Case report: Guided implant surgery with Planmeca all-in-one solution

Dr Seppo Lindroos is a specialist in aesthetic dentistry and implantology. Last spring, he was contacted by a patient who was having issues with her bite due to several missing teeth.

The patient, a female in her twenties, had congenitally missing permanent mandibular second premolars and second molars. She had lost her persistent primary second molar a couple of years earlier and was now experiencing problems with her weakened bite. A panoramic X-ray image was captured with Planmeca Promax® 2D imaging unit to get more information about the dentition.

Fig. 1 & 2: The patient’s lower teeth before the treatment.

Fig. 3: Panoramic X-ray captured with Planmeca ProMax® 2D X-ray unit showed the missing permanent teeth.

Treatment possibilities were discussed with the patient. As the patient was already old enough for an implantation, it was decided to place an implant to replace the mandibular second premolar to prevent further damages the missing tooth might cause for her dentition. Should the patient later lose her other persistent primary second molar, the treatment would have to be repeated for the other side as well.

For the implant treatment planning, a CBCT image was first captured using Planmeca Viso® G7 X-ray unit and the teeth were scanned with Planmeca Emerald™ intraoral scanner.

Fig. 4: A 3D image of the region was captured with Planmeca Viso® G7 X-ray unit.

The CBCT image and the intraoral scan were combined in Planmeca Romexis® software for the treatment planning. The implant planning was carried out in Planmeca Romexis® 3D Implant module, which includes an implant library with implant models from over 100 manufacturers. A CONELOG® SCREW-LINE implant by CAMLOG® with a 4,3 mm diameter and 9,0 mm length was chosen for the patient, and its placement was then carefully planned with the software’s implant-centric viewing mode.

Fig. 5: The implant planning was carried out in Planmeca Romexis®.

To achieve the planned implant position, Dr Lindroos decided to use a surgical guide for the implant placement. According to Lindroos, he prefers guided surgery in most of his implant cases to ensure the implant is placed in an optimal position and because it reduces operation time as well as the patient’s recovery time.

For this treatment, the guide was designed with Planmeca Romexis® 3D Implant Guide module. The guide was then 3D printed by Planmeca ProModel™ service, which offers patient-specific implants and surgical guides as a service for demanding surgical procedures and treatment planning.

Fig. 6: Implant surgery was performed with the 3D printed surgical guide.

After the implant was placed using the surgical guide, a temporary healing abutment was placed on the implant site to help gum tissue heal before the restoration could be planted.

Fig.7: Healing abutment was placed on the implant after the surgery.

After the healing period of three months, a scan abutment was placed on the implant. The teeth were scanned again with Planmeca Emerald intraoral scanner for the restoration design.

Fig. 8 & 9: The scan abutment was placed on the implant for restoration design.

The intraoral scans were sent to a partner laboratory for the final restoration design using the cloud-based image transfer service Planmeca Romexis® Cloud. As the service is an integrated part of Romexis, the laboratory was able to seamlessly quick launch the case files in Planmeca PlanCAD® Premium software module, which was used to design the abutment and the crown with screw channels. The restorations were then milled in the laboratory with Planmeca PlanMill® 50 S milling unit.

The final abutment was manufactured using a prefabricated titanium abutment block and IPS e.max CAD was used for the crown on top of the abutment. Those were post-processed, characterised and then bonded together in the laboratory to create a screw-retained restoration.

Fig. 10 & 11: Final restoration design in Planmeca PlanCAD® Premium.

Finally, the screw-retained restoration was placed on the implant. The laboratory-milled crown based on the intraoral scan was a perfect fit and did not need any changes on the approximal surfaces. When the restoration was placed, Lindroos made only a minor change to the bite.

“Overall, the Planmeca digital concept made the treatment more precise and faster. Combining different kind of patient data together in Romexis for the treatment planning is simple and straightforward. It is also easy to collaborate with external partners due to the open architecture of the software,” Lindroos comments.

Fig. 12 & 13: The final restoration in place.

The digital implant workflow offers numerous advantages for the patients as well, as it speeds up the complete treatment process, including the surgery itself. At the same time, the treatment is more predictable and convenient for the patient. Intraoral scanning, for example, is more comfortable for the patient than traditional impressions, and the recovery from guided surgery is easier and faster.

As the patients are more involved in the treatment planning and can see the predicted outcome in Romexis beforehand, they have more confidence for the actual treatment and the dentist. This can be especially beneficial if the patient fears dental treatments. In this particular case, the patient herself was also very happy with how the treatment was performed and how well the final restoration sits in her mouth.

Copy: Mari Koivunen & Anni Mattila
Images: Seppo Lindroos, Medident Oy