Computer-guided full-arch dental rehabilitation, which is highly technique-sensitive, benefits from advancements in 3-dimensional-printed guides and open-source software. Critical pre-surgical planning includes patient selection, health history evaluations, and detailed imaging like cone beam computed tomography scans. Various surgical guides—freehand, static, dynamic, stackable, and interchangeable—are used based on case complexity, with stackable guides improving workflow efficiency. Post-operative care involves verifying prosthesis occlusion and clear patient instructions, focusing on mitigating complications through thorough planning. Future enhancements in implant planning and guide design are expected with the integration of artificial intelligence into digital workflows.
Key points
- •
Computer-guided full-arch dental rehabilitation leverages advancements in 3-dimensional-printed guides and open-source software for in-house design and fabrication.
- •
Comprehensive pre-surgical planning, including patient selection, health history evaluations, and detailed imaging (eg, cone beam computed tomography), is crucial for successful outcomes.
- •
Various surgical guides (freehand, static, dynamic, stackable, and interchangeable) are employed based on case complexity, with stackable guides enhancing workflow efficiency.
- •
Effective post-operative care focuses on verifying prosthesis occlusion, providing clear patient instructions, and mitigating complications through meticulous planning.
- •
The integration of artificial intelligence into digital workflows promises future improvements in implant planning and guide design.
Computer-guided full-arch dental rehabilitation using stackable guides
Introduction/History/Definitions/Background
Computer-guided full-arch dental rehabilitation is highly technique-sensitive but can also be very rewarding. Over the past decade, advances in computer-guided 3-dimensional (3D)-printed guides using open-source digital software have enabled clinicians to design and print guides and dental prostheses in-house. A significant recent improvement in the digital workflow of full-arch rehabilitation is the static stackable guide. This guide reduces operating time without compromising quality. This article discusses the clinical uses, advantages, digital workflow, and potential complications of using stackable guides.
Pre-surgical planning
Patient Selection
- •
Health History:
- ○
Assess if the patient is a candidate for surgery
- ○
Determine if medical clearances or further medical workup are needed before implant surgery.
- ○
Check for medications such as blood thinners, bisphosphonates, or targeted therapies.
- ○
Review history of head and neck cancer treatments, such as chemotherapy or radiation.
- ○
Confirm if the patient smokes.
- ○
- •
Surgery Type:
- ○
Evaluate if the procedure will be minor or significant.
- ○
Decide if the case can be done under local anesthesia alone or if it requires sedation or general anesthesia.
- ○
- •
Esthetic Concerns:
- ○
Assess if the patient has high esthetic requirements or is more concerned with function.
- ○
- •
Intraoral/Extraoral Examination:
- ○
Determine the etiology of the patient’s current dental condition.
- ○
Identify any parafunctional habits.
- ○
Evaluate facial esthetics and form.
- ○
Check for a high or low smile line.
- ○
Assess lip support and dental midlines.
- ○
Identify missing teeth or those needing extraction.
- ○
Assess the condition of surrounding/remaining dentition and periodontium.
- ○
Evaluate the condition of surrounding soft tissue and underlying bone.
- ○
Determine the required restorative space and if there is enough.
- ○
Assess Angle’s classification and whether it will be maintained or corrected prosthetically.
- ○
Document mouth opening and the feasibility of getting instrumentation to the surgical site(s) intraorally.
- ○
Diagnostic Records and Imaging
- •
Photography:
- ○
Extraoral and intraoral photography.
- ○
- •
Diagnostic Models:
- ○
Intraoral scans or physical diagnostic models.
- ○
- •
Maxillomandibular Relation Records:
- ○
Records at the planned restorative vertical dimension of occlusion.
- ○
- •
Radiographs:
- ○
Cone beam computed tomography
- ○
Panoramic radiograph
- ○
Periapical radiographs
- ○
Bitewing radiographs
- ○
- •
Shade Records:
- ○
Tooth and/or gingival shade records.
- ○
Software Selection
- •
Open Source versus Commercial Software
- ○
Most dental implant planning software is associated with a specific commercial implant company. These programs usually allow free access to certain features, such as combining stereolithography (STL) with computed tomography (CT) data, evaluating CT data, and performing the virtual surgical plan. Some even permit the creation and adjustment of virtual surgical guides. Providers are typically charged only when the desired surgical guide STL file is exported for printing.
- ○
Most commercial software requires a recurring subscription, which includes a specific number of “exports” or “export credits” per month or year. Alternatively, users can purchase a specific number of exports/credits as needed. Some companies charge 1 credit per case, while others charge per arch. Additionally, exporting a file for the prosthesis may incur an additional full or half credit fee beyond the surgical guide export credit.
- ○
Once a credit is used, providers can import and export STL files within the software program as often as needed for that case or arch, depending on the program.
- ○
Open-source software, on the other hand, is typically free to download, use, and import/export files without any fees. For example, Meshmixer, though not dental-specific and not used in the implant planning phase, is often used to make adjustments or add features to files exported from implant planning software.
- ○
Virtual Surgical Planning
- •
Commercial 3rd Party Planning versus In-House Design and Fabrication: Pros and Cons of Cost, Quality, and Time
- ○
Using third-party companies for implant planning typically requires the provider to send cone beam computed tomography (CBCT) data (DICOM files) and STL files from intraoral scans or desktop scans (if using analog casts). Once received, the planning company coordinates an online virtual surgical planning (VSP) session with the provider, depending on the case’s complexity. During this session, software engineers, having merged the DICOM and STL files, work step-by-step with the provider to plan the 3D location of the implants and any other necessary steps, such as bone reduction and prosthesis planning. For simpler cases, like a single tooth implant, the engineer may plan everything independently and send the file/plan for edits or approval.
- ○
Third-party implant planning is advantageous in terms of time savings, especially for larger or more complex cases. While these services generally come at an increased cost, they may be offered at a reduced rate if the company’s implant system is used.
- ○
Alternatively, providers can use various implant planning software to plan the implants themselves and potentially print the guides in-house. This method reduces planning and printing costs but requires more time from the provider ( Figs. 1–4 ).
Fig. 1 ( A–D ) Virtual surgical planning of the maxillary full arch static stackable guide using Mesh Mixer and Blue Sky Plan software ( A ) The bone borne bone reduction guide in place on a cut bone model. Note three bone fixation holes and six indexed stacking points. ( B ) The stackable implant guide indexed on the bone reduction guide. ( C ) Occlusal view of the implant guide. ( D ) Prosthesis indexed onto the bone reduction guide.
Fig. 2 ( A–F ) Virtual surgical planning of the mandibular full arch static stackable guide using Mesh Mixer and Blue Sky Plan software ( A ) The bone borne bone reduction guide in place on a cut bone model. ( B ) Occlusal view of the bone reduction guide. Note three bone fixation holes and six magnetic index points. ( C ) The stackable implant guide indexed on the bone reduction guide. ( D ) Occlusal view of the implant guide. ( E ) Prosthesis indexed onto the bone reduction guide. ( F ) Occlusal view of the prosthesis. Note the 6 mm diameter holes for implant pick-up.
Fig. 3 ( A–G ) Designing the stackable components in Mesh Mixer.
Fig. 4 ( A–C ) Virtual surgical planning of both maxillary and mandibular full arch static stackable guide using Mesh Mixer and Blue Sky Plan software ( A ) The maxillary and mandibular bone borne bone reduction guide in place on an uncut bone model. ( B ) The stackable implant guides indexed on the bone reduction guides. ( C ) The maxillary and mandibular prosthesis indexed onto the bone reduction guides. This demonstrates the prosthesis in full occlusion.
- ○
Surgical Guide Options
- •
Freehand
- ○
Most commonly used method by most implant providers, especially for simpler implant cases.
- ○
Pros:
- ▪
Allows for same-day treatment.
- ▪
Requires minimal time, money, or resources for implant guide planning and fabrication.
- ▪
Permits intraoperative changes based on encountered surgical circumstances.
- ▪
- ○
Cons:
- ▪
Risk of provider error in placing implants in different locations than planned.
- ▪
Potentially more time spent intraoperatively placing implants.
- ▪
Increased room for error in critical anatomic or esthetic areas (eg, inferior alveolar nerve, sinus, and anterior maxilla).
- ▪
- ○
- •
Static Guides
- ○
Non-Restrictive:
- ▪
Older, traditional guides used before the advent of VSP and 3D printing typically consist of an acrylic denture or implant guide with a large window or open area through which the provider can place the implants. These are usually fabricated by the restoring provider as a zone where the implant can emerge within the guide’s boundaries.
- ▪
Pros:
- •
Provides the surgical provider with more freedom in placing implants.
- •
Allows for some intraoperative adjustments.
- •
- ▪
Cons:
- •
Not fully guided/restrictive, which can lead to non-ideal implant placement, especially in the vertical dimension.
- •
- ▪
- ○
Restrictive:
- ▪
Modern dental implant guides are typically based on VSP with a 3D-printed guide but can also include acrylic “pilot hole” guides used for initial twist drill placement. These guides are usually tooth or bone-borne with implant guide holes made with precise dimensions to match the corresponding implant system, minimizing error ,
- ▪
Pros:
- •
Provides extremely accurate implant placement if the guide hole is adequately restrictive and stable.
- •
Particularly accurate in the vertical dimension for implant depth placement.
- •
- ▪
Cons:
- •
The surgical provider must trust the guide due to reduced visibility without the guide in place.
- •
Inability to make intraoperative adjustments if needed. Some surgeons may choose to remove the guide at stages to confirm that the intraoperative placement matches the virtual plan.
- •
- ▪
- ○
- •
Dynamic Guides
- ○
Dynamic guides typically refer to guidance systems like X-Nav, which use static fiducial markers during CT capture. These markers are used intraoperatively to coordinate the planned implant’s exact location with the patient’s current position and the real-time location of the surgical provider’s handpiece. This information is displayed on a screen for the provider’s use. , ,
- ○
Pros:
- ▪
Allows the provider to make real-time changes to the planned implant location.
- ▪
- ○
Cons:
- ▪
Typically involves a large piece of equipment that can be cumbersome to use.
- ▪
Requires practice to coordinate the handpiece with the plan displayed on the screen.
- ▪
As a non-restrictive guidance system, it can have the same errors as freehand placement due to provider error
- ▪
- ○
- •
Stackable Guides (see Figs. 1–4 ; Figs. 5–9 )
- ○
Stackable guides refer to a tooth- or bone-borne static/restrictive guidance system with one or more superficial components, such as the implant guide or prosthesis, that attach to a static base component like a bone-borne reduction guide.
- ○
Pros:
- ▪
Once the static base is set intraoperatively, it never has to be removed.
- ▪
After each phase of treatment, the next subsequent component can easily be attached to the static base, allowing the provider to quickly move on to the next phase. This contrasts with interchangeable guides, which must be fully removed and replaced after each phase.
- ▪
Stackable guides can incorporate attachments such as magnets, which allow quick confirmation that the guide is fully seated and provide increased stability to the base.
- ▪
When performing an immediate pickup of a prosthesis, these attachments make it easy to determine if the prosthesis is fully seated and passive around the implant temporary cylinders.
- ▪
Using fully resin-based guides consumes less resin.
- ▪
A major benefit is the ability to include a stackable prosthesis for the pickup conversion of the surgical prosthesis, helping maintain the planned vertical dimension of occlusion, which can be particularly challenging in non-guided mandibular cases.
- ▪
- ○
Cons:
- ▪
Each superficial portion of the guidance system created off a base introduces another area of potential discrepancy, allowing for the possibility of deviation of the final implant location from the virtual plan.
- ▪
Depending on the material used, the superficial stackable implant guide is typically smaller and more flexible than 1 large interchangeable component for each phase of treatment. This flexibility may allow for improper implant placement. However, this can be mitigated by adding additional bulk to resin guides or using titanium guides.
- ▪
- ○
