The Scalloped Surgical Guide as an Alternative to Flat Bone Reduction Guide in Full-Arch Implant Restoration
The goal of this clinical report was to present an alternative to traditional flat bone reduction guides, using a custom-designed 3-dimensional (3D)–printed guide according to the future gingival margin of the planned dentition. A 61-year-old woman with concerns regarding her smile appearance was presented. The initial examination revealed excessive gingival show accompanied by excessive overjet. The dentition was in a failing situation. The proposed treatment plan, relying on the sufficient amount of bone and keratinized tissue, consisted of recontouring of the alveolar ridge and gingiva and placement of 6 implants and an FP-1 prosthesis after extraction of all remaining maxillary teeth. Digital smile design was completed, and a fully digitally guided surgery was planned. This consisted of using 3 surgical guides, starting with the fixation pin guide, continuing with the scalloped hard- and soft-tissue reduction guide, and finally the implant placement template. Following the surgery, the patient received a temporary restoration, and on the 4-month follow-up, a new polymethyl meta-acrylate temporary prosthesis was delivered. The patient’s 7-month follow-up is presented in the article. The report of this triple-template guided surgery indicated that digital 3D planning is a considerably predictable tool to properly establish and evaluate future occlusal plane, smile line, and lip support. Scalloped guides seem to be an excellent alternative to conventional bone reduction guides since they require less bone removal and improve patient comfort during surgery.
The intraoral examination revealed an Angle’s Class II division I malocclusion for the dentition. (a) Patient’s smile. (b) Intraoral photographs showing the upper and lower dentition. (c) Teeth in occlusion in the right side and (d) left side.
Panoramic view of the cone-beam computerized tomography indicates an overall poor prognosis for the teeth, with the presence of a large post in tooth #11, an apical lesion on tooth #9, and evidence of previous endodontic treatments on teeth #8, #9, #10, and #11.
Maxillary occlusal view (a) before and (b) after removal of the crowns. The maxillary arch had been restored with metal-ceramic crowns in the incisors area and a partial metal-ceramic prosthesis from canine to molars region bilaterally. The upper left bridge prosthesis was loosened and had been removed at the time of examination.
The presurgical phase of the treatment comprised removal of all old prostheses and replacement with a temporary prosthesis to provide a better healing situation for the soft tissue. This temporary prosthesis was designed to cover and overlap the gingiva, aiming to improve the predictability of the future smile. (a) Frontal and (b) occlusal views of the temporary restoration in place.
(a) Superimposed 3-dimensional (3D) scans onto the facial photo using Nemo Smile Design (Nemotec Software). (b) Created a new virtual smile design. (c) Presented a panoramic view of cone-beam computerized tomography with implants strategically distributed in the arch along with respective sleeves (CodiagnosticX). (d) Generated a 3D model based on the virtual planning, illustrating the implants in their designated positions.
Comparison between (a) conventional flat reduction guide design and the (b) novel scalloped functional and esthetic-driven guide design.
An overview of the triple-template technique surgical guide system. (a) The first guide is supported by natural teeth, enabling the placement of the fixation pin. (b) The second guide is designed for gingivectomy and alveoloplasty, determining the planned position for soft-tissue reduction and scalloped bone. This guide contributes to shaping the future natural contour of the gingiva and is used before and after extractions. (c) The third guide is connectable to the second guide and contains sleeves for fully guided implant placement. (d) The second and third guides are interconnected by pins (circled) and at the indicated parts (arrows), illustrating their attachment mechanism.
Surgical sequence. (a) The initial guide supported by the natural remaining teeth enabling the insertion of fixation pins. (b) The second guide was fixed in place by attaching to the fixation pins. (c) Soft tissue was measured to 3 mm below the guide, and excess coronal gingiva was removed. (d) Gingival contouring was carried out. (e) Following extractions, the third guide was connected, facilitating fully guided implant placement. (f) Scalloped bone reduction was performed subsequent to implant placement. (g) Installation of titanium cylinder over the SRA multi-unit abutments and suture.
(a) The 3-dimensional (3D)–printed model of the virtual digital smile design, (b) The temporary prosthesis was made with polymethyl meta-acrylate based on the 3D-printed virtual model using a PVS putty matrix.
(a) Frontal view of the prosthesis captured onto the cylinder abutments. (b) Occlusal view of the temporary prosthesis after installation, with holes sealed using polytetrafluoroethylene tape in the screws and filled with temporary light-curing restorative material resin. Occlusal contacts were carefully examined, and adjustments were made accordingly.
(a) Panoramic radiographic image with the implants in place in the 4-month follow-up visit revealed excellent osseointegration. (b) Occlusal view of the temporary before removal. (c) Evaluation of soft-tissue healing at 4 months.
After the healing period and the necessity to replace some abutments, intraoral scanning of the (a) provisional prosthesis, (b) gingiva, and (c) scan bodies was performed, enabling the fabrication of a new milled temporary prosthesis. A light-cure gingival barrier (top dam) was applied in the palate to help align the STL files.
Profile photos comparing the overjet (a) before and (b) after surgery.
(a) Patient smile with the milled temporary prosthesis at the 7-month follow-up. (b) Intraoral image showing the healing gingiva.
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