Guided surgery technique

associated to Morse taper

implants with a hexagonal
internal index
Guided surgery
technique associated
to Morse taper
implants with a
hexagonal internal
index
INTRODUCTION
The position in which an implant is installed influence
direct on aesthetics, function, comfort and patient
satisfaction (Sartori, 2007). In 1988, approximately 20
years after discovering osseointegration by Professor
Per-Ingvar Brånemark (Brånemark et al., 1969), Murrel
& Davis affirmed that when the study of ideal position
is not well done or when the communication between
surgeon and prosthesis technician is deficient, the
implants can be installed in not ideals positions,
committing, therefore, the prosthesis confection and
the patient satisfaction. As the primordial objective of
implant dentistry is to provide the oral rehabilitation
of edentulous patients, the successful finishing of the
prosthesis next to the analysis of adjacent anatomical
structures are the principles that should determine
the implants position. Ie, dentists should consider the
prosthetic objectives and surgical requirements for a
good planning of the surgery and implants installation
(Patel, 2010). In this context, the technological
evolution has favored the creation of sophisticated
software that assist the surgeon to plan the ideal
position of implants in a complex scenario, which
envolves the prosthetic planning and the identification
of anatomical structures.
Besides the reliability of diagnosis, planning and
surgical execution, through the association of CAD/
CAM technology and stereolithography to prototyping
confection and surgical guides (Rosenfeld, Mandelaro
& Tardieu, 2006; Nickenig & Eitner, 2007), another
advantage that came with the development of
the guided surgery technique is the possibility of
performing safe surgical procedures without opening
flaps (flapless surgery) (Thome, 2007; Padovan et al.,
2008; Thomé et al., 2009). The use of flapless guided
surgery allows considerable reduction of patient
discomfort, both during surgery and post surgical
(Thomé et al., 2009).
This article aims to describe the Neoguide guided
surgery technique (Neodent, Curitiba, Brazil)
associated with Morse taper implants with a internal
hexagonal index.
DESCRIPTION OF SURGICAL TECHNIQUE
The surgical procedure is initiated after the receipt
of the prototyped surgical guide, which must be
previously set in the mouth, before the surgery. The
adaptation of the prototyped guide to the tissues is
one of the main points to the success of the guided
surgery technique. It contains metal sleeves inserted
to transfer with precision the implants position
and inclination, according to a predetermined plan
during the “virtual surgery”. When you receive a full
edentulous arch guide, it is recommended that the
professional have the prototyped and tomographic
guide, to make a comparison between the correct
seating of both. By making the clinical test of the
prototyped guide, it should be noted if the seating of
the ridge is similar to that the tomographic guide shows.
If in guide installation, the professional notes that the
seating on the ridge is not equal to the tomographic
guide, he should seek the causes that are resulting in
misfit. These could be: lack of rings trimming or excess
of pressure in any area. The guide disinfection can be
made by chemical environment. Can be washed with
PVP-I (povidone) and dipped in antiseptic substance
(chlohexidine gluconate at 0.012%), maintained for
24 hours. For anesthesia, it is recommended to use
techniques of regional blocks away from areas where
the guide will be installed. The guide adaptation to
the fibromucosa is confirmed by uniform ischemic
appearance that is established when the professional
keeps the guide pressed.
If the guide adaptation is checked and the patient is
anesthetized, the following sequence must be done:
1 – Guide Stabilization:
The guide should be stabilized to enable its attachment
to the appropriate position. The stabilization of
edentulous jaws guides is performed through a self-
tapping graft screw in the center of the palate. Since
this is a region rich in gingival tissue with lower
thickness, it offers good chance for stability. In cases
of partial or single rehabilitation, the adjacent teeth
serve as support for the guide. Already in edentulous
jaws, the guides are stabilized with the aid of silicone
impression. To fix the guide, should be performed 3 or
4 perforations followed the insertion of the respective
fixer pins.
2 – Punch removal:
Then, the mucosa below the washers can be removed
with a rotational circular scalpel (mucosal punch 1)
at 80 rpm and supplemented with manual gingival
extractor or mucosal punch 2. This procedure is
optional and should be avoided especially in cases
where the thickness of the keratinized mucosa is small.
3 – Surgical instrumentation:
The surgical instrumentation should be done
respecting the progressive drills sequence, according
to the conventional surgical protocol, in which the
scheduling of surgical alveolus would be performed
progressively, until the final diameter of 2.8, 3.0 or 3.3
mm, depending on the bone quality of the area and
the type of selected implant. It should be noted the
corresponding guide to the diameter of each drill and
the diameter of the corresponding implant. Initially,
is used the initial drill, followed by a drill 2.0 with
respective guide. Drills with speed of 400-800 rpm are
used, depending on the bone quality, in order to avoid
excessive bone heating during installation.
Throughout instrumentation, the in and out movement
of the drills must be maintained with constant
irrigation. A detail on the technique is that it does not
use pilot drills, because the guides perform this work.
The use of pilot drills is recommended in cortical bone
for the correct seating of the implant in subcrestal
level.
4 – Capture of the implant:
After open the implant involucre, the surgeon will
repair the absence of mount, since the line of implants
with internal hexagonal index does not have this
piece. A Morse taper carrier (CM), model Neoguide
with index, will be used to capture the implant. The
company provides the contra-angle driver or ratchet.
To the appropriate capture of the implant, the Morse
taper connection should be pressed against the
implant positioned within the crystal. Once the
surgeon has sure to adjust the driver, he can lead
the implant to the surgical alveolus. For Neoguide
technique, the kit provides Morse taper connections
for different diameters of implants (3.5, 3.75 and 4.0).
Before the carrier installation, the washers that guide
the implants installation must be previously attached
on the sleeves of the prototyped surgical stent.
5 – Implant insertion:
The installation sequence of the implants should be
symmetric, installing an implant at a time, in a triangular
distribution. It is suggested to start by the implants
easier to install, aiding in the guide fixing. Initially, it is
avoided that the stop of CM driver presses the surgical
guide. This should lightly touch the implant washer.
After all implants are inserted, carefully, with the aid
of surgical ratchet, ends the installation.
It is important to highlight that the operator experience
in the conventional technique of implant installation is
important for the successful achievement of implants
primary stability. Care must be taken for that the
contact of CM carrier with the washer does not pass
a false impression of stability. The maneuvers of sub-
instrumentation and the choice of macrostructure in
the implants to allow high stability follow the same
procedures used in conventional technique.
For better guide fixation, perforate and install the
implants one by one, avoiding the surgical perforation
of all for posterior immediate installation of all
implants.
6 – Stabilizer installation:
The Neoguide kit presents four guide stabilizers
screws. Once the first implant is installed, the surgeon
should remove the CM carrier and screw the stabilizer
in position. This procedure should be repeated twice
at least, in the next two implants that will be installed.
So, after install the first three or four implants, the
surgeon must screw it the stabilizers, maintaining the
guide in position. Because of that, the first implants to
be installed should be those that offer more security
to the surgeon. cone beam CT data and surgical (guide) templates. J
7 – Guide removal:
The stabilizers should be removed with the digital
driver 1.2, as well as the graft screw of palate, with
the aid of a contra-angle and your respective driver
(Phillips), releasing the prototyped surgical guide.
FINAL CONSIDERATIONS
The possibility to perform the guided surgical
technique without opening flap (flapless surgery)
represents a significant advance in the procedures of
oral rehabilitation with osseointegration implants.
The Neoguide Surgical Kit allows performing
guided surgeries with safety, but the ability of
surgeon is extremely important to the success of the
technique. In relation to the surgical procedure, the
best advantages that can be listed are, definitely,
the minor discomfort in trans and postoperative, and
the reduced surgical time. Concerning the planning,
it brings a differential in the three-dimensional
positioning of implants in relation to the prosthesis.
This results in prosthetic structures more delicate,
with less possibility of phonetic discomfort. However,
should be emphasized that the technique presents
limitations that must be observed. The patient must
have good mouth opening, a sufficient quantity of
keratinized mucosa and appropriate bone availability.
Also should be remembered that the technique
requires multidisciplinary specialized training, as
well as credential to the technique. The procedures of
conversion and confection of the surgical guide should
be performed in agreement locations which execute a
process with quality. The main benefit of the technique
is obtained when used with immediate loading (Thomé
et al., 2009).
REFERENCES
Murrell GA, Davis WH. Presurgical prosthodontics. J
Prosthet Dent. 1988 Apr;59(4):447-52.
Nickenig HJ, Eitner S. Reliability of implant placement
after virtual planning of implant positions using
Craniomaxillofac Surg. 2007 Jun-Jul;35(4-5):207-11.
Padovan LEM, Sartori IAM, Thomé G, Melo ACM. Carga
imediata e implantes osseointegrados – Possibilidades
e técnicas. São Paulo: Editora Santos; 2008.
Patel N. Integrating three-dimensional digital
technologies for comprehensive implant dentistry. J Am
Dent Assoc. 2010 Jun;141 Suppl 2:20S-4S.
Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically
directed implant placement using computer software
to ensure precise placement and predictable prosthetic
outcomes. Part 1: diagnostics, imaging, and collaborative
accountability. Int J Periodontics Restorative Dent. 2006
Jun;26(3):215-21.
Thomé G, Sartori IAM, Bernardes SR, Melo ACM. Manual
Clínico para Cirurgia Guiada – Aplicação com Implantes
Osseointegrados. São Paulo: Editora Santos; 2009.
Thomé G. Planejamento Virtual para soluções reais. Rev
Implant news. 2007;4:359-75.
Figure 1 – Occlusal view of a model for demonstration Figure 2 – Occlusal view of Surgical Guide positioned over the model

Figure 3 – Options of drills for perforation of surgical guide Figure 4 – Palatine perforation of Surgical Guide
and definition of the fixation point with drill for graft screws

Figure 5 – Positioning of Surgical Guide after palatine perforation Figure 6 – Graft screw in contra-angle

Figure 7 – Graft screw fixation from palatine perforation Figure 8 – Occlusal view of the positioned graft screw
of Surgical Guide
Figure 9 – Perforation with the drills of guide fixers until the recommended level (posterior to the palatine fixation)

Figure 10 – Guide Fixers positioned on the vestibular face of the Surgical Guide

Figure 11 – Rotatory circular scalpel for mucosal extraction (optional of the technique)
Figure 12 – Drill sequence with respective Figure 13 – Respective rings and implants according to the diameter (3.5, 3.75 and
Neoguide Drill Guide 2.0, 2.8, 3.0, 3.3 4.0mm)

Figure 14 – Drill Guide 2.0 for position Figure 15 – Beginning of the surgical procedure with Drill 2.0

Figure 17 – CM Connection’s Neoguide model for contra-angle in

Figure 16 – Opening of package that supports the implant diameter 3.5mm.
Figure 18 – Implant capture with CM Connection for Contra-Angle

Figure 19 – Ring with diameter of 3.5mm in position after drilling indicated accord-
ing to the type of implant. Figure 20 – Installation of Titamax Ex CM implant with diameter 3.5mm.

Figure 22 – With CM Connection in position and use of ratchet until

Figure 21 – CM Connection model Neoguide for ratchet
the contact with the ring
Figure 23 – Final insertion torque of the implant, without excessive Figure 24 – CM Connection model Neoguide for Ratchet in position
force on the ring.

Figure 25 – Changing the direction of ratchet and small movement in opposite direction for remove the CM Connection

Figure 26 – Removing of CM Connection and ring

Figure 27 – Stabilizer Screw Guide with the Hex Driver 1.2 Figure 28 – Positioning of Stabilizer Screw Guide

Figure 29 – Ring positioned, to continued with the installation of second

implant – watch the stabilizer in the opposite side, in position Figure 30 – CM Connection’s Neoguide model for contra-angle

Figure 31 – Positioning of CM Connection’s Neoguide model for Ratchet

Figure 32 – Insertion torque until contact between the ring and the CM Connection

Figure 33 – Positioning of Stabilizer Screw Guide after the second Figure 34 – Positioning of Stabilizer Screw Guide after third
implant installation implant installation

Figure 35 – Positioning of ring for the fourth implant installation

Figure 36 – Removal of Pins and Stabilizer Screw Guides and Graft Screw, Figure 37 – Occlusal view after implants installation.
for removal of the Surgical Guide
Figure 38 – Initial radiographic aspect of the region of tooth 21 Figure 39 – Tomographic Guide
(conventional image and inverted image).

Figure 40 – Occlusal and frontal views of the region of tooth 21.

Figure 41 – Register of tomographic guide in position for tomographic taking Figure 42 – Occlusal and frontal view of prototyped Surgical in position
(supported by adjacent teeth)

Figure 43 – Implant of 3.75 captured by CM Connection’s Neoguide model for Figure 44 – Ring in position for implant installation
contra-angle
Figure 45 – Occlusal view of the installed implant in the
region of tooth 21.

Figure 46 – Anatomical Post in position.

Figure 47 – Radiographic aspect of the post with the cemented provisional crown
(inverted and conventional image).
Figure 48 – Clinical aspect intra and extra oral after cementation of provisional crown.