I M P L A N T C O M P A N Y

GUIDED
SURGERY
CLINICAL 2018
CASES

W W W.B E B DEN TA L . I T
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B&B DENTAL GUIDED SURGERY KIT

It is useful to know the surgical accessories that make up the kit. The kit is
provided with the drills are to be used successively in order to prepare the
implant site to a size suitable for the implant to be placed in position. It is
equipped with compactors to enhance the primary stability of implants in
case of spongy bone and countersinks to decrease the resistance given by
the cortical bone in harder kinds of bone, thus providing a wide range of
instruments to adapt to different clinical and anatomical needs.
All instruments are colour coded and laser etched with the sizes features
enabling the users to easily find and choose the right tool to use.
The morphology of the instruments inside the B&B DENTAL
SURGICAL KIT is specifically designed for the guided
insertion of the SLIM, 3P and EV line implants. The neck
of the drills allow for a precise insertion inside the guided
sleeve determining the depth of the osteotomy with
a known full-travel stop at a distance of 9 mm from the
crestal edge of the bone.
B&B Dental provides technical support to help during planning
and designing procedures, it also has an internal laboratory that can
print radiographic and surgical templates.

B&B Dental Implant Lines for guided surgery

The various lines of the B&B Dental implant
family (SLIM, 3P, EV and WIDE*) allow you
to use the most suitable implant design
and size for each surgical site.
The implants are available in diameters
of 3.0 - 3.4 - 3.5 – 4.0 - 4.5 - 5.0 and they
are characterized by one connection. The
uniform implant connection for upper-
diameter implants at 3.40 offers different
surgical options separated by morphology
(3P – narrow thread – EV – large thread)
but with a uniform prosthetic platform
facilitating the processing and selection of
prosthetic abutments.
* NOTE: the WIDE line can not be used in guided surgery.

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 GUIDED IMPLANTOLOGY

AUTHOR: DR. FRANCESCO GIARDINA

I mplant o lo gy i s t h e bran ch of dent i s try d e d i c a te d to re s to ri n g mi s s i n g te e t h , i n
t h e way mo s t si m i l ar to t h e natur a l o n e : b y i n s e rt i n g i mp l a n ts wh e re te e t h h a v e
been lo s t , for v ari ou s re ason s. The a b o ve te l l s u s t h a t i mp l a n to l o g y i s a s urg i ca l
d i s c ipl ine aimed at prost h e t i c rehab i l i ta t i o n w h i c h c a n n o t b e a c h i e ve d b y e x c l u d i n g
t h e pro s t het ic proj e ct.
R e al is ing al l t h i s, correct l y and w i t h re s u l t p re d i c ta b i l i ty, d e p e n d e d g re a t l y o n
t h e surgeon’s e xpe ri ence , e xpe rt eye a n d ma n u a l s k i l l u n t i l o n l y a f e w ye a rs a g o .
T he o per at o r’s man u al ski l l s an d e x p e ri e n c e a l s o a ff e c t t h e c h o i c e o f i m p l a n t
c h ar ac t er ist ics i n terms of d i am e ter a n d l e n g t h .
I n fo r mat ion Tech n ol ogy (u si n g ded i c a te d s o f twa re f o r i mp l a n t p ro s t h e s e s d e si g n
t h a t ac quire DICOM fi l es an d t hen re tu rn s t h re e -d i me n s i o n a l i ma g e s o f t h e j a w
bones) and robot i cs (u si n g 3D pri nt e rs ) h a ve re c e n t l y c h a n g e d t h e p i c tu re d e s c r i b e d
above, al lo wing us:
• vir t ual plann i n g of t h e surgi cal an d p ro s t h e t i c p h a s e ;
• real isat ion of a su rgi cal TEMPLATE, w i t h i n c o rp o ra te d
ri gid guides , t hat al l ow i n se rt i on of t h e d e s i g n e d i mp l a n t
at t he po s it ion , angl e an d dept h a s p l a n n e d i n t h e vi rtu a l p ro j e c t. Th e a b ov e i s
ac hieved us in g de d i cated ki ts wi t h b u rs t h a t h a ve a w o rk i n g p a rt a n d a p e rf e ct l y
c oax ial guide cy l i nde r for t he TEMP L ATE’s ri g i d g u i d e (F i g . 2)
• E x ec ut ion of a pre-con stru cte d p ro s t h e s i s : By p l a c i n g t h e s u rg i c a l TEM P L AT E
o n plas t er mode l s created prev i ous l y, “p l a s te r s u rg e ry” c a n b e c a rri e d o u t a n d a
te mpor ar y prost hesi s can be cre ate d , t h a t i s d e s i g n e d vi rtu a l l y a n d c a n b e p l a ce d
i n t he pat ien t ’s m out h i m med i atel y a f te r g u i d e d e n try o f t h e i mp l a n ts (i mmed i a t e
l o a d ing).
To day we are goi ng to tal k abou t Ass i s te d S o f twa re G u i d e d Imp l a n to l o g y a n d a s s i st e d
S oft ware G uid e d Im pl an tprost het i cs .

T H E C A SE
Woman aged 63 y ears wi t h upper bil a te ra l te rmi n a l e d e n tu l i s m; n o c o n tra i n d i c a t i o n s
c ont ained in med i cal h i s tory. Fi rml y a s k s f o r f i x e d re h a b i l i ta t i o n o n i mp l a n ts .
N ine mo nt hs pri or to t h e i n se rt i on o f t h e i mp l a n ts , a b i l a te ra l l a rg e -s c a l e M a x i l l a r y
S i nus Flo or Au gm e n tat i on was ca rri e d o u t, u s i n g h o mo l o g o u s b o n e g ra f ts . T h i s
s i tuat io n mad e us deci de to pe rform a s s i s te d S o f twa re G u i d e d Imp l a n to l o g y w i t h o u t
i mmed iat e load i n g, by i n se rt i ng s i x i mp l a n ts , t h re e e a c h s i d e i n t h e e d e n t u l o u s
areas.
A f t er inser t in g t h e surgi cal T EM PL ATE i n to t h e p a t i e n t ’s mo u t h ( i t i s
anc ho red t o t h e front teet h an d ma k i n g s u re i t i s c o n g ru e n t a n d s ta b l e a
n ec essar y c on d i t i on for carry i n g o u t t h e p ro j e c t) (F i g . 1), c i rc u l a r mu c o tom i e s
w e re c ar r ied ou t usi ng t h e g u i d e s , a f te r w h i c h mu c o s a c yl i n d e rs w e re
re mo ved. T he mi dd l e su rgi cal soc k e ts o n e a c h s i d e a re p re p a re d f i rs t o f a l l
( F ig. 2) where, u si n g t he TEMPLATE, t h e f i rs t tw o i mp l a n ts a re i n s e rte d (F i g . 3), u si n g
s pec ific as s embl y tool s t h at are fi rml y a n c h o re d to t h e i mp l a n ts t h e ms e l ve s .
T his proc edure ai ms to stabi l i ze t h e TEM PL ATE p e rma n e n t l y, p re ve n t i n g a n y
ac c ident al d ispl acem e n ts.
O nc e t he T EMPLATE i s stabi l i zed , t h e s a me p ro c e d u re i s c a rri e d o u t u s i n g t h e
re maining gui des.

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O nc e t he imp l an ts h av e be e n posit i o n e d (F i g .4), t h e a s s e mb l y to o l s a re re m o v e d ,

u n s c rewing t he con n e ct i on scre ws to t h e i mp l a n t i ts e l f a n d t h e TEM PL ATE , a n d
vi ewing t he c orre ct i m pl an t posi t i on (F i g . 5). Th e o p e ra t i o n e n d s i n a c l a s s i c a l m a n n e r
w i t h inser t io n of t he h e al i n g screws (F i g . 6).
C ont rol has be e n done afte r t h re e mo n t h s . (F i g . 7).
T he t ec hnique descri be d bel ow, whic h i s s i mp l e a n d s a f e to c a rry o u t o n t h e c o n d i t i o n
t h a t al l t he proj e ct phase s h av e been c a rri e d o u t c o rre c t l y, a l l o w s c o mp l e x s u rg er y t o
be c ar r ied o ut i n rel at i v el y short t i m e s (60-90 mi n u te s f o r a f u l l -a rc h o f 6/ 8 i mp l a n t s)
w i t h max imum pre d i ctabi l i ty Al so, t h e p o s s i b i l i ty o f h a vi n g a p re -c o n s tru c te d f i xe d
pro s t hesis t ha t can i mm e d i ate l y be f i t te d f o r t h e p a t i e n t

Fig . 1 Fig. 2 F ig. 3

Fig . 4 Fig. 5 F ig. 6

Fig . 7 Fig. 8 F ig. 9

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 GUIDED IMPLANTOLOGY

AUTHOR: DR. ALESSANDRO PREDA

Implantology is the branch of dentistry dedicated to restoring missing teeth, in the way most
similar to the natural one: by inserting implants where teeth have been lost, for various reasons.
The above tells us that implantology is a surgical discipline aimed at prosthetic rehabilitation
which cannot be achieved by excluding the prosthetic project.
Realising all this, correctly and with result predictability, depended greatly on the surgeon’s
experience, expert eye and manual skill until only a few years ago. The operator’s manual skills
and experience also affect the choice of implant characteristics in terms of diameter and length.
Information Technology (using dedicated software for implant prostheses design that acquire
DICOM files and then returns three-dimensional images of the jaw bones) and robotics (using
3D printers) have recently changed the picture described above, allowing us:.
• virtual planning of the surgical and prosthetic phase;
• realisation of a surgical TEMPLATE, with incorporated rigid guides, that allow insertion of
the designed implant at the position, angle and depth as planned in the virtual project.
The above is achieved using dedicated kits with drills that have a working part and a perfectly
coaxial guide cylinder for the TEMPLATE’s rigid guide
• Execution of a pre-constructed prosthesis: By placing the surgical TEMPLATE on plaster
models created previously, “plaster surgery” can be carried out and a temporary prosthesis
can be created, that is designed virtually and can be placed in the patient’s mouth immediately
after guided entry of the implants (immediate loading).
Today we are going to talk about assisted Software Guided Implantology and assisted
Software Guided Implant-prosthetics.

THE CASE
Man aged 67 with lower bilateral anterior edentulism (Fig. 1); no contraindications contained in
medical history. Firmly asks for immediate fixed rehabilitation on implants. This request made
us decide to perform assisted Software Guided Implantology with immediate loading, by
inserting six implants, three each side in the edentulous areas.
After proceeding with the panoramic X-Ray (Fig.2) and planning the case with Software Guided
Implantology (Fig. 3), by reconstructing mandibular patient bone, a surgical template (Fig. 4)
and a customized temporary fixed prothesis (Fig. 5) are constructed in the laboratory.
After inserting the surgical template into the patient’s mouth (it is anchored to the teeth and
making sure it is congruent and stable a necessary condition for carrying out the project) (Fig.
6), circular mucotomies were carried out using the guides, (Fig.7) after which mucosa cylinders
were removed. The middle surgical sockets on each side are prepared first of all (Fig. 8) where,
using the template, the first two implants are inserted (Fig. 9), using specific assembly tools that
are firmly anchored to the implants themselves. This procedure aims to stabilize the template
permanently, preventing any accidental displacements.
Once the template is stabilized, the same procedure is carried out using the remaining guides.
Once the implants have been positioned, the assembly tools are removed, unscrewing the
connection screws to the implant itself and the template, and viewing the correct implant
position. By using peek temporary abutments (Fig.10), the pre-constructed fixed prosthesis,
previously made by the technician in the laboratory (Fig. 5), were rebased with cold cured acrylic
resin (Fig.11).
The operation ends in a classical manner by fixing the prosthesis with prosthetic connection
screws to the implants (Fig.12) and the final X-Ray gives us a complete overview of the patient
mouth with implants perfectly inserted.
The technique described, which is simple and safe to carry out on the condition that all the
project phases have been carried out correctly, allows complex surgery to be carried out in
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relatively short times (60-90 minutes for a full-arch of 6/8 implants) with maximum predictability
The possibility of having a pre-constructed fixed prosthesis that can immediately be fitted for the
patient (where the right anatomic-functional conditions allow it) considerably improves not only
the aesthetics but also healing of the bone-implant interface that takes place under functional
loading.

Fig. 1 Fig. 2 F ig. 3

Fig. 4 Fig. 5 F ig. 6

Fig. 7 Fig. 8 F ig. 9

Fig. 10 Fig. 11 F ig. 12

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INSTALLATION OF TEMPORARY PROSTHESIS REINFORCED WITH PEEK

AUTHOR: DR. ALFREDO NATALI

We have alw ay s tri e d to tran spos e a s b e s t a s p o s s i b l e t h e c o n c e p tu a l p h a se o f
D i agnosis into t h e operat i on al pha s e o f Th e ra p y. Th i s p a s s a g e , f ro m p ro g ra m m i n g
to t he appl icat i on of t h e t herape u t i c d e c i s i o n s , c a n ma k e u s e o f t h e mo s t v a r i e d
m et hods and pract i cal ai ds i n al l d i s c i p l i n e s .
E v er y s urgic a l act i s de v el oped to re s p o n d to a n e e d a n d mu s t b e a c c u ra te l y p l a n n e d
f o r best res ul ts. In dent i stry, t h e i de a l o b j e c t i ve s h a ve a l wa ys b e e n t h e mo s t c o m p l e t e
and func t iona l rehabi l i tat i on possi b l e o f t h e s to ma to g n a t h i c s ys te m, w i t h mi ni m u m
i n vas iveness, t i m e , cost, an d i n con ve n i e n c e .
I n t he last t en y e ars, t han ks to te c h n o l o g i c a l p ro g re s s a n d t h e e vo l u t i o n o f D i g i t a l
Wor k flo w, it has been possi bl e to c o n c e i ve a n d re a l i z e a n u n i n te rru p te d wo rk f l o w
f rom D iagno si s to Rehabi l i tat i v e T h e ra p y t h a t i n c re a s i n g l y e x p a n d s i ts i n d i c a t i o n s
and possibil it i es.
I n implant o logy, we recogn i se t hi s e vo l u t i o n w i t h t h e g e n e ri c n a me o f C o m p u t e r
G uided Impla ntol ogy. The new pro p o s a l f ro m B&B DEN TAL o ff e rs , b e s i d e s t h e
s i mpl ific at io n of t h e tre atment fro m a d i g i ta l p o i n t o f vi e w, t h e p o s s i b i l it y o f
ac c ompanying t he cl i ni ci an ste p by s te p i n t h e i n e vi ta b l e l e a rn i n g c u rve f o r c o m p l e t e
training.
T his pro c edure i n cl ude s v ari ous p h a s e s , c o n c e p tu a l l y b e l o n g i n g to d i ff e re n t
e nvironment s, but bound toge t h e r i n a c o n s o l i d a te d s e q u e n c e . Du ri n g Pl a nn i n g ,
t h e c ont inuo us e xch ange be tween t h e va ri o u s a re a s ma k e s i t p o s s i b l e to c o rre ct l y
m a nage and programm e t h e e xecu t i ve p h a s e s , w i t h t h e o b j e c t i ve o f i n c re a si n g
o per at io nal speed, correctness, an d s a f e ty.
P l a nning c an be d i v i de d i n to t hree ma c ro a re a s :
1 . D iagno s t ic Area
2 . Surgic al A re a
3 . P ro s t het ic Area
We wil l pres ent a cl i ni cal case to i l l u s tra te t h e s a l i e n t p h a s e s :

1 . Dia gn o st ic Area
We rec o gnis e a fi rst Di agn ost i c Area i n w h i c h t h e p a t i e n t ’s p re l i mi n a ry a n d o b j e ct i v e
i n fo r mat ion is gat here d, i ncl u d i n g x -ra ys a n d t h e Co n e Be a m CT (Ima g e 1).
To per for m a fl apl ess te chni qu e , a n e c e s s a ry c o n d i t i o n re g a rd s t h e a va i l a b i l i t y o f
bone in t he a re as wh e re i m pl an ts ca n b e i n s e rte d a n d a s u ff i c i e n t re p re s e n ta t io n i n
te r ms of t hic kn e ss and si ze of gu m t i s s u e . It i s a l s o i n d i s p e n s a b l e to h a ve a g o o d
pat ient ’s mou t h openi ng to al l ow e a s y a c c e s s f o r d ri l l s a n d t h e i mp l a n t.
B efo re do ing t h e Cone Be am CT, i t i s s u i ta b l e to p e rf o rm a p re l i mi n a ry s tu d y, to c re a t e
a mas k wit h rad i opaqu e marke rs to b e wo rn b y t h e p a t i e n t d u ri n g t h e ra d i o l o g i ca l
e xam (Image 2).
T he ac quisit i on of t h e mask usi ng a n o p t i c a l s c a n n e r, o r i n c a s e a a n a tom i ca l
re f erenc es for d i gi tal al i gnm e n t (Ima g e 3).
W it h t hese anatomi cal reference s i t i s p o s s i b l e to a n t i c i p a te t h e d e n ta l a n a t o m y
desired for the patient, and have a consistent volume of information to define the number,
position, inclination, and type of each fixture and possible abutment. (Image 4).
T hese par ameters are fundam e n tal a n d n e c e s s a ry f o r Pl a n n i n g , b u t n o t s u ff i c i en t .
I n fac t , it is al so n e cessary to con s i d e r S u rg i c a l a n d Pro s t h e t i c f a c to rs a n d t h e
re ciproc al im pl i cat i on s.
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2 . Su rg ic a l Area
To per fo r m im med i ate rehabi l i tat i on i t i s n e c e s s a ry f o r t h e i mp l a n ts to h a ve e l e v a t e d
pri mar y s t abil i ty (i nsert i on torqu e ≥ 35 N c m). In t h e u p p e r ma x i l l a ry, d u e t o t h e
ty p ic al c har a cteri st i cs of t h i s area , i t c a n b e mo re d i ff i c u l t to h a ve a b o n e t h a t
guar ant ees t h e nece ssary pri mary s ta b i l i ty, n o twi t h s ta n d i n g t h e p re p a ra t i o n o f t h e
s i te and t he shape of t h e i mpl ant. To o ve rc o me t h i s c ri t i c a l i s s u e , B&B DEN TA L’s
D u r avit s yst em prov i de s a seri e s of o s te o c o n d e n s e rs f o r u s e i n b o t h G u i d e d S urg i ca l
and t r ad it iona l sy ste ms. Th e work of p ro g re s s i ve e x p a n s i o n i n c re a s e s t h e l o c a l b o n e
densit y and im prov es pri mary stabi l i ty.
T he advant ag e s of t hi s te chni qu e we re a l s o i n te g ra te d i n to t h e G u i d e d S urg i ca l
pro c edure propose d by B&B 3D (Ima g e 5). To tra n s f e r t h e p o s i t i o n o f t h e EV i mp l a n t s
f rom t heo r y t o pract i ce, a gu i de m a s k i s n e c e s s a ry (Ima g e 6). THIS i s t h e mo s t w e l l -
k n o wn st ep of Gui de d S u rgery, bu t yo u mu s t c o n s i d e r t h e s p e c i f i c c o n s truct i o n
n e eds t hat infl uence t h e desi gn . For e x a mp l e , t h e s p e c i a l g u i d e b u s h i n g c o n ce i v e d
by B&B D ental i n i ts speci al h i gh-p re c i s i o n h e x a g o n s h a p e h a s a g i ve n vo l u m e ,
and if implants are cl ose to each ot h e r t h e re c a n b e i n te rf e re n c e s . In a d d i t i o n , i t i s
n e c es s ar y t o con si der t h at gui de s h a ve a n o n -re d u c i b l e ve rt i c a l d e ve l o p me n t t h a t
l i m it s t he possi bi l i ty of si n ki ng t he i mp l a n t ve rt i c a l l y b e yo n d a c e rta i n l i mi t . T h e
s o ft ware was created by 3d i e mm e : i t ma k e s t h e n e c e s s a ry c o n tro l s a n d i n d i c a tes a n y
i n t er ferenc e.

F ig . 1 Fig. 2 F ig. 3

F ig . 4 Fig. 5 F ig. 6

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INSTALLATION OF TEMPORARY PROSTHESIS REINFORCED WITH PEEK

3 . Pro st h et ic Area
T hank s t o 3d i e mm e ’s Pl anni ng softw a re , t h e f i rs t to b e CE-c e rt i f i e d , i t i s p o s s i b l e t o
prepare t he te mporary dev i ce e v en b e f o re t h e s u rg i c a l o p e ra t i o n , e l i mi n a t i n g t h e
w a it for t he p rost h e si s construct i o n , s i n c e t h e p o s i t i o n o f t h e i mp l a n ts i s a lre a d y
k n own.
O bvious ly, t here must be a ce rta i n to l e ra n c e i n p o s i t i o n i n g t h e i mp l a n t d ue t o
m a t er ial elas t i ci ty and resi l i e n ce of t h e mu c o u s .
A n ot her adva n tage of t h i s met hod is re p re s e n te d b y t h e h e x a g o n s h a p e o f t h e g u i d e
bushing, repre se n t i n g t h e program me d p o s i t i o n o f t h e i mp l a n t c o n n e c t i o n (I m a g e
6 ) . If t he hex a gon of t h e ke y i s posi t i o n e d i n l i n e wi t h t h a t o f t h e g u i d e , i t i s p o ssi b l e
to fo res ee t he posi t i on of n on-rota t i o n a l a b u tme n t p ro s t h e t i c s , l i k e , f o r e x am p l e ,
angled M ul t i Use Abutment (MUA) (Ima g e 7). It i s a l s o p o s s i b l e to p ro g ra mm e t h e
o c c lusal redu ct i on of t h e tem porary t i ta n i u m c a n n u l a s a n d h e l p re p o s i t i o n t h e m w i t h
a spec ific al ly de si gned resi n tool (I ma g e 7).
T he int egr at i on of t h e 3d i e mm e Pl a n n i n g s o f twa re a n d t h e C AD/ C AM r a p i d
prot o t yping e n v i ron ment of t he B & B 3D p ro s t h o d o n t i c l a b o ff e rs a l mo s t i n f i n i t e
possibil it ies of choi ce as far as t he p ro d u c t i o n o f t h e te mp o ra ry d e vi c e i s c o n c er n e d .
I T is t herefore n e cessary to adapt t he d e s i g n to t h e re a l p ro d u c t i o n p o s s i b i l i t i e s a n d
t h e c har ac t eri st i cs of t he m ate ri al s a va i l a b l e f o r e a c h s i n g l e c l i n i c a l c a s e . F or t h e
c l i nic al c ase in quest i on a PEEK fram e wo rk i n c l a d a c ryl i c re s i n w a s p ro d u c e d (Im a g e
8 ) . A t t his poi n t t h e Pl an n i n g can b e c o n s i d e re d c o mp l e te a n d we c a n p ro c e e d w i t h
t h e O per at ion al phase .
S urgic al O perat i onal Phase
A f t er loc al infi l trat i on of an aest he t i c wi t h va s o c o n s tri c to r (Art i c a i n a 1:100, 0 0 0 ) ,
re mo ve t he g um t i ssu e of t he operc u l a b e f o re a t ta c h i n g t h e ma s k o n t h e f ro n t si d e

F ig . 7 Fig. 8 F ig. 9

F ig . 1 0 Fig. 11 F ig. 12

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w i t h t he pro vi de d pi n s. Thi s m ake s i t e a s i e r to re mo ve t h e f i b ro u s l a b ru m a nd t h e

as ses s ment of t he mucous t h i ckn e s s . (Ima g e 9). B&B DEN TAL s u p p l i e s a s p e ci a l
s u rgic al k it de si gned to faci l i tate t h e w o rk o f t h e c l i n i c i a n . Th e a t ta c h me n t of t h e
m a sk pro duc ed i n t he B&B 3D l ab i s a c ri t i c a l o p e ra t i o n a n d mu s t b e p e rf o rme d w i t h
m a x imum at t ent i on (Image 10). We t h e n p ro c e e d to c re a te t h e f i rs t o s te o to my w i t h
t h e lanc e dr il l i n al l si te s (Im age 1 1). Du ri n g t h i s p h a s e i t i s w o rt h wh i l e to te s t t h e
bo ne c ons ist e n cy to su i tabl y adapt t h e s u rg i c a l p ro to c o l a i me d a t a c h i e vi n g p r i m a r y
s ta bil it y.
To impro ve t he stabi l i ty of t h e mask , we d e c i d e to p ro c e e d f i rs t wi t h t h e a p p l i c a t i o n
o f t he most d i stal i m pl an t, bi l ateral l y. Th e s u p p o rt i n g a re a i s s u b p re p a re d a n d b o n e
i s not removed wi t h dri l l s, bu t com p a c te d t h a n k s to o s te o c o n d e n s e rs (Ima g e 1 2 ) .
T he more t he bon e i s found to be o f p o o r c o n s i s te n c y, t h e mo re n e c e s s a ry i s t h i s
pro c edure. T he d i stal m axi l l ary are a typ i c a l l y p re s e n ts t h e s e c h a ra c te ri s t i c s .
T he D ur avit EV i m pl an t produce d b y B&B DEN TAL i s p o s i t i o n e d w i t h a mo un t i n g
devic e and c ontri bu tes si gni fi cant l y to g e n e ra l s ta b i l i ty (Ima g e 13). IT i s p a rt i c u l a r l y
u s e ful t o loo k i n d i re ct l y to v eri fy t h a t t h e h e x a g o n o f t h e b u s h i n g a n d t h a t o f t h e
m ount ing devi ce are pe rfect l y al i gne d (Ima g e 14).
T he pro c edure of oste oconde n sa t i o n a n d s u b p re p a ra t i o n wa s u s e d f o r a l l t h e
pro gr ammed areas, ach i e v i ng sat i sf a c to ry s ta b i l i ty.
I n par t ic ular, we use t he tool d i re ct l y i n t h e p l a c e o f t h e mo u n t i n g d e vi c e f o r g re a t e r
pra c t ic al it y (Image 15). At t he e n d o f t h e s u rg e ry w e re mo ve t h e ma s k (Ima g e 1 6 ) .
P rost het ic Ope rat i onal Phase
I t was dec ided n ot to pl ace t he i mp l a n t i n p o s i t i o n 13 d u e to t h e b a re l y s u ff i ci e n t
s ta bil it y and t h e smal l d i amete r o f t h e f i x tu re . O n t h i s i mp l a n t we p o s i t i o n a
transmuc ous heal i ng cap i n PEEK, a l re a d y s te ri l e a n d i n c l u d e d i n t h e p a c k a g i ng

Fig. 13 Fig. 14 F ig. 15

Fig. 16 Fig. 17 F ig. 18

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 GUIDED MAXILLARY OSTEOCONDENSATION WITH IMMEDIATE
INSTALLATION OF TEMPORARY PROSTHESIS REINFORCED WITH PEEK

o f al l implants produce d by B&B D e n ta l . O n t h e o t h e r i mp l a n ts w e i n s ta l l t h e M U A

s tump. To be prope rl y posi t i on e d o n t h e i mp l a n t, t h e a n g l e d M U A ma y re q u i re t h e
u se o f t he B on e Mi l l (Image 17).
W hen t he M UA h as been fu l l y scre w e d i n , w e p ro c e e d wi t h a p o s i t i o n i n g i mp r i n t t o
f a cil it at e t he adaptat i on of t he bri d g e (Ima g e 18).
T his phase c oul d hav e e asi l y be e n p e rf o rme d i n tra o ra l l y, b u t w e p re f e rre d to a l l o w
t h e pat ient t o re st a fe w hou rs.
R e t ur ning from t h e break, we appl y t h e tw o mo s t me s i a l c yl i n d e rs , a n d t h e p ro s t h e si s
i s lo wered d irect l y i n to t he oral cav ity, l o c k i n g i ts p o s i t i o n (Ima g e 19). Af te rwa rd s t h e
re maining c yl i nde rs are appl i e d, t he p ro s t h e s i s s c re we d i n to p o s i t i o n , a n d a cr y l i c
re sin is injec te d to com pl ete t he l o c k i n g (Ima g e 20).
T he pro s t hes is i s cl ean e d and pol i s h e d i n t h e l a b (Ima g e 21).
We final ly proce e d wi t h t h e cl i nic a l a p p l i c a t i o n o f t h e p ro s t h e s i s , t h e o c cl u sa l
ad jus t ment , an d aest het i c fi ni shi ng (Ima g e 22).
T he pat ient h ad moderate pai n fo r a b o u t 24 h o u rs , p re s e n te d a l i g h t o e d e m a , n o
bl eed ing, and h i gh sat i sfact i on for t h e tre a tme n t. Th e te mp o ra ry p ro s t h e s i s w a s
c h ec k ed aft e r 7 and 14 day s for oc c l u s a l a d j u s tme n t, a n d a f te r 1-2 a n d 3 m o n t h s
( I mage 23). No com pl i cat i ons arose . Th e p ro s t h e s i s i s ma i n ta i n e d i n f u n c t i o n a s a
l o n g- t er m t emporary dev i ce, awai t in g t h e d e f i n i t i ve p ro s t h e s i s .

F ig . 1 9 Fig. 20 F ig. 21

F ig . 2 2 Fig. 23

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FULL ARCH IMMEDIATE LOAD WWW.BEBDENTAL.IT
GUIDED SURGERY CASE

AUTHOR: DR. ALESSANDRO CECCHERINI

T he 72- year- ol d pat i e n t, i n good he a l t h , a rri ve d a t t h e c l i n i c w i t h a n u p p e r f i xe d
prost hes is, whi ch at t hi s poi n t was b o t h a e s t h e t i c a l l y a n d f u n c t i o n a l l y c o mp ro m i se d ,
c e ment ed o nto 6 resi du al te e t h wi t h o u t a n y s ta b i l i ty (F i g . 1-2-3-4-5). F o l l o wi ng a n
x -r ay ex am, we found t hat t h e te e t h s u p p o rt i n g t h e p ro s t h e t i c s tru c tu re re q u i re d
re mo val and i nform e d t h e pat i e n t a b o u t t h e p a t h to f o l l o w i n o rd e r to o b t a i n a
f i x ed prost hesi s as requ e sted. Th e p a t i e n t a l s o p o i n te d o u t t h a t s h e d i d n o t w a n t
to remove t he prost hesi s be fore surg e ry o r l i ve wi t h a n i n te rme d i a te s i tu a t i o n t h a t
w a s aes t het ical l y unsat i sfactory. The re f o re , a s to me e t h e r re q u e s t a n d p e rmi t t h e
i n ser t ion o f impl ants i n areas t h at w e re n o t p o s t-e x tra c t i o n , we d e c i d e d to p e r f o r m
prevent ive extract i ons so t h at t h e s i te s wo u l d h a ve h e a l e d b e f o re s u rg e ry (F i g . 6 - 7 ) .
A l ginat e impre ssi ons were take n a n d d e ve l o p e d i n h a rd p l a s te r (F i g . 8) a f e w d a y s
af ter t he t eet h were e xtracte d to al l o w t i me f o r t h e mu c o s a to h e a l .
T he r ad iologi cal tem pl ate i s cre a te d f ro m t h e mo d e l . Ra d i o p a q u e ma rk e r s a re
appl ied, which wi l l al l ow us to match t h e DICO M f i l e s a n d S TL f i l e s (o b ta i n e d t h ro u g h
t h e s c anner ) of t he m ode l and t h e te mp l a te i ts e l f o n c e t h e C BCT h a s b e e n m a d e
( F ig. 9 - 10- 11).
I n t his c ase t h e tem pl ate we used to d o t h e C T s c a n i s a f u n c t i o n a l l y a n d a e s t h e t i ca l l y
i mproved dupl i cate of t h e pat i ent ’s p ro s t h e s i s e q u i p p e d w i t h ra d i o p a q u e mar ke r s.
T he dat a o btai ned from scan n i n g t h e mo d e l a n d t h e CT s c a n a re s u p e ri mp o s ed b y
m eans of a ded i cate d software t h a t i d e n t i f i e s t h e l o c a t i o n o f t h e ma rk e rs on t h e
C T s c an and al i gn s t hem wi t h t h e S TL f i l e . Th i s w a y w e a re a b l e to h a ve b o t h t h e
s o ft t issue da ta from t he i mpre ssi o n a s w e l l a s t h e h a rd t i s s u e d a ta d e ri ve d f ro m
t h e CT s c an. Thi s com bi ned i n forma t i o n a l l o ws u s to d i g i ta l l y p l a n f o r s u rg e ry ( F i g .
1 2 - 13- 14) and to con stru ct t h e su rg i c a l te mp l a te (F i g . 15) o r a d e vi c e c u s to mi ze d t o
t h e pat ient ’s an atom y t h at gu i des t h e d ri l l s a n d i mp l a n ts i n to t h e p re d e te rm i n e d
posit ion o f t he i mpl ant proj ect a c c o rd i n g to t h e b o n e c o n f o rma t i o n a n d t h e
anat o mic al pred i sposi t i on of t he ca s e . Th e p o s i t i o n i n g o f 5 i mp l a n ts i n t h e f ro n t a l
area is plann e d for t hi s pat i ent. So me o f t h e m a re i n p o s t-e x tra c t i o n s i te s , w h i l e
o t her s are locate d wh e re strate gi c e x tra c t i o n s w e re ma d e mo n t h s b e f o re to a ch i e v e
t h e pr imar y s tabi l i ty n e cessary to p e rf o rm a n i mme d i a te l o a d . Pl a n n i n g i s f a c i l i t a t e d
by t he c lear v i si on of t h e ov e ral l d i me n s i o n s a n d t h e b o n e c o n f o rma t i o n s p rov i d e d
by t he CT sc a n, al l owi n g for t he pos i t i o n i n g o f i mp l a n ts wi t h i n c l i n a t i o n s c o n s i st e n t
w i t h t he avail abi l i ty of bon e mat ter. Th e i n f o rma t i o n c o l l e c te d wi t h t h e i mp re ssi o n
al so provides t he choi ce of t h e tra n s mu c o s a l h e i g h t a b u tme n ts c o n s i s te n t wi t h t h e
prepared impl an t si te . Th e software a l s o o ff e rs t h e p o s s i b i l i ty to ro ta te t h e a b u t m e n t
i n order t o place t h e hol e s de d i cate d to t h e f i x i n g s c re ws a c c o rd i n g l y.

T hank s t o t he d i gi tal pl anni ng of t he c a s e , i t i s a l s o p o s s i b l e to b u i l d t h e p ro s t h e si s

i n t his phase so t hat i t can be fi xe d i n t h e p a t i e n t ’s mo u t h i mme d i a te l y a f te r s u rg e r y.
O n t he day of su rgery, t h e rem ai nin g te e t h a re re mo ve d (F i g . 16) a n d t h e s u rg i ca l
te mplat e is posi t i on e d t han ks to t he s u p p o rt o f a s i l i c o n b i te (F i g . 17-18). Th e si d e
pi ns are inserted i n to t h e h ol e wi t h t h e d e d i c a te d d ri l l (F i g . 19). To i n c re a s e s ta b i l i t y,
a c rest al pin i s i n se rte d i nto on e o f t h e f ro n ta l s l e e ve s (F i g . 20-21-22). Af te r ha v i n g
s ec ured t he stabi l i ty of t he te mpl a te , t h e o s to mi e s a re p re p a re d u s i n g t h e d ri l l s o f
t h e measureme n ts consi ste n t wi t h t h e i mp l a n ts to b e i n s e rte d i n e a c h s i te (F i g . 2 3 -
2 4 - 25- 26). A c cord i n g to t he B&B De n ta l p ro to c o l , t h e o s to my i s p re p a re d i n l e n g t h

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GUIDED SURGERY CASE

and t hen in d i am e ter. Insi de t he B& B De n ta l g u i d e d s u rg e ry k i t a re a l l t h e d i ff e re n t

dri l ls c o lo ur- coded for e asy se l e ct i o n . In t h i s c a s e t h e te mp l a te o n l y c o n ta i n s 4 . 2
m m d iamet er sl e e v es to av oi d u si n g t h e c o n ve rte r n e c e s s a ry i n t h e 5.5 mm s l e e v e s
f o r smal l d iam e ter dri l l s. Depe n d i n g o n t h e b o n e d e n s i ty o f e a c h s i te , EV i mp l a n t s
( i n areas wit h spongy bone) and 3P (f o r a re a s wh e re t h e b o n e i s d e n s e r) w e re p l a ce d
( F ig. 2 8- 29- 30-32). Th e two i mpl a n t l i n e s re q u i re d i ff e re n t p re p a ra t i o n s ; i n f a ct ,
s po ngy bone requ i re s sub-dri l l i ng t h e s i te a n d u s i n g a c o mp a c to r (F i g . 30): a t o o l
s u p pl ied in t he ki t wi t h t h e funct i on o f c o mp a c t i n g a n d c o n d e n s i n g t h e s u rro u nd i n g
bo ne, t hereby i mprov i n g pri mary st a b i l i ty. In t h e c a s e o f d e n s e r b o n e , t h e p ro t o co l
e xpec t s t he d ecre ase of resi stance wi t h t h e u s e o f a f l u te d d ri l l t h a t re mo ve s p a r t
o f t he c o r t ic al bon e . Im pl an ts are ta k e n f ro m t h e s te ri l e a mp o u l e u s i n g a h e x ag o n a l
m ount er (Fig. 27). Th e h e xagon h a s t h e s a me o ri e n ta t i o n a s t h e i n te rn a l h e x a g o n
o f t he implant, so by t i ghte n i n g t h e i mp l a n t o n i ts s i te wi l l b e e n o u g h to m a t ch
t h e mo unt er ’s h e xagon wi t h t h at of t h e s l e e ve to ma k e s u re t h a t t h e i mp l a n t i s i n
po s it io n t o c orrect l y host t he abutme n t a s p l a n n e d (F i g . 33). O n c e t h e i mp l a n ts h a v e
been inser t ed, i t wi l l be possi bl e to re mo ve t h e c re s ta l p i n a n d p ro c e e d w i t h t h e
prepar at io n an d posi t i on i n g of t he i mp l a n t i n t h e s l e e ve . Th e mo u n te rs t h e mse l v e s
w i l l provide stabi l i ty to t h e su rgi ca l te mp l a te . O n c e a l l t h e i mp l a n ts h a ve b e e n
i n s er t ed, simpl y unscre w t he i n tern a l s c re ws o f t h e mo u n te rs a n d re mo ve t h e m f ro m
t h e s leeves ( F i g. 33-34). By re l e asi n g t h e l a te ra l p i n s , t h e s u rg i c a l te mp l a te w i l l
be free (Fig.35) and t he abu tm e n ts c a n b e mo u n te d a n d l o c k e d i n t h e p ro s t h e t i c
s truc t ure (Fig . 37-38) pre v i ou sl y prep a re d o n t h e mo d e l i n t h e l a b o ra to ry t h a n ks t o
t h e projec t ’s e xpe ctat i on s (Fi g. 36 ). Th e p ro s t h e s i s p ro ve s to b e a n a e s t h e t i ca l l y
i m pro ved rep l i ca of t he pat i ent ’s s mi l e a n d i s a t ta c h e d to t h e a b u tme n ts in t h e
m out h (Fig. 39-40-41-42). The te mp o ra ry s c re ws a re re mo ve d a n d s c re w e d i n w i t h a
peek profile to al l ow for t he fi n i sh i n g to u c h e s (F i g . 43). Th e p e e k p ro f i l e f a c i l i t a t e s
t h e c losure of t h e poi n ts i n t he extra c t i o n a re a s (F i g .44). F o r t h e i n s e rt i o n of t h e
f i nished prost h e si s (F i g. 45-46-47) t h e te mp o ra ry s c re w s a re re mo ve d (F i g . 48 ) a n d
t h e prost het ic fi xat i on scre ws are i ns e rte d i n to t h e a b u tme n ts (F i g . 49-50). Th e b i t e
i s f unc t io nal ize d (Fi g. 51-52) be fore c o n c l u d i n g t h e s e s s i o n b y c l o s i n g t h e c o mp o si t e
h oles (Fig. 53-54).
T he k it is prov i ded wi t h a com pl et e l i n e o f to o l s f o r g u i d e d s u rg e ry i n c l u d i ng t h e
ra n ge of dr il ls n e cessary to fi n al i ze t h e i n s e rt i o n s u rg i c a l p h a s e o f t h e B& B D e n t a l
i m plant s .

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F ig . 1 Fig. 2 F ig. 3

F ig . 4 Fig. 5 F ig. 6

F ig . 7 Fig. 8 F ig. 9

F ig . 1 0 Fig. 11 F ig. 12

F ig . 1 3 Fig. 14 F ig. 15

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 FULL ARCH IMMEDIATE LOAD
GUIDED SURGERY CASE

F ig . 1 6 Fig. 17 F ig. 18

F ig . 1 9 Fig. 20 F ig. 21

F ig . 2 2 Fig. 23 F ig. 24

F ig . 2 5 Fig. 26 F ig. 27

F ig . 2 8 Fig. 29 F ig. 30

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F ig . 3 1 Fig. 32 F ig. 33

F ig . 3 4 Fig. 35 F ig. 36

F ig . 3 7 Fig. 38 F ig. 39

F ig . 4 0 Fig. 41 F ig. 42

F ig . 4 3 Fig. 44 F ig. 45

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GUIDED SURGERY CASE

F ig . 4 6 Fig. 47 F ig. 48

F ig . 4 9 Fig. 50 F ig. 51

F ig . 5 2 Fig. 53 F ig. 54

18
1 YEAR FOLLOW UP IN COMPLEX TREATMENT PLAN: WWW.BEBDENTAL.IT
CONVENTIONAL VS. GUIDED SURGERY

AUTHOR: DR. IOANA DATCU

I n tro duc tion:
I n rec ent decades t he rehabi l i t at i o n o f co mp l e x cl i n i ca l ca s e s h a s u n d e rg o ne a n
i mpo rtant tra nsfor m at i on i n t h e for mu l a t i o n o f t h e tre a tme n t p l a n a n d t h e s tra t e g i c
s equence o f t he var i ous cor re ct i ve t h e ra p i e s . Th e i n cre a s e d a t te n t i o n to t h e n e e d s
and w is hes of t he pat i e n t , as we l l a s t h e n e e d f o r a mi n i ma l l y i n va s i ve s u rg i c a l
approac h and t he re duct i on i n t h e n u mb e r o f s u rg i ca l p ro ce d u re s i s t h e re a s o n f o r
t h i s c hange. Pat i ent s wi t h t e r m i n al d e n t i t i o n h a ve co mmo n a e s t h e t i c-f u n ct i o n a l a n d
ps yc ho lo gic a l probl em s. They requ i re a p re ci s e a n d ca re f u l g a t h e ri n g o f me d i c a l ,
c l inical, techni cal an d r ad i ol ogi cal i n f o rma t i o n f o r t h e f o rmu l a t i o n o f t h e d i a g n o si s
and t he ident i fi cat i on of t he over a l l ri s k p ro f i l e o f t h e t h e ra p y.
T he proc edure for i mm e d i at e l oad i n g i mp l a n ts h a s ra d i ca l l y ch a n g e d t h e tre a t m e n t
t i mings and q ual i t y of l i fe of pat ie n ts , a vo i d i n g re mo va b l e te mp o ra ry p ro s t h e t i c
s o lut ions . T he aest het i cs, funct i on a l i ty a n d t h e co rre ct s tru ctu ra l co mp o n e n t a re
t h e ul t imate goal s of t he i m pl an t/ p ro s t h e t i c t h e ra p y. Th e re f o re , i t i s n e ce ssa r y
t o gat her t he cor re ct prost h e t i c i n f o rma t i o n b e f o re p l a n n i n g t h e i mp l a n t s u rg e r y,
pl a nned in a t r ad i t i onal m anner or vi a a g u i d e d co mp u te r.
C a se pres entat i on :
P a t ient R.S, a 68 ye ar-ol d wom an, no n -s mo k e r a n d i n g e n e ra l g o o d h e a l t h , ca m e t o
o ur cl inic in Ju n e 2 0 1 6 com pl ai n i n g a b o u t a e s t h e t i c a n d f u n ct i o n a l p ro b l e ms . T h e
pat ient ’s reque st was t o h ave a fi xe d p ro s t h e t i c s o l u t i o n . An i mp a rt i a l e x a mi n a t i o n
re vealed a bi l at er al par t i al ede n tu l i s m o f b o t h d e n ta l a rch e s a n d p e ri o d o n t a l
problems aff e ct i n g t he rem ai ni ng d e n ta l e l e me n ts . S h e wo re two i n a d e q u a t e
m a xil lary and man d i bul ar par t i al de n tu re s t h a t we re co mp l e te l y u n s a t i s f a cto ry b o t h
i n terms o f fu n ct i on and ae st h e t i cs ( f i g . 2 ) .
T he c omplexit y of t h e cl i ni cal si t ua t i o n re q u i re d a d e e p e r d i a g n o s t i c t h ro u g h x - r a y
e x aminat io ns an d a careful faci al e x tra o ra l , d e n to l a b i a l a n d i n tra o ra l a e s t h e t i c
analysis (Figure 5) as we l l as t h e t a k i n g o f p re l i mi n a ry i mp re s s i o n s a n d t h e f a c i a l
arch, t he regi st r at i on of i nt e r m axi l la ry re l a t i o n s h i p s a n d t h e mo u n t i n g o f t h e m o d e l s
i n t he art iculat or. X-r ays and pe r io d o n ta l e x a mi n a t i o n s ( PS R ) re ve a l e d a d i ff u se d
h orizo ntal bon e resor pt i on i n t he two d e n ta l a rch e s a n d t h e n o n -re co ve ra b i l i t y o f
re sidual dent al el em e n t s. It was d e ci d e d to te mp o ra ri l y p re s e rve s o me o f t h e se
dental elemen t s, such as t h e pi l l ars o f a te mp o ra ry re i n f o rce d p ro s t h e s i s t h a t h a s
al l t he aest het i c an d funct i on al m od i f i ca t i o n s o f t h e f u tu re p ro s t h e t i c re h a b i l i ta t i o n ,
and at t he s a me t i me al l ows t he pa t i e n t a n a d e q u a te s o ci a l l i f e b y a vo i d i n g t h e u se
o f a remo vabl e prost h e si s i n t h e pre -s u rg i ca l tra n s i t i o n p e ri o d . Th e two te mp o r a r y
re i nforc ed prost h e se s i n PMMA w i t h d e n ta l s u p p o rt we re i n s e rte d to g e t h e r w i t h
t h e avulsion of t h e e l e ment s 2 1 , 13 , 4 1 , 4 2 , a n d 3 2 b e i n g s tra te g i c e x tra ct i o ns f o r
t h e choice o f fu t ure i mpl ant si t e s (f i g . 9 ) .
A p pro ximately 8 we e ks aft er t h e h e a l i n g o f t h e s o f t t i s s u e , n e w a l g i n a te i mp re s si o n s
o f residual dent al abut ment s were ta k e n . Th e i n i t i a l d i a g n o s t i c wa x -u p wa s t a k e n
o n t he relat ive model s mou n t ed i n ce n tri c re l a t i o n , f ro m wh i ch t h e d u p l i ca t i o n o f
t h e tw o res in m asks was possi bl e ( F i g u re 1 0 ) .

C onvent io nal S u rger y: u ppe r arch

S urgical and prost het i c ope r at i ve sta g e :
F ol low ing t he el evat i on of a m u co-p e ri o s te a l f l a p , we p ro ce e d e d u s i n g a co n ve n t i o n a l

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 1 YEAR FOLLOW UP IN COMPLEX TREATMENT PLAN:
CONVENTIONAL VS. GUIDED SURGERY

Fig . 1

Fig . 2 a b c

Fig . 3 a b c

Fig . 4 a b c

Fig . 5 a b

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s urgical tec hni qu e i n t h e upper j a w wi t h t h e p l a ce me n t o f 6 i mp l a n ts : f o u r a x i a l

( # 2 1 w as an ear l y post -e xt r act i on i mp l a n t) a n d two i n cl i n e d i mp l a n ts ( # 1 6 a n d # 2 5 ) .
F or t he impla n t posi t i on i n g, t h e re s i n s u rg i ca l ma s k wa s u s e d a s a p ro s t h e t i c g u i d e .
T his mask cou l d al so be u se d as a tra n s f e r a re a to tra n s f e r t h e i mp l a n t p osi t i o n
from surgery t o t he pl ast er m ode l i n ca s e i t wa s d e ci d e d to ca rry o u t a n i mmed i a t e
l o a d.
B one qual ity, assessed accord i ng t o t h e L e k h o l m a n d Za rb cl a s s i f i ca t i o n wa s D 3 - D 4 :
l o w dens ity i n al most al l i m pl an t s i te s . De s p i te h a vi n g re a ch e d t h e mi n i mu m 3 0 N
t o rque o f prim ar y st abi l i t y at t h e l o a d i n g o f a l l t h e i mp l a n ts , i t wa s d e ci d e d n o t
t o proc eed wi t h an i mm e d i at e l oad i n g p ro s t h e t i c a n d to k e e p t h e t h re e re ma i n i n g
dental elemen t s t o suppor t t he re i n f o rce d te mp o ra ry p ro s t h e s i s u n t i l co m p l e t e
o s seointegrat i on was achi eved. Th e tra d i t i o n a l a p p ro a ch i n vo l ve d a s e co n d s urg i c a l
phase at 4 mon t h s for t h e uncove ri n g o f t h e i mp l a n ts , t h e ma n a g e me n t o f t h e so f t
t i ssues and a preci si on i mpre ssi on f o r t h e co n s tru ct i o n o f t h e s e co n d te mp o r a r y
s c rew - retained l oad i ng i m pl an t .
G uided Surger y:
L ow er arc h:
O ne mont h la t e r, i mpl ant su rger y i n t h e i n f e ri o r a rch wa s p e rf o rme d a l o n g wi t h t h e
i n sert io n of 6 st r ai gh t i mpl ant s by u s i n g a mu co s a l g u i d e d s u rg e ry te ch n i q u e .
T his choice was d i ct at ed by t h e p re s e n ce o f a s u ff i ci e n t q u a n t i ty o f k e ra t in i z e d
gi ngiva and t he n e e d t o m i n i mi z e t h e i n va s i ve n e s s o f t h e s u rg i ca l i n te rve nt i o n ,
av o id ing t he r ai si n g of a mucoper i o s te a l f l a p .
Vi rtual and prost h e t i c de si gn phase :
T he B & B D ent al gui de d su rger y p ro to co l re q u i re s t h e u s e o f a ra d i o l o g i ca l m a sk
during t he Con e -Be am CT scan a cq u i s i t i o n . Th e p re vi o u s l y cre a te d re s i n m a sk
w a s used for t h e case i n qu e st i on. 5 ra d i o p a q u e s p h e ri ca l ma rk e rs we re e q u a l l y
d i s tributed on t he vest i bu l ar and l i n g u a l s u rf a ce s . ( F i g u re 1 5 ) . Th a n k s to t h e se
r a d io lo gic al mar ke r s, i t was possi ble to ma tch t h e i n f o rma t i o n p re ci s e l y b e twe e n t h e
D i c om files obt ai ned from t h e Con e Be a m CT s ca n a n d t h e S TL f i l e s o b ta i n e d f ro m
t h e labo rator y scan of t he pl ast e r mo d e l a n d t h e ra d i o l o g i ca l ma s k i ts e l f ( F i g . 1 6 ,
1 7). This infor mat i on, ent e re d i n t o t h e 3 Di a g n o s i s s o f twa re , a l l o we d f o r t h e v i r t u a l
i mplant des ign, t aki ng i n t o accou n t t h e p ro s t h e t i c co n to u r, t h e i n te rf a ce b e t w e e n
s o ft and hard t i ssues, t h e cor re ct p o s i t i o n d i cta te d b y a n a to mi ca l s tru ctu re s, a n d
t h e number and d i st r i bu t i on of i mpl a n ts a cco rd i n g to t h e b i o me ch a n i ca l re q u e st s f o r
i mmed iate load i ng re h abi l i t at i on . T h e i mp l a n t d e s i g n a l l o we d f o r t h e mo d e l l in g o f
t h e surgic al mask wi t h t h e Pl ast i cad s o f twa re ( f i g . 1 9 ) . Wi t h t h e u s e o f a 3 D p ri n t e r, i t
w a s possible t o pr i n t bot h t he su rg i ca l ma s k a n d t h e p a t i e n t ’s 3 D s te ri o l i t h o g r a p h i c
m odel w it h t h e pre ci se posi t i on of t h e i mp l a n t a n a l o g u e s ( f i g . 2 0 , 2 1 ) .
O n t his mo del we bu i l t a scre w re t a i n e d te mp o ra ry p ro s t h e s i s i n PM M A o n a m i l l e d
P e ek s truc ture .
O nc e t he screw-ret ai ned t em pora ry p ro s t h e s i s wa s co mp l e te d , t h e p ro s t h e t i c
c y l inders w e re at t ached t o t h e s u p e rs tru ctu re u s i n g a s ma l l a mo u n t o f f l u i d
c o mpo s ite: t hi s way, each cyl i nde r co u l d b e e a s i l y d e ta ch e d a n d re a t ta ch e d d u r i n g
t h e intra- oral re l e asi ng proce dures o f t h e te mp o ra ry p ro s t h e s e s , wh i l e ma i n ta i n i n g
t h e posit ion obt ai n e d on t h e m ode l .
S urgical phase:

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 1 YEAR FOLLOW UP IN COMPLEX TREATMENT PLAN:
CONVENTIONAL VS. GUIDED SURGERY

F ig . 6 a b

Fig . 7 a b c

F ig . 8 a b

Fig . 9 a b F ig. 10

Fig . 1 1 Fig. 12 F ig. 13

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A f ter chec kin g for st abi l i t y an d pre ci s i o n u s i n g a f i t-ch e ck e r, t h e s u rg i ca l ma s k w a s

l o cked intraor al l y by mean s of t wo cre s ta l p i n s p o s i t i o n e d i n a b a l a n ce d ma n n e r
( fi g .23). E ach i m pl an t si t e was prepa re d b y u s i n g a d e d i ca te d s e q u e n ce o f ca l i b r a t e d
dr i l ls and manual com pact or s i nclu d e d i n t h e B&B De n ta l g u i d e d s u rg e ry k i t i n
ac c ordance wi t h t he d i amet e r s an d l e n g t h s o f t h e i mp l a n ts to b e p o s i t i o n e d ( f i g .
2 4- 25- 26). Virt u al pl anni ng i n vol ved t h e i n s e rt i o n o f 6 s tra i g h t i mp l a n ts i n t h e l o w e r
arch. Init ial ly, t h e fi r st 4 B&B De n t a l i mp l a n ts we re p u t i n to p o s i t i o n a n d t h e n , o n c e
t h e cres tal pi n s had been rem oved , t h e re ma i n i n g two i mp l a n ts we re p o s i t i o ne d .
A g oo d prima r y st abi l i t y was obt ai n e d f o r e a ch i mp l a n t, ve ri f i e d b y s cre wi n g w i t h a
m a nual torque wrench t o a t orqu e o f 4 0 N / cm. Ea ch i mp l a n t wa s p o s i t i o n e d p a y i n g
at tent io n t hat t he h e xagon pre se n t o n t h e g u i d e d s u rg e ry mo u n te rs ma tch e d e xa c t l y
w i t h t he hexa gon of t he sl eeve (fi g . 2 6 ) . Th i s ma tch i n g i s o f f u n d a me n ta l i mp o r t a n c e
e special ly in t h e case of i n cl i ned i mp l a n ts a s i t a l l o ws f o r t h e e x a ct p o s i t i o n i n g of t h e
h exago n o f t h e i m pl an t connect i on a n d co n s e q u e n t l y t h e p re ci s e p o s i t i o n i n g of t h e
angled c onic a l abu t m e n t s as pl an n e d vi rtu a l l y. Th e co n i ca l a b u tme n ts ( M UA ) w e re
s c rew ed o nto t h e i mpl ant s wi t h a to rq u e o f 2 5 N / cm wi t h d i ff e re n t tra n s mu c o sa l
h eights acc ord i n g t o t he h e i ght of t h e s o f t t i s s u e s ( f i g . 2 8 ) . In t h e p o s t-e x tra c t i o n
al veo l i, t he g aps around t he i mpl ants we re f i l l e d wi t h b o n e g ra f t ma te ri a l ( Bi o- O ss-
G eist l ic h) for t h e st abi l i zat i on of t h e co a g u l u m. Th e ma tch i n g p re ci s i o n b e t w e e n
t h e pro s t het ic cyl i n der s, t h e con i ca l a b u tme n ts a n d t h e f i x tu re s wa s a n a l yze d u si n g
i n trao ral rad i ogr aph s (fi g.2 9 ).
T he sc rew - retai ned t e mpor ar y prost h e s i s i n PM M A wi t h a re i n f o rce me n t b a r i n P e e k ,
prev io usly cre at e d i n t he vi r t ual proj e ct, wa s l o we re d i n to t h e mo u t h o n t h e p ro s t h e t i c
c y l inders w it h sel f-ph ot o-cu r i ng re s i n ( Pro te mp ) ( f i g . 3 0 ) . It wa s t h e n f i n i s h e d a n d
pol ished app ropr i at e l y t o provi de f o r a n o p t i ma l h e a l i n g a n d co n d i t i o n i n g o f t h e
s o ft t issues a n d t o pe r m i t a consi st e n t h o me h yg i e n e ma i n te n a n ce p ro ce d u re . O n c e
t h e oc clusion was checke d an d al l t h e p re co n ta cts we re re mo ve d , t h e p ro s t h e si s
w a s t ightene d by t i ght e n i n g t he f i x i n g s cre ws to 1 5 N . Th e te mp o ra ry p ro s t h e si s
w a s left in s it u for 5 mon t h s.
A t abo ut 6 mon t h s, t he i m pl an t osse o i n te g ra t i o n o ccu rre d wi t h o u t a n y co mp l i ca t i o n s
( after hav ing ve r i fi ed t he abse n ce o f s i g n s a n d s ymp to ms , o ccl u s a l p ro b l e m s,
l o osening of t h e fi xi ng scre ws or f ra ctu re o f t h e te mp o ra ry p ro s t h e s e s ) , t h e f i n a l
prec ision imp re ssi ons of t h e fol l o wi n g we re ta k e n : t h e two p o l ye t h e r a rc h e s
( I m pregum- 3M ESPE, S t Pau l , Mi nn e s o ta , U S A) , t h e i mp re s s i o n s o f t h e te mp o r a r y
prost heses , t h e faci al arch at ave ra g e va l u e s , a n d t h e o ccl u s a l wa x re g i s tra t i o n i n
RC at t he same ve r t i cal d i mensi on a s t h e te mp o ra ry p ro s t h e s i s . A t t h e s a me t i m e ,
t h e co rrect ion l i n e s of t h e t em pora ry p ro s t h e s i s we re a n a l yze d a n d t h e re q u i re d
aest het ic improve ment s for t h e d e f i n i t i ve p ro s t h e s i s we re i d e n t i f i e d . Th e c ro ss-
m ount ing of t h e m ode l s an d t h e i r p l a s te ri n g i n t h e a rt i cu l a to r we re p e rf o rm e d i n
t h e stud io , re posi t i oni ng t h e pat i e n t ’s te mp o ra ry p ro s t h e s e s o n t h e p l a s te r m o d e l s
( fi g .34). T hanks t o al l t h e gat h e re d i n f o rma t i o n , t h e te ch n i ci a n wa s a b l e to c re a t e
t h e prost het ic proj ect i n a d i gi t al f o rma t. Th e d e f i n i t i ve d i g i ta l wa x -u p ( f i g . 3 5 )
and t he zirc on i a su bst r uct u re de si g n ( f i g . 4 2 -4 3 ) we re ma d e f ro m t h e s h a p e o f t h e
t e mporary prost hesi s u si n g CAD. It wa s p o s s i b l e to cre a te a PM M A s p e ci m e n o f
t h e definit ive wor k from t he defi ni t i ve wa x -u p b y u s i n g t h e C AM mi l l i n g p ro ced u re ,
w hich w hen t r i ed i n t r aor al l y pe r m i t te d t h e te s t i n g o f t h e a e s t h e t i cs , p h o n e t i c s o f

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 1 YEAR FOLLOW UP IN COMPLEX TREATMENT PLAN:
CONVENTIONAL VS. GUIDED SURGERY

Fig. 14 Fig. 15 F ig. 16

Fig. 17 Fig. 18 F ig. 19

Fig. 20 Fig. 21 F ig. 22

Fig. 23 Fig. 24 F ig. 25

Fig. 26 Fig. 27 F ig. 28

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t h e o cc lus io n an d t h e ver i fi cat i on of t h e co rre ct p o s i t i o n i n g o f t h e i mp l a n ts o n t h e

m odel (Fig. 38 a.b). Th e var i ous mo d i f i ca t i o n s we re s u b s e q u e n t l y re a cq u i red b y
s c anning and desi gn i n g t h e m onol i t h i c zi rco n i a s tru ctu re s .
T he c as e w as fi nal i z e d wi t h a mon o l i t h i c f u l l zi rco n i a s cre we d p ro s t h e s i s ce me n t e d
o n t he t itaniu m connect i on pi l l ar s a n d l a ye re d wi t h ce ra mi c o n o n l y t h e ve s t ib u l a r
s urfaces o f t he u ppe r and l ower fron ta l s e cto rs ( f i g . 3 9 a -d , 4 0 ) .

C ONCLUSIONS
I n t he mo der n ph i l osophy of pl an n i n g a n d tre a tme n t, i n a d d i t i o n to t h e c l a ssi c
c l inical goals of su rgi cal and prost h e t i c s u cce s s , t h e mo s t i mp o rta n t o b j e ct i ves a re
t h e pat ient rel at ed ones: t o i mpro ve t h e q u a l i ty o f l i f e n o t o n l y a t t h e e n d o f t h e
t reatment bu t al so dur i n g t h e ent i re wo rk f l o w o f t h e tre a tme n t i ts e l f . R e d u ci ng t h e
n umber o f surgi cal st e ps, t h e i n vasi ve n e s s o f t h e s e s te p s a n d t h e o ve ra l l t i min g o f
t reatment are fu n dament al e l e ments i n i n cre a s i n g t h e s a t i s f a ct i o n o f o u r p a t i e n t s.
I n t his s ens e, gui de d surger y com p a re d to co n ve n t i o n a l s u rg e ry o ff e rs n u m e ro u s
advantages b ot h for t h e cl i n i ci an as we l l a s f o r t h e p a t i e n t: t h e a ch i e ve me n t o f a l e v e l
o f precis io n i n t h e t h ree-d i mensi on a l p o s i t i o n i n g o f t h e f i x tu re s i s mu ch h i g h e r t h a n
t h a t o btained m anual l y; a l evel of s e cu ri ty t h a t ca n b e s ta n d a rd i ze d ; t h e d u r a t i o n
o f operat ing procedu re s l owe r t han t h e i n te rve n t i o n wi t h a co n ve n t i o n a l a p p ro a c h ;
t h e po s s ibil ity of avoi d i ng maj or re g e n e ra t i ve s u rg e ri e s a n d t h e re l a te d s u rg i c a l
s equelae t hat make rehabi l i t at i on tre a tme n t mu ch mo re co mp l e x a n d e x p e n si v e ;
t h e po s s ibil ity of i n t egr at i n g prost h e t i c a s p e cts i n t h e ra d i o l o g i ca l d i a g n o s is a n d
t h e po s s ibil ity of pre-se t t i n g and cre a t i n g a n i mme d i a te l o a d i n g p ro s t h e s i s , t h ere b y
i n c reasing t h e pat i e n t com for t i n t h e i mme d i a te p o s to p e ra t i ve p e ri o d .
I n t he opinion of t he au t h or s, i f ev e ryt h i n g h a s b e e n ca re f u l l y p l a n n e d a n d ca r r i e d
o ut, new tec hn ol ogi es an d n e w m at e ri a l s a re e x ce l l e n t to o l s f o r s i mp l i f yi n g wo rk f l o w s
and guaranteei ng t he pat i e n t a su cce s s f u l re s to ra t i o n e ve n i n co mp l e x ca s e s .
T he pro cedures u se d present a va l i d cl i n i ca l ma n a g e a b i l i ty, b u t b o t h t h e v i r t u a l
design and t h e surgi cal per for man ce ca n n o t b e s e p a ra te d f ro m a ca re f u l s tud y o f
t h e c as e in quest i on , wi t h an i n t eg ra te d a p p ro a ch b y t h e d e n ta l a n d p ro s t h o d o n t i c
t e am in ful l respe ct of t h e comm o n b i o l o g i ca l p ri n ci p l e s o f co n ve n t i o n a l s u rg e r y.
T he s ame at te n t i on must be pai d to b o t h t h e te ch n i q u e s a n d ma n a g e me n t of t h e
peri- implant soft t i ssues t o gu ar ante e a n o p t i ma l a n d l o n g -l a s t i n g a e s t h e t i c re su l t .
T he c as e descr i be d was care fu l l y mo n i to re d o ve r t i me to ve ri f y b o t h t h e cl i n i c a l
e ffic acy o f v ir t ual pl an n i n g, as we l l a s t h e a ccu ra cy a n d t h e i n tra -o ra l re p ro d u cib i l i t y
o f w hat w as desi gn e d i n t he vi r t u al e n vi ro n me n t. In p a rt i cu l a r, o n e ye a r a f te r s u rg e r y,
a go od s tabil i t y of bone and soft p e ri -i mp l a n t t i s s u e s wa s f o u n d .

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 1 YEAR FOLLOW UP IN COMPLEX TREATMENT PLAN:
CONVENTIONAL VS. GUIDED SURGERY

Fig. 29 ab F ig. 30

Fig. 31 Fig. 32 F ig. 33

Fig. 34 Fig. 35 F ig. 36

Fig. 37 Fig. 38 ab

Fig. 39 abc F ig. 40

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FULL ARCH IMMEDIATE LOAD CASE WWW.BEBDENTAL.IT
WITH OSTEOPLASTY

AUTHOR: DR. FILANNINO

Temporary denture work as a long-term solution is increasingly more common due to
a series of combined factors, including the decisive factor of the patient’s financial
situation.
Though they may be designed and prepared with care, temporary dentures present
defects at a technical, functional and aesthetic level (due to the techniques and
materials used as well as the limited time available) that negatively affect the underlying
supports in the long term, be they natural teeth or implant abutments.
This article presents the case of a 64-year-old patient who wore a temporary denture
on natural teeth for a year and a half, in which time he presented various problems
such as chipping, splitting and cracking in several places.
Following an x-ray exam, a permanent solution was chosen in accordance with the
patient’s budget: the insertion of 7 implants with a guided surgery technique following
the extraction of the residual dentition.
The guided surgery approach for an expert operator is connected to the possibility
of improving surgery performance both in precision and speed, having planned all
the phases in advance through digital planning. It allows the operator to choose the
most suitable implant and diameter typology and place them in the most suitable
area in terms of bone availability, its position relative to nerves and the anatomical
structures present. In order to be able to carry out this planning stage, it is essential to
perform an analysis with a cone beam CAT scan where the patient wears an anatomical
mask dotted with radiopaque markers. It was necessary to take a two-phase silicone
impression upon which the technician made the resin trial provided with properly
positioned markers.
Since surgical planning software works on triangular plane portions, the markers must
be distributed by forming triangles on the prosthesis surface, observing it occlusally.
This way the program can automatically recognize them and create an automatic
matching between the cone beam CAT scan file and the model scan. Once the above
information has been obtained, it can be imported onto the software and used to
identify and trace the nerves and all other sensitive structures to be avoided during
implant placement. Thanks to the presence of B&B Dental implant library software,
not only can you choose the most appropriate implant line and size and positioning
them as necessary, but you can also select the prosthetic abutments in relation to the
mucous thicknesses and the subsequent prosthetic project. During the planning phase,
it was possible to notice beforehand the necessity of performing a bone resection in
order to improve the working conditions and create a uniform surface. Thanks to the
ductility offered by the system, it was possible to understand how much thickness
should be removed and plan for the implant surgery under these new conditions. To
carry out the surgery, it was necessary to create three surgical templates:
- the first is a dental support for the positioning of the lateral pins that act as reference
points and the repositioning of the templates thereafter;
- the second is for defining the thickness suitable for what was planned to be removed
during osteoplasty surgery;
- the third is a mixed support (mucosal and bone support), the surgical template for
implant insertion.
The three templates have the position of the lateral pins in common. Following the
variation of the bone structure, these pins act as the only reference points for the

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fixing of the templates in the same position as planned. As the planned surgery has
predictable results, it is possible to create the immediate loading prosthesis structure
(according to the project) to be inserted after surgery in the same session.
In order to obtain a highly aesthetic and functional prosthesis (by correcting the
implant divergences and facilitating the insertion phase of the structure), a prosthetic
project with customized abutments is prepared.
By simply exporting the STL file of the surgical plan and importing it onto a CAD
software, it will be easy to design the structure according to the required criteria as
well as including the three unknown brand implants already present in distal positions.
On the day of surgery we will have the following at our disposal: the surgical templates,
the prototyped model, the immediate loading prosthetic structure with customized
abutments and the B&B Dental guided surgery kit.
Once the temporary denture is removed, the first template (dental support) is
positioned to prepare the holes of the lateral pins.
We proceed with the extraction of the remaining teeth and the opening of a flap
from area 35 to area 45; the second mask is positioned to evaluate the areas to be
remodelled based on the contact points. It was not possible to create an open mask
as the bone thickness needed to be removed was very thin, which would have made
it less resistant with the consequent risk of rupture or flexion during surgery. When
the second mask is stably repositioned without any contact or problems, bringing the
lateral pin holes in correspondence to the previously prepared holes, it will be possible
to insert the third template and insert the implants according to the project. Once
the implants have been inserted, the surgical guide is removed and the customized
abutments are positioned; the edges are then sutured, and the PMMA structure is
positioned, adapted and functionalized before cementing it.

I n it ia l s itua t io n o f t he pa t ient – x- ray e xam

C o n e B e a m CAT sc a n w it h ra d iopaqu e marke rs on t h e bas e

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A B C

Surg ica l te m pla tes: A - tem plate for late ral pin s in s e rt ion ,
B - o s te o p la sty tem pla te, C - implan t in s e rt ion te mplate .

C u s to m i ze d a butm ents o n t he mode l, PMMA pros t h e t ic s tru ctu re .

I m p la nt i nsert io n surgic a l phas e s , mou n te rs in pos it ion , t h e mou n te r

hex a g o ns a re in l ine w it h t ho s e of t h e implan ts .

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F inis h ed p ro st hesis in pla c e a n d fin al x- ray e xam.

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 I M P L A N T C O M P A N Y

Via S. Benedetto, 1837 - 40018 S. Pietro in Casale (BO) Italy

Tel. +39 (0) 51.81.13.75 - Fax +39 (0) 51.666.94.00
info@bebdental.it - www.bebdental.it