Ten Myths of Guided Implant Surgery
Gary Orentlicher, DMD; Andrew Horowitz, DMD, MD; Batya Goldwaser, DMD, MD; and Marcus Abboud, DMD
Since their introduction, guided dental implant planning and surgery procedures, like most new techniques in medicine and dentistry, have undergone many modifications and advances. While some practitioners were early adopters, most dental surgeons have been cautious regarding this methodology. Despite more than a decade of literature, podium presentations, advances in instrumentation and technique, and successful cases, questions remain within the dental surgical community. This article attempts to address some of these by outlining common but erroneous beliefs about this technology and procedure.
Conventional freehand implant surgery has been taught, performed, modified, and refined by dental implant surgeons since the introduction of the first osseointegrated dental implants. Computed tomography (CT)-guided implant surgery was first introduced in the early 2000s. Guided implant surgery involves a reverse engineering workflow, first establishing the ideal position and morphology of the planned restoration, then virtually planning the ideal position of the dental implant(s) according to that restoration.1 Surgical guides are then produced to aid the surgeon in placing the implants accurately, according to the virtual plan. Surgical instrumentation, produced by most major dental implant manufacturers, is available to create osteotomies and place guided implants.
Since their introduction, guided dental implant planning and surgery techniques have undergone many modifications and advances. Some practitioners were early adopters of this technology, but many have been more wary, and some confusion seems to remain within the dental surgical community. This article will address some of the questions and what the authors consider to be “myths” regarding this technology and procedure.
Guided surgery is an easier way to place a dental implant.
Guided surgery is not an easier way to place a dental implant; it is a more accurate way.2-4 Guided surgery is an advanced implant placement technique and is not recommended for novice implant surgeons. A high level of training, experience, and skill is required to master the techniques and workflows. It is an endeavor for experienced implant surgeons who are willing to invest the time and money necessary to learn the techniques.
Guided surgery increases clinical time efficiency.
For a clinician who masters guided surgery techniques and instrumentation, chairside time efficiency can increase significantly. This improved efficiency is most obvious in multiple-implant and full-arch reconstructive patient cases. However, overall, guided surgery does not reduce treatment time, as additional time is spent on planning rather than the treatment itself. Taking impressions, wax-ups, and cone-beam computed tomography (CBCT) and optical scans; importing digital imaging and communications in medicine (DICOM) images; and conducting virtual treatment planning are all time-consuming activities.
Guided surgery is primarily indicated for more challenging cases.
Though many consider guided surgery to be reserved only for difficult cases, in the authors’ experience once clinicians have invested the time and resources into learning the techniques and acquiring the instrumentation, guided surgery alters the way they view a case, whether simple or complex. Although the first guided surgery workflows were developed for implant placement in fully edentulous patients and were given elaborate immediate-load marketing terms that implied teeth could be produced in as little as an hour, many patients who are partially edentulous and/or need only a single implant can benefit from guided surgery. This technique can be used for the replacement of a single tooth or for partially edentulous patients in addition to fully edentulous ones, with or without immediate load. If desired, techniques and armamentarium are available for the fabrication of provisional restorations in all types of cases, before guided implant insertion, for insertion immediately after implant placement.
Placement of implants using guided surgery can be performed fully guided or using pilot guides. Fully guided placement involves osteotomies and implant placement, using implant-specific guided surgery instrumentation, to final depth and angulation, through the surgical guide. Use of pilot guides is an option that simplifies case planning and implant placement by establishing the initial osteotomy depth and angulation without requiring fully guided instrumentation. Final implant placement is then done freehand using conventional instrumentation (Figure 1 and Figure 2).
Guided surgery techniques are similar to conventional implant surgery techniques.
Although placing an implant by using sequential burs to enlarge an osteotomy is common to both conventional and guided surgery implant placement, the surgical instrumentation and techniques are significantly different. An intimate knowledge and understanding of the principles and surgical instrumentation that are unique to guided surgery is necessary before treating patients. Drill guides, implant mounts, drill stops, altered drilling sequencing, different burs, and instrumentation specific for component removal are some of the unfamiliar instrumentation clinicians should understand (Figure 3). Most major implant manufacturers now have guided surgery instrumentation trays specifically designed for their implants (Figure 4 and Figure 5). Some manufacturers have implants packaged specifically for guided surgery placement (Figure 6). Techniques and instrumentation are available for both pilot (2-mm to 2.2-mm burs only) osteotomies and fully guided placement of dental implants.
Before performing guided surgery, implant surgeons must be comfortable with conventional implant placement techniques in the event that a case initially planned for guided surgery must be converted to one using conventional methods. For example, this may occur if surgical guides do not fit properly at surgery or if a patient cannot adequately open his or her mouth to accommodate the guided surgery instrumentation.
I am smarter than the guided surgery workflows, so I can skip steps.
Dentists generally try to develop treatment methods to minimize steps and maximize efficiency while treating patients. When using guided surgery, skipping steps should be avoided during the workup and treatment of patients. Errors made in guided surgery are both additive and cumulative. Workflows from most manufacturers are well established for all types of cases. Attention to detail from all team members (eg, laboratory, restorative, and surgical) is necessary in each step of the workflow to minimize error and maximize accuracy and patient outcomes.
One step that is sometimes skipped is the use of bite registrations to accurately position scanning appliances during scans and to position surgical guides to be used for implant insertion. Neglecting to use bite registrations can lead to inaccuracy in both the placement of a scanning appliance and in the positioning of the surgical guide at surgery, leading to potential errors in planning and implant placement. The use of bite registrations must be included in the protocol, especially in cases involving fully edentulous patients (Figure 7 and Figure 8).