- Email: [email protected]
In-office fabrication of dental implant surgical guides using desktop stereolithographic printing and implant treatment planning software: A clinical report
CLINICAL REPORT
In-office fabrication of dental implant surgical guides using desktop stereolithographic printing and implant treatment planning software: A clinical report Daniel Whitley III, DDS,a R. Scott Eidson, DDS,b Ivan Rudek, DDS, MS,c and Sompop Bencharit, DDS, MS, PhDd The proper positioning of dental ABSTRACT implants is essential to preGuided surgery is accepted as the most accurate way to place an implant and predictably relate the venting damage to vital strucimplant to its definitive prosthesis, although few clinicians use it. However, recent developments in tures, providing an optimal high-quality desktop 3-dimensional stereolithographic printers have led to the in-office fabrication prosthesis, and ensuring a of stereolithographic surgical guides at reduced cost. This clinical report demonstrates a protocol successful long-term outcome.1 for using a cost-effective, in-office rapid prototyping technique to fabricate a surgical guide for dental implant placement. (J Prosthet Dent 2016;-:---) Therefore, various surgical guide techniques have been developed to place a dental implant into the desired locathe turnaround from the laboratory, and the learning tion.1-4 A completely restricting surgical guide is the most curve for the technique can also be limiting factors.6,13 2-4 accurate technique. The most common adaptation of this The advantages of guided surgery include a high accutechnique integrates cone-beam computed tomography racy of approximately 0.1 mm, the conservation of (CBCT), digital scans of current oral tissues, and a template anatomic structures, a thorough examination of vital of the definitive prosthetics to produce a computer-aided structures and osseous topography, reduced surgical design and computer-aided manufacturing (CAD-CAM) time, less invasive surgery, and the promotion of optimal guide.1-10 This guide controls the drill angulation, depth, prosthetic outcomes.6,11-19 1-10 and location of the implant. The CAD-CAM guide is Affordable desktop 3D printers with high precision usually milled or additively manufactured (3-dimensionally can allow a dental office to produce anatomic casts and [3D] printed).11 A milled guide is dimensionally stable and implant drilling guides.13-16 Although many 3D printing 12 usually less brittle. However, the cost of the material and techniques are available, this report will focus on stermilling machine plus the material waste that results from eolithography because of its proven accuracy and its the milling process are drawbacks. Recently developed, history of use in dentistry.2-4 This is a method where a affordable, high-quality 3D printers offer an alternative that photosensitive resin bath is positioned between a build can produce a guide with limited material waste and minplatform and light-polymerizing source of a specific imal polymerization shrinkage.13 wavelength.7,13,19 The build platform is lowered into the Despite being the most accurate, CAD-CAM guides resin bath, and the light is directed by the computer to are the least used surgical guide, in part because of the polymerize the resin layer by layer to create the desired cost of the systems.14-18 The time involved with planning, 3D object (Fig. 1).13,20-26 The resin and printer combination
Supported in part by US National Institutes of Health grant HL092338 and an unrestricted educational grant from Zimmer Biomet Dental. a Private practice, Greenville, N.C. b Clinical Associate Professor, Department of Operative Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, N.C. c Research Assistant Professor, General and Oral Health Center, Department of Periodontics, University of North Carolina at Chapel Hill, Chapel Hill, N.C. d Associate Professor and Director of Digital Dentistry Technologies, Department of General Practice and Department of Oral and Maxillofacial Surgery, School of Dentistry, and Department of Biomedical Engineering, School of Engineering, Virginia Commonwealth University, Richmond, Va.
THE JOURNAL OF PROSTHETIC DENTISTRY
1
2
Volume
-
Issue
-
Figure 1. Schematic of form 2 stereolithographic desktop 3D printer demonstrating “bottom up” stereolithographic printer. A 405-nm laser projected through a transparent resin tank to accurately polymerize layers of resin to create desired 3D object.13
should be precisely paired to prevent inaccuracies in the process. Furthermore, the materials used for drill guides should at a minimum be compatible with United States Pharmacopeia (USP) class VI standards for biocompatibility before in vivo use is considered.27,28 This report presents the use of a desktop, stereolithographic printer (Form 2; Formlabs Inc) coupled with synergistic biocompatible resin (Dental SG; Formlabs Inc), which is certified to comply with the international standards for class I biocompatibility, International Organization for Standardization (ISO) standard 10993-1 and USP class VI. When the manufacturers’ instructions are followed, it is suitable for intraoral use of 24 hours or less.28 CLINICAL REPORT A 40-year-old Asian man presented with this chief complaint: “I cannot chew on the left side. I lost one of my upper molars.” Approximately 17 years previously, the patient had had endodontic treatment for the maxillary left first molar. Subsequently, the tooth fractured, was extracted, and ridge preservation was performed. The patient had a class II malocclusion on the right side with moderate crowding in the premolar area but declined orthodontic treatment at this time (Fig. 2). Preoperative CBCT scans were examined using software (Blue Sky Plan 3 v3.39.4; Blue Sky Bio LLC). A virtual tooth replacing the maxillary left first molar was created (Fig. 3). First, a virtual implant to mimic the a short implant (Zimmer Tapered Screw Vent, 4.7×8 mm; Zimmer Biomet Dental) was created. Then, because the treatment plan included a crestal sinus augmentation to place a 4.7×10 mm implant (Zimmer Trabecular Metal Implant; Zimmer Biomet Dental), a longer virtual implant was used. The surgical guide was fabricated as described previously.13 The surgical guide was planned using parameters that coincided with the Zimmer guided kit’s 19-mm
THE JOURNAL OF PROSTHETIC DENTISTRY
Figure 2. Preoperative digital casts of patient’s dentition. A, Buccal right. B, Mid-facial. C, Buccal left.
drills. A half-arch guide was designed to achieve optimal stability by using the teeth mesial and distal to the edentulous area. The stereolithography (STL) file was exported from the planning software and imported into the 3D printing software (Preform Software; Formlabs Inc) to set up and complete the print. The guide was oriented to minimize cross sectional peeling forces during printing and to allow for the drainage of excess resin, and support points were added in areas that did not interfere with an accurate fit of the guide (Fig. 4A).13 The resin volume used was 11.30 mL, and the settings for the print were 50-mm layers in the z-axis with a print time of 3 hours. Next, the guide was removed from the build platform, rinsed twice with 91% isopropanol for 20 minutes and allowed to air dry. Complete polymerization was accomplished with a polymerization chamber (LC3D print box; Vertex-Dental B.V.) by exposure for 10
Whitley et al
-
2016
3
Figure 3. Implant treatment planning. A, Implant positioning. B, Buccal view of virtual tooth positioning. C, Panoramic view of virtual tooth and implant position. D, Occlusal view of virtual tooth and implant screw access. E, Surgical guide planning. F, Placement of implant at 10-mm length.
minutes to 108 watts each of Blue UV-A (315-400 nm) and UV-Blue (400-550 nm) light in a heated environment at 60 C. Supports were removed, and a stainless steel guide tube (Blue Sky Bio LLC) that coincided with the Zimmer Guided Surgery size B keys (Zimmer Biomet Whitley et al
Dental) was inserted. The guide was then autoclavesterilized (Fig. 4). The patient was premedicated with 2 g of amoxicillin 1 hour preoperatively, and a 0.12% chlorhexidine gluconate rinse was used immediately before the surgery. THE JOURNAL OF PROSTHETIC DENTISTRY
4
Volume
-
Issue
-
Figure 4. Stereolithographic printing of surgical guide. A, Orientation of guide before printing. B, Printed guide removed from printer. C, After 20-minute alcohol bath. D, After 10-minute postpolymerization. E, After trimming and removal of supports. F, Guide tube added. G, After autoclave sterilization. Color change from bright yellow to orange to clear/honey color is normal for this resin.
The surgical guide was evaluated intraorally, and the guided surgery was performed using a flapless approach (Fig. 5A-K). The osteotomy site was prepared by using serial drills of 2.3, 2.8, 3.4, and 3.8 mm in width to 8 mm
THE JOURNAL OF PROSTHETIC DENTISTRY
in depth. An osteotome and demineralized bone matrix (Puros Demineralized Bone Matrix Putty; Zimmer Biomet Dental) was then used to lift the crestal sinus to about 13 mm from the alveolar crest. The site was threaded with
Whitley et al
-
2016
5
Figure 5. Clinical procedures. A, Surgical guide and cast. B, Edentulous site. C, Surgical guide in place. D, Guide with tube adapter and drill. E, Guide surgical tube adapter in place. F, G, Guided surgical osteotomy preparation. H, Implant fixture.
Whitley et al
THE JOURNAL OF PROSTHETIC DENTISTRY
6
Volume
-
Issue
-
Figure 5. (continued). Clinical procedures. I, Implant placement. J, Implant in place buccal view. K, Cervical part of implant. L, Postoperative periapical radiograph. M, Postoperative CBCTs, planned position in grey (4.7×8 mm) and placement position in green (4.7×10 mm).
the bone tap, and a 4.7×10 mm porous tantalum trabecular metal enhanced titanium dental implant (Zimmer Trabecular Metal; Zimmer Biomet Dental) was placed.29,30 Primary stability was approximately 50 Ncm, hemostasis was achieved, and a healing abutment was placed. Postoperative care included chlorhexidine mouthrinse (twice a day for 2 weeks, amoxicillin (500 mg 4 times a day for 2 weeks), oral pseudoephedrine decongestant (30 mg twice a day for 5 days), and nasal oxymetazoline (0.05% 2 sprays per nostril twice a day for 3 days). A postoperative periapical radiograph
THE JOURNAL OF PROSTHETIC DENTISTRY
and a CBCT scan were made 1 week after the surgery (Fig. 5 L, M). DISCUSSION Guided surgery can be used with or without elevating a full-thickness flap. In this patient, a flapless approach was chosen because of the availability of adequate keratinized tissue and bone volume that would require no contouring or other grafting procedures.23 Lack of flap elevation and subsequent interruption of blood flow can
Whitley et al
-
2016
7
Figure 6. Proposed digital workflow.
decrease postoperative discomfort, reduce surgical time, reduce healing time, and reduce bone loss. However, the flapless technique does have some drawbacks, including the inability to visualize anatomic landmarks and possible damage to anatomic structures, the inability to contour osseous topography or graft if the bone volume is insufficient, and the mal-positioned angle or depth of the implant body.31 With proper planning, guided surgery can limit complications. The workflow presented here (Fig. 6) uses an affordable desktop 3D printer, which, in turn, reduces cost compared with that of previous commercial printers and software, eliminates laboratory and shipping expenses and possibly increases the use of guided surgery. However, this method is only as accurate as the plan and technique used during the surgery. A knowledge of additive manufacturing and some calibration of the implant planning and the 3D printing software will be needed initially, as there are many areas where error may be introduced. Whitley et al
Although this workflow is practical and can produce an accurate outcome, this report is only a preliminary trial in 1 patient. The potential for this technology in dentistry is great and will only increase as the technology evolves.22,23 One example of ongoing research is such applications as 3D printing tissue engineered bone scaffoldings conceivably allowing for customized grafting materials.32 SUMMARY The use of desktop 3D printers is a practical option for the production of accurate implant drilling guides. REFERENCES 1. Le B, Nielsen B. Esthetic implant site development. Oral Maxillofac Surg Clin North Am 2015;27:283-311. 2. D’Souza KM, Aras MA. Types of implant surgical guides in dentistry: a review. J Oral Implantol 2012;38:643-52. 3. Greenberg AM. Digital technologies for dental implant treatment planning and guided surgery. Oral Maxillofac Surg Clin North Am 2015;27:319-40.
THE JOURNAL OF PROSTHETIC DENTISTRY
8
4. Kola MZ, Shah AH, Khalil HS, Rabah AM, Harby NM, Sabra SA, et al. Surgical templates for dental implant positioning; current knowledge and clinical perspectives. Niger J Surg 2015;21:1-5. 5. Edelmann AR, Hosseini B, Byrd WC, Preisser JS, Tyndall DA, Nguyen T, et al. Exploring effectiveness of computer-aided planning in implant positioning for a single immediate implant placement. J Oral Implantol 2016;42:233-9. 6. Dawood A, Marti Marti B, Sauret-Jackson V, Darwood A. 3D printing in dentistry. Br Dent J 2015;219:521-9. 7. Dada K, Pariente L, Daas M. Strategic extraction protocol: Use of an imagefusion stereolithographic guide for immediate implant placement. J Prosthet Dent 2016;116:652-6. 8. Hosseini B, Byrd WC, Preisser JS, Khan A, Duggan D, Bencharit S. Effects of antibiotics on bone and soft-tissue healing following immediate single-tooth implant placement into sites with apical pathology. J Oral Implantol 2015;41: e202-11. 9. Di Giacomo GA, Cury PR, da Silva AM, da Silva JV, Ajzen SA. A selective laser sintering prototype guide used to fabricate immediate interim fixed complete arch prostheses in flapless dental implant surgery: Technique description and clinical results. J Prosthet Dent 2016. 10. Liu YF, Wu JL, Zhang JX, Peng W, Liao WQ. Numerical and experimental analyses on the temperature distribution in the dental implant preparation area when using a surgical guide. J Prosthodont 2016. 11. Orentlicher G, Abboud M. Guided surgery for implant therapy. Oral Maxillofac Surg Clin North Am 2011;23:239-56. 12. Gross BC, Erkal JL, Lockwood SY, Chen C, Spence DM. Evaluation of 3D printing and its potential impact on biotechnology and the chemical sciences. Anal Chem 2014;86:3240-53. 13. Whitley D, Bencharit S. Digital implantology with desktop 3D Printing. Formlabs White Paper 2015:1-15. 14. Arisan V, Karabuda CZ, Mumcu E, Ozdemir T. Implant positioning errors in freehand and computer-aided placement methods: a single-blind clinical comparative study. Int J Oral Maxillofac Implants 2013;28:190-204. 15. Flugge TV, Nelson K, Schmelzeisen R, Metzger MC. Three-dimensional plotting and printing of an implant drilling guide: simplifying guided implant surgery. J Oral Maxillofac Surg 2013;71:1340-6. 16. Nickenig HJ, Eitner S, Rothamel D, Wichmann M, Zoller JE. Possibilities and limitations of implant placement by virtual planning data and surgical guide templates. Int J Comput Dent 2012;15:9-21. 17. Schneider D, Marquardt P, Zwahlen M, Jung RE. A systematic review on the accuracy and the clinical outcome of computer-guided template-based implant dentistry. Clin Oral Implants Res 2009;20(suppl 4):73-86. 18. Raico Gallardo YN, da Silva-Olivio IR, Mukai E, Morimoto S, Sesma N, Cordaro L. Accuracy comparison of guided surgery for dental implants according to the tissue of support: a systematic review and meta-analysis. Clin Oral Implants Res 2016 Apr 8. http://dx.doi.org/10.1111/clr.12841. [Epub ahead of print]. 19. Pozzi A, Polizzi G, Moy PK. Guided surgery with tooth-supported templates for single missing teeth: A critical review. Eur J Oral Implantol 2016;9(suppl 1): 135-53. 20. Torabi K, Farjood E, Hamedani S. Rapid prototyping technologies and their applications in prosthodontics, a review of literature. J Dent (Shiraz) 2015;16:1-9. 21. Orentlicher G. Digital technologies in oral and maxillofacial surgery. Preface. Atlas of the oral and maxillofacial surgery clinics of North America. St. Louis: Elsevier Health Sciences; 2012. p. 20.
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume
-
Issue
-
22. Suomalainen A, Stoor P, Mesimaki K, Kontio RK. Rapid prototyping modelling in oral and maxillofacial surgery: A two year retrospective study. J Clin Exp Dent 2015;7:e605-12. 23. da Rosa EL, Oleskovicz CF, Aragao BN. Rapid prototyping in maxillofacial surgery and traumatology: case report. Braz Dent J 2004;15: 243-7. 24. Nayar S, Bhuminathan S, Bhat WM. Rapid prototyping and stereolithography in dentistry. J Pharm Bioallied Sci 2015;7:S216-9. 25. Stansbury JW, Idacavage MJ. 3D printing with polymers: challenges among expanding options and opportunities. Dent Mater 2016;32:54-64. 26. Bikas H, Stavropoulos P, Chryssolouris G. Additive manufacturing methods and modelling approaches: a critical review. Int J Adv Manuf Tech 2016;83: 389-405. 27. Oskui SM, Diamante G, Liao CY, Shi W, Gan J, Schlenk D, et al. Assessing and reducing the toxicity of 3D-printed parts. Environ Sci Tech Let 2016;3: 1-6. 28. Centers for Devices and Radiological Health. Use of International Standard ISO 10993-1, “Biological evaluation of medical devices-Part 1: evaluation and testing within a risk management process” guidance for industry and Food and Drug Administration staff. June 16, 2016. US Department of Health and Human Services, Food and Drug Administration, CDRH. Washington DC. 2016:1-68. Available at: http://www.fda.gov/downloads/medicaldevices/ deviceregulationandguidance/guidancedocuments/ucm348890.pdf. Accessed November 30, 2016. 29. Bencharit S, Byrd WC, Altarawneh S, Hosseini B, Leong A, Reside G, et al. Development and applications of porous tantalum trabecular metalenhanced titanium dental implants. Clin Implant Dent Relat Res 2014;16: 817-26. 30. Bencharit S, Byrd WC, Hosseini B. Immediate placement of a poroustantalum, trabecular metal-enhanced titanium dental implant with demineralized bone matrix into a socket with deficient buccal bone: a clinical report. J Prosthet Dent 2015;113:262-9. 31. Romero-Ruiz MM, Mosquera-Perez R, Gutierrez-Perez JL, Torres-Lagares D. Flapless implant surgery: a review of the literature and 3 case reports. J Clin Exp Dent 2015;7:e146-52. 32. He HY, Zhang JY, Mi X, Hu Y, Gu XY. Rapid prototyping for tissueengineered bone scaffold by 3D printing and biocompatibility study. Int J Clin Exp Med 2015;8:11777-85. Corresponding author: Dr Sompop Bencharit Virginia Commonwealth University 520 N 12th St Richmond, VA 23284 Email: [email protected] Acknowledgments The authors thank the members of the University of North Carolina at Chapel Hill Department of Prosthodontics and Dental Faculty Practice. The authors also thank Drs Capps, Bowman, and Padgett, Greenville, NC, for allowing use of their laboratory space. Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
Whitley et al
In-office fabrication of dental implant surgical guides using desktop stereolithographic printing and implant treatment planning software: A clinical report Daniel Whitley III, DDS,a R. Scott Eidson, DDS,b Ivan Rudek, DDS, MS,c and Sompop Bencharit, DDS, MS, PhDd The proper positioning of dental ABSTRACT implants is essential to preGuided surgery is accepted as the most accurate way to place an implant and predictably relate the venting damage to vital strucimplant to its definitive prosthesis, although few clinicians use it. However, recent developments in tures, providing an optimal high-quality desktop 3-dimensional stereolithographic printers have led to the in-office fabrication prosthesis, and ensuring a of stereolithographic surgical guides at reduced cost. This clinical report demonstrates a protocol successful long-term outcome.1 for using a cost-effective, in-office rapid prototyping technique to fabricate a surgical guide for dental implant placement. (J Prosthet Dent 2016;-:---) Therefore, various surgical guide techniques have been developed to place a dental implant into the desired locathe turnaround from the laboratory, and the learning tion.1-4 A completely restricting surgical guide is the most curve for the technique can also be limiting factors.6,13 2-4 accurate technique. The most common adaptation of this The advantages of guided surgery include a high accutechnique integrates cone-beam computed tomography racy of approximately 0.1 mm, the conservation of (CBCT), digital scans of current oral tissues, and a template anatomic structures, a thorough examination of vital of the definitive prosthetics to produce a computer-aided structures and osseous topography, reduced surgical design and computer-aided manufacturing (CAD-CAM) time, less invasive surgery, and the promotion of optimal guide.1-10 This guide controls the drill angulation, depth, prosthetic outcomes.6,11-19 1-10 and location of the implant. The CAD-CAM guide is Affordable desktop 3D printers with high precision usually milled or additively manufactured (3-dimensionally can allow a dental office to produce anatomic casts and [3D] printed).11 A milled guide is dimensionally stable and implant drilling guides.13-16 Although many 3D printing 12 usually less brittle. However, the cost of the material and techniques are available, this report will focus on stermilling machine plus the material waste that results from eolithography because of its proven accuracy and its the milling process are drawbacks. Recently developed, history of use in dentistry.2-4 This is a method where a affordable, high-quality 3D printers offer an alternative that photosensitive resin bath is positioned between a build can produce a guide with limited material waste and minplatform and light-polymerizing source of a specific imal polymerization shrinkage.13 wavelength.7,13,19 The build platform is lowered into the Despite being the most accurate, CAD-CAM guides resin bath, and the light is directed by the computer to are the least used surgical guide, in part because of the polymerize the resin layer by layer to create the desired cost of the systems.14-18 The time involved with planning, 3D object (Fig. 1).13,20-26 The resin and printer combination
Supported in part by US National Institutes of Health grant HL092338 and an unrestricted educational grant from Zimmer Biomet Dental. a Private practice, Greenville, N.C. b Clinical Associate Professor, Department of Operative Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, N.C. c Research Assistant Professor, General and Oral Health Center, Department of Periodontics, University of North Carolina at Chapel Hill, Chapel Hill, N.C. d Associate Professor and Director of Digital Dentistry Technologies, Department of General Practice and Department of Oral and Maxillofacial Surgery, School of Dentistry, and Department of Biomedical Engineering, School of Engineering, Virginia Commonwealth University, Richmond, Va.
THE JOURNAL OF PROSTHETIC DENTISTRY
1
2
Volume
-
Issue
-
Figure 1. Schematic of form 2 stereolithographic desktop 3D printer demonstrating “bottom up” stereolithographic printer. A 405-nm laser projected through a transparent resin tank to accurately polymerize layers of resin to create desired 3D object.13
should be precisely paired to prevent inaccuracies in the process. Furthermore, the materials used for drill guides should at a minimum be compatible with United States Pharmacopeia (USP) class VI standards for biocompatibility before in vivo use is considered.27,28 This report presents the use of a desktop, stereolithographic printer (Form 2; Formlabs Inc) coupled with synergistic biocompatible resin (Dental SG; Formlabs Inc), which is certified to comply with the international standards for class I biocompatibility, International Organization for Standardization (ISO) standard 10993-1 and USP class VI. When the manufacturers’ instructions are followed, it is suitable for intraoral use of 24 hours or less.28 CLINICAL REPORT A 40-year-old Asian man presented with this chief complaint: “I cannot chew on the left side. I lost one of my upper molars.” Approximately 17 years previously, the patient had had endodontic treatment for the maxillary left first molar. Subsequently, the tooth fractured, was extracted, and ridge preservation was performed. The patient had a class II malocclusion on the right side with moderate crowding in the premolar area but declined orthodontic treatment at this time (Fig. 2). Preoperative CBCT scans were examined using software (Blue Sky Plan 3 v3.39.4; Blue Sky Bio LLC). A virtual tooth replacing the maxillary left first molar was created (Fig. 3). First, a virtual implant to mimic the a short implant (Zimmer Tapered Screw Vent, 4.7×8 mm; Zimmer Biomet Dental) was created. Then, because the treatment plan included a crestal sinus augmentation to place a 4.7×10 mm implant (Zimmer Trabecular Metal Implant; Zimmer Biomet Dental), a longer virtual implant was used. The surgical guide was fabricated as described previously.13 The surgical guide was planned using parameters that coincided with the Zimmer guided kit’s 19-mm
THE JOURNAL OF PROSTHETIC DENTISTRY
Figure 2. Preoperative digital casts of patient’s dentition. A, Buccal right. B, Mid-facial. C, Buccal left.
drills. A half-arch guide was designed to achieve optimal stability by using the teeth mesial and distal to the edentulous area. The stereolithography (STL) file was exported from the planning software and imported into the 3D printing software (Preform Software; Formlabs Inc) to set up and complete the print. The guide was oriented to minimize cross sectional peeling forces during printing and to allow for the drainage of excess resin, and support points were added in areas that did not interfere with an accurate fit of the guide (Fig. 4A).13 The resin volume used was 11.30 mL, and the settings for the print were 50-mm layers in the z-axis with a print time of 3 hours. Next, the guide was removed from the build platform, rinsed twice with 91% isopropanol for 20 minutes and allowed to air dry. Complete polymerization was accomplished with a polymerization chamber (LC3D print box; Vertex-Dental B.V.) by exposure for 10
Whitley et al
-
2016
3
Figure 3. Implant treatment planning. A, Implant positioning. B, Buccal view of virtual tooth positioning. C, Panoramic view of virtual tooth and implant position. D, Occlusal view of virtual tooth and implant screw access. E, Surgical guide planning. F, Placement of implant at 10-mm length.
minutes to 108 watts each of Blue UV-A (315-400 nm) and UV-Blue (400-550 nm) light in a heated environment at 60 C. Supports were removed, and a stainless steel guide tube (Blue Sky Bio LLC) that coincided with the Zimmer Guided Surgery size B keys (Zimmer Biomet Whitley et al
Dental) was inserted. The guide was then autoclavesterilized (Fig. 4). The patient was premedicated with 2 g of amoxicillin 1 hour preoperatively, and a 0.12% chlorhexidine gluconate rinse was used immediately before the surgery. THE JOURNAL OF PROSTHETIC DENTISTRY
4
Volume
-
Issue
-
Figure 4. Stereolithographic printing of surgical guide. A, Orientation of guide before printing. B, Printed guide removed from printer. C, After 20-minute alcohol bath. D, After 10-minute postpolymerization. E, After trimming and removal of supports. F, Guide tube added. G, After autoclave sterilization. Color change from bright yellow to orange to clear/honey color is normal for this resin.
The surgical guide was evaluated intraorally, and the guided surgery was performed using a flapless approach (Fig. 5A-K). The osteotomy site was prepared by using serial drills of 2.3, 2.8, 3.4, and 3.8 mm in width to 8 mm
THE JOURNAL OF PROSTHETIC DENTISTRY
in depth. An osteotome and demineralized bone matrix (Puros Demineralized Bone Matrix Putty; Zimmer Biomet Dental) was then used to lift the crestal sinus to about 13 mm from the alveolar crest. The site was threaded with
Whitley et al
-
2016
5
Figure 5. Clinical procedures. A, Surgical guide and cast. B, Edentulous site. C, Surgical guide in place. D, Guide with tube adapter and drill. E, Guide surgical tube adapter in place. F, G, Guided surgical osteotomy preparation. H, Implant fixture.
Whitley et al
THE JOURNAL OF PROSTHETIC DENTISTRY
6
Volume
-
Issue
-
Figure 5. (continued). Clinical procedures. I, Implant placement. J, Implant in place buccal view. K, Cervical part of implant. L, Postoperative periapical radiograph. M, Postoperative CBCTs, planned position in grey (4.7×8 mm) and placement position in green (4.7×10 mm).
the bone tap, and a 4.7×10 mm porous tantalum trabecular metal enhanced titanium dental implant (Zimmer Trabecular Metal; Zimmer Biomet Dental) was placed.29,30 Primary stability was approximately 50 Ncm, hemostasis was achieved, and a healing abutment was placed. Postoperative care included chlorhexidine mouthrinse (twice a day for 2 weeks, amoxicillin (500 mg 4 times a day for 2 weeks), oral pseudoephedrine decongestant (30 mg twice a day for 5 days), and nasal oxymetazoline (0.05% 2 sprays per nostril twice a day for 3 days). A postoperative periapical radiograph
THE JOURNAL OF PROSTHETIC DENTISTRY
and a CBCT scan were made 1 week after the surgery (Fig. 5 L, M). DISCUSSION Guided surgery can be used with or without elevating a full-thickness flap. In this patient, a flapless approach was chosen because of the availability of adequate keratinized tissue and bone volume that would require no contouring or other grafting procedures.23 Lack of flap elevation and subsequent interruption of blood flow can
Whitley et al
-
2016
7
Figure 6. Proposed digital workflow.
decrease postoperative discomfort, reduce surgical time, reduce healing time, and reduce bone loss. However, the flapless technique does have some drawbacks, including the inability to visualize anatomic landmarks and possible damage to anatomic structures, the inability to contour osseous topography or graft if the bone volume is insufficient, and the mal-positioned angle or depth of the implant body.31 With proper planning, guided surgery can limit complications. The workflow presented here (Fig. 6) uses an affordable desktop 3D printer, which, in turn, reduces cost compared with that of previous commercial printers and software, eliminates laboratory and shipping expenses and possibly increases the use of guided surgery. However, this method is only as accurate as the plan and technique used during the surgery. A knowledge of additive manufacturing and some calibration of the implant planning and the 3D printing software will be needed initially, as there are many areas where error may be introduced. Whitley et al
Although this workflow is practical and can produce an accurate outcome, this report is only a preliminary trial in 1 patient. The potential for this technology in dentistry is great and will only increase as the technology evolves.22,23 One example of ongoing research is such applications as 3D printing tissue engineered bone scaffoldings conceivably allowing for customized grafting materials.32 SUMMARY The use of desktop 3D printers is a practical option for the production of accurate implant drilling guides. REFERENCES 1. Le B, Nielsen B. Esthetic implant site development. Oral Maxillofac Surg Clin North Am 2015;27:283-311. 2. D’Souza KM, Aras MA. Types of implant surgical guides in dentistry: a review. J Oral Implantol 2012;38:643-52. 3. Greenberg AM. Digital technologies for dental implant treatment planning and guided surgery. Oral Maxillofac Surg Clin North Am 2015;27:319-40.
THE JOURNAL OF PROSTHETIC DENTISTRY
8
4. Kola MZ, Shah AH, Khalil HS, Rabah AM, Harby NM, Sabra SA, et al. Surgical templates for dental implant positioning; current knowledge and clinical perspectives. Niger J Surg 2015;21:1-5. 5. Edelmann AR, Hosseini B, Byrd WC, Preisser JS, Tyndall DA, Nguyen T, et al. Exploring effectiveness of computer-aided planning in implant positioning for a single immediate implant placement. J Oral Implantol 2016;42:233-9. 6. Dawood A, Marti Marti B, Sauret-Jackson V, Darwood A. 3D printing in dentistry. Br Dent J 2015;219:521-9. 7. Dada K, Pariente L, Daas M. Strategic extraction protocol: Use of an imagefusion stereolithographic guide for immediate implant placement. J Prosthet Dent 2016;116:652-6. 8. Hosseini B, Byrd WC, Preisser JS, Khan A, Duggan D, Bencharit S. Effects of antibiotics on bone and soft-tissue healing following immediate single-tooth implant placement into sites with apical pathology. J Oral Implantol 2015;41: e202-11. 9. Di Giacomo GA, Cury PR, da Silva AM, da Silva JV, Ajzen SA. A selective laser sintering prototype guide used to fabricate immediate interim fixed complete arch prostheses in flapless dental implant surgery: Technique description and clinical results. J Prosthet Dent 2016. 10. Liu YF, Wu JL, Zhang JX, Peng W, Liao WQ. Numerical and experimental analyses on the temperature distribution in the dental implant preparation area when using a surgical guide. J Prosthodont 2016. 11. Orentlicher G, Abboud M. Guided surgery for implant therapy. Oral Maxillofac Surg Clin North Am 2011;23:239-56. 12. Gross BC, Erkal JL, Lockwood SY, Chen C, Spence DM. Evaluation of 3D printing and its potential impact on biotechnology and the chemical sciences. Anal Chem 2014;86:3240-53. 13. Whitley D, Bencharit S. Digital implantology with desktop 3D Printing. Formlabs White Paper 2015:1-15. 14. Arisan V, Karabuda CZ, Mumcu E, Ozdemir T. Implant positioning errors in freehand and computer-aided placement methods: a single-blind clinical comparative study. Int J Oral Maxillofac Implants 2013;28:190-204. 15. Flugge TV, Nelson K, Schmelzeisen R, Metzger MC. Three-dimensional plotting and printing of an implant drilling guide: simplifying guided implant surgery. J Oral Maxillofac Surg 2013;71:1340-6. 16. Nickenig HJ, Eitner S, Rothamel D, Wichmann M, Zoller JE. Possibilities and limitations of implant placement by virtual planning data and surgical guide templates. Int J Comput Dent 2012;15:9-21. 17. Schneider D, Marquardt P, Zwahlen M, Jung RE. A systematic review on the accuracy and the clinical outcome of computer-guided template-based implant dentistry. Clin Oral Implants Res 2009;20(suppl 4):73-86. 18. Raico Gallardo YN, da Silva-Olivio IR, Mukai E, Morimoto S, Sesma N, Cordaro L. Accuracy comparison of guided surgery for dental implants according to the tissue of support: a systematic review and meta-analysis. Clin Oral Implants Res 2016 Apr 8. http://dx.doi.org/10.1111/clr.12841. [Epub ahead of print]. 19. Pozzi A, Polizzi G, Moy PK. Guided surgery with tooth-supported templates for single missing teeth: A critical review. Eur J Oral Implantol 2016;9(suppl 1): 135-53. 20. Torabi K, Farjood E, Hamedani S. Rapid prototyping technologies and their applications in prosthodontics, a review of literature. J Dent (Shiraz) 2015;16:1-9. 21. Orentlicher G. Digital technologies in oral and maxillofacial surgery. Preface. Atlas of the oral and maxillofacial surgery clinics of North America. St. Louis: Elsevier Health Sciences; 2012. p. 20.
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume
-
Issue
-
22. Suomalainen A, Stoor P, Mesimaki K, Kontio RK. Rapid prototyping modelling in oral and maxillofacial surgery: A two year retrospective study. J Clin Exp Dent 2015;7:e605-12. 23. da Rosa EL, Oleskovicz CF, Aragao BN. Rapid prototyping in maxillofacial surgery and traumatology: case report. Braz Dent J 2004;15: 243-7. 24. Nayar S, Bhuminathan S, Bhat WM. Rapid prototyping and stereolithography in dentistry. J Pharm Bioallied Sci 2015;7:S216-9. 25. Stansbury JW, Idacavage MJ. 3D printing with polymers: challenges among expanding options and opportunities. Dent Mater 2016;32:54-64. 26. Bikas H, Stavropoulos P, Chryssolouris G. Additive manufacturing methods and modelling approaches: a critical review. Int J Adv Manuf Tech 2016;83: 389-405. 27. Oskui SM, Diamante G, Liao CY, Shi W, Gan J, Schlenk D, et al. Assessing and reducing the toxicity of 3D-printed parts. Environ Sci Tech Let 2016;3: 1-6. 28. Centers for Devices and Radiological Health. Use of International Standard ISO 10993-1, “Biological evaluation of medical devices-Part 1: evaluation and testing within a risk management process” guidance for industry and Food and Drug Administration staff. June 16, 2016. US Department of Health and Human Services, Food and Drug Administration, CDRH. Washington DC. 2016:1-68. Available at: http://www.fda.gov/downloads/medicaldevices/ deviceregulationandguidance/guidancedocuments/ucm348890.pdf. Accessed November 30, 2016. 29. Bencharit S, Byrd WC, Altarawneh S, Hosseini B, Leong A, Reside G, et al. Development and applications of porous tantalum trabecular metalenhanced titanium dental implants. Clin Implant Dent Relat Res 2014;16: 817-26. 30. Bencharit S, Byrd WC, Hosseini B. Immediate placement of a poroustantalum, trabecular metal-enhanced titanium dental implant with demineralized bone matrix into a socket with deficient buccal bone: a clinical report. J Prosthet Dent 2015;113:262-9. 31. Romero-Ruiz MM, Mosquera-Perez R, Gutierrez-Perez JL, Torres-Lagares D. Flapless implant surgery: a review of the literature and 3 case reports. J Clin Exp Dent 2015;7:e146-52. 32. He HY, Zhang JY, Mi X, Hu Y, Gu XY. Rapid prototyping for tissueengineered bone scaffold by 3D printing and biocompatibility study. Int J Clin Exp Med 2015;8:11777-85. Corresponding author: Dr Sompop Bencharit Virginia Commonwealth University 520 N 12th St Richmond, VA 23284 Email: [email protected] Acknowledgments The authors thank the members of the University of North Carolina at Chapel Hill Department of Prosthodontics and Dental Faculty Practice. The authors also thank Drs Capps, Bowman, and Padgett, Greenville, NC, for allowing use of their laboratory space. Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
Whitley et al