Discuss “Is the surgeon redundant in the age of dental planning and workflow”

Gabriel Rodriguez-Ortiz /2017

Discuss “Is the surgeon redundant in the age of dental planning

and workflow”

By Gabriel Rodriguez-Ortiz

Abstract
The aim of this paper is to discuss the role of surgeons in the age of dental planning
and digital workflow.
A review of the current literature was performed with the intention to give an
overview of possible errors of guided surgery during dental planning and workflow
and the relevance of the surgeon intervention.
It was observed that although digital technology have rapidly evolved resulting in
further accuracy of the system, errors are still likely to occur that could jeopardize
the success of the final restoration. The surgeon should be in close interaction with
the restorative dentist, be involved in every step of the workflow and actively
provide feedback to the dental planning. At the time of surgery the clinician has to
ensure the guide fits accurately, pay attention to every detail of the surgery and be
able to correct possible pitfalls at the time of implant preparation. There is definitely
a learning curve; surgical skills and experience of the clinician go above and beyond
those necessary for providing regular implant surgery.
It is concluded that, although guided implant surgery may improve the outcomes in
implant–prosthetic rehabilitation, guided implant surgery is technically demanding
and not free from specific procedure-related complications.

Key words: dental implants, surgeon’s role, workflow, guided surgery, surgical
guide, digital planning, dental implant navigation, CBCT, restorative driven

Introduction

In the last decades, planning for implant dentistry has changed considerably from a

surgical approach that strictly focused on bone availability to planning for optimal

prosthetic outcomes prior to surgery. The implant should ultimately represent the

apical extension of an optimal prosthetic supra-structure and not the opposite,

‘‘restoration-driven’’ rather than ‘‘bone-driven’’ implant placement (Garber 1995;

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Garber & Belser 1995). This approach implies precise, three-dimensional implant

positioning, permitting an identical emergence of the prosthetic supra-structure

from the mucosa when compared to adjacent and/or contralateral teeth. (Belser et

al, 2004). Lately, the advances in 3-D technology has made possible to integrate

restorative treatment plans with the surgical placement of implants. The

introduction of multisliced computerized tomography (CT scans) and later on, cone

beam computed tomography (CBCT), as a 3-D imaging tool has provided a new

perspective in implant dentistry. The system in combination with implant planning

software allows to plan the implant in the ideal position, while taking into

consideration the prosthesis and the surrounding anatomy. Following an specific

workflow a surgical guide is fabricated and then the resultant information

transferred to the patient (Loubele et al, 2009).

The main purpose of guided surgery is primarily at improving diagnostic, surgical,

and prosthetic precision, simplifying technique-sensitive and operator-dependent

surgical procedures (Hultin et al, 2012). It has often been proposed that this new

technology provides the restoring clinician with a leadership role in the treatment

plan and treatment outcomes. It has been suggested that pre-operative, rather than

intraoperative drives the treatment and the placement of implants no longer relies

on traditional “mental navigation” but rather on precise, computer-guided implant

positioning that is planned pre-surgically (Rosenfel et al, 2006). However, this

concept is driven mostly by commercial marketing and has led to unrealistic

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expectations for the clinical efficacy and ease of use of these developing techniques,

which have wrongly been described as effective and easy to apply (Hammerle et al,

2009). A risk is the progressive misuses of a technique, which, if properly applied,

can improve the final result in implant–prosthetic rehabilitation (Cassetta et al,

2011). At the third EAO Consensus Conference 2012, Sicilia and Botticelli evaluated

the clinical advantages of computer guided implant placement. The authors

highlighted in this consensus that clinicians have to be aware that computer-driven

implant placement, in particular with flapless surgery often overlooks the ideal

location of important soft-tissue anatomy, such as the thickness, width and position

of keratinized tissue. Guided implant surgery is technically demanding and not free

from specific procedure-related complications. Hence, the belief that “less training is

needed” is far from accurate. Even more, it has been demonstrated that surgical

skills and experience of the clinician using this surgical technique go above and

beyond those necessary for providing regular implant surgery. The success of

guided surgery depends on a careful and detailed planning and execution, the role of

the surgeon has to be taken into account in every step of the workflow, starting from

the patient selection (Sicilia and Botticelli, 2012).

A review of the past and current literature, based in previous systematic reviews

and an additional electronic literature search of the PubMed, MEDLINE database

was performed with the intention of collecting information and give an overview of

the possible errors and drawbacks of guided surgery treatment planning and the

impact on the quality of execution and final outcome of the implant supported

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prosthesis. This review will focus on the factors that the surgeons should envisage

every time guided surgery is contemplated.

Dental Workflow And Digital Planning – Current Concepts

Nowadays, preoperative planning is performed on three-dimensional images

obtained from CBCT scans; they require specific software programs that are now

available for implant surgery planning. Companies such as Nobel Biocare and its

Nobel Clinician, Materialise Dental and the SimPlant digital alternatives, Dental

Wings and the development of CoDiagnostiX software, Sirona with Cerec solutions,

Align Technology with its iTero scanner, and the 3 Shape Dental system are some of

the most renowned names in the development of digital impressions and virtual

surgical solutions. These specific software programs transforms the original data

set in a Digital Imaging and Communication in Medicine (DICOM) format. After

secondary reformatting of the images, these programs allow implants of different

sizes to be ‘imported’ into the jawbone images. The virtual positioning of the

implants is mostly performed intuitively as is the case during surgery, starting from

the coronal part of the jawbone and moving to a more apical location.

Recently, intraoral scanning has been incorporated into the digital planning adding

considerable value to the whole process (Joda 2014). The intra-oral camera permits

the interposition of the CBCT scan, which provides a realistic view of the patient’s

hard and soft tissues. Therefore, implant planning can be done by integrating the

hard and soft tissue elements with the prosthetic requirements. The use of a scanner

has promoted new protocols that do not require the use of a radiographic guide.

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This is possible thanks to a procedure named surface mapping based on the

matching between numerous points on the surface of patient’s dental casts and the

corresponding anatomical surface points in the CBCT data. The full protocol is

examined focusing the attention on the clinical and laboratory procedures (De Vico

et al, 2016).

When the planned prosthesis is incorporated, the planning can take into account

both the jawbone anatomy and the planned superstructure. This may optimize the

mutual interaction between the ‘surgical’ and the prosthetic teams. Hence, it is often

proposed that a precise preoperative planning might propose immediate loading in

a relatively predictive manner and even more combine it with a flapless surgery

approach. However the extent of the use of static guided surgery are set by the

maximum deviation observed between planning and postoperative outcome.

Deviations may reflect the sum of all errors occurring from imaging to the

transformation of data into a guide, to the improper positioning of the latter during

surgery (Vercruyssen et al, 2015).

Types of Guided Implant Surgery

Currently there are two different types of guided implant surgery: Dynamic

approach, that is also called surgical navigation, the system reproduced the virtual

implant position directly from computerized tomography data. This system is based

on motion tracking technology that detects the position of the drill and patient

through surgery. One of the advantages of surgical navigation is, that the system

allows intraoperative changes in implant position. During computer-navigated

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surgery, the position of the surgical instruments in the surgical area is constantly

displayed on a screen with a three-dimensional image of the patient. In this way, the

system allows real-time transfer of the preoperative planning and visual feed- back

on the screen (Schneider et al, 2009; Jung et al, 2009).

The second type of guided surgery is the static approach; this system is also called

computer-guided surgery. The system requires the use of a static surgical template

that reproduces the virtual implant position directly from data and does not allow

intraoperative modification of the implant position. However, the bur sleeves of the

templates permit rigidly guided and highly controllable drilling, which may be an

advantage in areas where irregular bone is present. Furthermore, the intraoperative

set- up of a navigation system is not required, and there are no time constraints and

potential inconvenience of intraoperative registration and tracking. (Jung et al,

2009)

In terms of precision, studies have favor dynamic systems compared with the static

surgical guides. However, more preclinical studies on accuracy for the dynamic

systems and more clinical studies for the static systems have been made, which

could explain the difference. Although some clinical and accuracy studies are

available, dynamic systems currently have a very limited indication in implant

dentistry and are not in widespread use as a result of the initial high costs.

Therefore, these essay will focus in the static approach as it is the most popular

system in the market. (Vercruyssen et al, 2014).

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Digital Workflow And The Role Of The Surgeon

2
3
1 Digital
Planning Guided
Initial Implant
examination Implant Surgery
surgical plan
CBCT scan Immediate
Surgical Provisionalizat
Intraoral scan
Template ion
Fabrication

Fig 1. Digital Workflow for Implant Guided Surgery

1. Examination And Patient Selection And Factors Affecting The Quality Of

Data Contained In A CT Study

The basic preparatory steps, such as review of the patient’s goals, medical and

dental history, and a thorough clinical examination, are still an integral partof

implant guided surgery. The planning not only should include the hard and soft

tissue architecture, but also the occlusal and functional requirements in the area to

be restored. Different elements that have traditionally being considered for surgical

assessment of implant placement cannot be overlook and have to be combined with

a risk assessment and is responsibility of the surgeon to examine and assess the

patient prior to treatment planning. This risk assessment should incorporate a

thorough medical history, smoking habits, the amount of gingival display, width of

the edentulous space, shape of the crowns, periodontal status of the adjacent teeth,

history of periodontal therapy, gingival phenotype, presence or previous history of

infection or pathology, quality of the soft tissue and soft tissue anatomy, bone level

of adjacent teeth, facial bone wall phenotype, bone anatomy of the alveolar crest and

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whether ridge augmentation will be indicated, timing after extraction and patient’s

esthetic expectations. The incorporation of these patient data into the digital

planning permits sharing of the information and gives the opportunity for other

members of the team to provide feedback to the treatment plan. This process can

improve the preoperative diagnosis of the planned sites and oversee the potential

complications during the treatment process (Martin et al, 2017). A surgeon’s

understanding of the planned prosthetic outcome during surgical placement

improves the predictability of implant restorations based on a visual positioning

reference. (Califano et al, 2012)

Often, the first step in incorporating accurate prosthetic data into the CBCT study is

careful fabrication of a scanning prosthesis. The scanning prosthesis, derived from

the wax up, must be fully seated and stabilized by a radiolucent bite registration

during scanning. The clinician has to verify whether air is visible between the scan

prosthesis and the soft tissues. This is especially important for mucosa-supported

guides, where the basis of the future surgical guide will be the same as the basis of

the scan prosthesis. Furthermore, the prosthesis should have sufficient thickness, to

allow a correct segmentation. In case of insufficient thickness, it is not possible to

differentiate between the acrylic borders and the air. Motion and metal artifacts

may make difficult to visualize the alveolar bone and anatomical boundaries

(Vercruyssen et al, 2015) Sometimes the automatic superimposing procedure of the

markers proceed without notification and is responsibility of the surgeon to verify

the accuracy of the procedure (Pettersson et al 2012).

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Often a flapless approach for guided implant surgery is suggested for guided surgery

treatment, this is because is beneficial to patients, considerably less postoperative

morbidity and discomfort has been reported compared with open flap surgery

(Becker et al, 2009; Fortin et al, 2006, Landazuri-Del Barrio et al, 2013; Nikzard &

Azari, 2010). However, the consideration of a flapless technique can only be decided

by the surgeon, as there are a limited indications for this approach such as a broad

ridge and sufficient surrounding keratinized tissue after implant placement. In

addition, the successful outcome with this technique is dependent on advanced

imaging, clinical training and surgical judgment (Tahmaseb et al. 2014). Further

changes in the mucosa and alveolar bone during the time of examination and

intervention also have to be taken into consideration, changes of soft tissues after

tooth extraction, immature bone with low density that does not show up in the

CBCT will result in an inadequate planning (Vercruyssen et al, 2015).

2. Factors Affecting the Quality of the Surgical Plan in the Interactive Software

Accurate prosthetic information in the CT dataset is critical for surgical planning.

The knowledge and experience of the attending clinicians are also important factors

in developing a treatment plan. If the prosthetic workup and/or the quality of the

imaging and, or conversion process is compromised or is inaccurately represented

in the diagnostic setup and scanning appliance, the surgical planning and execution

will be inaccurate. This is especially important when a totally guided approach to

surgery is used. Outsourcing diagnosis and case-planning responsibilities to a third

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party should be avoided and considered carefully. In fact, it is the dentist who has

examined the patient and who will be executing the surgery in consultation with the

restorative dentist the responsible for completion of the surgical planning (Califano

et al, 2012).

Regardless of how precise is the planning; a degree of deviation has to be accepted.

For instance, the overall deviation in the production process of a stereolithographic

guide is <0.3 mm (Swaelens & Kruth 1993). The guide production executed in the

laboratory with the aid of a coordinate transfer apparatus or with the computer

numerical control (CNC) milling machine has a deviation of <0.5 mm (Dreiseidler et

al. 2009). An additional cumulative deviation error may be caused by either the

CBCT scan, the image segmentation, and/or by the creation of the model itself

(Bianchi et al. 1997; Schneider et al. 2002). This cumulative deviation and concealed

errors have to be taken into consideration at the time of surgery. For example, if the

3-D reconstruction for the creation of the surgical template is generated with a too

low gray value threshold, the surgical template will be thicker than the original

radiographic guide, resulting in a higher position toward the alveolar ridge and the

implants will be placed too superficially (Verhamme et al. 2012).

3. Execution And Factors Affecting The Quality Of The Surgical And Prosthetic

Outcome

The surgical outcome in any guided case is dependent on all the steps that preceded

the surgery (Fig 2). Any compromise in the quality of the data incorporated into the

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CT scan and/or surgical plan will be transferred to the stereolithographic guide. The

dimensional stability of the stone model (if needed for a tooth- or mucosa-

supported guide) and quality of the rapid prototype medical modeling and

stereolithographic surgical guide construction will further affect the accuracy of the

surgical procedure.

The guide must be fully seated and stable during the surgery. As it is also

recommended for the scanning appliances, when indicated, inspection windows can

ensure proper seating of the drilling guides. Cross-referencing can be made between

the stone models and the patient to confirm seating accuracy. In addition, a surgical

dress rehearsal can be performed on a stone model or stereolithographic medical

model before the actual surgery to further validate the accuracy of transfer of the

virtual plan to the patient before live surgery. Fixation of the guides during the

surgery can be considered, especially in totally guided cases. The major concern for

the transfer of the planning to the operative field is the accuracy, defined as the

deviation between the position of the “planned” and the “inserted” implant. The

latter is crucial in order to avoid anatomical boundaries and to prevent neurological

complications (Jacobs et al. 2014).

Precautions have to be taken to correctly fix the surgical guide and the bite index

(Verhamme et al, 2013). Certain tolerance of the drills within the sleeves is usually

observed, that means, the surgeon has to constantly check that the correct direction

is followed during the entire drilling sequence (Sun et al 2013). Adequate planning

using higher keys and decreasing the distance between the sleeve and the bone can

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reduce the tolerance. However, longer sleeves requires a larger mouth opening

(Schneider et al. 2014).

One of the most significant errors in guided surgery is the vertical inaccuracies, this

could be due to debris in the implant cavity, resilience of the mucosal tissues, during

segmentation and during guide reconstruction. The consequent result is that the

implant cannot reach its final position and would be placed too superficial. These

could be prevented at the time of implant planning by selection of a system that

includes drill stops that prevents inserting implants at the incorrect depth

(Tahmaseb et al. 2010) (Vercruyssen et al, 2015).

In situations were the level of guidance is partially guided, in which a bone-

supported computer-generated guide is used to carry the virtual plan to the surgery,

the guide determines the axial (mesio-distal and bucco- lingual) position of the

implant. The apico-coronal position of the implant is determined directly by the

surgeon. The surgeon can also verify the accuracy of the guide and preoperative

plan during the surgery. For instances, if the anatomy observed during the surgery

is different to the plan or there are other circumstances that decrease confidence in

the accuracy of the stereolithographic drilling guide, the surgeon can abort use of

the computer-generated guide and complete the procedure with a conventional

surgical approach.

When a tooth- or tooth–mucosa-supported drilling template of a fully guided case,

the surgery can be used with or without a flap (when appropriate). Use of full guides

requires experience and attention to detail in seating accuracy. In fact, there is a

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greater reliance on the guide in determining implant position. Although decreased

postoperative pain and swelling have been reported with flapless minimally

invasive options, there is a greater risk for an adverse event because visual

confirmation is not possible and tactile sensation is reduced (Wilson, 2010). The

diminished feedback decreases the information available regarding primary

stability in terms of insertion torque during the surgery. When it is not possible to

visually confirm implant position during the surgery, there is an increased risk of an

unfavorable outcome. A surgical dress rehearsal through ‘‘model surgery’’

performed preoperatively can help avoid these potential problems. (Califano et al,

2012).

Fig. 2. Deviations may reflect the sum of all errors occurring from imaging to

the transformation of data into a guide, to the improper positioning of the

latter during surgery (Vercruyssen et al, 2015).

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How Precise is Guided Surgery?

Guided surgery has always been suggested for critical anatomical situations, such

sites close to nerves, narrow ridges, whether angulation is critical, etc. Different

authors have investigated the level of accuracy of guided surgery, a discussion that

has become highly relevant in todays implant dentistry. At the proceedings of the

5th ITI Consensus Conference the data analyzed on computer guided surgery showed

a level of inaccuracy between planned and inserted implant position: irrespective of

the study design, the mean deviation of the implants at entry point was 1.12 mm

with a maximum of 4.5 mm; at the apex of implants of 1.39 mm, with a maximum of

7.1 mm; the overall mean deviation in angulation was 3.5° (95% CI 3.0–4.1), with a

maximum of 21.2 (Tahmaseb et al, 2014). On the other hand, there was significant

variation in the results and a large deviation was observed in two studies and was

far from the acceptable range (Cassetta et al, 2013; Di Giacomo et al, 2005).

The level of deviation could be associated to different factors. It has been proposed

that the movements of the surgical guide might cause deviations during implant

preparation; more in particular for unilateral bone supported and non-tooth

supported templates (Di Giacomo et al, 2005). Therefore, how guides are supported

may have an impact on accuracy. Implants supported by mini-implants showed high

level of accuracy more in particular in edentulous patients, compared with a lower

level of accuracy observed in bone-supported guides. This lower accuracy in bone-

supported guides could explain why flapped prosthesis is less accurate than flapless

procedures. In a great number of occasions where a flap is raised bone-support has

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been used for the surgical guides (Tahmaseb et al, 2014). Other studies also

reported that factors influencing the accuracy of the computer-guided approach in a

negative way are bone-supported guides, the use of multiple templates and the lack

of guide fixation. Unfortunately, most of the studies addressing computer-guided

implant placement looked at many different variables, making inter study

comparison difficult if not impossible (Van Assche et al in 2012). The level of

accuracy is reflected in the number of errors created during fabrication of the

surgical guide. It is important that all members of the team, including the surgeon

are aware of the problems and the consequent possible complications.

Complications

A systemic review by Tahmaseb et al 2014, reported the number of complications

reported on the literature. Within the 2,355 implants inserted in 343 treated cases, a

total of 125 cases reported complications. Although the numbers should be

interpreted with caution (not every study reports on all possible complications), a

cumulative complication rate of 36.4% per case was calculated. Eight studies

recorded template fractures occurring during surgery, with an incidence of 3.6% (7

out of 192 templates). All the fractures occurred in three of eight studies. Ten

studies reported surgical plan changes per implant. The overall incidence was 2.0%

(23 out of 1,133 implants). Five studies reported on implants lost during placement

because of the lack of primary stability. This complication was recorded as

occurring two times in one study and three times in another study and overall

incidence of 1.3% (5 out of 383 planned implants). These implants were not counted

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in the implant survival since they were not successfully inserted in the first place

(DiGiacomo et al, 2012; Kuhl et al, 2013).

Another study also investigated surgical and prosthetic complications with implant

guided surgery. This retrospective observational study was made on 19 patients,

and involved the placement of 122 implants with guided surgery. The authors

reported intraoperative surgical complications that comprised a lack of primary

stability, while the postoperative complications consisted of infections and a lack of

implant osseointegration. Ten implants failed. (Abad-Gallegos et al, 2011).

Discussion

The greater the dependence on the computer-generated stereolithographic drilling

guide to control implant position, the greater the importance of clinical and

prosthetic accuracy in the dental planning. Any concerns regarding the quality of the

preoperative data would dictate a lower level of control by the guide, with more

intraoperative verification by the surgeon using direct vision. Greater control by the

guide requires greater knowledge, skill, and experience by the clinician. The case

complexity and degree of risk to local anatomic structures are also important

considerations in guide selection. When the bone volume is limiting, the risk to

anatomic structures is increased, multiple implants are planned, and/or esthetic

concerns are more demanding, there is a greater need for precision and accuracy of

implant placement. In these clinical situations, use of a computer-generated

stereolithographic-drilling template for partially or totally guided implant therapy

may be critical (Califano et al, 2012).

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Computer-guided implantology is not a method that allows the operator to perform

surgeries that cannot be performed using standard implantology, but rather it

simplifies the treatment phases of complex clinical cases, performing minimally

invasive implant surgery more accurately (Cassetta et al, 2014). It seems that the

level of surgical experience affects the accuracy of the results. In the case of

surgeons who are already expert in implantology, computer-guided implant

placement may allows them to obtain high levels of accuracy from the beginning. In

a recent paper, Cassetta & Bellardini investigated the accuracy of implant insertion

performed by inexperienced versus experienced surgeons. Thirty-three implants

were inserted by the inexperienced group and 37 implants by the experienced

group. Planning and post-surgical computed tomography images were matched and

the accuracy data compared. The positioning error was also evaluated. The results

demonstrated that the positioning error was significantly higher in the

inexperienced group, resulting in higher coronal and apical deviations. This is in

agreement with other author that have also investigate the role of the surgeon

experience in computer guided surgery (Cushen et al, 2013; Hinckfuss et al, 2012).

The knowledge of different types of errors and their effects on the overall accuracy

of computer-guided systems should prove helpful to the surgeon who seeks a more

accurate result. Once again it is demonstrated that surgeons experience, training

and involvement in the digital workflow dental planning of guided surgery is crucial

for a successful final outcome, the persistent belief that computer- guided implant

therapy requires less surgical training is inaccurate (Cassetta & Bellardini, 2017).

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Table 1. Errors and role of the surgeon during the workflow and implant planning

Conclusions

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Digital technologies have rapidly evolved resulting in further accuracy of the guided

system. However, errors are still likely to occur and may affect the success of the

final restoration. Incorporating technological advances, such as 3D-guided

implantology, into clinical practice requires cooperative and collaborative input

from all those responsible for patient care. It is essential that surgeon in conjunction

with the restorative dentist must determine the most appropriate diagnostic

approach for a given situation. Success in radiological interpretation and guided

surgery execution is proportional to experience and detail in planning. Furthermore,

computer-generated stereolithographic surgical guides are not a substitute for

appropriate surgical training and experience. Instead they provide with valuable

anatomic and prosthetic information preoperatively that will improve treatment

planning and therefore a precise surgery and a successful restoration. The level of

expertise is proportional to the level of accuracy, in the case of surgeons who are

already expert in implantology, computer-guided implant placement may allows

them to obtain high levels of accuracy from the beginning. However is the team

collaboration and interest in every step of the dental planning and workflow that

could improve and excel the final outcome.

Conflict of Interest: The author reports no conflict of interest in relation to the

elaboration of this paper.

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Gabriel Rodriguez-Ortiz /2017

Additional notes

Pjetursson IJOMI 2014

5 ys survival and complication before years 2000 were not reported.
Review the paper

Veenering fracture is high after 5 ys, special;lly in full reconstrx

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