52 starget 1 i 12 cares vincenzo mirisola di torresanto...

52 STARGET 1 I 12

viNCeNzO MiriSOLA Di TOrreSANTO AND LUCA COrDArO

Guided surgery as a way to simpli fy surgical implant t reatment in complex cases

Background

A 41-year-old woman with an edentulous maxilla and bilateral

edentulous region (Kennedy Class I) in the mandible wanted

removable restorations for both arches (Figs. 1, 2).

Due to prosthetic constraints (reduced inter-arch distance and

short upper lip interfering with prosthetic flanges), a fixed im-

plant-supported restoration was suggested even though the

edentulous maxilla and posterior mandible exhibited atrophy

(Fig. 3).

Treatment plan

The following plan was worked out to provide the patient

with the simplest and most predictable surgical treatment pos-

sible.

Maxilla: conventional procedure

Complex reconstruction with bilateral sinus lift and autog-

enous particulate bone harvested from the chin and multiple

bone block grafts harvested from the ramus; four months after

insertion of six implants and loading after an additional eight

weeks with an FPD (Figs. 4 – 12).

Fig. 5Fig. 4 Fig. 6

Fig. 1

FiGS 4-12: MAxiLLA, CONveNTiONAL PrOCeDUre

Fig. 2 Fig. 3

S t r a U M a N N ® C a r e S ® G U i d e d S U r G e r yG U i d e d S U r G e r y

53STARGET 1 I 12

Vincenzo Mirisola di Torresanto, DDS

Degree in Dentistry and Dental Prosthetics. Clinical researcher

at the Department of Periodontology and Prosthodontics at

Eastman Dental Hospital in Rome, Italy. Awarded the H.M.

Goldman Prize by the Italian Society of Periodontology for his

clinical research in 2007. various national and international

publications and lectures. ITI member and co-director of the

ITI Study Club of Rome. Private practice in Rome.

Mandible: guided surgery

The mandible exhibited severe horizontal and vertical atrophy in the lateral-pos-

terior region and remaining frontal dentition (from canine to canine), which, even

if compromised, was considered maintainable after a periodontal non-surgical

phase. After all, bone-harvesting sites in the chin and retro-molar region had al-

ready been used for maxillary surgery.

A guided surgical procedure was planned and proposed in order to offer the

patient the possibility for a less invasive surgical procedure. In addition, this

would allow for the safe insertion of smaller implants, without requiring ad-

ditional bone augmentation.

Fig. 11 Fig. 12Fig. 10

Fig. 7 Fig. 8 Fig. 9

S t r a U M a N N ® C a r e S ® G U i d e d S U r G e r y

54 STARGET 1 I 12

Fabrication of templates and computer-assisted planning

The scan template was fabricated at the laboratory follow-

ing the official guidelines of the Straumann® Guided Surgery

system: the initial template was fabricated with a suck-down

technique and then filled with radiopaque material. Next, the

templix reference plate was attached to the suck-down tem-

plate on the Gonyx™ set with the D coordinate in the zero po-

sition before being completed for fitting in the patient’s mouth.

The DICOM data from the CT scan was processed with the

coDiagnostix™ software. The virtual planning strategy was to

bypass the anatomical structures and make use of all avail-

able bone by using a safe and predictable procedure that

remained simple and affordable for the patient. The proposed

restoration was designed as a three-unit (44 – 46, 34 and

3.6), bilateral implant-supported FDP (Figs. 13, 14).

The decision was made to insert two implants on each side in

the first premolar and first molar positions. The 3D bone scan

showed a reduced height and width in the molar sites and

reduced width in the premolar sites (Fig. 15).

All implants were planned so as to maintain a distance of

at least 2 mm from the alveolar nerve. Insertion of a Strau-

mann® Tissue Level Implant RN ø 3.3 mm SLActive® 10 mm

was planned for both premolar sites. However, despite the

selection of a reduced diameter implant, the virtual model of

the inserted implant at 4.4 showed a marginal dehiscence

(Fig. 16). For the distal implants, a Straumann® Tissue Level

Implant RN ø 4.1 mm SLActive® 6 mm was planned for each

side. Again, the virtual model of the implant inserted on the

right side showed a minor marginal dehiscence (Fig. 17).

Fig. 16Fig. 16 Fig. 17Fig. 17 Fig. 18Fig. 18


FiGS 13-30: GUiDeD SUrGery


55STARGET 1 I 12

Luca Cordaro, MD, DDS, Ph.D.

Currently, Head of the Department of Periodontology

and Prosthodontics at the Eastman Dental Hospital in

Italy. Private practice in Rome, Italy. Active member of

the Italian Society of Osseointegration. Fellow of the ITI

and Chairman for the Italy chapter of the ITI, Chairman

of the Study Club Committee and member of the Board

of Directors. Author and co-author of scientific papers

and literature, international lecturer. Dr. Cordaro’s

professional interests are periodontology, implantology

and oral surgery, with a special focus on reconstructive

treatments for alveolar atrophies.

gonyx™: Device for surgical template fabrication

S t r a U M a N N ® C a r e S ® G U i d e d S U r G e r y

The planning for the axial inclination of the implant was anatomically-driven rather

than prosthetically-driven.

Using coDiagnostix™, it was determined that a 20° angulated abutment for the

distal implants would make it possible to achieve the required parallelism with

the mesial implants.

Because of the dehiscences of the implants planned for 4.4 and 4.6, a traditional

open flap procedure was chosen for the right side, while a flapless approach

was taken for the left side. Two ø 2.8 mm sleeves were inserted in the right side

of the surgical template; two ø 5.0 mm sleeves were inserted in the left side to

prepare for the complete preparation of the site as well for the guided insertion of

the implant (Fig. 18).

56 STARGET 1 I 12

Fig. 19Fig. 19 Fig. 20Fig. 20

Surgical procedure

Bilateral local anesthesia was administered. The surgical tem-

plate was placed and carefully checked to ensure stability

before beginning the procedure. The mucotomy on the left

side was performed by inserting a ø 4.3 mm round mucosa

punch through the sleeves (Fig. 19).

Implant sites 3.4 and 3.6 were prepared according to the

drilling protocol suggested by the co-Diagnostix™ software

(long and short drill sequence, (Figs. 20 – 22)), and the im-

plants were inserted with the handpiece set with a force

of 35 N and tightened manually after the template was re-

moved. On the right side, a muco-periostal flap with hori-

zontal incision at the top of the ridge and a distal vertical

incision were made (Fig. 23). Both sites were drilled with a

ø 2.8 mm drill (short for 4.6 and long for 4.4) through the ø

Fig. 23Fig. 23 Fig. 24Fig. 24

2.8 mm sleeve, with or without drill handle as required (Fig.

24). Implant site 4.6 was prepared with a ø 3.5 mm drill,

drilling freehand to a depth of 6 mm. Both right-side implants

were inserted with the handpiece set with a force of 35 N

and tightened manually. Similar to the dehiscences seen in

the virtual models of the implants, a vestibular dehiscence

occurred in the case of both right side implants: a GBR pro-

cedure with a bone substitute and a resorbable collagen

membrane was performed around each implant (Figs. 25,

26). The flap was opened, repositioned and sutured around

the healing abutment.

Prosthetic restoration

The implants were observed two months after surgery and

showed stability accompanied by no inflammation or pain.

In addition, the radiographic evaluation showed successful


Fig. 22Fig. 22

Fig. 21Fig. 21

57STARGET 1 I 12S t r a U M a N N ® C a r e S ® G U i d e d S U r G e r y

healing of the bone, without radiolucencies. A standard pros-

thetic protocol was followed.

Two cemented fixed dental prostheses (FDPs) were planned:

solid abutments for both mesial implants and 20° B angu-

lated abutments were selected, again based on the virtual

models (Fig. 27). Two porcelain-fused-to-metal triplicate FDPs

were fabricated (3.4-3.5-3.6 and 4.4-4.5-4.6) and fixed in

place with temporary cement (Figs. 28, 29).

Conclusion

In this case, the virtual planning models and the actual out-

come (Fig. 30) demonstrated that the Straumann® Guided

Surgery System ensures a high level of precision for the

purposes of implant positioning.

To achieve the most accurate results, a guided implant inser-

tion is recommended. This case was treated with Straumann®

Soft Tissue Level Implants, according to the routine protocol for

lateral-posterior rehabilitations. As a further consideration: in

the author’s opinion selecting Straumann® Bone Level Implants

is the best way to maximize the benefits of the system, poten-

tiality making it easier for the clinician when it comes to soft

tissue management (especially for flapless procedures) and

providing a wider range of options for prosthetics.

Combined with the ability to perform a predictable and

safe flapless procedure, one interesting indication for the

Straumann® Guided Surgery system is potentially the

bypassing of anatomical structures which – in carefully

selected cases and in the hands of experienced clinicians

– can reduce or eliminate the need for bone augmentation

and the associated treatment complications.

Fig. 30Fig. 30Fig. 29Fig. 29Fig. 28Fig. 28


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