Dental Asia Jan/Feb 2018

36 CLINICAL FEATURE DENTAL ASIA JANUARY / FEBRUARY 2018 S ince 1969, Branemark and co-workers (1969) published the concept of implant surgery with extensive flap elevation for improved visualisation of surgical Ƥeld. In this approach, an incision in themucosa or the vestibular foldwas done, and then a full thickness mucoperiosteal ƪapwas reƪected to expose the underlying bone. The dental implant Ƥxtureswere then inserted and the ƪaps repositioned with sutures for primary closure (Branemark et. al 1977 ; Adell et al. 1981). Flap elevation during implant surgery has been associated with post-operative inflammation, bone resorption, post- operative bleeding, slower healing, higher infection risk and increased patient’s discomfort (Kohler & Ramfjord 1960; Lobene & Glickman 1963; Ca ơ esse et al. 1968; Wood et al. 1972 ; Becker et al. 2005). Flapless implant surgery has been established in recent years as a concept of minimally invasive surgery, leveraging on the advantage of advancements experienced in three dimensional diagnostic techniques, improved computer guided implant technology and inventionof speciƤc surgical instruments, to perform minimally invasive surgical implant procedures infringing the least trauma as possible to the patient’s soft and hard tissue(Kim et al. 2009 : You et al. 2009 ). The aim of this article is to present a clinical protocol for a single dental implant flapless surgery to replace a missing upper left first bicuspid tooth using computer aided implant planning, full guided osteotomy based on the principle of minimally invasive ƪapless implant surgery to achieve high precision and accuracy in implant Ƥxture installation. The superiority of this technique over the conventional full ƪap implant osteotomy technique is also presented. Background A 30 year old, healthy Chinese female presented with a chief complaint of missing upper left first bicuspid which was extracted eight months ago due to extensive carious lesion and fractured coronal tooth structure. She desires a Ƥxed tooth replacement to restore her eating function as well as to improve her smile aesthetics. She is currently wearing a single tooth acrylic removable prosthesis. Medical History Medical reviewwas non-signiƤcant. Shewas a non-smoker and non-alcohol drinker. No history of allergy experienced and recorded. Pre-operative Clinical assessment showed a completely healed partial edentuloussitewithadequate thickness of more than 2 mm keratinised mucosa. Theadjacentupperleftcanine was in pristine condition and herupperleftsecondbicuspid has an intact mesioocclusal amalgamrestorationwithout any significant history and in reasonably good condition (Fig. 3). Dental implant supported screw retained CAD CAM zirconia crown option was recommended and accepted by the patient to avoid irreversible tooth structure reduction in the conventional dental bridge treatment option. She is medically uncompromised, with no history of allergy, no diabetes and a non-smoker. However, she presented with high psychological anxiety and fear for surgery. The clinical assessment and cone beam computerised tomography has showed a conventional osteotomy was possible. Based on her request for minimal invasive surgery with the least surgical discomfort, it was decided that the 3D computer guided implant with ƪapless implant surgery be employed. The patient has also given her consent to follow the protocol of Blue Sky Bio (BSB, USA) computer aided planning interactive software and the flapless surgical approach customised to the Dentium (Korea) Guided Implant system to complete a full guided osteotomy and implant fixture installation. The digital workflow undertaken is described and discussedbasedon the illustration summary below (Fig. 1). by Dr. LeeBoon Soon Fig. 1: Overview of the digital workflow of computer-aided planning and guided ƪapless surgery. CBCT Acquisition and Rendering in BlueSkyBio implant planning software This single implant case does not require a customised radiographic stent for Cone Beam Computerised Tomography as Step 1. i) CBCT ii) Upper & Lower alginate impressions to fabricate stone models Step 4. i) The 3D printed surgical guide Ƥtting is checked clinically prior to surgery ii) Dentium Guided surgical ƪapless osteotomy protocol is followed to install Dentium implant Ƥxture. Step 3. i) Merging of CBCT dicom with STL to follow the Blue Sky Bio computer aided implant planning protocol ii) Virtual designing and creation of 3D surgical guide for 3D printing. Step 2. i) Load CBCT dicom Ƥle into BSB implant software ii) Scan stone models to convert image into Standard Tesselation Language ( STL) Ƥle