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STEREOLITHOGRAPHIC IMPLANT SURGICAL GUIDE FOR ACCURATE IMPLANT PLACEMENT-A CASE REPORT

ABSTRACT:
The placement of dental implants is a challenge for clinicians because of existing anatomy and high esthetic and functional demands1,2. This article presents a case for implant placement for complete oral rehabilitation with implants.

Guided surgery is accepted as the most accurate way to place an implant and predictably relate the implant to its definitive prosthesis, although few clinicians use it.3Virtual Implant placement was planned using CBCT scan, casts with trial denture bases, Implant planning software and prosthetic designing software  were used fabricate a stereolithographic surgical guide.

The article describes the successful application of digital technology in the production of the surgical template for accurate placement of Osseo integrated implants.

Keywords: Computer-aided design, computer-assisted manufacture, surgical template, guided implant surgery.

The implant location and type were finalised after fusing the cbct and Procera scanner generated surface scan. The Nobel Active Implants were selected and surgical guide template was generated within the software planning in Nobel Clinician.

The software generated surgical guide STL (Stereo Lithography file format) file was exported and stereolithographic 3D printed surgical guide was fabricated for Nobel Active Implant.

The surgical guide was checked for fit and seating. The guided surgical kit for Nobel active implants was used in the surgical protocol and implant insertion achieved using the prescribed drill sets for the selected implants .

The implant insertion was achieved in a flapless environment and immediate transmucosal healing abutments were placed. The immediate post operative intraoral periapical xray views were taken to verify the implant placement. The patient was recalled for check up and next phase of prosthetic rehabilitation.

Discussion
Digital technology has proved an invaluable tool in the way we diagnose the condition and plan the treatment.1,3,6 However, even the best of plans seems worthless if not properly executed.  Anatomical limitation and better prosthetics demands the clinician to gain more precision in surgical positioning of dental implants.5,6 During oral implant placement, the drill (position, depth and angulation) must be guided by the clinician according to the final form of the prosthetics. Ideal placement facilitates the establishment of favourable forces on the implants and the prosthetic component. In this regard, surgical guides have shown better predictability of placement improving better prosthetic results. Several guides have been reported in the literature such as self/light cure acrylic resin, metal reinforced acrylic templates, vacuum formed polymers, milling, CAD-CAM prosthesis, stereo lithographic models. Out of these; Milling, CAD-CAM prosthesis or stereo lithographic models have provided good results.

CONCLUSION:
Prosthetically driven implant restorations insures good esthetics, function and hygiene maintenance enabling long time success. Accuracy in treatment planning and execution of planned treatment is vital for this success. Continious advancements that have occurred in planning treatment (virtual software) for implant prosthesis have generated an equal rise in transferring the planned therapy to surgical realization. In this regard, surgical templates have enabled clinician to deliver predictable surgical & prosthetic results. Surgical guides have not only decreased the chances of operator driven damage of critical anatomic structures; they also increase the aesthetic and functional advantages of restoration-driven implant therapy. If clinician is considered a pilot, then surgical guide is his navigator.

REFERENCES
1.   Babbush CA, Kutsko GT, Brokloff J. The all-on-four immediate function treatment concept with NobelActive implants: a retrospective study. The Journal of oral implantology 2011;37:431-445.
2.  Sarment DP, Sukovic P, Clinthorne N. Accuracy of implant placement with a stereolithographic surgical guide. Int J Oral Maxillofac Implants 2003;18:571-577.
3. Malo P, de Araujo Nobre M, Lopes A. The use of computer-guided flapless implant surgery and four implants placed in immediate function to support a fixed denture: preliminary results after a mean follow-up period of thirteen months. The Journal of prosthetic dentistry 2007;97:S26-34.
4.  D’Urso PS, Atkinson RL, Lanigan MW, Earwaker WJ, Bruce IJ, Holmes A, et al. Stereolithographic (SL) biomodelling in craniofacial surgery. British journal of plastic surgery 1998;51:522-530.
5. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically directed implant placement using computer software to ensure precise placement and predictable prosthetic outcomes. Part 3: stereolithographic drilling guides that do not require bone exposure and the immediate delivery of teeth. Int J Periodontics Restorative Dent 2006;26:493-499.
6. Ramasamy M, Giri, Raja R, Subramonian, Karthik, Narendrakumar R. Implant surgical guides: From the past to the present. J Pharm Bioallied Sci 2013;5:S98-102