Simplified guided surgery user`s guide
Contents
1. TOLOMEO BIOL L et Coll IMPLANT Vol 7 n 4 2001 A global solution FOR IMPLANTOLOGY euroteknika 726 rue du G n ral De Gaulle 74700 SALLANCHES France T l 33 0 4 50 91 49 20 Fax 33 0 4 50 91 98 66 www euroteknika com MU CGS GB 1301 teknika GROUP ES NU mu m euro2. Make sure the plaster cast model comes with a support in order to avoid any break during transportation or handling Size use a plaster cast model of the full jaw The model should be large enough as no implant is planned out of the model Precise details all the teeth should be on the plaster cast model Do not remove teeth that will be extracted during the surgery Mark with a cross the teeth that will be extracted The maxillary model should include the full palate and the tuberosity for a good stability Send a recent plaster cast not dating from more than a month in order to avoid any adaptation problem due to a possible alteration of bone structures and teeth position L stroj teknika GROUP LU 1 1 121 e surgical INVESTIGATION Radiological guide manufacturing Six to eight orifices about 1mm in diameter and 1mm deep maximum are made in the extrados of the prosthesis or copy of the removable prosthesis then filled with radio opaque material Gutta Percha for example These references do not need to be aligned and are distributed over the entire extrados at various levels There is no rule for where they should be placed The partial removable prosthesis is used as an imaging guide Some radio opaque reference points are placed on it Technical aspect However in the case of partial or single tooth implantation where there are existing metal fillings the reference points should not be ne
3. SIMPLIFIED GUIDED SURGERY Users guide INTRODUCTION euroteknika is the result of 20 years of clinical applications and 24 years of research and development confi rmed by valuable help of international research laboratories The design of our implants is based on the skills of our teams wich are both reactive and experienced in implantology gt Technical and biomechanical skills of our engineers enabling to guarantee the resistance of the component and their adaptation to the oral environment thanks to modern means of simulation gt Biological and physiological skills of the associated laboratories enabling to validate the capacity of osseointegration of our systems gt Clinical and practical skills of our dentists advisers ensuring the ergonomics of our products the confi rmation of our protocols and the ranges adapted to the various clinical cases Warning p 6 I General information on guided surgery p 7 to 10 Presentation of the concept D 8 Major indications ae Advantages and benefits of guided surgerv D Y Limits of guided surgery p 9 Process of guided surgery p 10 II Pre implant Study p 11 to 18 Clinical radiological examinations E 12 Preparation of the radiological guide pb 15 Tomodensitometric examination o 17 Double scan technique D Imaging treatment p 18 Implant planning of the case o 18 II Surgery Guide p 19 to 23 Guide manufacturing p 20 Important information about the surgical guide p 21 IV
4. be created This is the case when the surgeon wants to visualize the position in the presence of a narrow crest or in the case of total lack of teeth in a terminal zone The supporting bone is not deformable However it is preferable to immobilize it with anchoring wedges The remarks about guide wedges for mucous support also apply to bone borne guides Customized guides for the entire process Surgical guides are used to guide the gum incision for the flapless technique the drilling and the positioning of the implant thanks to special instruments and dedicated implants Surgical guides can also be used to fabricate a provisional prosthesis thereby reducing the waiting time traditionally required to meet patients esthetic and functional demands Order process of the euroteknika surgical guides gt Step 1 Sending the files coming from our teknika3D software to our server gt Step 2 Processing of the received files to design the surgical guide gt Step 3 Validation of possible modifications carried out by teknika3D and the dentist gt Step 4 Confirmation of the planning gt Step 5 Manufacturing of the guide by teknika3D gt Step 6 Sending the guide with the implants and the printed treatment planning as a support SURGERY The surgical KIT The stake for the realization of the implant socket is on two levels gt The preparation through the guide of the first drilling Q 2 2 gives the axis and the in
5. precise advice available but must not be seen as recipes as every clinical case in different A very large number of factors act independently to achieve a successful implant lt is the practitioner s responsibility to understand the key principles and to apply his her clinical experience Although the methods described by euroteknika group may establish a treatment plan the practitioner remains solely responsible for the medical plan of the various choices and decisions in terms of implant planning feasibility of the treatment the implants themselves prosthetics and materials used etc The technical specifications and clinical advice in this manual are purely indicative for the purpose of assistance and cannot be used as grounds for any complaint All the most important information is in the notice provided with the products We have taken great care in the design and production of our products However we reserve the right to bring modifi cations or Improvements arising from new technical developments in our implantology system We will advise of any modifi cations having an implication in the operation mode According to the importance of the modifi cations a new manual will be issued Indeed a mark on the back page indicates the date of issue of your surgery manual and enables us to check if you have the latest up date version You will also be able to access our web site to check the latest version of this manual The reproduction
6. Eliminate an extra step by using flapless surgery greatly improving surgical outcomes saving time and making the procedure much more comfortable for the patient gt Combine the osseointegration period and post extraction implantation to achieve the least bone resorption and maximum precision gt Improve patient practitioner communication gt This system greatly contributes to better coordination between the members of the treating team practitioner prosthetist lab assistants as it has the advantage of being an excellent communication and therefore work tool for the group gt The distance between implants or between implant tooth is reduced and non compatible with classic guided surgery guides gt You can place any type of implant after finishing the bone preparation with a classic surgery system Limits OF SIMPLIFIED GUIDED SURGERY These are mainly technical gt The mouth opening must be large enough and suitable for the surgical instruments gt The anatomy of the site does not make it difficult to position and anchor the implant gt There must be sufficient bone depth gt The bone characteristics must be suitable guided surgery requires adequate bone quantity and quality gt Hygiene the patient must be informed willing and be able to offer good post procedure care Uncooperative patients should be discarded gt lt is important to emphasize that mucous surgery is extremely demanding in term
7. Pathologie Oro faciale Docteur J Francois GAUDY Maitre de conference service d Anatomie Facult de chirurgie dentaire de Paris V Les bases buccale Anesth sie Infiltrations locales d articaine associ es une analg sie intraveineuse en chirurgie buccale chez les malades risque B Lefevre J Lepine D Perrin G Malka Le chirurgien dentiste de France N 566 23 Mai 1991 k Implantologie orale 2003 Commission des dispositifs m dicaux de l ADF Facteurs de risques en implantologie F Renouard t Vers un implant universel Marcel G Le Gall Andr P Saadoun Nicolas Le Gall Implantologie F vrier 2005 Platform switching un nouveau concept implantaire de contr le des niveaux osseux apr s mise en charge Richard J Lazzara Stophan S Porter PDR volume 26 n 1 2006 R In vitro evaluation of the implant abutment bacterial seal locking taper system S Didart M Warbington M Fan Su Z Skobe The international journal of oral amp maxillofacial implants 2005 10 732 737 tude de suivi clinique sur 10 ans d implants avec projetat de dioxide de titane L Rasmusson J Roos H Bystedt Implant volume 12 n 2 2006 Le col de 1 implant doit il tre lisse ou muni d l ments de r tention 7 Une tude par la m thode des l ments finis S Hansson Implant volume 6 n 2 06 2000 R Carl Mitch Francisco H Nociti J R k Al Shammari J Steingenga Dr Hom Lay W
8. Surgery p 25 to 34 The surgical Kit p 26 Flapless technique flapless surgery p 28 Guided Surgery is a very specific treatment concept which demands experience of classic dental implant technology as well as a dual learning process gt Computer assisted implant planning is a revolutionary tool but for many practitioners it means acquiring new computer skills Do not hesitate to contact our team led by a dental surgeon and our engineers who are always contactable during office hours to help you use the teknika3D software and planning for your case Our advisers are also available in the field to help you master the kits and protocols in the surgical guide gt The coordination between you and your team of assistants must be perfect And the special organization that goes along with this system can be the source of major per operative stress for a new user You need to train your team and offload to them as many tasks as possible during your interventions so you can concentrate on your main objectives The surgeon s experience is paramount as he is the one who needs to take things in hand when events do not happen as anticipated The implant planning the instructions and protocols described here must be implemented in full using the components and instruments provided by euroteknika These instructions will help you roll out the various phases to be implemented to carry out your implant treatments They are accompanied by the most
9. Termes Dra Zaira Martinez Vargas 2007 R Int ret des BETA TCP dans les greffes intra sinusiennes mixtes a viss e implantaire analyse histologique de l interface os implant sur les implants Aesthetica Universit d Angers Dr Bernard Guillaume 2007 Effect of lactofferin on osseo integration amp bone healing around the Aesthetica implant Cukurova University Turquey Dr Mehmet Kurkcu 2007 amp Les proth ses ost o int gr es Branemark Zarb Albrektsson Quintessence R Osseointegrated implants in the treatment of th edentulous jaw Experience from a 10 years period Br nemark Hansson Adell Breine Lindstrom Hallen Ohman Almqvist and wiksell international Stockholm R The Br nemark osseointegrated implant Albrektsson Zarb Quintessence t Osseointegration in oral rehabilitation Naert Jan Steenberghe Wortington Quintessence k Limplantation en 1985 D sespoir ou des espoirs Analyse exhaustive de la m thode de Br nemark Exp rience clinique de 5 ann es G Hur Enclyclop die m dico chirurgicale Odontologie 9 1989 23345 A10 t Th rapeuthique implantologique Endo osseuse originale Le site Tubero pterygo dien G Hur Les cahiers de proth se n 67 Septembre 1989 R propos de l tat de surface des implants en titane pur G Hur Implantodontie 1994 n 14 15 Comment choisir un anesth sique en odonto stomatomogie Soci t d Anatomie et de
10. and distribution of all or part of this manual need previous agreement from euroteknika General information ON GUIDED SURGERY L euro tek ika MB 6 gt TA ROUP E gt TTD ES S I Pa Ta 2 E General information ON GUIDED SURGERY Presentation OF THE CONCEPT Guided Surgery GS can be defined as the possibility of transferring to a mouth an implant plan produced on a computer using data from the tomodensitometric examination scanner Cone Beam The transition from a virtual project to a surgical reality is possible thanks to a surgical guide developed by stereolithography using the data of the prosthetic intrados and the implant plan produced with the teknika3D planning software The benefits of guided surgery are indisputable It provides a solution for pre implant anatomical investigation better prior visibility of anatomical complications and improves the safety of implant surgery All the important decisions can be taken into account prior to surgery choice of implant site of the size and the diameter of the implant etc Since only the first drilling Y 2 is done any implant type can be then placed by continuing the site preparation with the implant system used MAJOR INDICATIONS It is a treatment concept applicable to all indications and offers a wide range of flexible solutions gt A single tooth partial dentition or full dentition gt Incisionless surgical p
11. andard quence that must be adapted to suit the patient s ne quality density and implant site To put another implant with a smaller diameter it is better to wait for the complete healing of the socket It is important to analyse the reasons of the failure before placing a new implant The doctor decides whether it is necessary to use bone material to fill in the socket STUDIES PUBLICATIONS t Analyse comparative de l tat de surface des implants Euroteknika Straumann Nobel Zimmer Astra analyse de la topographie de surface mesure et homog n it des impacts identification des mol cules pr sentes la surface de l implant University of Barcelona Consejo Superior de Investigaciones Cientificas Dr Lluis Giner Dr Josep Miquel Dr Jordi Ferre 2007 k Analyse de la r partition des contraintes autour des assemblages implants pi ces proth tiques mis en fonction sur une mandibule dynamique d formation lastique analyse de la r partition des contraintes valuation de la r sistance m canique des l ments University of Otago Dunedin New Zealand 2007 Etude de l tanch it des connexions internes et externes analyse au microscope balayage lectronique des ajustements implants pi ce proth tiques test du bleu de bromofenol sur des l ments enferm s l int rieur des assemblages recherche d ventuelles micro infiltrations University of Barcelona Dr Josep Cabratosa
12. ang J Periodontol 2004 75 1233 1241 R Kim WT amp al J Korean Assoc Oral Maxillofac Surg 2001 Apr 27 2 111 117 r Risque h morragique ARNAL H Information dentaire n 12 Mars 2005 k La p ri implantite en 2008 ASSEMAT TESSANDIER X et Coll Implant Vol 14 n 3 2008 amp Le canal mandibulaire post rieur AUDRY P C Th se Odontologie Reims 2009 un stress en implantologie mandibulaire amp Le Site donneur mandibulaire post rieur BENOIT PHILIPPE Information dentaire n 18 Mars 2006 r Complications et checs en implantologie BERT Marc Edition CDP 1993 amp Le risque infectieux la p ri implantite BIOSE DUPLAN MARTINI Information dentaire n 12 Mars 2009 r Implantologie et patients risque CAMPANA F et Coll Revue implantologie Mai 2008 R Pr vention et traitement des p ri implantites CHARGE L Revue implantologie Nov 2008 k Analyse des checs implantaires en pratique liberale COLIN Ph Hors s rie IMPLANT Les checs 2008 amp Echecs et complications en implantologie DAVARPANAH M et Coll Le Fil Dentaire n 11 Mars 2006 R Collaboration entre ORL et implantologie DOUGE T VERNEULEM J Revue Implantologie F v 2008 k Les augmentations osseuses complexes et les reconstructions en 3D JABBOUR M et Coll IMPLANT Vol 14 n 4 2008 k Report of the Sinus Consensus Conference o
13. ar fillings The radio opaque references allow the two acquisitions to be superposed which is essential for a surgical guide In the maxilla In the mandible It is recommended to do several openings where the imaging guide leans on the teeth These openings allow to see the guide is properly seated in the mouth They will be copied on the surgical guide thanks to the precision of the stereolytographic process and will so allow to control the guide is properly seated during the operation Tomodensitometric EXAMINATION CBCT scanner Double scanning technique Once the prosthesis is transformed into a radiological During the radiography if the radiological guide is guide the patient is scanned with the guide in the not in the originally intended position the information mouth Then only the radiological guide The image transmitted to the implant planning software will be is acquired at euroteknika using Cone Beam wrong and the implants will be placed in the wrong technology Instrumentarium position The stability of the radiological guide is even more important for a full set procedure as the prosthesis must be maintained in perfect occlusion Double scan TECHNIQUE SCAN 1 scan the patient wearing the radiographic guide For optimal results please observe the following Check the radiologic guide is perfectly stable it should be seated in the mandible or maxilla without interstice Scan the mandibl
14. ation the cutter The implant site soft tissue is removed with the gingival punch Guide euro teknika 8 Preparation of the implant sites and implant placement Continue the implant site preparation with the traditional surgery kit of the used system 9 Osseointegration The conventional obtain a osseointegration Is e 3 months in the mandibular e 6 months in the maxilla due to a softer bone period to good The dentist should define this period by taking into account the bone quality the implant primary stability and the prosthetic plan In certain cases the dentist can decide to connect the prosthetic parts without waiting for the osseointegration However the dentist must be able to analyze if the conditions of the clinical case are appropriate to an immediate loading In case of failure To remove an implant use a trephine with a greater diameter than the placed implant and remove the bone cylinder obtained Implant removal is facilitated by using an implant holder screwed on the implant The socket can possibly be re implanted e if the patient is fit to receive a new implant e with an implant of wider diameter in the case that the Studies and scientifi c datas indicate that immediate loading has proven to be successful at the mandibular when the prosthesis is built on 4 implants or more linked together Immediate loading is not recommended on single je drilling sequence that we propose is a st
15. ction A treatment planning is then realized in teknika3D software This planning should include the selected implant type length diameters and positions of the implants The number of implants is a key factor for the long term success of the implant supported restoration Once the implant positioning is validated and according to the case to be treated fixing pins are placed they are sometimes indispensable to stabilize the surgical guide during the operation Make sure there is no interference between the different elements fixing pins and implants or between these elements and the anatomic obstacles nerve sinus Once the planning is validated and saved the next step consists in viewing the future surgical guide teknika3D software offers 3 choices tooth mucosa or bone support Sallanches 74 France For full guided surgery only euroteknika implants are available with this SURGERY GUIDE 4 ka d S euro teknika 1 Surgery GUIDE Guide MANUFACTURING Sending an implant project Once your treatment plan has been prepared send it to our teknika3D production center When the surgical guide is on a dental base the plaster model must be sent with the treatment plan Surgical guide manufacturing As the teeth are non deformable the surgical guide that sits on top cannot be approximate and must be as accurate as possible When the base is mucous the double scan technique does not require
16. e profile Two situations are possible Full set of implants The imaging guide can be prepared with the existing removable prosthesis in which case it is necessary to verify that the initial prosthesis fits properly in order to guarantee perfect stability of the surgical guide Partial dentition or single tooth The patient is not wearing a removable prosthesis therefore two possibilities gt Ask your laboratory to make a radiological guide In this case if the patient is wearing a restoration with metal material in the antagonist jaw there is a higher risk of artefacts false signals To reduce this risk a patient with partial dentition should be asked to keep their mouth half open during radiography The placement of the radiological guide must be accurate That can be obtained by close adaptation against the remaining teeth Some suggest using a check bite over the salivary glands but the risk of shifting cannot be totally excluded gt Plaster models of the patient s arches are prepared and scanned In this case the plaster model is superposed on the patient s skeleton by aligning the remaining teeth using the teknika3D software This solution is less accurate The model should be intact Repaired models or models with broken teeth or mucosa region models with air bubbles in the teeth or the mucosa region or with engraving done in laboratory are unusable Remove from the model the fixing pieces to the articulator
17. e with a bite key Remove any unfixed metal part from removable prosthesis for instance The teeth of the maxilla or mandible should not be in contact with the references points of the radiologic P guide g pi A The occlusion plan should be parallel m to the sections A s B a meh 1 SCAN 2 a scan of the prosthesis Make sure the prosthesis is scanned in a position similar to the one of the scan 1 Verify the prosthesis is supported by a highly translucent material Scanning parameters Ideally between 0 3 and 0 6 mm Imaging TREATMENT DICOM file import The DICOM files are imported and converted into teknika3D software teknika3D offers simultaneously an axial sagittal panoramic view and a 3d reconstruction On each view it is possible to access all and each of the plans successively piled up Implant planning OF THE CASE treatment plan with teknika3D software Requirements to planning allow to exploit the patient s bone volume to position optimally the implants Before placing the first implant you should identify the different anatomical constraints Indeed the doctor can examine the bone volumes in the mandible or maxilla identify and locate the anatomical elements such as the mental foramen the dental nerve or the anterior incisive in the mandible the nasal cavities or the sinus in the maxilla He can also determine the healing level after an extra
18. eatment to avoid persistence of residual infection stive infected sites constitute a contraindication mediate treatment De Kok 2006 Healing potential It is conditioned by some general diseases such as gt Osteoporosis gt Phosphocalcic disorders gt Diabetes gt Hyperparathyroidism gt Patients who have undergone radiotherapy gt Weakened immune system gt Patients who smoke more than ten cigarettes a day In these patients the bone quality and or healing quality is mediocre TMJ mouth opening and occlusion The insertion of implants in particular posterior requires The clinical examination must also determine the a sufficiently large mouth opening suitable for the presence or not of occlusal anomalies or parafunctional surgical instruments a 4 to 6cm opening habits such as bruxism or crossbite If that is the case a Some TMJ disorders limit the mouth opening and can treatment must be included in the overall treatment plan contraindicate implant insertion In this respect condyle The reversibility of the disorder must be determined travel and opening and closing movements of the mouth before inserting implants must be assessed Preparation OF THE RADIOLOGICAL GUIDE The imaging guide is indispensable when computer aided implantology CAI is used for the guided positioning of implants It identifies the thickness of the mucous tissue the edentulous space and or the teeth and the ideal implant emergenc
19. edone The surgery must therefore be postponed A ZH 2 Disinfection of the surgical guide k The surgical guide is not sterilizable by autoclave only disinfection is possible Soak the guide in the chlorohexidine for maximum 20 mins then put it in the mouth rapidly 3 Local anesthesia Injections of anesthetics must be away from the guide support zone The anesthesia step is a source of mis positioning in relation to the intended project The injection of local anesthetic creates mucous swelling which is sometimes hardly perceptible but which can hinder the insertion of the dental or mucosa borne guide or favor incorrect positioning which can induce great instability of the guide in particular the mucosa borne guide Analgesic techniques must be mastered to ensure correct and painless guided surgery This problem does not occur with the bone borne guide as the flap Is created after the anesthesia step Photo credit Dr Ella Bruno 33 4 Stabilization of the surgical guide The guide is stabilized by placing three anchoring needles after preparing the sites for them with the 1 5 drill at 1 000 rpm Photo credit Dr Ella Bruno 33 Surgery 5 Initial drilling through the guide Choice of the length of the Y 2 2 mm drill The preparatory drilling is to determine the axis and the depth of implant sockets drill 2 2 direc
20. f 1993 JANSENOT et Coll Int J Oral Maxillofacial Implantology 1993 R Condition de r alisation des actes d implantologie orale environnement technique Haute Autorit de Sant Juillet 2008 Gestion des complications implantaires LOUISE F J P I O 2005 k Expertise ORL pr implantaire quand la demander MAAREK H IMPLANT Vol 14 n 3 2008 amp Les Therapeutiques parodontales et implantaires MATTOUT PAUL Quintessence 2003 R Un cas de fracture implantaire Observation Clinique eten microscopie lectronique a balayage MATTOUT PAUL et Coll IMPLANT Vol 8 n 1 2002 R Peut on placer des implants chez un patient sous biphosphonals MILLIEZ S Information dentaire n 12 Mars 2009 k Complications post implantaires gestion et pr sentation MAAREK HARRY IMPLANT Vol 15 n 1 2009 amp Les checs en implantologie PANIS ROUZIER Th se Doctorat en Odontologie Montpellier 2006 k Facteurs de risques en chirurgie implantaire RENOARD F J P I O n 3 1998 r Rapport du Conseil M dical du SOU M dical SICOT C Groupe MACSF sur l exercice 2005 Les reconstructions osseuses en implantologie SOLYOM ERIC et Coll Revue implantologie Mai 2008 k Risques anatomiques a la mandibule en chirurgie implantaire StopHAN G et Coll IMPLANT Vol 12 n 1 2006 Evaluation quantitative de la r ussite implantaire
21. ical guides The surgical guide is made to measure for each case to ensure optimal fit regardless whether it is supported by bone mucosa or teeth Guide supported by Guide supported by Guide supported by bone mucosa teeth gt Guide supported by teeth This is indicated for partial implantation lt is simpler to use and put in place This is particularly useful when filling gaps When the dentition is terminal the guide has an anterior dental support but not posterior This zone is less stable in which case the anchoring wedges are used to ensure better guide stability gt Guide supported by mucosa This type of guide is required in the case of total or partial absence of teeth or a 30mm toothless zone its advantage over a bone borne guide is that it avoids flap surgery The guide rests on mucous membrane an excellently deformable surface and to ensure better guide stability anchoring wedges are used However these wedges must be inserted carefully and particular care must be taken not to generate asymmetric forces that can shift the guides in one direction or another The best way to avoid errors of this type during this step is to use the rigid occlusion positioning key Obviously the surgical guide should be positioned under the same conditions as the radiological guide during the acquisition so as to obtain the equivalent deformation of the mucosa gt Guide supported by bone This is indicated when a flap needs to
22. ithography is now what we could call the missing link in classic implant treatments as well as for other techniques in development robotization magnetic navigators and infrared drill positioning Guide manufacturing process g S Manufacturing machine L Guide after cleaning k J Guide at the exit from the machine Cleaning of the guide pa A Setting up of the titanium guiding rings Surgery GUIDE Composition and storage of the surgical guide It is composed of a material resin that is sensitive to gt Store the surgical guide in a dry place away from light ultraviolet rays to temperature and to humidity light in particular away from direct sunlight at room We therefore recommend temperature 10 30 C gt The surgical guide should be stored with a humidity gt Never expose the guide to liquids water or other absorbant never take it out as it runs the risk of for more than 30 minutes as there is a high risk of altering its dimensional stability It must be kept in the deformation protective packaging in which it was delivered until as close as possible to the time of surgical intervention Disinfecting the surgical guide The surgical guide is not sterilizable by autoclave only disinfection is possible Soak the guide in chlorohexidine for maximum 20 mins then dry it quickly without using a heat source Types of euroteknika surg
23. n assessing a patient before any implant surgery A detailed study of the patients general state of health their clinical history their oral hygiene their motivation and their expectations are an integral part of the pre operative assessment lt is recommended that a physician be consulted if the patient s clinical history reveals a pre existing condition or a potential problem that may compromise their treatment and or well being Intra oral examination gt Bone quality and quantity gt Cooperation This is necessary during the treatment as strict hygiene is rigorously necessary To obtain the patient s cooperation motivation is essential The practitioner must inform motivate and teach their patient how to brush and to use each of the personally adapted instruments The practitioner must determine whether the patient has an acceptable basic anatomy favorable to inserting an implant The patient must have sufficient bone volume qualitatively and quantitatively Primary stability is easily obtained with the preservation of cortical bone and minimal bone loss Most authors report the best success with type to III bone Lekholm and Zarb classification rather than type IV bone The classification of osseous structures 1 very high density of compact bone 2 thick layer of cortical bone around a dense core of spongious tissue 3 thin layer of cortical bone around a big core of spongious tissue 4 thin layer of cortical b
24. one around a big core of low density of spongious tissue important quality of remaining alveolar bone limited resorption of the alveolar bone crest important resorption of the alveolar bone crest beginning of the basal resorption bone important resorption of the basal bone Moo gt Misch 1998 Lekholm and Zarb 1985 Classification of partially edentulous arches for implant dentistry Some areas must be avoided in particular when immediate treatment is undertaken as they have a low proportion of trabecular bone lt is therefore more difficult to obtain good primary fixation in these zones For example in front of the sinuses in the premaxillary the bone is type II or III while behind in the tuberosity the bone is often type IV The surgical procedure must therefore need to be adapted to these low density zones under drilling and search for bi cortical anchorages Furthermore if a bone fault is present in the cortical bone or If there is a major fault in the trabecular bone the GS as well as the immediate treatment of the implant can become complicated This could also contraindicate the insertion of the implant with bone regeneration at the same time gt In the vestibulo lingual sense If possible leave 2x1mm of bone thickness a vestibular and ligual bone wall of 1mm around the implant When implants need to be placed in an esthetic sector the thickness of the vestibular wall must be greater than
25. or equal to 2mm gt In the corono apical sense In the maxilla the crestal height necessary is equal to the length of the implant a penetration of 1 to 2mm in the sinus is tolerated Nadir et al 2004 In the mandible the height necessary is equal to the length of the implant 2 5mm Note that bone density is a determining factor in selecting the implant We recommend using the largest implants in low density bone in order to compensate for the loss of bone implant surface contact due to the cavities Sufficient quantity of keratinized tissue In the case of deficit at the implant site a prior arrangement or flap procedure will be necessary to an apical displacement of tissue gt In the mesio distal sense Ensure 1 5 to 2mm between the external surface of the implant and the adjacent teeth Ensure 3mm between the external surfaces of two adjacent implants Minimum recommended buried length D1 8 mm S D2 10 12 mm 2 D3 12 14 mm D4 14 mm stroj teknika GROUP LI I I f Pre surgical INVESTIGATIONS Presence or not of infection Caution is rigorously required Healing must be total An implant treatment cannot be started before complete after a graft procedure extraction or curettage of an cleaning of all infectious sites infectious site curettage of the rest of the periodontal ligament of a periodontal or periapical infection or granuloma must be done before the tr
26. plaster models Any modifications can be done by teknika3D in collaboration with the practitioner The practitioner approves the treatment plan in writing The surgical guide is then fabricated using the stereolithographic process in our production center in Sallanches 74 France This is a highly accurate fast prototyping technique Receiving the surgical guide It takes about 10 days between the simulation being sent via internet validation by our teknika3D team and the surgical guide being received see the table of the steps involved in the treatment It is necessary to incorporate this length of time into the planning of any intervention Practitioners who are used Verification of the surgical guide fit in the mouth Once received the surgical guide should be tried in the mouth to ensure its conformity It can happen that the guide is not properly adapted that it wobbles in which case it must be redone There is thus a risk of the surgery being postponed if the timing is too tight Surgical procedure For more details about the surgical procedure see pages 26 to 32 step by step operative procedure to treating patients for whom treatment time is critical or in an emergency must take the time to explain to them the benefits of guided surgery in terms of effectiveness accuracy and reduced post operative complications Important information ABOUT THE SURGICAL GUIDE The customized surgical guide produced by stereol
27. rocedure flapless technique with mini flap or with flap gt Immediate treatment or deferred treatment gt A prefabricated prosthetic or a conventional one Note that all the following criteria must be met gt The patient meets all the necessary health requirements for surgical intervention gt Healing is total after a graft procedure gt Bone quantity and quality is satisfactory gt The mouth opening is large enough and suitable for the surgical instruments Advantages and benefits OF GUIDED SURGERY gt It helps you decide on an implant treatment with the ability to preview the results as the system is very reliable allowing optimal positioning of implants with no margin for error gt Analysis of bone density this presents surgical and prosthetic choices the surgical sequence the number of implants their positions their Angolaziones their prosthesis type etc gt Maximum use of bone volume implantations gt Calculate the volumes to be grafted choose the donor site gt Orient the implant precisely mesiodistally and vestibulolingually gt Simplify protocols and increase the surgical treatment success rate gt Control bone grafts and even in some cases reduce graft indications by using the maximum remaining bone volume gt Allow perilous or difficult implantations research bicortical support lateralization of implant vector compared to the dental nerve no more timid gt
28. s of indications These guides are very precise but are not absolute and should not detract from ensuring adequate surgical leeway aye teknika GROUP I I 1 11 General information ON GUIDED SURGERY Process OF GUIDED SURGERY Examination of the patient TTT gt y Partial or total implantation y With radiological guide y Elaboration of the radiological guide for more details see page 15 y Imaging Double scanning y Transferring the DICOM files of the guide itself and of the patient s bone mass to the teknika3D planning software Partial implantation only y Without radiological guide y Taking an impression and making plaster models y Imaging Scanning the patient y Sending the DICOM file and plaster models to the teknika3D production center y Scanning plaster models and transferring the two files DICOM of the bone mass and the scanner model to the teknika3D software Treatment plan y Surgical guide manufacturing teknika3D Making the provisional or definitive prosthesis PRE IMPLANT STUDY Pre implant STUDY Clinical radiological EXAMINATIONS Successful guided surgery requires substantial prior clinical and implant experience The diagnosis must be minutely precise as many factors need to be taken into consideration for the therapy to work Patient profile gt General condition Many important factors must be taken into account whe
29. sertion depth of the implant gt Minimum overheating to avoid all irreversible bone necrosis The socket preparation will be made under constant external irrigation with sodium chloride at 0 9 The critical temperature threshold is 47 C for 1mn At 50 C the necrosis is irreversible minimum heating will be achieved with irrigation with a proper selection of drills with a good Ing aration drills after 10 uses The obtainment of a calibrated socket assuring a good airtightness The instruments are sorted by their stage of use as shown by arrows on the kit Numbers notify the main stops of each stage This kit contains all the instruments necessary to the guide fixing the first drilling 2 2 and the gingival punch Positionning needles Drill for positionning needles Drills 2 2 with stops Gingival cutters guides NP sleeve the distance bet l ween the surface of the sleeve and the neck of the implant is 10 mm Placement OF TITANIUM SLEEVES The position of the titanium sleeves on the surgical guide is fixe The top of the sleeve is 10 mm above of the implant neck Gum lt 4 mm Flapless TECHNIQUE 1 Verification of the stability of the surgical guide Once received the surgical guide should be tried in the mouth to ensure Its conformity lt can happen that the guide is not properly adapted that it wobbles in which case it must be r
30. tly guided in the sleeve The 2 2 drills have stops and come in five different lengths 6 8 10 12 14 mm Drill 2 2 Drill until the fixed stop under constant irrigation with sodium chloride at a speed of 1000 rpm Do not force the drill If it binds it indicates that bone debris is not exiting up the flutes A carefully controlled simple back amp forth movement creates easy drilling Doing this at the right moment avoids needing to reverse the motor If the drill is stuck it can be released by using reverse mode It is also important to make back amp forth movements to keep the drill tip cool inside the guide NP sleeve Guide sleeve Y 2 2 Surgical guide When drilling check that the bone is bleeding If it is not scrape the bone a bit to make it bleed with a probe or a curette which can pass through the guide sheath without compromising the stability of the surgical guide In the absence of blood flow it is preferable to close and wait for blood flow For example on a implant 10mm long following the gum height 6 Removal of the guide At the end of the intervention the guide is removed and any excess mucous tissue that may hamper the insertion of the prosthesis is removed 7 Removal of soft tissue Setting of the gingival punch guiding tool and passing the I gingival punch Gingival punch nn guide of Set the motor speed at 400 rpm with irrig
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