Along with the site of the implants in keeping with the prosthetic recovery, interior or exterior sinus raise can also be deliberate within the CAD device and transferred with assistance from surgical guides. It will strengthen the preoperative briefing of the affected person, minimise the surgical chance and succeed in a predictable outcome. The next case items a corresponding workflow with a focal point at the making plans and 3-d printing of the surgical information.
Case presentation
A 56-year-old feminine affected person offered to our outpatient division with a Kennedy Magnificence II, lacking enamel #14 and 15, and asked closure of the space. Her current recovery was once a provisional bridge from enamel #13 to enamel #16 (Fig. 1). The affected person’s basic scientific historical past didn’t disclose any abnormalities. The affected person was once knowledgeable of the to be had remedy choices, taking her basic scientific and dental historical past into account. In gentle of the affected person’s request for a hard and fast denture, the choices had been a bridge from enamel #13 to enamel #16 or implants in areas #14 and 15 with next crown recovery of the implants and enamel #16. In response to the integrity of enamel #13, the affected person opted for an implant recovery. This was once adopted through complete briefing at the scientific process and the taking of a CBCT scan and an affect of the placement.
Remedy making plans
Desire will have to at all times be given to a CBCT scan with a small box of view (CS 9300, Carestream Dental; 5 × 5 × 5 cm, 78 kV, 6.3 mA, 20 seconds). This makes it imaginable to scale back the affected person’s publicity to radiation and succeed in a smaller voxel measurement, which equates to a better degree of element. A cotton roll is inserted within the buccal area for higher matching of the DICOM and STL knowledge units by way of the cushy tissue within the CAD device. The STL knowledge set is acquired by the use of an intra-oral scanner or in-laboratory scanning of the plaster type.
The prosthetic restorations had been first designed in making plans device (Implant Studio, 3Shape). The DICOM quantity knowledge set (from the CBCT scan) was once then merged with the STL floor knowledge set (from the intra-oral scan; Fig. 2), and the implants had been aligned at the foundation of the prosthetic restorations (Fig. 3).
The vertical size in area #14 was once 10.5 mm and lowered distally from 5 mm to 7 mm in area #15. Straumann Same old Plus implants had been deliberate for area #14 (3.3 × 10.0 mm) and area #15 (4.3 × 8.0 mm). The usage of implants of those lengths will require an interior sinus raise.
To be able to permit guided preparation of the osteotomy to simply sooner than the maxillary sinus and the Schneiderian membrane, implant #15 was once moved coronally within the making plans device and its duration shortened. The making plans was once finished with the introduction of the surgical information and the corresponding drilling protocol.
Manufacturing of the surgical information
Uploading the STL surgical information knowledge set into the corresponding nesting device makes it imaginable to align the surgical information and furnish it with supporting buildings (Fig. 4). The cutting of the surgical information is carried out routinely in accordance with the fabric to be published and the printer. On this case, we used the clear 3-d-printing subject material V-Print SG (VOCO) together with the D20 II DLP printer (Speedy Form; Fig. 5). Printing is adopted through post-processing, involving ultrasonic cleansing in isopropanol and lightweight polymerising, to succeed in the general subject material traits of the surgical information (Fig. 6). As soon as the supporting buildings had been indifferent, the corresponding drilling sleeves can also be inserted into the surgical information (Fig. 7). Sterilisation of surgical guides published with V-Print SG is imaginable and really useful. Absolutely the dimensional steadiness of the surgical information with the drilling sleeves inserted is assured with out restriction.
Implantation
After native anaesthesia, a mid-crestal incision was once carried out and a mucoperiosteal flap was once raised (Fig. 8). The flap design will have to be selected such that the flap is not going to have an effect on the site of the surgical information. The osseous scenario corresponded to the CBCT findings of a buccally atrophied alveolar ridge. After pilot drilling, the totally guided preparation was once carried out according to the drilling protocol (Fig. 9). The vertical drilling as much as simply sooner than the maxillary sinus was once managed through the surgical information. The cortical bone of the sinus flooring may then be selectively fractured the usage of osteotomes and the Schneiderian membrane lifted to 11 mm, and due to this fact bone replace subject material was once inserted (Bio-Oss, Geistlich; Fig. 10). After placement of the implants (Figs. 11 & 12), the buccal atrophy in areas #14 and 15 was once reconstructed with bone replace subject material and coated with a resorbable membrane (Bio-Gide, Geistlich; Fig. 13). Saliva-proof wound closure was once carried out the usage of e-PTFE suture subject material.
The provisional bridge was once changed on the base to make space in case of swelling and inserted with methacrylate-based brief luting subject material (Bifix Temp, VOCO). The screw-retained ultimate restorations had been manufactured from a multilayered monolithic zirconia (DD cubeX2 ML, Dental Direkt; Fig. 14).
Dialogue
Placement of an implant in a suboptimal place can affect the osseointegration, cleanability and serve as of the implant. Along with aesthetic compromises within the prosthetic recovery, an insufficient implant place could also be related to purposeful problems and an larger chance of peri-implantitis.7, 8
To be able to succeed in a prosthetically and biologically ok implant place, surgical guides are used in this day and age to switch virtual making plans to truth. The fabrics used for the printing of surgical guides are normally methacrylate-based and range of their homes, such because the modulus of elasticity. The precision of guided implant surgical treatment is normally outlined because the discrepancy between the deliberate and precise postoperative scientific place of the implant. Similarly just right ends up in switch precision had been acquired in research with milled and published guides in edentulous areas corresponding to within the offered case.9, 10 Sterilisation at 135 °C for five mins had no vital impact at the subject material used.9 On the other hand, the surgical information subject material and printer used did have a vital impact.9 In in vivo research, deviations had been evaluated with implants positioned with surgical guides and been discovered to be considerably under the deviations the usage of freehand procedures.11 Along with positioning, surgical guides facilitate the process for the surgeon, as demonstrated on this case. Corresponding making plans permits guiding of the drill as much as simply sooner than the maxillary sinus, permitting extra environment friendly fracturing of the cortical bone of the maxillary sinus flooring with an osteotome and lifting of the Schneiderian membrane. This shortens the total period of the surgical treatment, making it extra agreeable for the affected person.