assessed in an appropriate manner to determine whether a dental implant is suitable. This involves the use of different imaging protocols and it’s important to use the right ones for the right reasons.

For example, when assessing patients with multiple metal filled restorations or metal crowns in their mouths, CBCT scans will produce a lot of scatter due to beam hardening creating artefacts and making it very difficult to accurately stitch the CBCT scan and the STL surface. The precise overlaying of STL surface with the CBCT scan is crucial for the design and fabrication of the surgical guide – get it wrong and the guide may well still fit in the mouth perfectly, but the implant will be in completely the wrong place.

It’s also crucial to take care with case selection. Guided surgery is not suitable for every patient and there are many variables to consider. These include the number of teeth requiring replacement and the existing bone volume. Limited access when patients have a reduced mouth opening can also make it difficult to get the guide and burs into position for precise dental implant placement. In addition, the type of bone should be considered. Dense bone can deflect the bur and cause the drill to move out of position when preparing the osteotomy. By verifying each drill position with your plan as you go, you can ensure that you are drilling in exactly the right locations. A common misconception about guided surgery is that it takes the difficulty out of dental implant treatment, but the reality is that the guide only aids brain-driven implant surgery.

To avoid these and any other mistakes, thorough planning is key. It’s also important for clinicians to gain practical experience in the field before attempting guided surgery.

Training and experience

Guided surgery is not something you can jump straight into. You need adequate analogue skills first and then it’s necessary to start with simple cases and work your way up. How quickly you progress will depend on your past dental implant experience. Regardless of where you start, I would always strongly recommend specific training for guided surgery before doing it in practice. There are various comprehensive training programmes available, such as those run by BlueSkyPlan, that can help you build up the foundation of knowledge you need.

More advanced topics include utilisation of the guided surgery technique for immediately loaded dental implants. This involves various different guides depending on treatment objectives. I would typically use a pin location guide to place pins as reference points; followed by a bone reduction guide to set the plane for the desired bone level; and finally a drilling sequence guide through which to place the dental implants. When done correctly, these guides encourage ideal positions for the dental implants and restorations, ensuring a predictable outcome.

Reach new standards

Guided surgery definitely provides better results than conventional dental implant techniques, particularly in terms of predictability and accuracy. There are various cases in which I could say with complete confidence that I wouldn’t have been able to complete them to the same standard using a conventional approach. For example, when placing multiple implants to replace lower free end saddle. The ideal prosthetic envelope can be designed digitally and then the implants planned with all the screw access holes within the prosthetic envelope. Using analogue methods it can very difficult to visualise the future prosthetic envelope after the surgical flap is elevated and the natural anatomical landmarks are displaced. 

This is one of many interesting topics covered by the ADI Study Clubs this year. To enhance your knowledge and skills with industry-leading professionals, discover the ADI Study Clubs and many other membership benefits with the ADI by joining today.

 

For information on upcoming ADI Study Clubs, or to book, please visit www.adi.org.uk/studyclubs

ADI Study Clubs are free to members. Join online today.

The views expressed in this article are those of the author, and not necessarily those of the ADI.

 

Author bio:

David Veige

Originally from Toronto Ontario, Canada, David qualified firstly as a dental technician from George Brown College and then as a dentist from the University of Newcastle with a distinction in academic dentistry and the top restorative dentistry prize. He was shortlisted for the Young Dentist of the Year UK at The Dentistry Awards in 2009 and has been awarded membership to the Royal College of Surgeons Joint Dental Faculty by way of examination.

He graduated with merit from the University of Warwick with a MSc. degree in Implant Dentistry. He is currently studying a MClinDent at King’s College, London in fixed and removable prosthodontics. He is a member of the ITI (International Team for Implantology) and ADI an organisation focused on advancing the science of implant dentistry. David’s practice is limited to implant and advanced restorative dentistry.

David lectures both nationally and internationally on the digital and laboratory aspects of implant dentistry. He is the director of Smile Designs Dental Laboratory, Harrogate, a private boutique laboratory focused on high quality crown, bridge and implant restorations.


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