Navigating the future of dentistry: a journey into guided implant dentistry
In the world of dentistry, the evolution of technology has transformed traditional practices into highly sophisticated, precise, and patient-friendly procedures. Guided implant dentistry, with
its roots dating back to around the late 90s, has become a cornerstone of modern implant dentistry. It has not only streamlined the implantation process but also revolutionised patient communication and engagement. In this article, we will embark on a journey through the realm of guided implant dentistry, exploring its evolution, benefits and future prospects.
Guided Implant Surgery
The advent of guided implant surgery marked a significant turning point in the field of dentistry. Guided implant surgery involves meticulously planned and executed dental implant procedures with the aid of digital technologies. Driven by a quest for precision, predictability and enhanced patient experiences, many clinicians like the author ventured into the world of guided implant dentistry.
Restoratively driven versus bone-driven surgical guide design
One fundamental choice in guided implant dentistry is deciding between restoratively driven and bone-driven surgical guide design. Restoratively driven design focuses on the final aesthetic outcome, ensuring that the implant placement aligns with the desired tooth position. On the other hand, bone-driven design emphasises optimal bone health and integration with existing bone structures. The choice between these two approaches greatly influences the surgical plan and, ultimately, the patient’s outcome. The author’s journey into guided implant dentistry began in 2009. With a shift from positioning implants based on the available bone to a superior restoratively driven approach. Rather, than plan implant positions from a 2D OPGs, periapical radiographs or better still 3D CBCTs, planned software allowed consideration of the 3D position of teeth to ultimately deliver a more natural restoration, in keeping with the surrounding dental setup.
The benefits of guided implant dentistry are manifold. It offers predictability, accuracy, and safety, reducing errors and increasing efficiency
The digital advantage: working behind the scenes
One of the most significant advantages of guided implant surgery is the ability to work behind the scenes without the patient, assembling the pieces of the puzzle before the patient arrives for the procedure. This removes the pressure of time and having to manage the patient with the focus on the planning.
This is made possible by a suite of digital equipment, including an SLR camera, a smartphone, intraoral scans, a CT scan machine, and digital planning software. These tools work in unison to ensure that every step of the implantation process is meticulously pre-planned.
Benefits of guided implant dentistry
The benefits of guided implant dentistry are manifold. It offers predictability, accuracy and safety, reducing errors and increasing efficiency. With precise pre-planning, procedures can be completed in less chair time, leading to higher patient satisfaction. The ability to show the patient the visual plan, making communication and engagement more effective, enables them to better understand the process as well as your professional recommendations.
Guided implant surgery also minimises invasive protocols. In many cases large flaps or sutures are not necessary which means less disruption of the anatomy and the blood supply and faster healing. With increased accuracy of intraoral scans, soft tissue volume can be accurately measured allowing for better and more natural emergence profiles while respecting the biological width.
The ability to pre-plan at an unprecedented level allows for multiple procedures to be undertaken in one sitting. This reduces the treatment time and increases the uptake of treatment. No matter how much your patients love you, they want to minimise their visits to you!
Seamless collaboration between patient, restorative, and surgical dentist
Guided implant dentistry promotes seamless collaboration between the patient, restorative dentist and surgical dentist. With all stakeholders working from a meticulously designed plan, the patient is more involved and aware of the steps involved in the process. This collaborative approach ensures that the final outcome is a predictable, aesthetically pleasing and optimally functioning dental implant supported restorations.
Cons of guided implant dentistry
While guided implant dentistry offers numerous advantages, it is not without its drawbacks. The cost of acquiring and implementing the necessary technology can be substantial. Dental professionals also need to invest in further training to harness the full potential of these digital tools. And, like a pilot who always has a manual control option, it’s essential to have a fallback plan in case the technology fails during a procedure. While rare, technical glitches can occur, and having a backup strategy is a prudent approach.
The evolution of guided surgery
Guided dentistry has undergone several iterations over the years. It began with physical guides with radiographic markers as simple as a ball bearing which allowed one to calibrate the distortion of an x-ray thus allowing for more accurate measurements in terms of distance from vital structures.
Next came restorative lab guides based on a mock-up of the tooth position, allowing the operator to visualise the envelope of the planned tooth during the surgery. One could go a step further and use a radio-opaque tooth which then allowed calibration and hence accurate measurement of the position and size of the tooth in relation to the bone volume.
With the advent of planning software, one was able to design and order lab-made surgical guides. These used sleeves together with a guided drill system to direct the operator to the planned position of the implants. While this improved the speed and predictability of the procedure it still presented drawbacks. There was a lab cost (which could be considerable and added to an already expensive procedure), and the accuracy could be influenced by sleeve positioning and rigidity of the guide which meant some operator technical know-how was mandatory. If the patient had limited mouth opening or long teeth this meant limited working space further challenged by long surgical drills.
What if during the surgery you find that the bone is not sufficiently dense to allow immediate loading or during extraction and immediate placement, the intra-furcal bone that you were reliant on to place the implant snaps? Do you abandon the procedure? Or do you abandon the guide and all the planning and go freehand? Not ideal as the 3D planned position of implants that you so meticulously determined is now difficult to replicate in the mouth.
This is where navigation-guided surgery has the edge. The same planning as with conventional guided but you no longer need a physical guide; it has a similar tactile feedback to conventional surgery (but which is lost in guide-based surgery). This means that you achieve real-time bone density feedback. No clunky guides mean you can use normal implant drills. This means one less kit as well as less reliance on the patient being able to open their mouth to accommodate a tennis ball, especially for molar sites. The biggest benefits are real-time information on the vital structures as you drill; the real-time angulation and drilled depth are shown on a magnified display not too dissimilar to what you would expect if you were docking a spacecraft on the space station. And, of course, the ability to change your plan in real time with the luxury of still visualising your restorative envelope.
Planning software
With the explosion in digital implant dentistry there are many planning software available. The author’s personal experience is with Trios intraoral scan software and Planmeca Romexis. One provides the intra-oral scan data whilst the latter provides the CT scan information. Both these digital files are then uploaded into the DTX implant studio software. This is where the planning happens. Once planned the planned files links seamlessly with X-guided navigation technology.
Conclusion: embracing the digital revolution
The future of guided implant dentistry is bright and promising. Embracing digital technology is no longer an option but a necessity for dental professionals who seek to provide top-tier care. The evolution of guided dentistry has made it more accurate, predictable and user-friendly. As technology continues to advance, the role of AI and robotics in dentistry will likely expand. In fact, Yomi robotic-guided surgery is already a reality, offering a glimpse into the future of dental surgery.
Guided implant dentistry has come a long way from its inception in the 90s. It has evolved from simple lab guides to highly sophisticated navigation systems, offering numerous benefits in terms of accuracy, efficiency and patient engagement. While it does come with certain challenges, the advantages outweigh the drawbacks, making it a crucial component of modern dentistry. As technology continues to advance, guided implant dentistry will play an even more significant role in delivering superior patient care, driven by AI and robotics. It is a promising future that all dental professionals should be prepared
to embrace and adapt to.
In 2007, I journeyed to the Nobel Biocare World Symposium where Team Japan presented flapless implant placement. I was awestruck and couldn’t understand how they could accurately place implants which are surrounded by at least one 1mm of bone with optimal restoratively driven implant placement. But with navigation guided implant placement this is a daily reality.
Neeraj Puri BDS (University of Glasgow, 1996) Private general dentist at Integrated Dentalcare & Inverleith Dentalcare. Practice limited to Periodontal and Implant Surgery. Clinical Mentor for the MSc Implantology programme at UCLan
Case study
A fifty-five year old male attended wearing a four tooth denture. He had four front teeth removed a year ago due to periodontal disease. All other teeth were sound and periodontal health was stable. He was an occasional smoker.
He had short upper lip with a consequential low smile line.
He was keen to replace the denture with a fixed solution. Following consideration of all the options, he consented to an implant-based solution. Two implants were placed using a flapless X-guide protocol. A Waterlase was used to raise a partial thickness flap without releasing incisions to place a connective tissue graft. This created labial tissue to improve the emergence profile of the teeth. A temporary bridge was made to contour the tissue to help recreate and this was replaced a final two tooth bridge three months later.
