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The advent of new assisted design software in combination with computed tomography (CT) has increased the possibility of rehabilitating edentulous jaws with implant-supported fixed prostheses, allowing flapless surgery and immediate loading even in the presence of critical bone volume. Aim: The aim of the present study is to demonstrate how the use of advanced technologies supported by specific software allows the design and execution of optimal implant surgery while going on to decrease what could be intra- and postoperative risks.
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1971-1441
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Matteo Nagni 
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Annali di stomatologia
Virtual implant surgery planning
Guided implant-prosthetic rehabilitation: a clinical case report
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Case Report
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Ann Stomatol (Roma)
Matteo Nagni 
2023/11/20
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Dental School, Vita-Salute San Raffaele University, Milan, Italy and Department of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy
1971-1441
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Virtual implant surgery planning
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Guided implant-prosthetic rehabilitation: a clinical case report
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                                                                                                           Case report


Guided implant-prosthetic rehabilitation: a clinical
case report



Oddi Carlo                                                      landmarks for surgery [4]; second, the direct transfer of
Collina Giorgio                                                 implant position from the pre-surgical plane to the dental
Palmacci Matteo*                                                laboratory makes possible the pre-fabrication of an im-
Sgreggia Roberto*                                               mediate-load fixed acrylic resin complete denture.
Grassi Alessia*                                                 Thus, it becomes evident that the software-guided sur-
Nagni Matteo*                                                   gical-prosthetic protocol has several clinical advantages
                                                                such as optimizing all available residual bone to avoid re-
*Dental School, Vita-Salute San Raffaele University, Mi-        generative procedures, reducing the number of surgical
lan, Italy and Department of Dentistry, IRCCS San Raf-          procedures, decreasing the invasiveness of the surgery,
faele Hospital, Milan, Italy                                    and shortening the time between surgery and delivery
                                                                of the prosthesis, minimizing the patient’s postoperative
Corresponding author: Palmacci Matteo                           discomfort, with good predictability of functional and aes-
dr.mpalmacci@outlook.com                                        thetic results [5] [6].
                                                                Therefore, flapless-guided surgery requires less time and
                                                                at the same time allows reducing bleeding and post-surgi-
Abstract                                                        cal complications (trismus, swelling, hematoma).
The advent of new assisted design software in combi-            In addition, a flapless approach maintains high osteo-
nation with computed tomography (CT) has increased              genic potential and blood supply to the underlying im-
the possibility of rehabilitating edentulous jaws with          plants, allowing intimate contact between the periosteum
implant-supported fixed prostheses, allowing flapless           and bone while preserving the integrity of the supra-peri-
surgery and immediate loading even in the presence              osteal plexus [7] [8].
of critical bone volume. Aim: The aim of the present            The current work-flow for guided implant surgery incor-
study is to demonstrate how the use of advanced                 porates new technologies such as intra-oral optical scan-
technologies supported by specific software allows              ners, in-office CBCT, virtual implant planning software,
the design and execution of optimal implant surgery             and 3D printers. Which of these advanced modalities the
while going on to decrease what could be intra- and             practitioner chooses to use will depend on equipment
postoperative risks.                                            availability and experience level [9].

Keywords: All-on-six, Computer guided implant sur-              Materials and Methods
gery, Flapless implant surgery, Dental implants, Com-
                                                                The patient, a 52-year-old man in good general health,
puted Tomography, Virtual implant surgery planning.
                                                                presents on objective examination having several eden-
                                                                tulous areas at the level of the two arches, with greater
Introduction                                                    impairment of function and aesthetics at the level of the
The advent of new assisted design software in combi-            upper jaw. His request is to regain optimal morpho-func-
nation with computed tomography (CT) has increased              tional restoration by performing a fixed prosthetic solu-
the possibility of rehabilitating edentulous jaws with          tion; therefore, for this reason, an immediate-loaded
implant-supported fixed prostheses, allowing flapless           implant-prosthetic rehabilitation of the upper maxilla
surgery and immediate loading even in the presence of           was proposed to the patient according to the All-on-six
critical bone volume [1]. CT-guided surgery has become          technique.
even more accessible with the increased availability of
virtual implant planning software [2]. In fact, computed        Results
tomography (CT) or cone-beam CT (CBCT) scans and
                                                                No implants were lost during the follow-up monitoring
three-dimensional surgical planning software allow the
                                                                period; furthermore, no intra- and postoperative compli-
clinician to analyze the patient’s anatomical structures
                                                                cations were recorded.
and prosthetic parameters, while at the same time virtu-
ally visualizing the optimal position and direction of inser-
tion of each implant [3].
                                                                Conclusion
Virtual prototyping makes it possible to: produce stere-        Through the use of guided technology, it is therefore
olitho-graphic models that, by transferring virtual plan-       possible to perform implant surgery with reduced num-
ning to the surgical field, are particularly useful in the      ber of implants with greater precision and safety realiz-
presence of edentulous portions lacking anatomical              ing a durable result with a favorable prognosis.


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    Guided implant-prosthetic rehabilitation: a clinical case report




    Figure 1. Pre-operative OPT.



    CASE REPORT                                                        5 mg, Roche) and under local anesthesia with 2% me-
                                                                       pivacaine and adrenaline 1:100000 (Carbocaine, Astra-
    A 52-year-old male patient presents for his first visit to         Zeneca, Milan, Italy). The implants were placed with a
    the Department of Dentistry and Prosthodontics of the              flapless technique.
    Vita-Salute San Raffaele Hospital directed by Prof. E.F.
    Gherlone. The patient presents good general health;
    however, following a thorough intra- and extra-oral ob-
                                                                       FOLLOW-UP
    jective examination, several areas of edentulousness               Follow-up visits, aimed at clinical and radiographic ex-
    in the four quadrants are evident, compromising proper             amination, were performed one week after implant place-
    masticatory function. A good state of impairment of the            ment. Thereafter they were performed at three months,
    last remaining elements of the upper arch is also evi-             six months and then annually until a follow-up of one
    dent. In fact, the patient came to our attention with the          year was reached. The patient was adequately instruct-
    desire to be able to regain optimal masticatory as well            ed, by a dental hygienist, in mechanical plaque control
    as esthetic function, with a request for a fixed prosthetic        through the use of the electric or manual toothbrush, in-
    solution.                                                          terproximal brushes, and Super Floss type floss (Oral B,
    With the purpose of performing accurate morpho-func-               Procter & Gamble, Cincinnati, OH, USA). Whereas, pro-
    tional restoration, the patient was proposed an immedi-            fessional oral hygiene procedures were performed every
    ate-loaded implant-prosthetic rehabilitation of the upper          three months following implant placement.
    jaw according to the All-on-six technique.
    Planning of the surgery was carried out through the use            Parameters evaluated
    of CREA-3D Software (BioSAFin). Through the realized
    surgical protocol, four axial implants were planned at the         Implants survival rate
    level of the anterior area; the implants placed in place           Implant survival rate is based on the number of implants
    12 and 22 having a diameter of 3.8 mm and a length of              that were not lost or removed, throughout the follow-up
    6 mm; in place, instead, 14 and 24, having a diameter of           period [9].
    3.8mm and a length of 9 mm. In contrast, the two tilted
    implants placed at sites 16 and 26 were planned with a             Marginal bone loss
    diameter of 3.8 mm and a total length of 15 mm.                    Endoral radiographs, using the parallel cone technique,
    Cross-sections were also performed at the level of the             were taken after implant placement, at three, six, and
    planned implant sites through the software; these al-              12 months. In order to assess the marginal bone trend,
    lowed us to evaluate their position in relation to the bone        measurements were taken through the use of CREA-3D
    structure, the relevant noble anatomical structures and            software (BioSAFin). First, the instrument was calibrated
    the related prosthetic aspects. In order to have with              (pixels/mm), using the diameter of the implants as the
    greater clarity a visualization of the axes of implant in-         unit. Next, changes in peri-implant marginal bone height
    sertion, an axial section was made.                                relative to the most coronal portion of the implant fixture
    The support of the CREA 3D software was of relevant                and the point of contact between the implant fixture and
    importance as it allowed, through the use of the 3D func-          the marginal ridge itself were measured. To assess the
    tion, a three-dimensional evaluation of the position of the        trend of the bone, a line passing over the shoulder of
    implants, thus additionally assessing the parallelism of           the implant was considered as the reference point for
    the EAs.                                                           measurement from which a straight line was drawn par-
    The surgery was performed under aseptic conditions                 allel to the long axis of the implant to the most coronal
    under oral sedation with diazepam 0.25 mg/kg (Valium               point at which the bone made contact with the fixture


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C. Oddi et al.




                 Figure 2. Cross-section at the site level of planned plants.



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    Guided implant-prosthetic rehabilitation: a clinical case report




    Figure 3. Planning the intervention using the CREA-3D BIOSAFIN Software.




                                                                       both mesially and distally. The software automatically
                                                                       provided the distance between the two points measured
                                                                       in millimeters.
                                                                       Then, to calculate the marginal bone level, a mesial
                                                                       measurement was taken, a distal measurement was tak-
                                                                       en, and then the average of the values of the mesial,
                                                                       distal portion, and the average between the two values
                                                                       of a single implant site was quantified.


                                                                       RESULTS
                                                                       Implants survival rate
                                                                       The patient was monitored over one year after implant
                                                                       placement; what could be inferred was that no implants
                                                                       were lost, thus demonstrating a promising implant sur-
                                                                       vival rate of approximately 99% [11]. Since 2010, several
                                                                       reviews, including systematic ones, have been written
                                                                       in order to evaluate the accuracy of flapless guided sur-
                                                                       gery in clinical trials. In general, it can be concluded that
                                                                       the implant survival rate ranges from 91% to 100%, thus
                                                                       having confirmation of the results obtained in this clinical
                                                                       case [12].

                                                                       Marginal bone loss
    Figure 4. Three-dimensional assessment of implant po-
    sition and parallelism of EAs using CREA-3D BIOSAFIN               Axial and tilted implants revealed minimal bone loss not
    Software.                                                          relevant to implant stability [13].



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C. Oddi et al.




Figure 5. Radiography in the immediate postoperative period.




Figure 6. Postoperative radiography at one year.




        MARGINAL                 Axial Implants in place       Axial Implants in place
                                                                                         Tilted implants
        BONE LOSS                       1.2 e 2.2                     1.4 e 2.4


       6 months (mm)                   0.53 ± 0.76                  0.61 ± 0.65           0.71 ± 0.69

        1 year (mm)
                                       0.85 ± 0.87                  0.85 ± 0.88           0.90 ± 0.88



10.59987/ads/2023.3.3-9                                                                                    7
    Guided implant-prosthetic rehabilitation: a clinical case report

    Discussion                                                               Jan;65(1):67-80. doi: 10.1016/j.cden.2020.09.005. Epub
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    Individually analyzed risk factors show that several pre-          3.    (La Monaca G, Pranno N, Annibali S, Di Carlo S, Pompa
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    ware-guided surgery.                                                     of edentulous jaws on 4 or 6 implants according to the
    One advantage in accuracy is having more than seven                      prosthetic-driven planning and guided implant surgery: A
    unrestored teeth to perform CBCT and surface scan                        retrospective study on clinical and radiographic outcomes
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                                                                             2022 Oct 5. doi: 10.1111/cid.13134. Epub ahead of print.
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    Last but not least, it should be emphasized that the us-                 ture. Clin Implant Dent Relat Res. 2012; 14(3):321-335. do
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                                                                             2016;31(Suppl): s103-s117. doi:10.11607/jomi.16suppl.
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