Digital possibilities of making surgical templates. What are surgical templates for dental implantation and what are they for. What is the cost of implantation using a template

SURGICAL PATTERN FOR DENTAL IMPLANTATION

The success of dental implant surgery depends on a number of factors: the right choice implants, thorough training, professionalism of doctors. The accuracy of the pin placement is also very important. There is a specially designed surgical template for this. The function of the surgical template is to determine the exact location of the implant. Dental implantation performed using a surgical template is characterized by maximum accuracy (up to 5 microns). The template is similar to a perforated tray that fits over the teeth. Places for implants are selected according to the holes.

Regardless of the material or manufacturing method, the template must meet certain standards.

The template should be:

tough enough;
convenient for sterilization;
stable in the mouth;
clearly defining the shape and position of the teeth.

APPLICATION AREA

Basically, surgical templates are used in the absence of a large number teeth. Because if the patient does not have teeth, the doctor does not have a guide for accurate implantation of implants. The surgical template is also used for further prosthetics. Their use is also effective in restoring anterior teeth to achieve maximum aesthetics.

TYPES OF SURGICAL PATTERNS

For dental implantation, there are 3 types of surgical templates:

1. Template with support on bone tissue - the electronic form of the template is modeled using a three-dimensional model of a computer tomograph and is made on a stereolithographic device. This type of template is the most accurate because it is based on bone tissue.

2. Template supported by a row standing teeth (on each side of the defect there should be two adjacent teeth).

3. Template supported on the mucous membrane (gums).

By type of manufacture in modern dentistry several types of surgical templates are used. The most commonly used templates:

Acrylic, polymer plastic, made by type removable dentures in the laboratory: an impression is taken in the clinic, sent to the laboratory, where the models are cast, on which the necessary surgical template is made. These templates are used quite often due to the affordable price.
Transparent plastic templates made in a vacuum former are not in demand recently due to their softness.
Templates made using CAD / CAM technology. This template is made on a special high-precision machine. An impression is taken from the patient's teeth, which is processed by a digital scanner, then the received data is sent to a computer. Thanks to a special program, precise planning of the operation is carried out. The selection of the length and shape of the implants, determination of the exact location and angle of inclination are carried out. The finished data is transmitted to the machine for making a real template. Special devices on the machine allow the drills to be guided as accurately as possible, which makes the template extremely accurate. However, this type of template is used less frequently because it is a more expensive technology and there is not always an indication for such an expensive template. It is used exclusively when necessary, based on the indications at the decision of the implant surgeon.

ADVANTAGES OF IMPLANTATION USING THE SURGICAL PATTERN:

Thanks to the surgical template dental implantation passes with maximum accuracy and excluded possibility mistakes attitudes (negative influence of the human factor).
With implantation using templates, there is no need to determine the exact location of the implant during the operation, which significantly reduces the time of the operation.
Temporary crowns are made according to the template and are installed immediately upon implantation.
Due to the fact that when using a surgical template, there is no need to open the mucous membrane, after the operation there are no swelling, pain, inflammation; the time for wound healing and implantation is reduced.
Virtual simulation allows you to see the final result in advance and, if necessary, correct it.

The use of surgical templates for prosthetics can significantly reduce the cost of prosthetics, shorten the time of the implantation operation and, most importantly, eliminate the negative influence of the human factor.

Modern dentistry strives to individualize the field of implantology as much as possible. It is for this purpose that surgical templates are used, made according to an individual layout. 3D printers have helped make this process more efficient and effective. In addition, the printing of surgical templates is carried out in the shortest possible time, and the materials used are absolutely biocompatible.

More recently, making custom templates was very expensive. And this was a very significant drawback. With the advent of CAD / CAM technology, customized surgical templates have become much more accessible.

What is a Surgical Template

The surgical template is a stencil mouthpiece used in orthodontics and dental implantology. For the placement of implants, this template contains special holes... With their help, the dentist-surgeon precisely positions and places the implant. Thanks to this, the occurrence of errors is simply excluded. When using surgical guides, the operation will be 100% successful. The advantages of surgical guides are as follows:

the ability to install several implants at once;
significant reduction in the time of the operation;
extremely accurate placement of the implant;
modeling the template allows you to show the client the final result;
reliable fixation;
correct distribution of the load on the implant;
increase in the service life of the implant due to its correct installation and load distribution.

The use of surgical templates is a concern for the patient, because they provide minimal trauma to the operation, as well as a high-precision result.

Surgical template printing

Surgical templates are printed on high quality professional 3D printers. A prime example of the ProJet 3510 MP from 3D Systems. Used photopolymer printing technology and biocompatible material. The advantages lie in the thinnest layer of no more than 25 microns, high printing speed and material transparency. Modern manufacturers have developed unique materials specifically for this purpose. For manufacturing, an STL file is used, which is formed on the basis of 3D scanning and modeling. All this allows us to provide guaranteed accuracy, perfect geometry and moderate cost of the template.

3DMall provides services for printing surgical templates for dentistry.

Production of a surgical template with bushings for a pilot cutter of 2.0 and 2.2 mm (up to 7 implants inclusive) - 5,000 rubles.

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To determine the exact cost of the service, you need to send a request to our specialists for a calculation.

WORK EXAMPLES

Modern implantology strives to ensure that implant placement operations are performed using a surgical template made according to an individual project for the patient.

Implant-Guide templates are of two types:

surgical template has small diameter bushings for pilot drilling;
the implant template has large diameter sleeves, through which you can not only drill, but also install implants without removing the template.

The doctor chooses the template option based on the clinical situation in the Implant-Assistant program.

Implant-Guide fabrication

The 3D model Implant-Guide (surgical or implant guide) is created in the Implant-Assistant software module. The main convenience is that all information, from processed CT scan to template creation, is contained in a single format. From the Implant-Assistant, the file of the computer model Implant-Guide goes to the Implant-Guide module, and then to the 3D printer.

Our Center uses printers from Objet, a world leader and expert in prototyping. The template is made within a few hours by layer-by-layer application of photopolymer materials on the platform. Each layer is very thin (16 microns), UV-cured.

Next, titanium bushings are pressed into the template, which contain information calculated to a hundredth of a millimeter on the direction of the drills and the drilling depth. It is also possible to manufacture a template with bushings for fixing screws, which ensures its rigid attachment to the jaw. The Implant-Guide can be used almost immediately after fabrication.

An essential advantage of the Implant-Guide is that it is assembled in one place, very quickly, absolutely accurately and does not require a specialized laboratory.

Video of operations using templates.

The surgical template for implantation outwardly resembles a splint or a jaw impression. Made by a dental technician using computer modeling technologies.

The navigation template is indispensable for implantation in patients with partial and complete adentia. Used for accurate placement of implants and correct prosthetics in the future. The design of the template includes metal guides through which the implants are screwed.

What is a surgical template for?

The postoperative recovery of the patient and the successful engraftment of the screw depend on how correctly the implant is installed in the jaw. To calculate the location of the implant, the doctor needs landmarks. Therefore, the more teeth are missing in the jaw, the more justified the use of a template.

In most cases, surgical templates are used for All-on-4 or All-on-6 implants.

The use of 3D computer technology has important advantages:

allows you to accurately assess the anatomical features of the patient, such as the size of the maxillary sinus or the location of the alveolar nerve in lower jaw;
provides information on the size, direction and position of the bone for accurate positioning of implants.

Another purpose of the navigation template is prosthetics planning. First, the doctor determines the purpose of the prosthetics: materials, the shape of the teeth, the type of abutment. In accordance with the set goals, the best position of the implants is selected using a computer program. And only after that the template is made.

One and the same product serves as an auxiliary tool for both prosthetics and implantation.

Benefits of guided implantation

Placement of implants with an accuracy of 0.1 mm
Preservation of anatomical structures
No errors during implantation
Reduced operation time
Less invasive, flapless surgery and therefore less chance of edema
Fast postoperative recovery
Material transparency to allow you to see through the model
The ability to make a crown on the implant before the operation, which will allow prosthetics to be performed immediately after implantation.

Kinds

Templates can be conditionally divided into several groups, depending on materials and manufacturing methods:

Acrylic
Polymer plastic
Made by impression
Manufactured by CAD / CAM technology
Manufactured in a vacuum former
Jawbone-supported
Based on adjacent teeth

The dentist decides which template to use, depending on the clinical situation, as well as the wishes of the patient.

Product manufacturing process

3D tomography of the jaw is performed
Impressions of the jaw are taken
A computer program designs the ideal place for implants, their size, inclination and shape of the prosthesis
Based on the results obtained, holes for the implants are made in the template. A metal guide is installed in each hole

How are surgical templates used for implantation at the NovaDent clinic

The patient comes to any of our clinics in Moscow and Moscow region for a consultation. The doctor examines and directs for computed tomography. All the data required to make a template is collected.

Surgical template production time: 3-7 days.

Before starting the implantation, the dentist places the navigation template on the patient's jaw. To keep the structure well, there are special fasteners in it.

The next step is to place the implants through the pre-drilled holes. Further, the template is used to create prostheses for implants.

Price

In NovaDent dentistry, the price of a surgical template per jaw is 14,150 rubles. The cost computed tomography jaws - 3900 p.

Prices for implantation and others dental services clinics, you can see.

FormLabs Management

annotation

Computer planning of dental implantation and the use of a surgical template ensure high accuracy of dental implant placement and make the results of orthopedic treatment more predictable. However, not all physicians use this technique due to the high cost of commercially available template making equipment. A protocol was developed for the use of CAD / CAM surgical templates and printed with biocompatible material on an inexpensive 3D printer. The development process used FormLabs Dental SG Resin and a Form 2 desktop 3D printer that uses laser stereolithography (SLA) technology. A clinical case carried out according to this protocol is presented. The deviation between the planned and final position of the implant turned out to be clinically insignificant and within the average accuracy values \u200b\u200bfor 3D technologies currently used in dentistry. These results suggest that surgical templates can be printed with high degree accuracy on the Form 2 and can be used to position dental implants in such a position to achieve acceptable clinical results.

Daniel Wheatley ( Daniel Whitley, DDS) received his Dentistry Degree from the University of North Carolina at Chapel Hill after earning a bachelor's degree in biology. The doctor is a member of the American dental association (ADA), the Academy of General Dentistry (AGD), the North Carolina and New York State Dental Society (NCDS, 5DDS), serves on the Commission of the East Central Dental Society of Indiana, and is also a member of the International Association for Dental Implantation (ICOI) ). Areas of interest CAD / CAM technology and digital dentistry that improve patient care. The doctor is currently visiting a private clinic in Greenville, North Carolina.

Sompop Benkarit ( Dr. Sompop Bencharit, DDS, MS, FACP) is a Fellow of the American College of Prosthetic Dentistry (ACP). He is one of the few clinical scientists who is both board certified and Ph.D. He is engaged in structural biology, specializing in X-ray crystallography. His research area is focused on the study of structural biology in the onset of diseases, in particular the role of membrane proteins involved in the construction of bones and blood vessels, as well as the study of proteomics and the composition of intestinal flora. The doctor is a member of the editorial board or reviewer in numerous scientific and dental journals such as PLOS ONE and Scientific Reports.

Introduction

Correct use of surgical guides can improve clinical outcomes through detailed preoperative planning and accurate placement of the implant body. During planning, prosthetically oriented positioning can be used, which determines the required position of the dental implant, and cone beam tomography (CBCT) can be used to assess topography, bone condition and reveal vital structures. Using templates can help doctors avoid making certain decisions during, before, or after surgery, and can also help reduce operating time.

In addition, the use of templates provides a higher implantation accuracy compared to manual placement. In cases of manual implantation, the deviation between the planned and actual position of the implant is in the range from 2 to 2.5 mm and can reach 8 mm. Studies have shown that even the most experienced surgeons in most cases, the final position of the implant differs from the ideal. Knowing this will help prevent a range of unwanted effects (from iatrogenic to aesthetic).

As a result, various templates have been developed with a guide key for drilling and subsequent positioning of the implant body according to the desired result. There are three main types of templates: a bone-supported template, a teeth-supported template, and a mucosal template.

Types of surgical templates:

· Non-limiting guide. The model provides the surgeon with an idea of \u200b\u200bthe optimal prosthetic position, but not the direction and control of the drilling depth.

· Partially restricting guide. The model achieves higher accuracy because it guides the pilot drill completely, but the next larger drills are manually set.

· Completely limiting guide. Provides full guidance and depth control so that the most accurate result is achieved. There are two common methods of making these templates: by transferring the prosthetic plan to a plaster model and using CAD / CAM technology (computer-aided design / computer-controlled production).

These templates fully guide and control drill depth.

Made using the program using CBCT data and intraoral images of the patient.

After probing the area for subsequent implantation and x-ray examination Surgical templates (cast-based guides) are made in the dental laboratory on a plaster model using the hot forming method.

Surgical templates made using CAD / CAM technology (CAD / CAM guides) are fabricated from the patient's CBCT data and from the template of the final prosthetic construction. After a treatment plan has been drawn up, optical impressions of the patient can also be obtained.

Combining CBCT data and intraoral optical scans facilitates detailed and accurate preoperative planning.

Benefits of CAD / CAM Templates

There is evidence that when using CAD / CAM templates, a high positioning accuracy of the installed dental implant is achieved, compared to implantation using the “free hand” method, as well as templates made in the laboratory. It has been shown that for implantation with simple templates, the mean deviation in the position of the planned and placed implant is 1.5 mm, and the inclination value is 8˚. Compared with the CAD / CAM guiding templates: deviation of 1 mm in the planned position and 5˚ in the value tilt. It is noted that it is possible to achieve the position of the implant with an accuracy of 0.1 mm.

Since the patient's CBCT data processed by specialized software is used for competent pre-surgical planning, the duration of the operation is reduced, and the results of implantation are improved. This makes the treatment less invasive, faster and more predictable, which improves the quality of the prosthetics. Ultimately, this gives surgeons confidence in the success of dental implantation.

Despite the significant advantages of CAD / CAM templates in practice, they are not used very often. This is due to the high cost of 3D printing equipment, which limits its use.

We decided to demonstrate how a desktop 3D printer can be used to produce accurate surgical templates and achieve acceptable clinical results. To do this, consider a clinical case, in which a Form 2 3D printer and FormLabs' Dental SG biocompatible photopolymer resin were used.

Accuracy study

In order for CAD / CAM templates to meet the requirements, they must be produced within very narrow tolerances. It is currently believed that with a printed model, the guide template will fit tightly onto the dentition or edentulous jaws if 80% of their occlusal surface and surgical design falls within the +/- 100 μm (micron) range, provided the model the template is correctly designed. We first decided to verify that this stage could be achieved using Dental SG resin on a Form 2 printer, before quantifying the fit during a clinical trial.

In order to confirm that the printed templates meet or exceed this standard, a set of 6 surgical templates (4 full and 2 partial) was made. A total of 84 templates were produced, which were digitized using a 3Shape D900 orthodontic scanner.

After scanning, each model was compared with its STL file and a schematic map was drawn up showing the difference in indicators using measuring device from 3Shape (Convince Analyzer). To ensure that the most important template sites were used in the count, only occlusal sites and surgical constructs were involved.

On average, approximately 93% of these plots were within the +/- 100 micron tolerance range, which clearly exceeds the required standard. The distribution interval shows that the value of 95% of the templates produced in this way is within the acceptable range, taking into account the standard deviation of the measurements (+/- 5%). This data indicates that using a Form 2 printer in combination with Dental SG Resin and proper handling in the final steps will result in practical application guide templates.

Clinical case

Treatment has been carried out to determine whether acceptable clinical results can be achieved with a given level of printing.

History and clinical examination

A 26-year-old female patient consulted. The main complaint was: “I want to do something more permanent at the missing tooth and enlarge the small tooth on the other side.” Objectively: primary adentia of the tooth 1.2., Lack of space in the area of \u200b\u200bthe tooth 2.2. History of early orthodontic treatment, after which a retainer was installed on the teeth 1.1. and 2.1 to save space in the area of \u200b\u200bthe missing tooth for subsequent implantation, and a plate with a replacement tooth in area 1.2 was made for aesthetic purposes. A treatment plan was drawn up, which included implantation of tooth 2.3, making a veneer for tooth 2.2 and composite restoration of teeth 1.3 and 1.1. The plan was approved by the patient. We decided that at the time when the implantation will be carried out, the oral cavity will be sanitized for the presence of carious lesions of the teeth.

Treatment planning: evaluation of smile aesthetics, impression taking, analysis x-rays

We determined the ideal dimensions of the lateral incisor, taking into account the smile aesthetics and carried out a wax-up modeling of the tooth. The patient received a referral for a CBCT study (Sirona Orthophos XG 3D apparatus, Sirona Dental; Bensheim, Germany). The upper and lower dental arches were separated by 3-4 mm in the area of \u200b\u200bthe chewing surfaces of the teeth, so that possible chipping of the restorations did not occur.

Preoperative examination

A patient with a primary edentulous tooth of 1.2 wants to replace a defect using an implant.

CBCT analysis was performed in the Blue Sky Bio's implant treatment planning software. The minimum thickness of the alveolar ridge was 5-6 mm. It would be very difficult to predict the outcome of implantation without bone grafting without the use of a pilot drill. On the contrary, the use of high-precision 3D templates, with guides for surgical cutters, gives confidence that we can carry out the implantation with a predictable result.

Anatomical structures, implant position and surgical template model

The program created a virtual implant simulating the dimensions of the used implant (Zimmer Eztetic 3.1 mm x 11.5 mm, Zimmer Biomet Dental, Palm Beach Gardens, FL). In the same way, the crown was modeled from the measurements of the wax tooth. We chose this implant because it is necessary to preserve the maximum amount of bone in the area of \u200b\u200bthe thin alveolar ridge in the frontal area, besides, it will be possible to avoid invasive and costly manipulations, while achieving good aesthetics.

After all the patient's examination data were loaded into the preoperative planning program, a plan for the implantation was drawn up. The virtual implant was placed in an ideal position in relation to tooth 1.2 and wax-up. The shaping of the template area was carried out with the possible achievement of optimal stability, using mesial and distal teeth from the edentulous area. The parameters used were those that matched the drill size (Zimmer Guided Kit's 22 mm drill).

Optical scanning of the dentition was performed using the Cerec Omnicam apparatus (Sirona Dental; Bensheim, Germany). Then the images were formatted in the .STL format for use in the program (Blue Sky Plan 3; Blue Sky Bio; Grayslake, IL, USA).

Highest resolution .STL file obtained by Blue Sky Bio. The fee was charged only when exporting a file and ranged from 1,400 to 2,800 rubles, depending on the volume. The cost of other programs is different.

The CBCT analysis in the implantation planning program shows an area of \u200b\u200bminimum bone thickness (5-6 mm).

Modeling a surgical template:

defining the tilt for the guide cutter and positioning the guide handle.

Manufacturing, assembly and sterilization steps

The electronic form of the surgical template is imported into free program PreForm (Formlabs) for 3D printing preparation. The template was positioned in the program in such a way that the force of "drawing" the section of the object was small, but the excess polymer was removed. The fixation pins were not placed on the occlusal surfaces - this is done to accurately fit the template. The pins were then carefully removed to allow the metal cutters to pass freely in the next step. The fully prepared form was sent to print, which took 10.49 ml of polymer.

After printing is complete, the template is removed from the platform and placed in two containers containing 91% isopropyl alcohol for 20 minutes. Let it dry. The final step is to install a stainless steel guide sleeve that matches the size of the Zimmer keys (Size A).

At the end, the template is packed in a kraft bag and autoclaved.

The final model of the radiological template before transferring to the model.

The surgical template was printed with photopolymer on a Form 2 printer, immersed in isopropyl alcohol, then finished, a metal guide sleeve mounted and sterilized.

Operation progress

The patient was prescribed a four-day course of antibiotics Azithromycin 500 mg per day, which was started one day before the operation. In the preoperative preparation, rinsing with 0.12% chlorhexidine gluconate was prescribed for 1 minute. Infiltration of 1 capsule of a solution of 4% septocaine in a dilution of 1: 100 and 1 capsule of a 2% solution of lidocaine in a dilution of 1:50 in the area of \u200b\u200btooth 1.2 from the vestibular and palatal sides was performed.

Having previously fitted the template in the patient's oral cavity and, having made sure of its stable position, a hole (bed) was formed along the guide sleeve. During drilling, a wrench with a section of 2.85 x 22 mm was used with irrigation with a 9% sodium chloride solution.

Then the template is removed and the condition of the bone structures is checked for the presence of fenestrations or degistencies. After making the hole to the required distance, the implant was installed using a handpiece (motor torque 30 Ncm). After that, a control X-ray of the installed implant was made to make sure that it fully penetrated the bone.

A construction consisting of a temporary abutment (Zimmer) and a plastic crown with a corresponding shape was made and installed directly into the implant. After some time, the patient was referred for a second CBCT. She continued to wear a retention plate with a replacement tooth at the direction of the orthodontist, but the apparatus was corrected, since it was necessary to reduce the pressure of the artificial tooth on the area of \u200b\u200bthe installed implant. The patient was released and given recommendations.

Postoperative examination

Positive results have been obtained. A repeat CBCT was performed to verify the planned and final position of the implant.

Dr. Whitley, Dr. Bencharit

Discussion

To evaluate the clinical results of the implantation operation, we compared the preoperative plan of the implant position and the final position of the implant. Postoperative CBCT scans were superimposed on the original plan in the Blue Sky Bio program. The density of the images was adjusted so that the implant was displayed in one window and the teeth in the other. This arrangement allows you to superimpose two images on top of each other for the corresponding teeth.

An analysis of the deviation by superimposing images between the initially planned and final actual position of the implant revealed the exact positioning. Due to the scattering effect of metal on the CBCT image, the exact degree of deflection was difficult to determine. The maximum deviation of the position of the implant at the insertion point was 0.23 mm. The maximum deviation along the long axis of the implant is 2.5 °. Apical measurements were not performed, since the image was distorted both in the area of \u200b\u200bthe exit hole in the screw and in its absence in the virtual cylinder of the implant.

Most clinical research operations with a 3D-printed CAD / CAM surgical template, the final implant positioning accuracy was considered successful within the expected limits.

Planned (red) implant.

Actual (green) implant.

The printed template used during the operation was compared to the surgical template of the STL model, which was converted into a scheduling program for printer errors. The overlapping of the planned and actual model showed that the maximum position deviation in the template was 0.1 mm. Based on this, we concluded that from the 0.23 mm maximum deviation in the position of the implant at the insertion point, the value of 0.1 mm was associated with the printing process on the printer. The remaining percentage of errors came from other sources.

The most important thing is that the accuracy of the implant placement was high enough - it was possible to achieve a good clinical result in the patient. Moreover, the postoperative CBCT scan showed the preservation of the thickness of the bone tissue at the proper depth of implant placement.

In addition, the use of a surgical template shortens the operation time, while the drilling axis is not defined and tissue reposition is not performed. Thus, a standard 60 minute procedure takes time only 20 minutes.

Factors leading to errors in the manufacture of surgical templates:

The quality of intraoral images

CBCT quality

Accuracy of calculations in the planning program

Printer resolution

Permissible values \u200b\u200bof the dimensions of cutters

· human factor

Patient movement while taking pictures

Conclusion

As practice shows, the high cost of manufacturing a surgical template limits its use. More often than not, there was no need to transfer the template plan to the dental laboratory for the final design and production. The price depended on the laboratory and the complexity of the case and amounted to 31,500 - 63,000 rubles.

The results make it clear that the technological process may not be costly, while the accuracy of the manufactured surgical templates is quite high. The cost of Form 2 printers, in comparison with other equipment for 3D printing, currently used in dental practice, is significantly lower than the latter (420,000 rubles and 3,150,000 rubles, respectively). And the small size of the desktop printer allows you to use it even in dental office.

Surgical templates can be manufactured and affordable price... In our study, the cost of producing one template was only 3 765.35 rubles.

Cost of materials for making a surgical template

Template model sent for export to the implantation planning program - 2,394 rubles *

Photopolymer Dental SG Resin (11 ml) - 605 rubles

Original container (for 1 template) - 123.75 rubles **

Stainless steel guide bushing (reusable) - 642.60 rubles

The total cost of production - 3 765.35 rubles

* Prices depend on the chosen planning program. The cost of exporting one template in the Blue Sky Bio program varies from 1,400 - 2,800 rubles, depending on the purchase volume.

** The calculation was carried out by dividing the total cost of a container (9,900 rubles) by the volume of printing 80 templates using one container.

Most importantly, with the given production costs, the quality of the surgical templates remains at the proper level.

A clinical case showed the ability to accurately place the implant in the final position, which is within the acceptable values \u200b\u200bthat were achieved using previous versions of 3D printing systems, which ultimately gives good results in patient care.

You can purchase FormLabs Form 2 3D Printer in iGo3D at a special price!