Volume 8, Issue 10, October – 2023 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Free Hand Vs Guided Implant Surgery

Dr. Preethi Gummadidala

Abstract:- Even though implant success depends  Advantages

primarily on osseointegration, prosthesis plays a crucial  Bone augmentation can be done if required.
role in determining the longevity of the implant.  Economically less than guided surgery.
Additionally, esthetics should also be served to please the  Good irrigation is possible.
patient. To fulfill these objectives effectively,  Can be done in patients with less mouth opening.
prosthetically driven implant placement technique is
recommended. This article aims to explore various  Disadvantages
implant placement techniques, delving into their  Excessive bleeding.
respective advantages and disadvantages.  Increased healing time due to complete flap elevation.
 Traumatic experience to the patient due to increased
I. INTRODUCTION duration of the treatment.
 Swelling and pain.
In the field of dentistry, while there exist alternative
 Difficult to place implants in desired position in full
methods for replacing missing teeth, dental implants offer
mouth rehabilitation.
distinct advantages compared to other options. That is,
implants closely mimic natural teeth, preserving adjacent  Possibility to place implants close to adjacent tooth or
teeth and preventing underlying bone loss. tooth root due to improper planning consequently leading
to bone loss or periimplantitis.
The placement of dental implants can be carried out  Implant placement based on thickness of the bone
through two primary methods: freehand or with the assistance sometimes leads to incorrect positioning of the implant or
of a surgical guide. It is crucial to carefully select the most in non-esthetic zones.
suitable implant placement technique for each individual case
to minimize the risk of potential complications. Hence, free hand implant placement is best indicated for
single tooth replacements and economically poor patients.
II. FREE HAND VS GUIDED IMPLANT
PLACEMENT III. DIGITAL IMPLANT PLACEMENT

Replacement of teeth with implants is done majorly to The significance of surgical guides in implantology
preserve the underlying bone and to provide good functional becomes particularly evident in cases of full mouth
efficiency. If the implant is replacing an anterior tooth rehabilitation, where there is a deficiency in both bone and
esthetics become the primary concern. Hence, whatever the tissue, making it challenging to control the drilling process.
requirement may be, it is crucial to choose the ideal implant Additionally, the absence of natural teeth possesses a
size and its optimal position which is accurately possible with challenge in determining the spatial position for implant
3D radiographic interpretation. Through CBCT not only placement. In such scenarios, surgical guides serve a crucial
important landmarks, ideal implant position is identified, but role by either guiding the clinician to the precise target site or
also the DICOM data can be used to create a surgical guide. exerting complete control over the movement, speed, and
depth of the drills.
Implant placement can be done either by free hand
placement or using a surgical guide. Free hand placement and Before the surgery, measurement of available bone at
guided surgery have their own advantages and disadvantages. the intended implant site and the identification of critical
Hence, the technique that must be used varies from case to anatomical landmarks, such as the Inferior Alveolar Nerve
case. (IAN), using CBCT scans can be done.

A. Free hand implant placement Furthermore, the size and diameter of the implant to be
Free hand implant placement allows the clinician to placed can be carefully determined as well. Subsequently,
assess the bone directly and to graft the site after elevating the merging of the DICOM data of the CBCT and intraoral scans
flap. Selection of the implant size prior to surgery is possible in the implant planning software makes it possible to plan the
when CBCT is used as radiographic assessment but if there's surgery according to the knowledge and visualization of the
only 2D radiograph, caliper can be used to determine the clinician.
bone diameter and length after flap elevation in direct vision.
The adjacent tooth is taken as reference to decide the position The desired position of both the prosthesis and the
of the implant. The distance between the implant and tooth is implant can be visualized and simulated using implant
supposed to be 1.5 mm and distance between the two planning software. Nevertheless, prosthesis path of insertion,
adjacent implants should be 3 mm at least. Below are listed screw channel and abutment type and size can also be
the advantages and disadvantages of this technique. determined and altered. The complete data is then transferred

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Volume 8, Issue 10, October – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
onto the surgical guide. Surgical guides can be classified into 3 types based on
the guidance they provide to the practitioner.
The sleeve of the surgical guide encapsulates vital  Nonlimiting
information about the diameter, direction, and depth at which  Partially limiting
the implant should be positioned. This approach facilitates
 Completely limiting
implant placement that is driven by prosthetic considerations
and minimizes deviations apically and coronally, ultimately
A. Nonlimitng Guides
leading to more precise and successful outcomes.
This technique only replaces the edentulous area with
prosthesis. Therefore, guiding the clinician to determine the
Guided implant surgery is recommended in patients
implant position and where the initial drill is supposed to be
with satisfactory bone quantity for implant insertion as well
drilled. It does not control the drilling length and direction.
as for complete edentulous arches in the maxilla or mandible.
Thus, allowing too much flexibility and increased chances of
Additionally, guided surgery is the preferred treatment option
human error.
for patients with specific constraints, such as those
undergoing mandible reconstruction using free flaps
following oncological resection.

Figure 1 - Locating implant initial drill position using nonlimiting guide

B. Partially Limiting Guides based surgical guide.

This technique uses a pilot drill guide where the initial
drill is controlled and directed by the surgical guide into the  Cast based surgical guide
osteotomy site providing an accurate entry point and rest of In this technique, initially bone volume is measured
the drilling protocol is done using free hand technique. using techniques such as bone sounding and periapical
radiographs which then are amalgamated, and the data of the
C. Complete Limiting Guides implant analog platform positions are transposed onto a
This technique limits all the 3D movements of the drills. surgical guide which usually is useful for conventional
Mesio-distal, bucco-lingual and depth of penetration in the flapless guided surgery. This allows the procedure to be less
osteotomy site are controlled by these guides. This includes invasive and to have precise implant and prosthesis
two designs, i) cast based surgical guide and ii) CAD-CAM placement.

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Volume 8, Issue 10, October – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Fig 2 - Cast based guide

 CAD-CAM based Implant Surgical Guide

CAD CAM-based guides exhibit remarkable precision
due to their incorporation of a virtual 3D visualization of the
patient's bone structure. This comprehensive view highlights
potential errors and complications, allowing for preemptive
measures before the surgery.

Consequently, this technology aids in sidestepping the

need for bone augmentation procedures, facilitating flapless
techniques, and actively guiding and governing the three-
dimensional movement of the drills within the osteotomy
site.

Fabrication of this kind of guides includes the following

steps: Fig 3 - CAD-CAM based guide (consists of guide sleeves and
 Fabrication of radiographic template anchor pin holes)
 Dual scan technique is done (DICOM data of CBCT and
STL file of digital impressions / scan of the cast) While digital implantology offers numerous benefits, it
 Superimpose both the files using implant planning can potentially introduce complications stemming from
software issues like an ill-fitting guide causing drill wobbling,
 Visualize and plan prosthetically driven implant inaccurate measurements of the necessary implant due to
placement CBCT imprecision, flaws in the scan appliance, or the
 Fabrication of stereolithographic drill guide clinician's misjudgment.

The following is a compilation of factors that may

contribute to complications in the realm of digital
implantology.
 Wrong superimposition of the scan
 Incorrect judgement of the drill hole diameter
 Incorporation of wrong metal cylinder
 Improper understanding of the guided surgery software
leading to errors
 Inaccurate CBCT and digital impressions
 Improper curing of the resin
 Uncured resin left in the guide

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Volume 8, Issue 10, October – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Improper orientation of the guide Despite these limitations, complications in the static
 Resin shrinkage approach can be minimized through careful patient selection
 Improper understanding of the drilling protocol of the and meticulous implant planning.
respective system
V. DYNAMIC NAVIGATION
A surgical guide can be an excellent choice for
achieving minimally invasive procedures, but it requires Dynamic navigation in implant dentistry involves using
careful consideration and precision during implant planning virtual implant planning based on CBCT scans and real-time
and the 3D printing process. tracking of drills and the spatial position of the implant
during surgery. This advanced technique offers several
Computer aided guided surgery is divided into 2 types significant advantages. Firstly, it enables precise monitoring
based on the protocol followed of each step of the drilling protocol, ensuring accurate
 Static guided surgery implant placement. Additionally, the 3D position of the
 Dynamic navigation implant is constantly displayed on a screen for real-time
visualization. The larger working area provided by dynamic
IV. STATIC GUIDED SURGERY navigation allows for ample irrigation during the procedure,
contributing to better cooling effect.
This approach is typically employed in cases requiring
full mouth rehabilitation, utilizing a CAD-CAM- based One notable benefit is the elimination of the need for a
surgical guide template to enhance precision during drilling physical surgical guide, which is typically required in static
and reduce the risk of lateral errors. While it offers several guided surgery. This not only simplifies the process but also
advantages, it also comes with certain limitations. allows clinicians to take on cases with patients who have
limited mouth opening. As a result, dynamic navigation can
One of the limitations pertains to the patient's mouth save time compared to traditional static guided surgery.
opening, which should ideally be sufficient to accommodate
the surgical guide comfortably. Additionally, once the guide However, it's essential to note that dynamic navigation
is fabricated, the surgery must be performed within a two- requires a thorough understanding of the system, not only by
week timeframe to mitigate the potential issue of resin the clinician but by the entire surgical team. This technology-
shrinkage. It's worth noting that in this static approach, driven approach may not be cost-effective compared to
adjustments to implant size or length cannot be made during conventional methods, making it important for practitioners
surgery if necessary. to weigh the benefits against the associated costs and training
requirements.

Fig 4 - Dynamic navigation approach - live navigation of the drills

VI. CONCLUSION limited mouth opening is observed and bone augmentation is

required, freehand surgery may be the preferred method.
Freehand surgery is a versatile approach suitable for
single implant procedures and situations where a sudden On the other hand, guided surgery is highly
change in the treatment plan is necessary during guided recommended for full-mouth rehabilitation cases where no
surgery. In cases where complications arise during guided reliable reference is available. This technique involves virtual
surgery, such as guide breakage, improper fit, or incorrect planning of the implant position and the use of a surgical
implant size sleeve, freehand surgery can be employed to guide, which can streamline the surgical process and enhance
address and complete the procedure. Additionally, when precision.

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Volume 8, Issue 10, October – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Both freehand and guided surgery approaches have their
unique advantages and disadvantages. Choosing the
appropriate method for a specific case is crucial to maximize
the benefits of each technique.

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