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Optimization in Multi-implant Placement for
Immediate Loading in Edentulous Arches
Using a Modified Surgical Template and
Prototyping: A Case Report
Sérgio J. Jayme, DDS, MScD1/Valdir A. Muglia, DDS, MScD, DSc2/ Rafael R. de Oliveira, DDS, MScD3/Arthur B. Novaes Jr, DDS, MScD, DSc4 Immediate loading of dental implants shortens the treatment time and makes it possible to give thepatient an esthetic appearance throughout the treatment period. Placement of dental implantsrequires precise planning that accounts for anatomic limitations and restorative goals. Diagnosis canbe made with the assistance of computerized tomographic scanning, but transfer of planning to thesurgical field is limited. Recently, novel CAD/CAM techniques such as stereolithographic rapid proto-typing have been developed to build surgical guides in an attempt to improve precision of implantplacement. The aim of this case report was to show a modified surgical template used throughoutimplant placement as an alternative to a conventional surgical guide. (Case Report) INT J ORAL MAXILLO- Key words: computerized tomography, dental implants, immediate function/loading, stereolithography,surgical templates Patient desires for shorter treatment periods and and in most cases it is possible to obtain bicortical preservation of the esthetics at all stages of treat- anchorage and primary stability of the inserted ment have stimulated clinicians to explore immedi- implants. Primary stability is considered key to imme- ate loading of dental implants. The majority of imme- diate loading7,8; however, due to a lower bone den- diate-loading studies have limited their interest to sity in the maxilla, immediate loading in this region is the anterior region of the mandible.1–6 In this region perceived as a greater challenge than in the both bone quantity and quality are usually excellent, mandible. Furthermore, implant anchorage in thetotally edentulous maxilla is often restricted due tobone resorption, which is especially frequent in theposterior region of the maxillary arch, where bonegrafting is often indicated.
1Graduate Student of Prosthodontics, Department of Dental Rehabilitation of the maxilla requires a protocol in Materials and Prostheses, School of Dentistry of Ribeirão Preto, which implants are positioned according to the University of São Paulo, Ribeirão Preto, SP, Brazil.
requirements of the restorative phase and not by the 2Assistant Professor of Prosthodontics, Department of Dental bone condition available in the region.9 This Materials and Prostheses, School of Dentistry of Ribeirão Preto,University of São Paulo, Ribeirão Preto, SP, Brazil.
approach requires an appropriate bone volume to 3Graduate Student of Periodontology, Department of Bucco-Max- sustain the implant and consequently provide sup- illo-Facial Surgery and Traumatology and Periodontology, School port to the soft tissues, which is essential to an ade- of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão quate prosthetic profile. The selection and positions of the implants are defined by the prosthetic restora- Chairman of Periodontology, Department of Bucco-Maxillo-FacialSurgery and Traumatology and Periodontology, School of Den- tions from the diagnostic waxup and later from the tistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, surgical template.10 The healing and maturation of the soft tissues are guided by the temporary restora-tion, which aids the formation of the papillae Correspondence to: Dr Arthur B. Novaes Jr, Faculdade de Odonto- through the orientation of the emergence profile, logia de Ribeirão Preto, Universidade de São Paulo, Av. do Café s/n,14040-904, Ribeirão Preto, SP, Brasil. E-mail: novaesjr@forp.usp.br which is shaped by the temporary prosthesis.
The International Journal of Oral & Maxillofacial Implants COPYRIGHT 2007 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER In cases where the treatment requires the place- ment of several implants for the rehabilitation of thefull arch, the positions of the implants should be A healthy male patient, 50 years old, with a noncon- ideal because the prosthetic restoration should tributory medical history, presenting with multiple be able to reproduce exactly what was obtained in tooth loss with some remaining maxillary teeth (right the diagnostic waxup. For diagnosis, computerized second molar, left canine, left second molar) was tomographic (CT) scanning is a precise, noninvasive referred to the authors for oral rehabilitation treat- surveying technique.11–15 Visualization of CT scan ment. At the first periodontal visit, the compromised images by the clinician can be achieved using periodontal sites were detected by clinical and radio- printed film or computer software packages,16,17 graphic examination. Occlusal adjustments and full- which allow for 3-dimensional viewing using com- mouth scaling and root planing were performed.
puter-aided design technology.18,19 When coupled After comprehensive oral hygiene instruction and with templates worn at the scanning visit, visualiza- the achievement of satisfactory levels of plaque con- tion of the restorative plan also improves presurgical trol, the patient was ready for the reconstructive evaluation.20–23 In addition to visualization and the surgeries. Severe residual ridge resorption was ability to evaluate bone density,24 these software detected in a radiographic analysis, and since the programs allow for placement of virtual implants to treatment of choice was implant placement, bone further assist the surgeon in foreseeing positioning grafting was necessary (Fig 1). For the posterior and size of implants prior to surgery.25,26 However, region of the maxilla, a bone graft (anorganic bovine the transfer of a sophisticated plan to the surgical matrix/P-15 [PepGen P-15 flow; Dentsply Friadent, field remains difficult. To overcome this issue, several Mannheim, Germany] and calcium phosphate of novel approaches have been developed, one of plant origin [Algipore; Dentsply Friadent]) plus which utilizes a computer-aided manufacturing tech- platelet-rich plasma was per formed bilaterally nique to generate bone-supported surgical guides as through maxillary sinus floor elevation by the Cald- well as anatomic models that can fit intimately with well-Luc approach. For the anterior region of the maxilla, guided bone regeneration was performed Prototyping produces a physical cast of a selected using an e-PTFE nonresorbable membrane (TefGen- anatomic region in real scale, making it possible to Plus, Lifecore Biomedical, Chaska, MN) plus calcium plan the position, distribution, and size of the phosphate of plant origin (Algipore) as the grafting implants as well as facilitating the construction of a material. After a healing period of 6 months, the more accurate surgical template.27 The use of acrylic bone topography was reacquired and the surgical- resin dental casts obtained from the CT scan, allows the best surgical planning in obtaining the precise 3- During treatment planning, the immediate load- dimensional position of the implant.28 The aim of this ing protocol was selected, and a CT scan for the max- case report was to show a modified surgical tem- illa prototype construction was obtained (Fig 2). This plate which remains stable, with the assistance of the examination allowed precise planning of the surgical antagonist arch, throughout the surgical procedure and prosthetic treatment. Initial study dental casts as an alternative to the conventional surgical guide.
were obtained to define the sequential phases of the COPYRIGHT 2007 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER Implants positioned in the prototype.
the drilling procedure. Note the stabilizationof the mandibular arch.
treatment planning. The dental casts were mounted 1:100,000. Antibiotics (amoxicillin 875 mg + clavulanic in a semiadjustable articulator, and a diagnostic acid 125 mg) were given 1 hour prior to surgery and waxup was produced. The waxup was transferred to daily for 6 days thereafter. A mucoperiosteal flap was the prototype, and an artificial gingiva was added to raised at the ridge crest with bilateral relieving inci- visualize the final result. The next step was pre-estab- sions on the buccal aspect in the second molar area.
lishing the implant diameter/length, position, and The surgical template was inserted and maintained in inclination. For that, 2 acrylic resin templates were position during the surgical procedure (Figs 5 and 6).
constructed, one for the maxilla and other for the Twelve rough-surface acid-etched self-tapping screw- mandible. Titanium tubes with a diameter of 2 mm type implants 3.8 mm in diameter and 13 mm in were placed in the maxillary surgical template in a length were used to replace the missing maxillary predetermined position and inclination. With the teeth. The implant sites were sequentially enlarged to template in position, the patient was sent to a radiol- 3.8 mm in diameter with pilot and spiral drills accord- ogy center for a linear tomography. With the tomog- ing to the standard surgical protocol. After this, the raphy it was possible to check the inclination of the implants were placed according to the manufacturer’s titanium tubes in relation to the bone ridge and con- instructions. In sequence, the transfer posts were sequently the position and inclination of the initial placed, and an impression was made from the already-placed implants to build a model in which Simulation of the implant placement surgery in the adjustments to the temporary prostheses could be prototype was performed with the surgical template.
performed. After impression making the flaps were After this, it was possible to individualize the abut- repositioned and sutured with nonresorbable sutures.
ments and to construct the temporary prosthesis (Fig Sufficient primary stability plays an important role 3). After checking all inclinations, the maxillary and in immediate loading. In order to maintain this stabil- the mandibular templates were joined through lip ity, rotational forces should be avoided. Here the and cheek retractors with acrylic resin, becoming a abutment of the implant used (Tempbase; Dentsply Friadent) was ideal because it is a premounted abut- Following the review of all planning procedures ment that served as an insertion abutment and was a the surgical procedure was scheduled. The surgical basis for temporary restorations. A change of abut- procedures were performed under local anesthesia ments was not necessary, and torque stress was with mepivacaine chlorhydrate with epinephrine avoided. A torque of more than 30 Ncm during inser- The International Journal of Oral & Maxillofacial Implants COPYRIGHT 2007 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER 8. Ostman PO, Hellman M,Wendelhag I, Sennerby L. Resonance fre- quency analysis measurements of implants at placementsurgery. Int J Prosthodont 2006;19:77–84.
9. Garber DA, Belser VC. Restoration-driven implant placement with restoration-generated site development. Compend Contin EducDent 1995;16:796–804.
10. Touati B. Double guidance approach for the improvement of the single-tooth replacement. Dent Implantol Update1997;8:89–93.
11. Klinge B, Petersson A, Maly P. Location of the mandibular canal: Comparison of macroscopic findings, conventional radiography,and computed tomography. Int J Oral Maxillofac Implants 1989;4:327–332.
12. Quirynen M, Lamoral Y, Dekeyser C, et al. CT scan standard recon- sional restorations in position (occlusal view).
struction technique for reliable jaw bone volume determination.
Int J Oral Maxillofac Implants 1990;5:384–389.
13. Todd AD, Gher ME, Quintero G, Richardson AC. Interpretation of linear and computed tomograms in the assessment of implantrecipient sites. J Periodontol 1993;64:1243–1249.
14. Tyndall AA, Brooks SL. Selection criteria for dental implant site imaging: A position paper of the American Academy of Oral andMaxillofacial Radiology. Oral Surg Oral Med Oral Pathol OralRadiol Endod 2000;89:630–637.
15. Tepper G, Hofschneider UB, Gahleitner A, Ulm C. Computed tion indicates that temporary restoration of the tomographic diagnosis and localization of bone canals in the implant is possible. The temporary abutment was mandibular interforaminal region for prevention of bleedingcomplications during implant surgery. Int J Oral Maxillofac placed on the model and finished in the laboratory.
The provisional restoration was then placed and 16. Rothman SL, Chaftez N, Rhodes ML, Schwarz MS, Schwartz MS. CT cemented (Fig 7) for refinement, and occlusal adjust- in the preoperative assessment of the mandible and maxilla for ments were performed. The patient was instructed to endosseous implant surgery.Work in progress. Radiology 1988; eat a soft diet for 4 weeks postsurgery. Biting any- 17. Cavalcanti MG,Yang J, Ruprecht A,Vannier MW.Validation of spi- thing hard or tearing food was discouraged. At 1 ral computed tomography for dental implants. Dentomaxillofac month the patient was converted to a harder diet.
Analgesics were given on the day of surgery and 18. Kraut RA. Utilization of 3D/Dental software for precise implant postoperatively for the first 3 days as needed.
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19. Verstreken K,Van Cleynenbreugel J, Martens K, Marchal G, van Steenberghe D, Suetens P. An image-guided planning system forendosseous oral implants. IEEE Trans Med Imaging 1998;17: 20. Israelson H, Plemons JM,Watkins P, Sory C. Barium-coated surgi- 1. Balshi TJ,Wolfinger GJ. Immediate loading of Brånemark cal stents and computer-assisted tomography in the preopera- implants in edentulous mandibles. A preliminary report. Implant tive assessment of dental implant patients. Int J Periodontics 2. Brånemark P-I, Engstrand P, Öhrnell LO, et al. Brånemark Novum.
21. Basten CH.The use of radiopaque templates for predictable A new treatment concept for rehabilitation of the edentulous implant placement. Quintessence Int 1995;26:609–612.
mandible: Preliminary results from a prospective clinical follow- 22. Mizrahi B,Thunthy KH, Finger I. Radiographic/surgical template up study. Clin Implant Dent Relat Res 1999;1:2–16.
incorporating metal telescopic tubes for accurate implant place- 3. Chiapasco M, Abati S, Romeo E,Vogel G. Implant-retained ment. Pract Periodontics Aesthet Dent 1998;10:757–765.
mandibular overdentures with Brånemark System MkII implants: 23. Sarment DP, Misch CE. Scannographic templates for novel pre- A prospective comparative study between delayed and immedi- implant planning methods. Int Oral Implantol 2002;3:16–22.
ate loading. Int J Oral Maxillofac Implants 2001;16:537–546.
24. Norton MR, Gamble C. Bone classification: An objective scale of 4. Ericsson I, Randow K, Nilner K, Peterson A. Early functional load- bone density using the computerized tomography scan. Clin ing of Brånemark dental implants. 5-year clinical follow-up study.
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25. Jeffcoat MK. Digital radiology for implant treatment planning 5. Schnitman PA,Wöhrle PS, Rubenstein JE, DaSilva JD,Wang NH.
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Ten-year results for Brånemark implants immediately loaded 26. Verstreken K,Van Cleynenbreugel J, Marchal G, Naert I, Suetens P, with fixed prostheses at implant placement. Int J Oral Maxillofac van Steenberghe D. Computer-assisted planning of oral implant surgery: A three-dimensional approach. Int J Oral Maxillofac 6. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches.Ten consecu- 27. Sarment DP, Sukovic P, Clinthorne N. Accuracy of implant place- tive case reports with 1- to 5-year data. Int J Oral Maxillofac ment with a stereolithographic surgical guide. Int J Oral Maxillo- 7. Lioubavina-Hack N, Lang NP, Karring T. Significance of primary 28. Klein M, Abrams M. Computer guided surgery utilizing a com- stability for osseointegration of dental implants. Clin Oral puter-milled surgical template. Pract Periodontics Aesthet Dent COPYRIGHT 2007 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER

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Algunos problemas del cambio del Núcleo Normativo Constitucional del Derecho como sistema complejo1 Profesora de carrera académica, Facultad de Jurisprudencia, Universidad del Rosario, Bogotá, Colombia Teléfono: 57 1 2970200 Ext.: 455. Fax: 57 1 2970296. Dirección electrónica: ropena@urosario.edu.co Resumen Actualmente el derecho se considera un sistema dinámic

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