Dental Implants and the Need for Fully Guided Placement

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Implant therapy has come a long way since the early days. The results we can achieve are close to miraculous. We are able to give patients their teeth back, with comfortable, functional, and esthetic results. This has only been possible for 30 years of the 200,000 that we have been a species! But as implant science progresses, our responsibility does too. It is not acceptable to place implants “where the bone was” and expect patients to accept results that are non-esthetic or difficult to clean. Proper site preparation via bone and/or soft tissue augmentation pays off in the years after implants have been placed and restored. But equally importantly, implant placement must be precise, every time, for every patient. We can’t afford to have an off day. No one cares how good you were on yesterday’s case. The patient lying in front of you is unique to himself or herself. So given that even surgeons are fallible (who knew?), how can we consistently avoid a compromised result? Guided surgery.

Studies have shown that fully guided implant placement is significantly less likely to result in deviations from ideal. Free-hand placement averages 7 degrees off-angled and 2 mm away from ideal depth. And a high degree of variability means that errors range up to 20 degrees and 5 mm! Fully guided placement reduces angle deviation to 2 degrees and depth deviation to 1 mm, with much less variability in results (Younes F et al, Clin Oral Impl Res 2019:1-8). This improved precision often means the difference between an implant that can be restored ideally and one that ties the restorative doctor in knots. Since we began placing all implants fully guided 2 years ago, we have found that the great majority of cases can be restored screw-retained with proper contours, embrasures, and esthetics.

The images above are from a patient who had her implants placed locally without a surgical guide. All are less than one year old. As you can see, #31 was placed 2 mm distal to ideal, requiring a mesial cantilever in the crown. This impedes hygiene and increases the risk of peri-implantitis. The implants in sites #18 and 19 were also placed too far distally. Due to challenges with access and visual perspective, lower posterior implants are often placed distally when a guide is not used. Implants #18 and 31 were also placed too shallow. All three implants have probing depths of 5-7 mm with suppuration. These problems could have been avoided with fully guided placement.