In this month’s edition, I wanted to discuss advances in full arch implant dentistry specifically on the guided surgical aspect. Technology such as Cone Beam CT (CBCT) and digital scanning have become more common in use, leading to the next logical progression of alignment of this information with photographs and digital smile design (Fig 1). Traditionally, full arch dental implant surgery and teeth in a day procedures require a temporary denture for the conversion process. The temporary denture is soft tissue supported and often will require chair side modification to allow for fixation to the dental implants. The chrome guided surgery procedure allows for a prefabricated temporary to be attached to the dental implants in a sequential step by step fashion. This helps to speed up the procedure accuracy and prevent any potential misfit or alignment issues.
A typical case workup will involve obtaining a CBCT in order to plan implant positioning including any required bone adjustment or removal. Implant orientation and multiunit abutments required are chosen ahead of time based on positioning relative to the planned temporary prosthetic. A series of photographs helps in the 3D design process of the temporary prosthetic including increase in case acceptance with simulated before and after shots. (Fig 2)
Traditionally, a temporary denture is fabricated ahead of time and it is converted chair side by attaching it to the implants on day of surgery. The temporary denture is typically soft tissue supported and requires modification to align relative to the implant positions. Often, the prosthetic phase of treatment in a same day conversion can be longer than the surgical placement of the dental implants. In contrast, the chrome guide system provides a temporary that does not require flange removal or extensive modification for delivery. (Fig 3)
The chrome guide system is a custom made surgical guide based on the patient’s 3D planning from CBCT data in conjunction with smile design photos. Typical guides often require multiple inserts and removal for each step in the process (extractions, bone reduction, implant placement, multi-unit abutment insertion, temporary positioning and attachment to implants.) This can cause error and deviation if each subsequent guide is not aligned perfectly in the steps to follow. Furthermore, most guides designed obstruct the view of osteotomy preparation or may not allow adequate irrigation. (Fig 4) The chrome guide system has an open design, which once fixated on the base guide, allows for an unobstructed view of your osteotomy preps while ensuring rigidity of the implant placement guide to minimize any potential deviation. The temporary prosthetic and alignment of dental implants is planned ahead of time to coincide as based on CBCT data. It is important to note the strength of the temporary prosthetic in the chrome guide protocol, which is typically made of a nanoceramic material in comparison to typical acrylic in a converted denture.
Typical teeth in a day procedures will have a patient in a temporary prosthetic for several months. This is important to ensure stability and integration of the dental implants but also to work out any issues related to occlusion or esthetic concerns. It is important to work out any of these discrepancies prior to fabrication of the final prosthetics. (Fig 5)
Advances in dental implant surgery, 3D printing and digital smile design have made it easier and faster to perform full arch rehabilitation. Although technology can be a great tool, it does not replace the clinical judgment and the required surgical and prosthodontic training for these cases.
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