534 Volume 34, Number 7 compendium July/August 2013

I
mplnt plcement using !guided" tec#nologies #s been
s#o$n to #%e greter ccurcy nd precision $#en compred
to &ree#nd tec#ni'ues( 534 Volume 34, Number 7 compendium July/August 2013
I
mplnt plcement using !guided" tec#nologies #s been
s#o$n to #%e greter ccurcy nd precision $#en compred
to &ree#nd tec#ni'ues(
1)7
*#is cn reduce t#e incidence o&
unto$rd in%ol%ement $it# %itl ntomic structures nd
minimi+e ptient morbidity(,)1-
.sing proprietry implnt)plnning so&t$re, implnts cn be !%irtully" plced t
/no$n pre)plnned dept#s nd ngultions in t#ree dimensions( 0urgicl guides
re t#en &bricted &rom t#e %irtul tretment pln &or #ig#ly ccurte
implnt plcement into t#e plnned implnt positions(
*#is use o& %irtul, guided tec#nologies contrsts $it# t#e prctice
commonly employed &or t#e plcement o& dentl implnts using t#e
con%entionl All)on)4
1
2Nobel 3iocre, $$$(nobelbiocre(com4 pro)tocol, concept t#t #s gined
cceptnce &or complete rc# restor)tion( *rditionlly, &ter clinicl e%lution,
t#e All)on)4 surgicl
$or/5o$ 6rst in%ol%es stndrd pnormic nd/or computed
tomogrp#y 27*4/cone bem 7* 2737*4 e%lution o& t#e ptient8s
ntomy $it# routine pre)tretment plnning( *#is leds to surgery
in%ol%ing &ull)rc# incision $it# &ull)rc# 5p ele%tion( I& neces)sry, l%eolr crest
le%eling is per&ormed( A prlleling guide is used
to %eri&y implnt ngultion( 9steotomies nd implnt plcement re
done &ree#nd( Implnts re commonly plced t30)degree ngles
2:)4 m;ill nd V)4 mndible4, nd ngled butments re t#en
plced s needed( *#e implnts re usully immeditely loded by
retro6tting n e;isting or ne$ denture prost#esis or by plcing 6;ed
pro%isionl restortion bsed on n butment)le%el impression t/en
t t#e time o& surgery( *#e pro%isionl restortion is scre$ retined(
*#e use o& computer)ided design/computer)ided mnu&ctur)ing 27A</7A:4 nd
digitl tec#nologies in orl nd m;illo&cil
surgery nd dentistry is no longer &uturistic concept( *#ese tec#)nologies re
being commonly used in dentl prctice tody(
17,1,
9%er
t#e pst decde t#e use o& 7*)guided dentl implnt surgery #s
incresed signi6cntly s concepts nd tec#ni'ues #%e become
more re6ned nd mny implnt mnu&cturers #%e dpted t#eir
implnt systems to t#ese ne$ tec#nologies( *#e All)on)4 concept
&or dentl implnt plcement nd restortion #s been discussed &or
mny yers( =ecently, t#e tec#ni'ue #s generted incresed interest
s #ig#ly &unctionl, est#etic, more cost)e>ecti%e lternti%e &or
lrger group o& ptients $#o could bene6t &rom &ull)rc#, implnt)supported 6;ed
restortion(
*#e purpose o& t#is rticle is to describe t#e All)on)4 7*)guided
surgery tec#ni'ue nd report on t#e 6ndings o& t#ree ptients
treted( ?c# o& t#e cses #d di>erent prost#odontic mngement(
*ec#ni'ue
7*)guided implnt plnning nd surgery is restorti%ely dri%en
tretment pln( It 6rst in%ol%es plnning n idel dentl restortion
Abstrct@ No longer merely concept &or t#e &uture, t#e use o& digitl tec#nologies
in dentistry #s become
common prctice tody( 7omputed tomogrp#y 27*4)guided dentl implnt surgery
#s gretly e;pnded
o%er t#e pst decde s concepts nd tec#ni'ues #%e become incresingly re6ned
nd more implnt
mnu&cturers #%e dpted t#eir implnt systems to t#ese ne$ tec#nologies( *#e
All)on)41 tec#ni'ue &or
dentl implnt plcement nd restortion, $#ile de%eloped some t$o decdes go,
#s recently generted
incresed interest s #ig#ly &unctionl, est#etic, cost)e>ecti%e lternti%e &or
lrge group o& ptients
$#o could bene6t &rom &ull)rc#, implnt)supported 6;ed restortion( *#e ut#ors
s/, !Are t#ese t$o
tec#nologies mrrige mde in #e%enA" *#is rticle describes t#e All)on)4 7*)
guided surgery tec#ni'ue
nd reports on t#e tretment 6ndings on t#ree ptients, ec# $it# di>erent
prost#odontic mngement(
7ombining All)on)4 *retment
$it# 7*)Buided *ec#nology@
*ec#ni'ue nd =eport o& *#ree 7ses
Bry 9rentlic#er, <:<C 9le Jensen, <<0, :0C Andre$ Doro$it+, <:<, :<C :r/
Adms, <<0, :0C
nd :rcus Abboud, <:<
7se report
All)9n)4 7*)Bui<e<0urBery
535 $$$(dentlegis(com/cced July/August 2013 compendium
&or ptientC t#is my be complete denture or, &or prtilly
edentulous ptient, dignostic $;)up o& t#e plnned restortions(
In t#e typicl guided surgery $or/5o$, t#e ptient t#en $ers n
crylic resin pplince 2!scn prost#esis"4, $#ic# incorportes t#e
idel ntomy nd position o& t#e plnned restortion2s4, $#ile
#%ing 7*/737* scn t/en o& #is or #er E$( Vrious types o&
6ducil mr/ers re embedded in t#e scn prost#esis(
*#e digitl imging nd communiction in medicine 2<I79:4
imges generted &rom t#e scns re t#en imported into t#ird)prty
proprietry so&t$res( *#e so&t$res use t#e 6ducil mr/er points
to lign t#e dt generted &rom t#e scn2s4, creting computer
imges t#t ccurtely relte t#e plnned restortion2s4 to t#e p)tient8s underlying
bony ntomy( Implnt positions nd ngultions
cn t#en be precisely plnned in %irtul en%ironment(
*#is %irtul tretment pln is t#en sent to mnu&cturer
or lbortory &or &briction o& n pplince t#t is used t t#e
time o& surgery to ccurtely plce t#e implnts in t#eir plnned
position2s4( :ost lrger implnt mnu&cturers o>er guided
surgery)speci6c instrumenttion &or 5pless implnt plcement(
F#en desired nd indicted, tec#ni'ues nd rmmentrium
re %ilble &or e;trctions, bone reduction, immedite implnt
plcement, nd immedite loding, ll o& $#ic# re commonly
used in t#e All)on)4 protocol(
Gtient 1
A 50)yer)old &ully edentulous mn presented desiring &ull)rc#,
6;ed m;illry restortion( De #d been $ering m;illry denture
&or - yers &ter premturely losing #is teet# &rom decy nd peri)odontl disese(
*#e denture #d ne%er been relined( Dis pst medicl
#istory $s noncontributory( Hinnces $ere problem &or t#e ptient(
An initil clinicl e;mintion t#t included con%entionl dentl
nd pnormic rdiogrp#s $s per&ormed 2Higure 14( A&ter n
e;tensi%e discussion o& t#e surgicl nd prost#odontic options,
n All)on)4/- option $it# retro6t o& #is e;isting m;illry den)ture s n immedite
#ybrid pro%isionl restortion $s plnned(
Hirst, #rd denture reline $s per&ormed on #is e;isting m;illry
Hig 5(
Hig ,(
Hig -(
Hig I(
Hig 2( Hig 3(
Hig 4(
Hig 7(
Hig 1(
Hig 1( Gtient 1(Greoperti%e rdiogrp#, &ully edentulous m;ill( Hig 2( Drd relined
m;illry denture, gutt perc# 6ducil mr/ers inserted( Hig3(
Virtul tretment pln@ si; implnts, ngled butments in plce( Hig 4( Virtul
tretment pln, le&t side( Note 30)degree ngled posterior implnt(
Hig 5(0urgicl guide creted stereolit#ogrp#iclly &rom t#e tretment pln(
Hig-(0urgicl guide secured in plce $it# guided stbili+tion pins(
Implnts plced &ully guided to plnned dept# nd ngultion $it# implnt mounts(
Hig7(Gostoperti%e pnormic rdiogrp#( Note #eling but)ment on implnt
m;illry le&t posterior implnt site, not immeditely loded( Hig ,( :;illry
denture dEusted nd retro6tted to llo$ &or titnium
butments to be embedded $it# lig#t)cured crylic resin( HigI(Gro%isionl
restortion secured $it# prost#etic scre$s s n immedite lod(
53- Volume 34, Number 7 compendium July/August 2013
7A0erep9r* J All)oN)4 7*)BuIded 0urBery
denture &or idel denture dpttion to t#e mucos( An occlusl
registrtion bet$een t#e denture nd opposing rc# $s &bricted(
Butt perc# points $ere dded to t#e m;illry denture s 6ducil
mr/ers 2Higure 24( As per t#e double)scn protocol, t$o ppropri)te scns $ere
t#en t/enKone o& t#e ptient $it# t#e denture nd
occlusl registrtion in plce nd second one o& Eust t#e denture(
*#e <I79: sets $ere t#en imported into t#e Nobel7linicin1
2Nobel3iocre4 plnning so&t$re( 3ecuse o& t#e trop#y o& t#e
m;illry ridge in $idt#, plcement o& si; implnts $s plnned
%irtully( 9ne 30)degree, regulr)dimeter ngled implnt $s
tretment)plnned posteriorly on ec# sideC &our nrro$)plt&orm,
%erticlly positioned implnts $ere plnned in t#e nterior res
2Higure 3 nd Higure 44( 9nce completed, t#e pln $s digitlly
sent to t#e mnu&cturer &or &briction o& stereolit#ogrp#ic
surgicl guide 2Higure 54(
At surgery, t#e surgicl guide $s properly positioned using n
occlusl registrtion bet$een t#e guide nd t#e opposing rc#( *#e
pplince $s stbili+ed using stbili+tion pins( Implnt)speci6c
instrumenttion $s used to plce t#e si; plnned implnts to
&ull dept# nd ccurte direction using guided)surgery tec#ni'ues
$it# implnt mounts 2Higure -4( *#irty)degree stoc/ butments
$ere plced on t#e t$o posterior implnts, nd 0)degree stoc/
butments $ere plced on t#ree o& t#e &our nterior implnts( A
#eling butment $s plced on one implnt becuse o& subopti)ml initil stbility
2Higure 74( *emporry titnium slee%es $ere
t#en plced on t#e remining 6%e butments, t$o t time( *#e
denture $s modi6ed by creting ccess openings &or t#e titnium
slee%es 2Higure ,4( Lig#t)cti%ted crylic resin $s used to ttc#
t#e titnium slee%es to t#e modi6ed denture( 9nce trimmed nd
dEusted, t#e denture $s secured using prost#etic scre$s 2Higure
I4( It s#ould be noted t#t one %erticl implntKnot t#e one $it#
suboptiml initil stbilityK&iled during t#e pro%isionli+tion
period nd $s remo%ed nd not replced( *#e implnt t#t $s
not initilly loded $ent on to osseointegrte nd $s success&ully
used in t#e 6nl restortion(
Gtient 2
A -5)yer)old $omn presented $it# multiple missing nd nonre)storble
mndibulr teet#( 0#e re&used to $er &ull mndibulr
denture nd $nted 6;ed restortion( Der medicl #istory $s
noncontributory( Hinnces $ere n issue &or #er(
0tndrd dentl records nd rdiogrp#s 2Higure 104 $ere t/en
s i& t#e ptient $ere to recei%e n immedite mndibulr den)ture &ter
e;trctions( A 6nis#ed complete mndibulr denture
Hig 10( Gtient 2(Greoperti%e pnormic rdiogrp# prior to e;trctions( Hig11(
:ultiple)piece rdiogrp#ic guide, t$o pieces( double)scn tec#)ni'ue plnned(
Hig12( Hull)rc# tretment pln@ t$o 30)degree posterior implnts, t#ree %erticl
nterior implnts( Hig13( *retment pln, nterior
%ie$, 6%e implnts plnned(
Hig 11(
Hig 10(
Hig 12( Hig 13(
53, Volume 34, Number 7 compendium July/August 2013
$s &bricted by t#e dentl lbortory &or lter modi6ction s
pro%isionl 6;ed restortion( A multiple)piece scnning prost#esis
$it# gutt perc# 6ducil mr/ers nd n occlusl registrtion $s
&bricted by t#e dentl lbortory ccording to t#e mnu&cturer8s
guided)surgery protocol 2Higure 114( 737* scns 2i7t
1
, Imging
0ciences Interntionl, LL7, $$$(i)ct(com4 using t#e double)scn
tec#ni'ue $ere t/en $it# t#e ptient $ering t#is pplince nd
occlusl registrtion( *#e 737* dt $s con%erted into <I79:
imges nd imported into t#e Nobel7linicin so&t$re &or guided)surgery tretment
plnning( 9ne 30)degree ngled implnt $s
tretment)plnned posteriorly on ec# side( *#ree %erticl im)plnts $ere plnned
nteriorly, t$o in plnned e;trction soc/ets
2Higure 12 nd Higure 134( *#e completed pln $s digitlly sent to
t#e mnu&cturer &or surgicl guide &briction(
.nder intr%enous sedtion nd locl nest#esi, t#e remining
mndibulr teet# $ere e;trcted $it# miniml trum 2Higure 144(
A bite registrtion $s used to correctly position t#e surgicl guide(
0tbili+tion pins $ere t#en plced to secure t#e surgicl guide(
Implnt)speci6c instrumenttion $s used to prepre t#e ppropri)te osteotomies
nd plce 6%e implnts, &ully guided, using implnt
mounts t#roug# t#e surgicl guide to t#e plnned dept# nd ngul)tion 2Higure 154(
*#irty)degree stoc/ butments $ere plced on t#e
t$o posterior implnts, nd 0)degree stoc/ butments $ere plced
on t#e t#ree nterior implnts 2Higure 1-4( At t#e time o& surgery,
open)try impression copings $ere plced on t#e butments, nd
n butment)le%el impression $s mde o& t#e postsurgicl implnt
positions 2Higure 174( 7losed)try impression copings $ere used
to m/e n occlusl registrtion bet$een t#e rc#es( *#e bo%e
impression nd occlusl registrtion, long $it# t#e immedite
mndibulr denture nd prior)&bricted mounted csts, $ere sent
Hig 14(:inimlly trumtic teet# e;trctions( Hig 15( Hi%e implnts plced, &ully
guided using implnt mounts( Hig 1-( Hi%e implnts in plce,
surgicl guide remo%ed, butments in plce( Hig 17( Impression nd !pic/)up" o&
open)try impression copings( Hig 1,( Immedite postoperti%e
pnormic rdiogrp#( Hig 1I(Insertion o& immedite pro%isionl restortion,
mndible(
Hig 1,( Hig 1I(
Hig 15( Hig 1-(
Hig 17(
Hig 14(
to t#e dentl lbortory &or o%ernig#t retro6tting o& t#e mndibulr
denture( *#e &ollo$ing morning, t#e retro6tted crylic pro%isionl
restortion $s returned nd secured on t#e implnts in t#e p)tient8s mndibulr
rc# by prost#etic scre$ retention 2Higure 1,
nd Higure 1I4( A miniml occlusl dEustment $s necessry( *#e
ptient $s disc#rged $it# e;plicit dietry instructions regrding
e;trctions nd immedite loding o& dentl implnts(
Gtient 3
A -2)yer)old $omn presented $it# nonrestorble m;illry
dentition, $#ic# $s indicted &or &ull)mout# e;trction( 0#e
$nted &ull)mout#, implnt)supported 6;ed restortion $it#
n immedite pro%isionl restortion( Der pst medicl #istory
$s negti%e( Hinnces $ere concern &or #er(
*#e ptient $s e%luted nd $or/ed)up cliniclly nd rdio)grp#iclly 2Higure
204( :;illry nd mndibulr dignostic csts
$ere mde nd mounted on n rticultor( An idel dignostic $;)up o& t#e
plnned m;illry dentition $s creted nd con%erted
into multiple)piece #rd crylic scnning pplince( Butt perc#
points $ere dded s 6ducil mr/ers 2Higure 214( 737* scns
$ere t/en using t#e double)scn tec#ni'ue( *#e <I79: imges
$ere t#en imported into t#e Nobel7linicin so&t$re( 0i; implnts
$ere tretment)plnned 2Higure 22 nd Higure 234( *#e pln $s
sent to t#e mnu&cturer %i t#e Internet &or &briction o& ste)reolit#ogrp#ic
surgicl guide bsed on t#e %irtul tretment pln
2Higure 244( 9ne 30)degree ngled implnt $s tretment)plnned
posteriorly on ec# sideC &our %erticl implnts $ere plnned n)teriorly( Hour o& t#e
si; implnts $ere plced t#roug# e;trction
soc/ets( 9nce recei%ed, t#e surgicl guide $s sent to t#e dentl
lbortory &or &briction o& &ull)rc# pro%isionl restortion
7A0erep9r* J All)oN)4 7*)BuIded 0urBery
540 Volume 34, Number 7 compendium July/August 2013
7A0erep9r* J All)oN)4 7*)BuIded 0urBery
prior to surgery( *#e pro%isionl restortion $s &bricted by
creting mster cst using mnu&cturer componentry de%eloped
speci6clly &or t#is ppliction 2Higure 25 nd Higure 2-4( *#e
mster cst nd n opposing rc# dignostic cst $ere mounted
on n rticultor( .sing digitl prost#odontic plnning so&t$re
nd 7A: milling tec#nologies, t#e pro%isionl 6;ed restortion
$s milled in one unit 2Higure 27 nd Higure 2,4(
.nder intr%enous sedtion, t#e remining m;illry teet# $ere
remo%ed( *#e surgicl guide $s ccurtely plced using bite reg)istrtion nd
secured $it# guided)surgery pins 2Higure 2I4( .sing
implnt)speci6c guided)surgery instrumenttion, t#e si; implnts
$ere plced to t#e plnned dept# nd ngultion( All implnts $ere
plced &ully guided $it# implnt mounts, s per guided)surgery pro)tocols 2Higure
304( *#irty)degree stoc/ butments $ere plced on t#e
t$o posterior implnts, nd 0)degree stoc/ butments $ere plced
on t#e &our nterior implnts( *itnium slee%es $ere plced on t#e
butments, nd lig#t)cured crylic $s used to ccurtely secure t#em
to t#e presurgiclly &bricted pro%isionl prost#esis( *#e pro%isionl
prost#esis $s t#en secured into plce using prost#etic scre$s 2Higure
31 nd Higure 324( A slig#t occlusl dEustment $s necessry( *#e p)tient $s
disc#rged $it# e;plicit dietry nd &unctionl instructions(
<iscussion
*#ere is no 7*)guided drill)guide tec#nology $it# bsolute preci)sion(
0tereolit#ogrp#ic guide de%itions bet$een %irtul plnning
nd obtined implnt positions #%e been s#o$n in ll dimensions(
1I
*#e #ig#est men de%itions re &ound in implnts plced by bone)supported
guides, $#ile implnts plced by mucos)supported
guides mesure lo$er de%itions(
20
*oot#)supported drill guides
mesure t#e lo$est de%itions(21
<e%itions re &urt#er minimi+ed
Hig 20( Gtient 3(Initil e%lution, pnormic rdiogrp#( Hig21( :ultiple)piece
rdiogrp#ic guide, &ull)rc# e;trctions( Hig22( Virtul tret)ment pln@ si; implnts
plnned, butments in plce, occlusl %ie$( Hig23( Virtul tretment pln, le&t side(
Hig24( 0urgicl guide produced
stereolit#ogrp#iclly &rom tretment pln( Hig 25( lbortory componentry secured
in surgicl guideC mster cst creted by pouring stone
into surgicl guide( Hig 2-(:ster cst creted nd seprted( Hig 27(Gro%isionl
restortion milled s one unit using digitl 7A: tec#nologies(
Hig 2,(7ompleted pro%isionl restortion creted preoperti%ely(
Hig 27( Hig 2,( Hig 2-(
Hig 24( Hig 25(
Hig 21( Hig 22(
Hig 23(
Hig 20(
541 $$$(dentlegis(com/cced July/August 2013 compendium
by using rigid)scre$ or pin 6;tion o& single guide, metl guide
slee%es, drilling instrumenttion speci6c to t#e implnt to be plced,
nd instrumenttion 2implnt)speci6c implnt mounts4 &or t#e
&ully guided plcement o& implnts t#roug# t#e surgicl guide( :ost
systems use scre$s or pins to stbili+e mucosl)supported guidesC
some systems recommend t#em to stbili+e ll guides(
:inimlly in%si%e procedures m;imi+e ptient com&ort by mini)mi+ing trum to
t#e tissues( Hlpless dentl implnt insertion mini)mi+es potentil so&t)tissue
ele%tion complictions suc# s in&ection,
de#iscence, nd so&t) nd #rd)tissue necrosis nd #s been s#o$n
to #%e dentl implnt success rtes e'ul to con%entionl tec#)ni'ues(
15,22)24
A 5pless tec#ni'ue using surgicl guidnce &or optiml
control o& drill dept# nd ngultion minimi+es potentil inEury to
underlying ntomicl structures during implnt osteotomies(
:lM populri+ed t#e All)on)4 concept initilly reported by
:t#e$s(25
*#e concept in%ol%es t#e plcement o& &our dentl
implnts in ec# rc#( *$o implnts re typiclly plced in t#e
m;illry or mndibulr nterior lterl incisor/cnine region in
con%entionl %erticl &s#ion( *$o dditionl nterior)posterior
ngled implnts re plced in t#e posterior regions, usully in t#e
premolr regions, t 30)degree ngultion( *#e posterior ngled
implnts re plced in order to %oid t#e m;illry sinuses nd t#e
mentl &ormin, $#ile enlrging t#e nterior)posterior spred o&
t#e implnt plt&orms in order to m;imi+e t#e number o& teet#
&bricted in t#e 6nl restortion( *#ese tec#ni'ues minimi+ed
t#e need &or preprtory bone)gr&ting procedures nd lessened
t#e number o& implnts needed &or complete)rc# restortion(
:nu&cturers begn creting stoc/ 30)degree ngled butments
speci6clly &or t#is tec#ni'ue( *#e 6nl restortion is commonly
complete)rc#, $#ic# is usully limited to t#e second premolr or
6rst molr teet#( As t#e All)on)4 concept #s gined cceptnce, ne$
modi6ctions to t#e tec#ni'ue #%e been de%eloped nd presented
in order to lle%ite t#e problems o& se%ere trop#y $it# limited
bone stoc/ or limited interocclusl spce &or restortions(
2-)31
Intentionl ngled implnt plcement is not ne$ surgicl tec#)ni'ue, s &or mny
yers implnt mnu&cturers #%e creted stoc/
ngled butments &or intentionl or unintentionl ngled implnt
plcement( <entl lbortories #%e been &bricting customi+ed
butments using trditionl lb tec#ni'ues lmost s long s titnium
root &orm implnts #%e been in e;istence( 7A</7A: tec#nologies
re no$ commonly used to &bricte customi+ed butments in digi)tl
en%ironment to sol%e implnt plcement nd est#etic problems(
0uccess&ul immedite nd erly loding o& implnts using t#e lt)est genertion o&
implnts #s been described in t#e literture(
32)34
=igid cross)rc# stbili+tion success&ully permits t#e immedite
loding o& titnium implnts in n edentulous ridge, llo$ing rpid
re#bilittion o& t#e rc#, $it# -) to 24)mont# implnt sur%i%l
rtes o& I1N to I-(IN,
35)37
but it is dependent on proper ptient
Hig 2I(0urgicl guide secured in plce $it# guided stbili+tion pins( Implnts in
plce, &ully guided to plnned dept#s nd ngultions $it#
implnt mounts( Hig 30( Gostoperti%e pnormic rdiogrp#, immedite lod $it#
pro%isionl restortion( Hig 31( Gro%isionl restortion in plce,
immeditely &ter implnt surgery( Hig 32( Gro%isionl restortion in plce, occlusl
%ie$(
Hig 30(
Hig 31(
Hig 2I(
Hig 32(
542 Volume 34, Number 7 compendium July/August 2013
7A0erep9r* J All)oN)4 7*)BuIded 0urBery
selection( Ne$ implnt designs nd sur&ce tec#nologies llo$ im)medite
plcement o& n implnt)supported restortion &ollo$ing
surgery s predictble tretment option &or single)toot# implnts
nd multiple)unit 6;ed prost#eses(
3,)41
Immedite loding o& dentl
implnts #s positi%e e>ect on t#e tissue di>erentition nd bone
&ormtion round titnium implnts(
42
Implnt plcement &ollo$ed by immedite loding is lso not ne$(
Ledermnn, 0c#nitmn, nd *rno$ $ere mong t#e 6rst to intro)duce t#is
tec#ni'ue(
3,,43)45
Fol6nger presented c#nge in concept
by plcing &e$er implnts but loding ll t#e implnts t t#e sme
time(
4-
Grior to t#is, immedite)loding concepts in%ol%ed loding
select &e$ implnts mong lrger number o& dentl implnts in
edentulous mndibles( Long)term sur%i%l rtes o& I-(-N to II(4N
&or scre$)type dentl implnts in edentulous mndibles using bot#
concepts #%e been reported(
3,,4-)50
F#ile *rno$ et l stted t#t
immedite loding must include t lest 6%e dentl implnts in eden)tulous
mndibles,
3,
ot#er ut#ors #%e s#o$n t#t &e$er implnts
cn be used &or immedite loding(
25,41,4-,51)52
*#is is comprble to
ot#er reports o& immedite loding on dentl implnts, suc# s t#e
I,(2N cumulti%e sur%i%l rte &ter - mont#s reported by :lM,
25
t#e cumulti%e sur%i%l rte o& I-N 2men &ollo$)up, 3- mont#s4
presented by Vlente,
53
nd systemtic re%ie$ o& t#e 7oc#rne
dtbse regrding di>erent times &or loding o& implnts presented
in 200I, in $#ic# t#ere $ere no sttisticlly signi6cnt di>erences in
t#e met)nlyses &or t#e loding o& osseointegrted implnts in ny
tretment time&rme, ie, immedite 2$it#in 1 $ee/4, erly 2bet$een
1 $ee/ nd 2 mont#s4, nd con%entionl 2&ter 2 mont#s4(
54
Alt#oug# t#e success rtes o& immeditely loded implnts in t#e
edentulous E$ is comprble to stged #eling protocol, scre$
loosening, prost#esis bre/ge, o%erloding, nd/or pr&unction
cn ll led to implnt micromo%ement, resulting in potentil &il)ure(
55
Dence, proper cse selection nd ptient $reness, educ)tion, nd complince
re ll criticl &ctors &or success(
7onclusion
*#e use o& 7*)guided surgery to per&orm t#e All)on)4 procedure is
combintion o& tec#nologies t#t is in t#e erly stges o& common
prctice( Do$e%er, erly e;perience suggests success&ul !mr)rige" o& t#ese t$o
tec#ni'ues, $it# t#e possibility o& impro%ed
ptient outcomes( Huture reserc# is re'uired to &ully e;mine t#e
limittions o& bot# tec#nologies in t#e myrid situtions &ound in
t#e terminl dentition or trop#ic E$(
A39u* *DeAu*D9r0
Bry 9rentlic#er, <:<
7#ie&, <i%ision o& 9rl nd :;illo&cil 0urgery, F#ite Glins Dospitl :edicl
7enter, F#ite Glins, Ne$ Oor/C Gri%te Grctice, Ne$ Oor/ 9rl, :;illo&cil, nd
Implnt 0urgery, 0crsdle, Ne$ Oor/
9le Jensen <<0, :0
<irector, 7olordo *issue ?ngineering Institute, <en%er, 7olordoC Gri%te Grctice,
Breen$ood Villge, 7olordo
Andre$ Doro$it+, <:<, :<
Gri%te Grctice, Ne$ Oor/ 9rl, :;illo&cil, nd Implnt 0urgery,
0crsdle, Ne$ Oor/
:r/ Adms, <<0, :0
Gri%te Grctice, Grost#odontics, Breen$ood Villge, 7olordo
:rcus Abboud, <:<
7#irmn, <eprtment o& Grost#odontics nd <igitl *ec#nologies,
0tony 3roo/ .ni%ersity 0c#ool o& <entl :edicine, 0tony 3roo/, Ne$ Oor/
A7Pn9Fle<B:en*0
*#e ut#ors $ould li/e to c/no$ledge t#e contributions o&@
:r/ 3ris/in, <<0, Ardsley, Ne$ Oor/, on Gtient 1C =ymond
Feiss, <:<, 0crsdle, Ne$ Oor/, nd :rott <entl Lbortory,
Hrmingdle, Ne$ Oor/, on Gtient 2C nd :tt#e$ *eic#, <<0,
F#ite Glins, Ne$ Oor/, nd Lbortory)3EQrn Rpp, 9ldenburg,
Bermny, on Gtient 3(
reHeren7e0
1( %n 0teenberg#e d, Bluser r, 3lombSc/ u, et l( A computed
tomogrp#ic scn)deri%ed customi+ed surgicl templte nd 6;ed
prost#esis &or 5pless surgery nd immedite loding o& implnts in
&ully edentulous m;ille@ prospecti%e multicenter study( 7lin Implnt
<ent =elt =es( 2005C72suppl 14@0111)0120(
2( *rdieu G, Vrielinc/ l( Implntologie ssistTe pr ordinteur@ le
proprmme 0imGlnt/0urgi7seU et le 0AHe0ystemU mis en c#rge
immedite d8unbridge mndibulire %ec des implt trnsmu'ueu;(
Implnt(2003CI@15)2,(
3( rosen&eld Al, :ndelris BA, *rdieu G3( Grost#eticlly directed im)plnt
plcement using computer so&t$re to ensure precise plcement
nd predictble prost#etic outcomes( Grt 3@ stereolit#ogrp#ic drilling
guides t#t do not re'uire bone e;posure nd t#e immedite deli%ery
o& teet#( Int J Geriodontics =estorti%e <ent(200-C2-254@4I3)4II(
4( Vrielinc/ l, Golitis 7, 0c#epers 0, et l( Imge)bsed plnning nd
clinicl %lidtion o& +ygom nd pterygoid implnt plcement in
ptients $it# se%ere bone trop#y using customi+ed drill guides( Gre)liminry results
&rom prospecti%e clinicl &ollo$)up study(Int( J 9rl
:;illo&c 0urg(2003C32214@7)14(
5( 0rment dG, 0u/o%ic G, 7lint#orne N( Accurcy o& implnt plce)ment $it#
stereolit#ogrp#ic surgicl guide( Int J 9rl :;illo&c
Implnts(2003C1,244@571)577(
-( 0ores ::, Drri Nd, 7rdoso e0, et l( An in %itro model to
e%lute t#e ccurcy o& guided surgery systems(Int J 9rl :;illo&c
Implnts(2012C27244@,24),31(
7( Vn Assc#e N, %n 0teenberg#e d, Buerrero :e, et l( Accurcy o&
implnt plcement bsed on pre)surgicl plnning o& t#ree)dimensionl
cone)bem imges@ pilot study( J 7lin Geriodontol(2007C342I4@,1-),21(
,( rme+ J, don++n :, 7#n%+ :, et l( V*#e contribution o& scnner
imgery in implnt surgery nd sinus o%er5o$ using &rontl obli'ue or)t#ogonl
reconstruction(W =e% 0tomtol 7#ir :;illo&c( 1II2CI3234@212)214(
I( GttiEn V, %n 7leynenbreugel *, %nder 0loten J, et l( 0tructurl
nd rdiologicl prmeters &or t#e nondestructi%e c#rcteri+tion o&
trbeculr bone(Ann 3iomed ?ng( 2001C2I2124@10-4)1073(
10(0onic/ :, Abr#ms J, Hiell r( A comprison o& t#e ccurcy o& peri)picl,
pnormic, nd computeri+ed tomogrp#ic rdiogrp#s in locting
t#e mndibulr cnl( Int J 9rl :;illo&c Implnts( 1II4CI244C455)4-0(
11(*odd A, B#er :, Xuintero B, ric#rdson A7( Interprettion o& liner
nd computed tomogrms in t#e ssessment o& implnt recipient sites(
J Geriodontol( 1II3C-42124@1243)124I(
12(B#er :e, ric#rdson A7( *#e ccurcy o& dentl rdiogrp#ic
tec#ni'ues used &or e%lution o& implnt 6;ture plcement( Int J
Geriodontics =estorti%e <ent( 1II5C15234@2-,)2,3(
13(D#n J( 0ingle)stge, immedite loding, nd 5pless surgery( J
9rl Implntol( 2000C2-234@1I3)1I,(
14(7mpelo ld, 7mr Jr( Hlpless implnt surgery@ 10)yer clinicl
544 Volume 34, Number 7 compendium July/August 2013
retrospecti%e nlysis( J 9rl :;illo&c Implnts( 2002C17224@271)27-(
15(3ec/er F, Boldstein :, 3ec/er 3e, 0ennerby l( :inimlly in%si%e
5pless implnt surgery@ prospecti%e multicenter study( 7lin Implnt
<ent =elt =es( 2005C72suppl 14@021)027(
1-(3ec/er F, Fi/esEQ u:, 0ennerby l, et l( Distologic e%lution o&
implnts &ollo$ing 5pless nd 5pped surgery@ study in cnines( J
Geriodontol( 200-C772104@1717)1722(
17( orentlic#er B, Boldsmit# d, Doro$it+ A( Applictions o& 3)dimension)l %irtul
computeri+ed tomogrp#y tec#nology in orl nd m;illo&cil
surgery@ current t#erpy( J 9rl :;illo&c 0urg( 2010C-,2,4@1I33)1I5I(
1,( orentlic#er B( <igitl *ec#nologies in 9rl nd :;illo&cil 0urgery,
An Issue o& Atls o& 9rl nd :;illo&cil 0urgery 7linics( Vol 20( No( 1(
G#ildelp#i, GA@ else%ierC 2012(
1I( d8#ese J, Vn de Velde *, Pomiym A, et l( Accurcy nd com)plictions using
computer)designed streolit#ogrp#ic surgicl guides
&or orl re#bilittion by mens o& dentl implnts@ re%ie$ o& t#e
literture( 7lin Implnt <ent =elt =es( 2012C14234@321)335(
20(Arisn V, Prbud R7, o+demir *( Accurcy o& t$o stereolit#o)grp#ic guide
systems &or computer)ided implnt plcement@
computed tomogrp#y)bsed clinicl comprti%e study( J Geriodon)tol(
2010C,1214@43)51(
21( o+n o, *ur/yilm+ I, ersoy Ae, et l( 7linicl ccurcy o& 3 di>erent
types o& computed tomogrp#y)deri%ed stereolit#ogrp#ic surgicl
guides in implnt plcement( J 9rl :;illo&c 0urg( 200IC-7224@3I4)401(
22(Arisn V, Prbud 7R, o+demir *( Implnt surgery using bone)
nd mucos)supported stereolit#ogrp#ic guides in totlly edentulous
E$s@ surgicl nd post)operti%e outcomes o& computer)ided %s(
stndrd tec#ni'ues( 7lin 9rl Implnts =es( 2010C212I4@I,0)I,,(
23(7nni++ro B, *orc#io 7, leone :, esposito :( Immedite %ersus
erly loding o& 5pless)plced implnts supporting m;illry &ull)rc#
prost#eses@ rndomised controlled clinicl tril( ?ur J 9rl Implntol(
200,C1224@127)13I(
24(Abboud :, F#l B, Buirdo Jl, orentlic#er B( Appliction nd
success o& t$o stereolit#ogrp#ic surgicl guide systems &or implnt
plcement $it# immedite loding( Int J 9rl :;illo&c Implnts(
2012C27234@-34)-43(
25(:lM G, rngert 3, Nobre :( All)on)Hour immedite)&unction concept
$it# 3rYnemr/ 0ystem implnts &or completely edentulous mndibles@
retrospecti%e clinicl study( 7lin Implnt <ent =elt =es( 2003C52suppl 14@2)I(
2-(Jensen o*, Adms :F( All)on)4 tretment o& #ig#ly trop#ic mn)dible $it#
mndibulr V)4@ report o& 2 cses( J 9rl :;illo&c 0urg(
200IC-7274@1503)150I(
27(Jensen o*, Adms :F( *#e m;illry :)4@ A tec#nicl nd
biomec#nicl note &or ll)on)4 mngement o& se%ere m;illry tro)p#yKreport o&
3 cses( J 9rl :;illo&c 0urg( 200IC-72,4@173I)1744(
2,(Jensen o*, Adms :F, 7ottm Jr, et l( *#e All)on)4 s#el&@ m;il)l( J 9rl
:;illo&c 0urg( 2010C-,2104@2520)2527(
2I(Jensen o*, Adms :F, 7ottm Jr, et l( *#e All)on)4 s#el&@ mn)dible( J 9rl
:;illo&c 0urg( 2011C-I214@175)1,1(
30(Jensen o, 7ottm J, Adms :, Adms 0( 3uccl to lingul
trnsl%eolr implnt plcement &or ll)on)&our immedite &unction
in posterior mndible@ report o& 10 cses( J 9rl :;illo&c 0urg(
2011C-I274@1I1I)1I22(
31(Jensen o*, 7ottm J, ringemn J, Adms :( *rns)sinus dentl implnts,
bone morp#ogenetic protein 2, nd immedite &unction &or ll)on)4 tret)ment o&
se%ere m;illry trop#y( J 9rl :;illo&c 0urg( 2012C70214@141)14,(
32(Bps/i r, Fng Dl, :scren#s G, lng NG( 7riticl re%ie$ o& im)medite implnt
loding( 7lin 9rl Implnts =es( 2003C14254@515)527(
33( og$ *, Nis#imur I( di>erent bone integrtion pro6les o& turned
nd cid)etc#ed implnts ssocited $it# modulted e;pression o& e;tr)cellulr
mtri; genes( Int J 9rl :;illo&c Implnts( 2003C1,224@200)210(
34(Rec#ner F, *ngl 0, HZrst B, et l( osseous #eling c#rcteristics o&
t#ree di>erent implnt types( 7lin 9rl Implnts =es( 2003C14224@150)157(
35( loren+oni :, Gertl 7, R#ng P, Fegsc#eider FA( In)ptient
comprison o& immeditely loded nd non)loded implnts $it#in -
mont#s( 7lin 9rl Implnts =es( 2003C14234@273)27I(
3-(J[n rA, Pumr A, 3ermn 7l( Immedite loding o& dentl im)plnts in t#e
completely edentulous m;ill@ clinicl report( Int J 9rl
:;illo&c Implnts( 2004C1I254@721)730(
37(Btti 7, De5iger F, 7#ipsco :( Implnt)retined mndibulr
o%erdentures $it# immedite loding@ prospecti%e study o& I*I im)plnts( Int J 9rl
:;illo&c Implnts( 2000C15234@3,3)3,,(
3,(*rno$ dG, emti+ 0, 7lssi A( Immedite loding o& t#reded
implnts t stge 1 surgery in edentulous rc#es@ ten consecuti%e
cse reports $it# 1) to 5)yer dt( Int J 9rl :;illo&c Implnts(
1II7C12234@31I)324(
3I(7#t+ist%rou :, Helton dA, 7ooper lH( Immedite loding o&
dentl implnts in prtilly edentulous ptients@ clinicl report( J
Grost#odont( 2003C12214@2-)2I(
40(Bluser r, lundgren AP, Bottlo$ J, et l( Immedite occlusl lod)ing o&
3rYnemr/ *iunite implnts plced predominntly in so&t bone@
1)yer results o& prospecti%e clinicl study( 7lin Implnt <ent =elt
=es( 2003C5 suppl 1@47)5-(
41(Abboud :, Poec/ 3, 0tr/ D, et l( Immedite loding o& single)toot# implnts in
t#e posterior region( Int J 9rl :;illo&c Implnts(
2005C20214@-1)-,(
42(Vndmme P, Nert I, Beris l, et l( Distodynmics o& bone tissue
&ormtion round immeditely loded cylindricl implnts in t#e rbbit(
7lin 9rl Implnts =es( 2007C1,244@471)4,0(
43( ledermnn d( V-)yer clinicl tril $it# titnium plsm)coted I*I
2Interntionles *em &ur Implntologie4 scre$ implnts in t#e mn)dibulr
inter&orminl regionW( 009 0c#$ei+ :ontssc#r R#n#eil/d(
1I,3CI32114@1070)10,I(
44( ledermnn G( V3r)prost#etic mngement o& t#e edentulous
mndible by mens o& plsm)coted implnttion $it# titnium
scre$sW( <tsc# R#nr+tl R( 1I7IC342124@I07)I11(
45(0c#nitmn GA, FQ#rle G0, rubenstein Je, et l( *en)yer results
&or 3rYnemr/ implnts immeditely loded $it# 6;ed prost#eses t
implnt plcement( Int J 9rl :;illo&c Implnts( 1II7C12244@4I5)503(
4-(Fol6nger BJ, 3ls#i *J, rngert 3( Immedite &unctionl loding o&
3rYnemr/ system implnts in edentulous mndibles@ clinicl report o&
t#e results o& de%elopmentl nd simpli6ed protocols( Int J 9rl :;il)lo&c Implnts(
2003C1,224@250)257(
47(Doriuc#i P, uc#id D, ymmoto P, 0ugimur :( Immedite loding o&
3rYnemr/ system implnts &ollo$ing plcement in edentulous ptients@
clinicl report( Int J 9rl :;illo&c Implnts( 2000C152-4@,24),30(
4,(Bneles J, rosenberg ::, Dolt rl, reic#mn lD( Immedite lod)ing o& implnts
$it# 6;ed restortions in t#e completely edentulous
mndible@ report o& 27 ptients &rom pri%te prctice( Int J 9rl
:;illo&c Implnts( 2001C1-234@41,)42-(
4I(Alm AA, No$+ri D, Pri%its/y A( Hunctionl restortion o&
implnts on t#e dy o& surgicl plcement in t#e &ully edentulous mn)dible@ cse
series( 7lin Implnt <ent =elt =es( 2005C7214@10)1-(
50( degidi :, Gittelli A, Helice G, 7rinci H( Immedite &unctionl lod)ing o&
edentulous m;ill@ 5)yer retrospecti%e study o& 3,, titnium
implnts( J Geriodontol( 2005C7-2-4@101-)1024(
51(3rYnemr/ GI, engstrnd G, o#rnell lo, et l( 3rYnemr/ No%um@
ne$ tretment concept &or re#bilittion o& t#e edentulous mndible(
Greliminry results &rom prospecti%e clinicl &ollo$)up study( 7lin
Implnt <ent =elt =es( 1IIIC1214@2)1-(
52( de 3ruyn D, Pisc# J, 7ollert 3, et l( Hi;ed mndibulr restor)tions on t#ree
erly)loded regulr plt&orm 3rYnemr/ implnts( 7lin
Implnt <ent =elt =es( 2001C3244@17-)1,4(
53(Vlente H, 0c#iroli B, 0brenn A( Accurcy o& computer)ided orl
implnt surgery@ clinicl nd rdiogrp#ic study( Int J 9rl :;illo&c
Implnts( 200IC24224@234)242(
54( esposito :, Bruso%in :B, Ac#ille D, et l( Inter%entions &or
replcing missing teet#@ di>erent times &or loding dentl implnts(
7oc#rne <tbse 0yst =e%( 200IC1@7d003,7,(
55(:isc# 7:( Immedite loding o& de6niti%e implnts in t#e edentu)lous mndible
using 6;ed pro%isionl prost#esis@ *#e denture con%er)sion tec#ni'ue( J 9rl
:;illo&c 0urg(2004C-22I suppl 24@10-)115(
7A0erep9r* J All)oN)4 7*)BuIded 0urBery
1)7
*#is cn reduce t#e incidence o&
unto$rd in%ol%ement $it# %itl ntomic structures nd
minimi+e ptient morbidity(,)1-
.sing proprietry implnt)plnning so&t$re, implnts cn be !%irtully" plced t
/no$n pre)plnned dept#s nd ngultions in t#ree dimensions( 0urgicl guides
re t#en &bricted &rom t#e %irtul tretment pln &or #ig#ly ccurte
implnt plcement into t#e plnned implnt positions(
*#is use o& %irtul, guided tec#nologies contrsts $it# t#e prctice
commonly employed &or t#e plcement o& dentl implnts using t#e
con%entionl All)on)4
1
2Nobel 3iocre, $$$(nobelbiocre(com4 pro)tocol, concept t#t #s gined
cceptnce &or complete rc# restor)tion( *rditionlly, &ter clinicl e%lution,
t#e All)on)4 surgicl
$or/5o$ 6rst in%ol%es stndrd pnormic nd/or computed
tomogrp#y 27*4/cone bem 7* 2737*4 e%lution o& t#e ptient8s
ntomy $it# routine pre)tretment plnning( *#is leds to surgery
in%ol%ing &ull)rc# incision $it# &ull)rc# 5p ele%tion( I& neces)sry, l%eolr crest
le%eling is per&ormed( A prlleling guide is used
to %eri&y implnt ngultion( 9steotomies nd implnt plcement re
done &ree#nd( Implnts re commonly plced t30)degree ngles
2:)4 m;ill nd V)4 mndible4, nd ngled butments re t#en
plced s needed( *#e implnts re usully immeditely loded by
retro6tting n e;isting or ne$ denture prost#esis or by plcing 6;ed
pro%isionl restortion bsed on n butment)le%el impression t/en
t t#e time o& surgery( *#e pro%isionl restortion is scre$ retined(
*#e use o& computer)ided design/computer)ided mnu&ctur)ing 27A</7A:4 nd
digitl tec#nologies in orl nd m;illo&cil
surgery nd dentistry is no longer &uturistic concept( *#ese tec#)nologies re
being commonly used in dentl prctice tody(
17,1,
9%er
t#e pst decde t#e use o& 7*)guided dentl implnt surgery #s
incresed signi6cntly s concepts nd tec#ni'ues #%e become
more re6ned nd mny implnt mnu&cturers #%e dpted t#eir
implnt systems to t#ese ne$ tec#nologies( *#e All)on)4 concept
&or dentl implnt plcement nd restortion #s been discussed &or
mny yers( =ecently, t#e tec#ni'ue #s generted incresed interest
s #ig#ly &unctionl, est#etic, more cost)e>ecti%e lternti%e &or
lrger group o& ptients $#o could bene6t &rom &ull)rc#, implnt)supported 6;ed
restortion(
*#e purpose o& t#is rticle is to describe t#e All)on)4 7*)guided
surgery tec#ni'ue nd report on t#e 6ndings o& t#ree ptients
treted( ?c# o& t#e cses #d di>erent prost#odontic mngement(
*ec#ni'ue
7*)guided implnt plnning nd surgery is restorti%ely dri%en
tretment pln( It 6rst in%ol%es plnning n idel dentl restortion
Abstrct@ No longer merely concept &or t#e &uture, t#e use o& digitl tec#nologies
in dentistry #s become
common prctice tody( 7omputed tomogrp#y 27*4)guided dentl implnt surgery
#s gretly e;pnded
o%er t#e pst decde s concepts nd tec#ni'ues #%e become incresingly re6ned
nd more implnt
mnu&cturers #%e dpted t#eir implnt systems to t#ese ne$ tec#nologies( *#e
All)on)41 tec#ni'ue &or
dentl implnt plcement nd restortion, $#ile de%eloped some t$o decdes go,
#s recently generted
incresed interest s #ig#ly &unctionl, est#etic, cost)e>ecti%e lternti%e &or
lrge group o& ptients
$#o could bene6t &rom &ull)rc#, implnt)supported 6;ed restortion( *#e ut#ors
s/, !Are t#ese t$o
tec#nologies mrrige mde in #e%enA" *#is rticle describes t#e All)on)4 7*)
guided surgery tec#ni'ue
nd reports on t#e tretment 6ndings on t#ree ptients, ec# $it# di>erent
prost#odontic mngement(
7ombining All)on)4 *retment
$it# 7*)Buided *ec#nology@
*ec#ni'ue nd =eport o& *#ree 7ses
Bry 9rentlic#er, <:<C 9le Jensen, <<0, :0C Andre$ Doro$it+, <:<, :<C :r/
Adms, <<0, :0C
nd :rcus Abboud, <:<
7se report
All)9n)4 7*)Bui<e<0urBery
535 $$$(dentlegis(com/cced July/August 2013 compendium
&or ptientC t#is my be complete denture or, &or prtilly
edentulous ptient, dignostic $;)up o& t#e plnned restortions(
In t#e typicl guided surgery $or/5o$, t#e ptient t#en $ers n
crylic resin pplince 2!scn prost#esis"4, $#ic# incorportes t#e
idel ntomy nd position o& t#e plnned restortion2s4, $#ile
#%ing 7*/737* scn t/en o& #is or #er E$( Vrious types o&
6ducil mr/ers re embedded in t#e scn prost#esis(
*#e digitl imging nd communiction in medicine 2<I79:4
imges generted &rom t#e scns re t#en imported into t#ird)prty
proprietry so&t$res( *#e so&t$res use t#e 6ducil mr/er points
to lign t#e dt generted &rom t#e scn2s4, creting computer
imges t#t ccurtely relte t#e plnned restortion2s4 to t#e p)tient8s underlying
bony ntomy( Implnt positions nd ngultions
cn t#en be precisely plnned in %irtul en%ironment(
*#is %irtul tretment pln is t#en sent to mnu&cturer
or lbortory &or &briction o& n pplince t#t is used t t#e
time o& surgery to ccurtely plce t#e implnts in t#eir plnned
position2s4( :ost lrger implnt mnu&cturers o>er guided
surgery)speci6c instrumenttion &or 5pless implnt plcement(
F#en desired nd indicted, tec#ni'ues nd rmmentrium
re %ilble &or e;trctions, bone reduction, immedite implnt
plcement, nd immedite loding, ll o& $#ic# re commonly
used in t#e All)on)4 protocol(
Gtient 1
A 50)yer)old &ully edentulous mn presented desiring &ull)rc#,
6;ed m;illry restortion( De #d been $ering m;illry denture
&or - yers &ter premturely losing #is teet# &rom decy nd peri)odontl disese(
*#e denture #d ne%er been relined( Dis pst medicl
#istory $s noncontributory( Hinnces $ere problem &or t#e ptient(
An initil clinicl e;mintion t#t included con%entionl dentl
nd pnormic rdiogrp#s $s per&ormed 2Higure 14( A&ter n
e;tensi%e discussion o& t#e surgicl nd prost#odontic options,
n All)on)4/- option $it# retro6t o& #is e;isting m;illry den)ture s n immedite
#ybrid pro%isionl restortion $s plnned(
Hirst, #rd denture reline $s per&ormed on #is e;isting m;illry
Hig 5(
Hig ,(
Hig -(
Hig I(
Hig 2( Hig 3(
Hig 4(
Hig 7(
Hig 1(
Hig 1( Gtient 1(Greoperti%e rdiogrp#, &ully edentulous m;ill( Hig 2( Drd relined
m;illry denture, gutt perc# 6ducil mr/ers inserted( Hig3(
Virtul tretment pln@ si; implnts, ngled butments in plce( Hig 4( Virtul
tretment pln, le&t side( Note 30)degree ngled posterior implnt(
Hig 5(0urgicl guide creted stereolit#ogrp#iclly &rom t#e tretment pln(
Hig-(0urgicl guide secured in plce $it# guided stbili+tion pins(
Implnts plced &ully guided to plnned dept# nd ngultion $it# implnt mounts(
Hig7(Gostoperti%e pnormic rdiogrp#( Note #eling but)ment on implnt
m;illry le&t posterior implnt site, not immeditely loded( Hig ,( :;illry
denture dEusted nd retro6tted to llo$ &or titnium
butments to be embedded $it# lig#t)cured crylic resin( HigI(Gro%isionl
restortion secured $it# prost#etic scre$s s n immedite lod(
53- Volume 34, Number 7 compendium July/August 2013
7A0erep9r* J All)oN)4 7*)BuIded 0urBery
denture &or idel denture dpttion to t#e mucos( An occlusl
registrtion bet$een t#e denture nd opposing rc# $s &bricted(
Butt perc# points $ere dded to t#e m;illry denture s 6ducil
mr/ers 2Higure 24( As per t#e double)scn protocol, t$o ppropri)te scns $ere
t#en t/enKone o& t#e ptient $it# t#e denture nd
occlusl registrtion in plce nd second one o& Eust t#e denture(
*#e <I79: sets $ere t#en imported into t#e Nobel7linicin1
2Nobel3iocre4 plnning so&t$re( 3ecuse o& t#e trop#y o& t#e
m;illry ridge in $idt#, plcement o& si; implnts $s plnned
%irtully( 9ne 30)degree, regulr)dimeter ngled implnt $s
tretment)plnned posteriorly on ec# sideC &our nrro$)plt&orm,
%erticlly positioned implnts $ere plnned in t#e nterior res
2Higure 3 nd Higure 44( 9nce completed, t#e pln $s digitlly
sent to t#e mnu&cturer &or &briction o& stereolit#ogrp#ic
surgicl guide 2Higure 54(
At surgery, t#e surgicl guide $s properly positioned using n
occlusl registrtion bet$een t#e guide nd t#e opposing rc#( *#e
pplince $s stbili+ed using stbili+tion pins( Implnt)speci6c
instrumenttion $s used to plce t#e si; plnned implnts to
&ull dept# nd ccurte direction using guided)surgery tec#ni'ues
$it# implnt mounts 2Higure -4( *#irty)degree stoc/ butments
$ere plced on t#e t$o posterior implnts, nd 0)degree stoc/
butments $ere plced on t#ree o& t#e &our nterior implnts( A
#eling butment $s plced on one implnt becuse o& subopti)ml initil stbility
2Higure 74( *emporry titnium slee%es $ere
t#en plced on t#e remining 6%e butments, t$o t time( *#e
denture $s modi6ed by creting ccess openings &or t#e titnium
slee%es 2Higure ,4( Lig#t)cti%ted crylic resin $s used to ttc#
t#e titnium slee%es to t#e modi6ed denture( 9nce trimmed nd
dEusted, t#e denture $s secured using prost#etic scre$s 2Higure
I4( It s#ould be noted t#t one %erticl implntKnot t#e one $it#
suboptiml initil stbilityK&iled during t#e pro%isionli+tion
period nd $s remo%ed nd not replced( *#e implnt t#t $s
not initilly loded $ent on to osseointegrte nd $s success&ully
used in t#e 6nl restortion(
Gtient 2
A -5)yer)old $omn presented $it# multiple missing nd nonre)storble
mndibulr teet#( 0#e re&used to $er &ull mndibulr
denture nd $nted 6;ed restortion( Der medicl #istory $s
noncontributory( Hinnces $ere n issue &or #er(
0tndrd dentl records nd rdiogrp#s 2Higure 104 $ere t/en
s i& t#e ptient $ere to recei%e n immedite mndibulr den)ture &ter
e;trctions( A 6nis#ed complete mndibulr denture
Hig 10( Gtient 2(Greoperti%e pnormic rdiogrp# prior to e;trctions( Hig11(
:ultiple)piece rdiogrp#ic guide, t$o pieces( double)scn tec#)ni'ue plnned(
Hig12( Hull)rc# tretment pln@ t$o 30)degree posterior implnts, t#ree %erticl
nterior implnts( Hig13( *retment pln, nterior
%ie$, 6%e implnts plnned(
Hig 11(
Hig 10(
Hig 12( Hig 13(
53, Volume 34, Number 7 compendium July/August 2013
$s &bricted by t#e dentl lbortory &or lter modi6ction s
pro%isionl 6;ed restortion( A multiple)piece scnning prost#esis
$it# gutt perc# 6ducil mr/ers nd n occlusl registrtion $s
&bricted by t#e dentl lbortory ccording to t#e mnu&cturer8s
guided)surgery protocol 2Higure 114( 737* scns 2i7t
1
, Imging
0ciences Interntionl, LL7, $$$(i)ct(com4 using t#e double)scn
tec#ni'ue $ere t/en $it# t#e ptient $ering t#is pplince nd
occlusl registrtion( *#e 737* dt $s con%erted into <I79:
imges nd imported into t#e Nobel7linicin so&t$re &or guided)surgery tretment
plnning( 9ne 30)degree ngled implnt $s
tretment)plnned posteriorly on ec# side( *#ree %erticl im)plnts $ere plnned
nteriorly, t$o in plnned e;trction soc/ets
2Higure 12 nd Higure 134( *#e completed pln $s digitlly sent to
t#e mnu&cturer &or surgicl guide &briction(
.nder intr%enous sedtion nd locl nest#esi, t#e remining
mndibulr teet# $ere e;trcted $it# miniml trum 2Higure 144(
A bite registrtion $s used to correctly position t#e surgicl guide(
0tbili+tion pins $ere t#en plced to secure t#e surgicl guide(
Implnt)speci6c instrumenttion $s used to prepre t#e ppropri)te osteotomies
nd plce 6%e implnts, &ully guided, using implnt
mounts t#roug# t#e surgicl guide to t#e plnned dept# nd ngul)tion 2Higure 154(
*#irty)degree stoc/ butments $ere plced on t#e
t$o posterior implnts, nd 0)degree stoc/ butments $ere plced
on t#e t#ree nterior implnts 2Higure 1-4( At t#e time o& surgery,
open)try impression copings $ere plced on t#e butments, nd
n butment)le%el impression $s mde o& t#e postsurgicl implnt
positions 2Higure 174( 7losed)try impression copings $ere used
to m/e n occlusl registrtion bet$een t#e rc#es( *#e bo%e
impression nd occlusl registrtion, long $it# t#e immedite
mndibulr denture nd prior)&bricted mounted csts, $ere sent
Hig 14(:inimlly trumtic teet# e;trctions( Hig 15( Hi%e implnts plced, &ully
guided using implnt mounts( Hig 1-( Hi%e implnts in plce,
surgicl guide remo%ed, butments in plce( Hig 17( Impression nd !pic/)up" o&
open)try impression copings( Hig 1,( Immedite postoperti%e
pnormic rdiogrp#( Hig 1I(Insertion o& immedite pro%isionl restortion,
mndible(
Hig 1,( Hig 1I(
Hig 15( Hig 1-(
Hig 17(
Hig 14(
to t#e dentl lbortory &or o%ernig#t retro6tting o& t#e mndibulr
denture( *#e &ollo$ing morning, t#e retro6tted crylic pro%isionl
restortion $s returned nd secured on t#e implnts in t#e p)tient8s mndibulr
rc# by prost#etic scre$ retention 2Higure 1,
nd Higure 1I4( A miniml occlusl dEustment $s necessry( *#e
ptient $s disc#rged $it# e;plicit dietry instructions regrding
e;trctions nd immedite loding o& dentl implnts(
Gtient 3
A -2)yer)old $omn presented $it# nonrestorble m;illry
dentition, $#ic# $s indicted &or &ull)mout# e;trction( 0#e
$nted &ull)mout#, implnt)supported 6;ed restortion $it#
n immedite pro%isionl restortion( Der pst medicl #istory
$s negti%e( Hinnces $ere concern &or #er(
*#e ptient $s e%luted nd $or/ed)up cliniclly nd rdio)grp#iclly 2Higure
204( :;illry nd mndibulr dignostic csts
$ere mde nd mounted on n rticultor( An idel dignostic $;)up o& t#e
plnned m;illry dentition $s creted nd con%erted
into multiple)piece #rd crylic scnning pplince( Butt perc#
points $ere dded s 6ducil mr/ers 2Higure 214( 737* scns
$ere t/en using t#e double)scn tec#ni'ue( *#e <I79: imges
$ere t#en imported into t#e Nobel7linicin so&t$re( 0i; implnts
$ere tretment)plnned 2Higure 22 nd Higure 234( *#e pln $s
sent to t#e mnu&cturer %i t#e Internet &or &briction o& ste)reolit#ogrp#ic
surgicl guide bsed on t#e %irtul tretment pln
2Higure 244( 9ne 30)degree ngled implnt $s tretment)plnned
posteriorly on ec# sideC &our %erticl implnts $ere plnned n)teriorly( Hour o& t#e
si; implnts $ere plced t#roug# e;trction
soc/ets( 9nce recei%ed, t#e surgicl guide $s sent to t#e dentl
lbortory &or &briction o& &ull)rc# pro%isionl restortion
7A0erep9r* J All)oN)4 7*)BuIded 0urBery
540 Volume 34, Number 7 compendium July/August 2013
7A0erep9r* J All)oN)4 7*)BuIded 0urBery
prior to surgery( *#e pro%isionl restortion $s &bricted by
creting mster cst using mnu&cturer componentry de%eloped
speci6clly &or t#is ppliction 2Higure 25 nd Higure 2-4( *#e
mster cst nd n opposing rc# dignostic cst $ere mounted
on n rticultor( .sing digitl prost#odontic plnning so&t$re
nd 7A: milling tec#nologies, t#e pro%isionl 6;ed restortion
$s milled in one unit 2Higure 27 nd Higure 2,4(
.nder intr%enous sedtion, t#e remining m;illry teet# $ere
remo%ed( *#e surgicl guide $s ccurtely plced using bite reg)istrtion nd
secured $it# guided)surgery pins 2Higure 2I4( .sing
implnt)speci6c guided)surgery instrumenttion, t#e si; implnts
$ere plced to t#e plnned dept# nd ngultion( All implnts $ere
plced &ully guided $it# implnt mounts, s per guided)surgery pro)tocols 2Higure
304( *#irty)degree stoc/ butments $ere plced on t#e
t$o posterior implnts, nd 0)degree stoc/ butments $ere plced
on t#e &our nterior implnts( *itnium slee%es $ere plced on t#e
butments, nd lig#t)cured crylic $s used to ccurtely secure t#em
to t#e presurgiclly &bricted pro%isionl prost#esis( *#e pro%isionl
prost#esis $s t#en secured into plce using prost#etic scre$s 2Higure
31 nd Higure 324( A slig#t occlusl dEustment $s necessry( *#e p)tient $s
disc#rged $it# e;plicit dietry nd &unctionl instructions(
<iscussion
*#ere is no 7*)guided drill)guide tec#nology $it# bsolute preci)sion(
0tereolit#ogrp#ic guide de%itions bet$een %irtul plnning
nd obtined implnt positions #%e been s#o$n in ll dimensions(
1I
*#e #ig#est men de%itions re &ound in implnts plced by bone)supported
guides, $#ile implnts plced by mucos)supported
guides mesure lo$er de%itions(
20
*oot#)supported drill guides
mesure t#e lo$est de%itions(21
<e%itions re &urt#er minimi+ed
Hig 20( Gtient 3(Initil e%lution, pnormic rdiogrp#( Hig21( :ultiple)piece
rdiogrp#ic guide, &ull)rc# e;trctions( Hig22( Virtul tret)ment pln@ si; implnts
plnned, butments in plce, occlusl %ie$( Hig23( Virtul tretment pln, le&t side(
Hig24( 0urgicl guide produced
stereolit#ogrp#iclly &rom tretment pln( Hig 25( lbortory componentry secured
in surgicl guideC mster cst creted by pouring stone
into surgicl guide( Hig 2-(:ster cst creted nd seprted( Hig 27(Gro%isionl
restortion milled s one unit using digitl 7A: tec#nologies(
Hig 2,(7ompleted pro%isionl restortion creted preoperti%ely(
Hig 27( Hig 2,( Hig 2-(
Hig 24( Hig 25(
Hig 21( Hig 22(
Hig 23(
Hig 20(
541 $$$(dentlegis(com/cced July/August 2013 compendium
by using rigid)scre$ or pin 6;tion o& single guide, metl guide
slee%es, drilling instrumenttion speci6c to t#e implnt to be plced,
nd instrumenttion 2implnt)speci6c implnt mounts4 &or t#e
&ully guided plcement o& implnts t#roug# t#e surgicl guide( :ost
systems use scre$s or pins to stbili+e mucosl)supported guidesC
some systems recommend t#em to stbili+e ll guides(
:inimlly in%si%e procedures m;imi+e ptient com&ort by mini)mi+ing trum to
t#e tissues( Hlpless dentl implnt insertion mini)mi+es potentil so&t)tissue
ele%tion complictions suc# s in&ection,
de#iscence, nd so&t) nd #rd)tissue necrosis nd #s been s#o$n
to #%e dentl implnt success rtes e'ul to con%entionl tec#)ni'ues(
15,22)24
A 5pless tec#ni'ue using surgicl guidnce &or optiml
control o& drill dept# nd ngultion minimi+es potentil inEury to
underlying ntomicl structures during implnt osteotomies(
:lM populri+ed t#e All)on)4 concept initilly reported by
:t#e$s(25
*#e concept in%ol%es t#e plcement o& &our dentl
implnts in ec# rc#( *$o implnts re typiclly plced in t#e
m;illry or mndibulr nterior lterl incisor/cnine region in
con%entionl %erticl &s#ion( *$o dditionl nterior)posterior
ngled implnts re plced in t#e posterior regions, usully in t#e
premolr regions, t 30)degree ngultion( *#e posterior ngled
implnts re plced in order to %oid t#e m;illry sinuses nd t#e
mentl &ormin, $#ile enlrging t#e nterior)posterior spred o&
t#e implnt plt&orms in order to m;imi+e t#e number o& teet#
&bricted in t#e 6nl restortion( *#ese tec#ni'ues minimi+ed
t#e need &or preprtory bone)gr&ting procedures nd lessened
t#e number o& implnts needed &or complete)rc# restortion(
:nu&cturers begn creting stoc/ 30)degree ngled butments
speci6clly &or t#is tec#ni'ue( *#e 6nl restortion is commonly
complete)rc#, $#ic# is usully limited to t#e second premolr or
6rst molr teet#( As t#e All)on)4 concept #s gined cceptnce, ne$
modi6ctions to t#e tec#ni'ue #%e been de%eloped nd presented
in order to lle%ite t#e problems o& se%ere trop#y $it# limited
bone stoc/ or limited interocclusl spce &or restortions(
2-)31
Intentionl ngled implnt plcement is not ne$ surgicl tec#)ni'ue, s &or mny
yers implnt mnu&cturers #%e creted stoc/
ngled butments &or intentionl or unintentionl ngled implnt
plcement( <entl lbortories #%e been &bricting customi+ed
butments using trditionl lb tec#ni'ues lmost s long s titnium
root &orm implnts #%e been in e;istence( 7A</7A: tec#nologies
re no$ commonly used to &bricte customi+ed butments in digi)tl
en%ironment to sol%e implnt plcement nd est#etic problems(
0uccess&ul immedite nd erly loding o& implnts using t#e lt)est genertion o&
implnts #s been described in t#e literture(
32)34
=igid cross)rc# stbili+tion success&ully permits t#e immedite
loding o& titnium implnts in n edentulous ridge, llo$ing rpid
re#bilittion o& t#e rc#, $it# -) to 24)mont# implnt sur%i%l
rtes o& I1N to I-(IN,
35)37
but it is dependent on proper ptient
Hig 2I(0urgicl guide secured in plce $it# guided stbili+tion pins( Implnts in
plce, &ully guided to plnned dept#s nd ngultions $it#
implnt mounts( Hig 30( Gostoperti%e pnormic rdiogrp#, immedite lod $it#
pro%isionl restortion( Hig 31( Gro%isionl restortion in plce,
immeditely &ter implnt surgery( Hig 32( Gro%isionl restortion in plce, occlusl
%ie$(
Hig 30(
Hig 31(
Hig 2I(
Hig 32(
542 Volume 34, Number 7 compendium July/August 2013
7A0erep9r* J All)oN)4 7*)BuIded 0urBery
selection( Ne$ implnt designs nd sur&ce tec#nologies llo$ im)medite
plcement o& n implnt)supported restortion &ollo$ing
surgery s predictble tretment option &or single)toot# implnts
nd multiple)unit 6;ed prost#eses(
3,)41
Immedite loding o& dentl
implnts #s positi%e e>ect on t#e tissue di>erentition nd bone
&ormtion round titnium implnts(
42
Implnt plcement &ollo$ed by immedite loding is lso not ne$(
Ledermnn, 0c#nitmn, nd *rno$ $ere mong t#e 6rst to intro)duce t#is
tec#ni'ue(
3,,43)45
Fol6nger presented c#nge in concept
by plcing &e$er implnts but loding ll t#e implnts t t#e sme
time(
4-
Grior to t#is, immedite)loding concepts in%ol%ed loding
select &e$ implnts mong lrger number o& dentl implnts in
edentulous mndibles( Long)term sur%i%l rtes o& I-(-N to II(4N
&or scre$)type dentl implnts in edentulous mndibles using bot#
concepts #%e been reported(
3,,4-)50
F#ile *rno$ et l stted t#t
immedite loding must include t lest 6%e dentl implnts in eden)tulous
mndibles,
3,
ot#er ut#ors #%e s#o$n t#t &e$er implnts
cn be used &or immedite loding(
25,41,4-,51)52
*#is is comprble to
ot#er reports o& immedite loding on dentl implnts, suc# s t#e
I,(2N cumulti%e sur%i%l rte &ter - mont#s reported by :lM,
25
t#e cumulti%e sur%i%l rte o& I-N 2men &ollo$)up, 3- mont#s4
presented by Vlente,
53
nd systemtic re%ie$ o& t#e 7oc#rne
dtbse regrding di>erent times &or loding o& implnts presented
in 200I, in $#ic# t#ere $ere no sttisticlly signi6cnt di>erences in
t#e met)nlyses &or t#e loding o& osseointegrted implnts in ny
tretment time&rme, ie, immedite 2$it#in 1 $ee/4, erly 2bet$een
1 $ee/ nd 2 mont#s4, nd con%entionl 2&ter 2 mont#s4(
54
Alt#oug# t#e success rtes o& immeditely loded implnts in t#e
edentulous E$ is comprble to stged #eling protocol, scre$
loosening, prost#esis bre/ge, o%erloding, nd/or pr&unction
cn ll led to implnt micromo%ement, resulting in potentil &il)ure(
55
Dence, proper cse selection nd ptient $reness, educ)tion, nd complince
re ll criticl &ctors &or success(
7onclusion
*#e use o& 7*)guided surgery to per&orm t#e All)on)4 procedure is
combintion o& tec#nologies t#t is in t#e erly stges o& common
prctice( Do$e%er, erly e;perience suggests success&ul !mr)rige" o& t#ese t$o
tec#ni'ues, $it# t#e possibility o& impro%ed
ptient outcomes( Huture reserc# is re'uired to &ully e;mine t#e
limittions o& bot# tec#nologies in t#e myrid situtions &ound in
t#e terminl dentition or trop#ic E$(
A39u* *DeAu*D9r0
Bry 9rentlic#er, <:<
7#ie&, <i%ision o& 9rl nd :;illo&cil 0urgery, F#ite Glins Dospitl :edicl
7enter, F#ite Glins, Ne$ Oor/C Gri%te Grctice, Ne$ Oor/ 9rl, :;illo&cil, nd
Implnt 0urgery, 0crsdle, Ne$ Oor/
9le Jensen <<0, :0
<irector, 7olordo *issue ?ngineering Institute, <en%er, 7olordoC Gri%te Grctice,
Breen$ood Villge, 7olordo
Andre$ Doro$it+, <:<, :<
Gri%te Grctice, Ne$ Oor/ 9rl, :;illo&cil, nd Implnt 0urgery,
0crsdle, Ne$ Oor/
:r/ Adms, <<0, :0
Gri%te Grctice, Grost#odontics, Breen$ood Villge, 7olordo
:rcus Abboud, <:<
7#irmn, <eprtment o& Grost#odontics nd <igitl *ec#nologies,
0tony 3roo/ .ni%ersity 0c#ool o& <entl :edicine, 0tony 3roo/, Ne$ Oor/
A7Pn9Fle<B:en*0
*#e ut#ors $ould li/e to c/no$ledge t#e contributions o&@
:r/ 3ris/in, <<0, Ardsley, Ne$ Oor/, on Gtient 1C =ymond
Feiss, <:<, 0crsdle, Ne$ Oor/, nd :rott <entl Lbortory,
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