Journal of Oral Implantology Real vs. virtual position of single implants installed in pre-maxilla via guided surgery: A proof of concept analyzing positional deviations --Manuscript Draft-Manuscript Number:
aaid-joi-D-17-00288R2
Full Title:
Real vs. virtual position of single implants installed in pre-maxilla via guided surgery: A proof of concept analyzing positional deviations
Short Title:
Real vs. virtual position of implants: guided surgery
Article Type:
Research Letter
Keywords:
computer-assisted surgery, flapless surgery, dental implants, cone beam computed tomography, stereolithography
Corresponding Author:
Fernanda Faot, PhD Federal University of Pelotas, School of Dentistry Pelotas, Rio Grande do Sul BRAZIL
Corresponding Author Secondary Information: Corresponding Author's Institution:
Federal University of Pelotas, School of Dentistry
Corresponding Author's Secondary Institution: First Author:
Flávia Noemy Gasparini Kiatake Fontão, PhD
First Author Secondary Information: Order of Authors:
Flávia Noemy Gasparini Kiatake Fontão, PhD Jacques Luiz, MsC Rubens Moreno Freitas, PhD Luiz Eduardo Marques Padovan, PhD Geninho Thomé, PhD Fernanda Faot, PhD
Order of Authors Secondary Information: Abstract:
The aim of this research letter was to report the results of a pilot study designed to compare the real and virtual position of implants placed using computer-guided flapless implant surgery for single restorations in the pre-maxilla. A total of 8 patients (2 men and 6 women) with a mean age of 40 years (32-73 years) had a total of 11 implants inserted using a tooth-supported stereolithographic guide. After implant placement, the positions (coronal, central, and apical) and angulation of the implants installed in relation to those planned were determined via the superposition of pre- and postoperative 3D models using Dental Slice software (Bioparts, Brasília, Brazil). The mean angular deviation was 2.54 ± 0.71°. The deviations found for the coronal, central, and apical positions were 1.3 ± 0.77 mm, 1.49 ± 0.58 mm, and 2.13 ± 1.32 mm, respectively.
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Real vs. virtual position of single implants installed in pre-maxilla via guided surgery: A proof of concept analyzing positional deviations Short title: Real vs. virtual position of implants: guided surgery Flávia Noemy Gasparini Kiatake Fontão a, DDS, MSc, PhD a, Jaques Luiz, DDS, MSc b, Rubens Moreno de Freitas, DDS, PhD a, Luis Eduardo Marques Padovan, DDS, MSc, PhD a, Geninho Thomé, DDS, MSc, PhD a, Fernanda Faot, DDS, MSc, PhD c
a Professor, Latin American Institute of Dental Research and Education – ILAPEO, Department of Post-Graduation, Curitiba, Paraná, Brazil. b Private practice, Curitiba, Paraná, Brazil. c Professor, Federal University of Pelotas, School of Dentistry, Department of Restorative Dentistry, Pelotas, Rio Grande do Sul, Brazil.
Acknowledgments Special thanks to the employees of ILAPEO (Latin American Institute of Dental Research and Education) that were involved in this study and definitely played an important role on the final results. Some of the material used in the study protocol, was supported by Neodent, Curitiba/PR, Brazil, that kindly donated the implants, prosthetic components and surgical guide.
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Conflict of interest statement
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Dr. G. Thomé claims to have conflict of interest, once, he is the president of Neodent`s
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Scientific and Administrative Council (Neodent, Curitiba/PR, Brazil). All other authors claim
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to have no financial interest in any company or any of the products mentioned in this
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manuscript.
6 7
Corresponding Author
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Prof. Fernanda Faot, PhD, Associate Professor, School of Dentistry, Federal University of
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Pelotas. Address: Gonçalves Chaves Street 457; 96015-560; Pelotas, RS, Brazil; e-mail:
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[email protected]
11 12
Real vs. virtual position of single implants installed in pre-maxilla via guided surgery: A
13
proof of concept analyzing positional deviations
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Short title: Real vs. virtual position of single implants: guided surgery
15 16
Keywords: computer-assisted surgery, flapless surgery, dental implants, cone beam computed
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tomography, stereolithography
18 19
ABSTRACT
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The aim of this research letter was to report the results of a pilot study designed to compare the
21
real and virtual position of implants placed using computer-guided flapless implant surgery for
22
single restorations in the pre-maxilla. A total of 8 patients (2 men and 6 women) with a mean
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age of 40 years old (32-73 years) had a total of 11 implants inserted using a tooth-supported
24
stereolithographic guide. After implant placement, the positions (coronal, central, and apical)
25
and angulation of the implants installed in relation to those planned were determined via the
26
superposition of pre- and postoperative 3D models using Dental Slice software (Bioparts,
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Brasília, Brazil). The mean angular deviation of 2.54 ± 0.71°. The deviations found for the
28
coronal, central, and apical positions were 1.3 ± 0.77 mm, 1.49 ± 0.58 mm, and 2.13 ± 1.32
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mm, respectively.
30 31 32 33 34
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1. INTRODUCTION
36 37
Computer-guided flapless implant surgery, a surgical method prosthetically guided via
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computerized planning, is performed using a prototype surgical guide and represents one of the
39
great advances in implantology
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flapless implants has become increasingly popular because it is faster, is less invasive, and has
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enabled the restoration in more challenging cases
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absence of flaps increases the postoperative peri-implant vascularization12 and promotes the
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reduction of gingival inflammation, the height of the junctional epithelium, and bone loss
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around the implant
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rehabilitation success rates, as this non-invasive technique is directly associated with precise
46
and predictable aesthetic and functional planning.
13
1-10.
Compared with conventional surgery, the placement of
2,11
. From a biological point of view, the
. The adoption of this surgical approach is thought to increase the oral
47
However, flapless guided surgery also has also limitations. First, the surgeon works in a
48
closed field, and the incorrect angulation of the implant can lead to complications. Second,
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multiple steps are required, including preoperative computed tomography (CT) examination
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(double scanning), the preparation of the CT guide, surgical-prosthetic planning using software
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(computer-assisted implant planning), and the manufacturing and use of a prosthetic surgical
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guide. These complex presurgical procedures, the possibility of errors is high and might result
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in deviations between the planned and placed implant 3,5,14-16.
54
Several studies have aimed to improve the precision of computer-guided flapless implant
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surgeries, mainly focusing on the discrepancies during the transference of virtual planning by
56
superimposing 3D pre- and postoperative CAD models. In vitro studies with dry or epoxy resin
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mandibles5,17 revealed mean angular deviations between 1.54° and 4.5°, and controlled clinical
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studies reported mean angle deviations between 1.72° and 7.9° 1,3,4,7-10,14-16,18.
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However, few clinical studies have evaluated single restorations in aesthetic areas using
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computer-guided flapless implant surgery. Furthermore, the clinical studies conducted using
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tooth-supported guides did not calculate the angular deviations in the maxilla and mandible
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separately to precisely evaluate the predictability of guided surgical systems for implant
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placement. The hypothesis tested is that the virtually planned position and the guided surgical
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implant installation do not present clinically relevant deviations. Therefore, this pilot study
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aims to compare the real and virtual positions of implants inserted via computer-guided flapless
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implant surgery in the premaxilla using tooth-supported stereolithographic guides in patients
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with implant-supported single prostheses.
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2. MATERIALS AND METHODS
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The Research Ethics Committee approved this prospective clinical study under protocol
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no. 0001273 (PUC-PR, Curitiba, Paraná, Brazil). The study was conducted in accordance to
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the Declaration of Helsinki (1964). Eight patients from the Dental Implant Clinic of the Latin
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American Institute of Research and Dental Education (ILAPEO, Curitiba, Paraná, Brazil) who
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had lost at least one tooth in the premaxilla were selected. The inclusion criteria used to select
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patients were the availability of bone tissue with a sufficient height and thickness to install
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implants of at least 3.5 mm in width by 10 mm in length; the presence of edentulism in the
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premaxilla of the upper jaw; the presence of teeth adjacent to the prosthetic space, with or
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without fixed prosthesis; and the absence of systemic problems and local inflammatory,
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degenerative, or infectious lesions as assessed by medical history, clinical examination, and
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laboratory tests. The exclusion criteria were systemic involvement; local inflammatory,
80
degenerative, or infectious lesions; and insufficient amount of bone for implant placement. All
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patients enrolled in the study signed a free and informed consent document. Impressions of the
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maxillary and mandibular arches were acquired using condensation silicone (Speedex,
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Vigodent, , Rio de Janeiro, Brazil) and used to prepare a CT guide in colorless self-curing
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acrylic resin (VIP Flash, Pirassununga, São Paulo, Brazil). In the vestibular flange of the CT
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guide, five random perforations were performed with a No. 4 round drill and filled with gutta-
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percha (Figures 1A and B).
87
2.1 Preoperative CT scan (double scanning) and virtual planning
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All patients underwent the double scanning technique 19. First, a CT was performed using
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a CT guide in occlusion (Figures 2A and B); next, a scan of only the CT guide was performed.
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This technique enables the segmentation and combination of the patient images with those of
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the CT guide and the visualization of the positioned CT guide in relation to the bone structure
92
of the patient. The CT scans were performed using a standardized protocol: The patient head
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was positioned along the occlusal plane, parallel to the ground, and in the median sagittal plane,
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perpendicular to the ground, using cone-beam CT (CBCT; I-Cat, Imaging Sciences, Hatfield,
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USA). The acquisition factors for the CT scans were constant: 5 mA, 120 kV, a voxel size of
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250 µm, and an exposure time of 26 s. The CBCT images contained in the DICOM files were
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converted and input into Dental Slice (Bioparts, Brasília, Brazil), where the virtual surgical and
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prosthetic planning was performed (Figure 3). Based on the information concerning bone
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height and thickness, the implant positions and the prosthetic abutments dimensions (i.e.,
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diameter, length, number, and height of the transmucosal portion of the abutments) were
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selected (Table 1). Subsequently, the stereolithographic guide (SG) was generated based on the
102
planning information.
103
2.2 Flapless implant surgery and prosthesis installation
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A tooth-supported stereolithographic guide was tested in position on the patient before
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surgery to assess the stability of the guide and the need for adjustment to prevent an undesired
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position (Figure 4). The patients underwent local terminal infiltrative anesthesia with 2%
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mepivacaine hydrochloride and epinephrine at a dilution of 1:100,000. The stereolithographic
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guide was fixed using 10 fastening pins, and the implants were inserted using a guide surgery
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method (Neoguide, Neodent, Curitiba, Paraná, Brazil), which involves the use of surgical
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instruments with a progressive sequence of drill diameters. Implants with a Morse taper
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platform (Neodent, Curitiba, Paraná, Brazil) were used for all of the patients, and the diameter
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and length varied according to bone quality and availability. During the irrigation of the
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implants, the rotor rotation remained at 30 rpm, and the irrigation was complemented with
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syringes. After implant installation, the prosthetic components were installed, and the
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provisional crowns was performed.
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117
2.3 Post-operative CBCT and image overlap analysis
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After the completion of the postoperative CBCT approximately 7 days after surgery,
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the DICOM files were used to overlap the images of the planned and installed implants using
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DentalSlice (Bioparts Prototipagem Biomedica) based on the anatomical anomalies and
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markings of the CT guide following the methodology proposed by Soares et al. (2012) [20]
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(Figure 5). The postoperative CBCT examinations were performed using the same parameters
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used to acquire the preoperative CBCT to compare the positions between the installed and
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planned implants. The outcomes variables were analyzed using the 3D CAD model used to
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plan the position of the implants superimposed and aligned with the postoperative model, and
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the following references were subsequently captured on the long axis of each planned and
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placed implant: one point at the apical end of the implant (D1); one point at the central region
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of the implant (D2); one point at the coronal limit of the implant (D3); and one direction vector
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along the long axis of the implant. D1, D2, and D3 were determined by calculating the linear
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distances between the apical, central, and coronal reference points of the implants in relation
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to the positions of the installed and planned implants, respectively. The angular deviation was
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also calculated (A) (Figure 6). A summary of the sequence applied in the methodology is
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described in the Figure 7.
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3. RESULTS
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The study sample included 8 patients (6 women and 2 men) with a mean age of 40 years
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(32-73 years). Four implants were installed in the central incisor region, 2 implants were placed
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in the lateral incisor region, and 5 implants were placed in the premolar region. The summary
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of the data related to surgical and prosthetic phases are listed in the Table 1. The linear and
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angular values for the 11 implants, as well as the mean and standard deviations (SDs), are
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presented in Table 2. Deviations were observed for all measured distances. The highest linear
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distance recorded was 4.72 mm in the apical region, and the lowest value recorded was 0.13
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mm in the central region. The maximum angular deviation measurement was 3.1°, and the
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minimum deviation was 0.5°. The evaluation of the anterior and posterior segments (Figure 8)
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indicated that the mean linear values tended to be higher in the anterior region, whereas the
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mean angular values were similar between the segments.
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4. DISCUSSION
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This study evaluated the transference of virtual planning using overlapping pre- and
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postoperative 3D CAD models as described by previous studies applying similar
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methodologies
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guided surgical implant installation do not present clinically relevant deviations was accepted.
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The use of computer-guided flapless implant surgery with tooth-supported stereolithographic
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guides among 8 patients over a total of 11 implants placed in the anterior and posterior regions
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of the maxilla showed similar results to those of previous studies. The mean angular deviation
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was 2.54±0.71°, which varied between 0.50° and 3.10°. The mean coronal distance was
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1.37±0.77 mm, whereas the mean apical distance was 2.13±1.32 mm (Table 2 and Figure 8).
1-5,7,8,10,11,14,17,20
. The hypothesis that the virtually planned position and the
156
Ersoy et al. (2008)3 evaluated patients who used a tooth-supported guide (7 patients
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and 9 implants) and found a mean angular deviation of 3.71±0.93°, which was significantly
158
higher than the results presented in this pilot study (2.54±0.71°). Ozan et al. (2009)3 found a
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mean angular deviation of 2.91 ± 1.3° in a sample of 30 implants for single restorations in the
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mandible and maxilla; their mean was similar to that of the present study. The deviations in the
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coronal (0.87 ± 0.4 mm) and apical (0.95 ± 0.6 mm) distances were also similar. Arisan et al.
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(2010)15 compared two guided surgery systems using 10 tooth-supported guides and found
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mean angular deviations of 3.5 ± 1.38° and 3.39 ± 0.84° for systems I and II, respectively. The
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angular deviations found in these cited studies were larger than those found in the present study.
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This difference might have occurred, in part, because the techniques used in previous studies
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were partially guided, and the implants were manually inserted, thereby resulting in greater
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inaccuracy. In contrast, the current surgery was guided from beginning to end. Similarly, the
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mean angular deviations found by Di Giacomo et al. (2005)1 and Valente et al. (2009)14 of 7.25
169
± 2.67° and 7.9 ± 4.7°, respectively, were considered as high compared with those obtained in
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the present study (2.54 ± 0.71°). This difference might have occurred because the surgical
171
technique was partially guided and the surgical guides were changed during the surgery
172
depending on the drill diameter used in the instrumentation. The present study used a single
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surgical guide from beginning to end, and the surgery was fully guided. Only the drill guide
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coupled to the surgical guide was changed, keeping the surgical guide fixed in place; this
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procedure generated greater precision in implant positioning. In contrast, Van Assche et al.
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(2010)7 conducted a clinical study and observed that the mean angular deviations of the planned
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and placed implants were lower (2.2 ± 1.1°) than those obtained in the present study (2.54 ±
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0.71°). Unlike the present study, those authors scanned all tomographic guides using spiral CT
179
and used an additional fixation procedure with intraosseous screws in the tooth-supported
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surgical guide during surgery.
181
Other in vitro studies5,7 and clinical studies 1,3,4,7,8,11,14,18 employed this methodology
182
to evaluate the transference of virtual planning by superimposing pre- and postoperative 3D
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CAD models. Sarment et al. (2003)17 compared the virtual position with the actual position of
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five implants placed in dry jaws using a prototyped guide and found mean deviations of 1.5
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mm and 2.1 mm in the cervical and apical regions, respectively. Viegas et al. (2010)5 conducted
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an in vitro study to evaluate the variations in the transference of the virtual planning of 22
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implants in 11 identical replicas of the human jaw and found a mean angular deviation of 1.45°.
188
However, Soares et al. (2012)20 observed a mean angular deviation of 2.16° when studying 18
189
implants inserted into polyurethane jaws. However, any comparison between a clinical study
190
and an in vitro study should be made with caution because various parameters (in addition to
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the technique itself) must be controlled in studies involving patients such as mouth opening,
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saliva, blood, guide adjustment, procedure speed, etc. Controlling the surgical procedure is
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simpler when using dry or epoxy resin mandibles and stable surgical guides.
194 195
The final result of accurate implant positioning using the flapless surgical technique depends on various factors
10,15,16,21
. The first factor concerns patient indications. Patients
196
should be selected primarily based on bone availability and mouth opening. In guided surgery,
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the height of the surgical guide requires the use of long drills. Valente et al. (2009)14 observed
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that the final drill had to be used without the guide, resulting in significant deviations in the
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final positioning of the implants for patients whose mouth opening did not allow for the use of
200
long drills. Hahn (2000)22 indicated the appropriate clinical conditions for patient selection
201
regarding single restorations using flapless implant surgery: a sufficient bone height and
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thickness to allow the placement of an implant 3.8 mm in diameter by 12-16 mm in length;
203
keratinized mucosa with a thickness of least 3 mm; the presence of one adjacent tooth that can
204
withstand masticatory loads in occlusion; and the ability to stabilize the implant during
205
installation. In addition, monitoring the bone density during drilling is essential to avoid apical
206
deviations between the position of the planned and placed implants
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the maxilla can influence the trajectory of the implant and cause higher apical deviations in the
208
maxilla than the mandible 16.
4,14
. Low bone density of
209
The proper preparation of the CT guide is of fundamental importance to the success of
210
flapless implant surgery. After the scanning process, the image segmentation, and the software
211
integration, the CT images guide the planning of the positions of the implant and prosthesis. In
212
addition, the surgical guide is generated based on 3D images of the CT guide. Depending on
213
the region to be implanted (full edentulous arch, partial edentulous arch, partial tooth loss, or
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single restorations), the CT guide should meet certain criteria. Given that the present study
215
involved single restorations, a tooth-supported CT guide constructed of colorless acrylic resin
216
was used to evaluate its adjustment to the occlusal/incisal surface of the teeth.
217
When working with tooth-supported stereolithographic guides, a few adjustments are
218
often necessary for occlusal adaptation. These adjustments are necessary because of the
219
difficulty in reproducing the occlusal anatomical details via the CT apparatus in the presence
220
of artifacts (e.g., hard beam). In an attempt to overcome this deficiency, some researchers have
221
performed 3D laser scanning directly on the teeth or a plaster model to merge this image with
222
the CT image. This method results in a detailed image of the occlusal surface of the teeth and
223
a more suitable tooth-supported guide 8. Another factor that should be considered is the
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deviation during the preparation of the stereolithographic surgical guide (approximately 0.1 to
225
0.2 mm), which is related to the accuracy of the stereolithography system, the physical
226
properties of the material used, and the placement method of the washers in the guide 15.
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CT quality can also influence image segmentation and the consequent adaptation of the
228
surgical guide. The deviations in image acquisition and data processing can reach 0.5 mm [23].
229
Previous clinical trials of guided surgery involving a prototyped surgical guide used spiral CT
230
scans to achieve dual scanning (a CT of the patient using the CT guide and one of the CT guide
231
alone 3,4,14. With the advent of CBCT, however, many researchers have used CBCT images for
232
guided surgery
233
including the reduced radiation dose, the speed and ease of performance, the lower cost, the
234
capacity to accurately reproduce maxillofacial anatomical structures 24-26 and adequate image
235
quality to enable image segmentation and stereolithography
236
performed dual scanning (i.e., CBCT of the patient with the tooth-supported guide and CBCT
237
of the guide alone), whereas Van Assche et al. (2010)7 exclusively used CBCT to acquire
238
patient images using the guide. Because the surgical guide is generated based on the segmented
239
image of a 3D volume and the difficulty in segmenting the guide images generated by the
240
CBCT device, these authors chose to scan all CT guides using spiral CT to achieve greater
241
accuracy. Based on the results of studies concerning the transference of virtual planning, these
242
authors concluded that the deviations in the implants relative to their expected positions were
243
acceptable (mean angular deviation = 2.2°; horizontal deviation = 0.6 mm; apical deviation =
244
0.9 mm). These authors obtained similar results using CBCT and spiral CT scans; therefore,
245
they argued that CBCT could be efficiently used to prepare a stereolithographic surgical guide.
10,15,16
. The CBCT was adopted in this study because of its advantages,
7,25
. In addition, this pilot study
246
The deviations observed in the guided surgery systems can also be related to the surgical
247
ability of the clinician and can include errors in the positioning and fixation of the surgical
248
guide, the movement of the guide during drilling, and the definition of the drill stop in the
249
wrong position 14. Professionals with extensive experience in conventional implant placement
250
techniques should perform guided surgeries. Extensive knowledge about the anatomy of the
251
maxillo-mandibular complex as well as a strong ability and great sensitivity during
252
instrumentation are required to guarantee high predictability for this surgical technique. When
253
a guided surgery is performed using drills that pass through the interior of the metal washers,
254
manual sensitivity can become impaired, often producing the sensation that the bone is denser
255
than in reality. In addition, the surgeon should account for the degree of tolerance between the
256
drill and the washer, which varies between 0.15 and 0.20 mm 14. Finally, comparative studies
257
on the accuracy of implant placement using different types of surgical guides have found that
258
tooth-supported guides show less deviation than mucosa-supported and bone-supported guides.
259
Mucosa-supported guides allow micro movements because of their mucosal flexibility,
260
whereas tooth-supported guides are more stable4,10,15,21,27.
261
The present study did not find complications, such as trepanation of the nasal cavity,
262
fenestration of the bone wall, or fracture of the surgical guide, during surgery. Van Assche et
263
al. (2010)7 performed a clinical study of eight patients who underwent flapless guided surgery
264
using tooth-supported stereolithographic guides for the insertion of 21 implants and observed
265
that fracture occurred in one surgical guide that had to be modified. In that case, the analysis
266
of the planned and placed implants indicated a considerable angular deviation between 6.2°
267
and 8.3°. Those researchers argued that the production of a CT guide with a minimum thickness
268
ranging from 2.5 mm to 3.0 mm is essential to prevent fractures. Tooth-supported guides used
269
for single restorations tend to have increased stability compared with traditional surgical guides
270
prepared in case of multiple teeth absence. Therefore, the former might present lower
271
probabilities of fracture and micro-movements 16.
272
Different technologies have been used to improve the accuracy and to facilitate the
273
guided surgery treatment planning 28,29. A common way to prepare a case for a guided surgery
274
technique it is by scanning either the impression cast of patient jaws or performing an intra-
275
oral scanning. In the first case, an impression of the edentulous area and its antagonist is
276
performed, a cast is produced, and the desired tooth is waxed; with a digital surface scanner
277
(laboratory), both casts (work area and antagonist arch) are scanned, with the waxed tooth in
278
and out of position. This scanned images (STL file), together with the patient CBCT, will be
279
used to do the virtual planning using a software. An alternative would be using the intraoral
280
scanner directly in the patient mouth, avoiding the necessity of doing the impression30. The
281
present pilot study was conducted in a different way, using the “double scanning” technique,
282
which is well support in the literature as a viable and predictable technique20,31. The most
283
notable difference, it that the double scanning technique do not need any type of scanner, what
284
may facilitate and spreads its use for any situation, once the CBCT is a pre-requisite for both
285
“double scanning” or using the scanner techniques. CBCT is a technology more accessible for
286
most dentists, once the scanners, either the laboratory or intra-oral, are expensive technologies
287
and not always available, therefore, may reduce the indication of the guided surgery technique
288
for part of the dentists worldwide.
289
Despite the limitations of this pilot study associated with the small sample size that
290
reduce the external validity of the results, based on this proof of concept study, single crown
291
computer-guided flapless implant surgery presented angular and positional inclinations
292
comparable to those reported in the literature, and then, may be indicated as a safe and
293
predictable treatment plan. However, the advantages offered by guided surgery for single
294
restorations (particularly in aesthetic regions), the computerized planning and prototyped
295
surgical guides method can result in additional treatment costs, what can be justified as a benefit
296
of more accurate planning, especially with regard to complex rehabilitation cases with multiple
297
implants in different bone regions 17.
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16. Behneke A, Burwinkel M, Behneke N. Factors influencing transfer accuracyof cone beam CT-derived templatebasedimplant placement. Clin Oral Implants Res. 2012; 23: 41623 17. Sarment DP, Sukovic P, Clinthorne N. Accuracy of implant placement with a stereolithographic surgical guide. Int J Oral Maxillofac Implants. 2003; 18:571-7 18. Vieira DM, Sotto-Maior BS, Barros CA, Reis ES, Francischone CE. Clinical accuracy of flapless computer-guided surgery for implant placement in edentulous arches. Int J Oral Maxillofac Implants. 2013; 28:1347-51 19. Verstreken K, Van Cleynenbreugel J, Marchal G, Naert I, Suetens P, van Steenberghe D. Int J Oral Maxillofac Implants. 1996; 11:806-10 20. Soares MM, Harari ND, Cardoso ES, Manso MC, Conz MB, Vidigal GM Jr. An in vitro model to evaluate the accuracy of guided surgery systems. Int J Oral Maxillofac Implants. 2012; 27:824-31. 21. Tahmaseb A, Wismeijer D, Coucke W, Derksen W. Computer technology applications in surgical implant dentistry: a systematic review. Int J Oral Maxillofac Implants. 2014; 29: 25-42 22. Hahn J. Single-stage, immediate loading, and flapless surgery. J Oral Implantol. 2000; 26:193-8 23. Reddy MS, Mayfield-Donahoo T, Vanderven FJ, Jeffcoat MK. Acomparison of the diagnostic advantages of panoramic radiographyand computed tomography scanning for placementof root-form dental implants. Clin Oral Implants Res. 1994; 5:229–38 24. Hashimoto K, Kawashima S, Araki M, Iwai K, Sawada K, Akiyama Y. Comparison of image performance between cone beam computed tomography for dental use and four-row multidetector helical CT. J Oral Sci. 2006; 48:27-34
25. Loubele M, Guerrero ME, Jacobs R, Suetens P, Van Steenberghe D. A comparison of jaw dimensional and quality assessments of bone characteristics with cone beam CT, spiral tomography, and multi-slice spiral CT. Int J Oral Maxillofac Implants. 2007; 22:446-54 26. Suomalainen A, Vehmas T, Kortesniemi M, Robinson S, Peltola J. Accuracy of linear measurements using dental cone beam and conventional multislice computed tomography. Dentomaxillofac Radiol. 2008; 37:10-7 27. Turbush SK, Turkyilmaz I. Accuracy of three different types of stereolithographic surgical guide in implant placement: an in vitro study. J Prosthet Dent. 2012; 108: 181-8 28. Pozzi A, Polizzi G, Moy PK. Guided surgery with tooth-supported templates for single missing teeth: A critical review. Eur J Oral Implantol. 2016; 9 (Suppl 1): S135-53 29. Vercruyssen M, Fortin T, Widmann G, Jacobs R, Quirynen M. Different techniques of static/dynamic guided implant surgery: modalities and indications. Periodontol 2000. 2014; 66: 214-227 30. Oh J, An X, Jeong S, Choi B. Digital workflow for computer-guided implant surgery in edentulous patients: a case report. J Oral Maxillofac Surg. 2017; 75 (12): 2541-49 31. Motta M, Monsano R, Velloso GR, de Oliveira Silva JC, Luvizuto ER, Margonar R, Queiroz TP. Guided Surgery in Esthetic Region. J Craniofac Surg. 2016; 27:262-5.
Table 1. Planning the bone beds of eight implants, including the diameter, length, amount, and transmucosal height of the prosthetic abutments
Case 1 2 3
4
5
6 7 8
Region
Bone type
Bone height
Bone thickness
Cortical thickness
#5
III
15.46
5.85
0.98
Titamax CM EX
3.75/13
#5
III
19.48
4.15
0.54
Titamax CM EX
3.5/15
#9
II
13.24
4.47
1.19
Titamax CM EX
3.75/11
#12
III
11.00
4.06
0.92
Titamax CM EX
3.5/9
#10
II
17.03
4.20
1.46
Titamax CM EX
3.5/15
#5
III
16.98
4.02
0.66
Drive CM
4.3/13
#10
III
17.49
5.11
0.59
Titamax CM EX
3.5/15
#12
III
14.52
5.27
0.71
Drive CM
4.3/11.5
#9
II
19.31
4.62
1.01
Titamax CM EX
3.75/15
#9
II
15.22
4.21
1.93
Titamax CM EX
3.5/13
#9
II
17.13
4.58
0.95
Implant type
Titamax CM EX
Diameter / length (mm)
3.5/17
Prosthetic Abutments Universal angled abutment (30°) 3.3 x 6.0 x 1.5 cm Universal angled abutment (30°) 3.3 x 6.0 x 1.5 cm Universal standard abutment 3.3 x 6.0 x 3.5 cm Universal standard abutment 3.3 x 6.0 x 3.5 cm Universal standard abutment 3.3 x 6.0 x 3.5 cm Universal standard abutment 3.3 x 6.0 x 2.5 cm Universal standard abutment 3.0 x 6.0 x 2.5 cm Universal angled abutment (17°) 3.3 x 6.0 x 3.5 cm Anatomical abutment CM 1.5 Anatomical universal abutment CM 2.5 Lateral anatomical abutment CM 1.5
Table 2. Comparison between the planned and placed implants Implant Patient
Implant region
length
Coronal distance
Central distance
Apical distance
(mm)
(mm)
(mm)
(mm)
Angle (degrees)
1
#5
13
1.79
1.51
1.26
3.00
2
#5
15
1.56
1.24
0.93
2.40
3
#9
11
0.88
0.88
0.98
3.00
#12
9
1.81
1.94
4.72
2.10
#10
15
0.62
1.96
3.94
2.90
#5
15
1.29
2.26
3.27
2.40
#10
15
0.90
1.70
2.69
2.90
#12
13
3.27
1.62
1.66
2.90
6
#9
15
1.15
1.16
1.19
0.50
7
#9
13
0.19
0.13
0.43
2.70
8
#9
15
1.56
1.96
2.38
3.10
Mean
1.37
1.49
2.13
2.54
SD
0.77
0.58
1.32
0.71
4
5
Legends to figures Figure 1. A: Frontal view of the CT guide; B: Occlusal view of the CT guide. Figure 2. (A) Trying on the CT guide; (B) CT guide stabilized via molding in condensation silicone for scanning in the occlusion position. Figure 3. Dental Slice software showing the virtual planning. Figure 4. Trying on the tooth-supported surgical guide to evaluate adaptability and stability. Figure 5. The alignment of the virtual implant planning image (pink) and the position of the placed implant (yellow) using Dental Slice. Figure 6. Calculation of the deviations between the planned and placed implants. Figure 7. Summary of the sequence applied in the methodology. Figure 8. Linear and angular measurements of the implants in the anterior and posterior segments of the maxilla.
Figure 1A
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Figure 1B
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Figure 2A
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Figure 2B
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Figure 3
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Figure 4A
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Figure 4B
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Figure 5A
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Figure 5B
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Figure 6
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Figure 7
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Figure 8
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