Luigi Vito Stefanelli,D.Eng.,DDS

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1 LYON, 27-28/09/2013 Luigi Vito Stefanelli,D.Eng.,DDS Assistant Researcher, Department of Oral Sciences, Sapienza University of Rome, Italy, School of Dentistry. Private practitioner dental office Stasi Stefanelli Tozzi in Rome

Sapienza University of Rome, Italy, School of Dentistry.

2 Technological progress is significantly influencing the implant therapy. Recent improvement in computer technology have made possible the use of computers not only in the planning of surgical implant placement but also in the implant site preparation and implant guided insertion. Hämmerle C.H.F., Stone P., Jung R.E., Kapos T.,Brodala N. Consensus statements and recommended clinical procedures regarding computer- assisted implant dentistry. Int J Oral Maxillofac Implants 2009; 24(suppl.):

implant placement but also in the implant site preparation and implant guided insertion. Hämmerle C.H.F., Stone P., Jung R.E.

3 The insertion of six implants in the upper arch using a fixed External Hex Safe surgical guide.

4 The possibility of operating with a minimally invasive approach (no flap elevation), leading to a shorter surgical time and reduction in patient morbidity The integration of the restorative determinants into a surgical planning, resulting in predictability of the prosthetic outcome and allowing for production of a prosthesis before surgery, simplifying immediate loading protocols Simplification of the technique- sensitive and operator- dependent surgical procedures, which may significantly affect current implant surgical practices

prosthetic outcome and allowing for production of a prosthesis before surgery, simplifying immediate loading protocols Simplification

5 Sources of error - Cone- beam computed tomography (CBCT) or multi- slice CT (MSCT) imaging, during different phases, including image acquisition and data processing - Software planning (conversion, segmentation, volume rendering manual removal of artefacts, transfer of the planning data) ; - Manufacturing of the surgical template (simulation software, stereolithographic machine, production and quality control, rigidity and physical properties of the material used, precision of the guide cylinders and metal tubes, verification of the guide). - Inaccurate positioning of the guide in the mouth (flap intervention, improper or tilted seating, resilience of the anatomical structures that support the guide); - improper guide fixation (angle, location, number of fixation screws); - the presence of a rotational allowance of drills in tubes; - the shape (straight or tapered) and sharpness of the drills; - reduced mouth opening; - non- guided insertion may cause a deviation between the postoperative position of the implants and the preoperative plan.

quality control, rigidity and physical properties of the material used, precision of the guide cylinders and metal tubes, verification of the guide).

7 STEP 1 Fabrication of a radiopaque diagnostic template.

9 STEP 2 CT scan of the patient s arch, performed with spiral CT devices.

10 STEP 3 Digital 3D CT-based surgical planning.

11 STEP 4 CAD of stereolithographic surgical template.

12 STEP 5 CAM of stereolithographic surgical template.

13 Esternal Hex Safe The Esternal Hex Safe surgi-guide system is a totally guided implant system, allowing for controlled osteotomy site preparation and implant placement in three dimensions. The system uses a single guide for site preparation and implant placement.

site preparation and implant placement in three dimensions.

14 The bone- or mucosasupported template was fixed to the jaw using at least three fixation screws(safe Fixed Group). Safe Fixed Group

15 Safe Not-Fixed Group The surgical template was manually held in place by the surgeon as well during the site prepatation as during the implants insertion.

16 Surgical components and instruments used in a single stereolithographic guided surgery system (External Hex Safe; Materialise Dental, Leuven, Belgium): (A) stereolithographic surgical guide; (B) internal tube; (C) fixation screw drill; (D) fixation screw; (E) mucotome for flap- less surgery; (F) and (G) diameter and depth calibrated drills for guided osteotomy; (H) implant holder for guided implant insertion. *Guide sleeve for fixation screw installation. **Internal tube inserted in the guide sleeves to guide the drilling procedure.

for flap- less surgery; (F) and (G) diameter and depth calibrated drills for guided osteotomy; (H) implant holder for guided implant

17 STEP 6 Computer-aided surgery.

18 STEP 7 Image fusion and measure of deviations.

19 The total error between the planned (red) and the placed implants, performed by aligning the preoperative three- dimensional representations of the jaws with their counterparts in the postoperative three- dimensional images. The matching of preoperative three- dimensional computed tomography representations of maxilla with the postoperative using Mimics software.

the postoperative three- dimensional images.

23 RESULTS

24 Tolerance between the various components of External Hex Safe1 surgi-guide determines the possibility of drill movement and an increase in the space between inter tube and master tube on the opposite side to the flexion of the drill (A, B). In the higher magnification images (A1, B1) the increase of the space between internal and the master tube (red arrow) can be identified on the opposite side to the one that comes into contact with the drill (white arrow). How the systematic error may occur. Implants are planned using the diagnostic template (in red), but if the surgical guide (in blue) is not placed in the same position as the diagnostic template, the inserted implants (in blue) deviate from the planned implants (in red). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)

26 RESULTS How does an error in positioning the template affect the accuracy of implants inserted using a single fixed mucosa-supported stereolithographic surgical guide? Cassetta M, Di Mambro A, Giansanti M, Stefanelli LV, Barbato E. Int J Oral Maxillofac Surg Aug 2. doi:pii: S (13) /j.ijom [Epub ahead of print]

27 (A) The freedom of movement of the pilot drill inside the internal tube due to the tolerance between the second tract of the drill and the inner surface of the internal tube. (B) The freedom of movement of the final drill inside the internal tube due to the tolerance between the second tract of the drill and the inner surface of the internal tube. (C) The freedom of movement of the implant during the guided insertion because of the tolerance between the master tube and implant holder.

28 arctg AD/ED=4/0.2 = 2,86 arctg 5/0.2 = 2.29

29 A guide tube directly screwed to the head of the surgical handpiece. Guide tubes of decreasing length used to advance the surgical osteotomy screwed to the head of the surgical handpiece. Device realised by MMT enterprise Velletri - Italy Info@mmtgroup.it

30 One of the decreasing guide tubes screwed to the head of the surgical handpiece inserted into the master tube.

31 RESULTS The Influence of the Tolerance between Mechanical Components on the Accuracy of Implants Inserted with a Stereolithographic Surgical Guide: A Retrospective Clinical Study. Cassetta M, Di Mambro A, Di Giorgio G, Stefanelli LV, Barbato E. Clin Implant Dent Relat Res Jul 24. doi: /cid [Epub ahead of print]

32 RESULTS The Influence of the Tolerance between Mechanical Components on the Accuracy of Implants Inserted with a Stereolithographic Surgical Guide: A Retrospective Clinical Study. Cassetta M, Di Mambro A, Di Giorgio G, Stefanelli LV, Barbato E. Clin Implant Dent Relat Res Jul 24. doi: /cid [Epub ahead of print]

33 PATENT N VI2012U STASI - STEFANELLI - SARTORI Device realised by MMT enterprise Velletri - Italy Info@mmtgroup.it

34 PATENT N VI2012U STASI - STEFANELLI - SARTORI Device realised by MMT enterprise Velletri - Italy Info@mmtgroup.it

35 Conclusion The most important sources of error using stereolitographic surgical templates are: o Intrinsic error (60%); o Positioning error (20%).

36 THANKS FOR YOUR ATTENTION

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