CC
A 47-year-old male was referred for consultation regarding the periodontal condition and implant placement in the upper and lower jaws. The patient had bleeding during brushing and reported pain and discomfort in the gums when eating. He wanted to replace his missing tooth as well.
HPI
The patient has a history of removal of teeth for orthodontic reasons. He has no history of bruxism, smoking, diabetes, use of bisphosphonates, immune-compromised diseases, chemotherapy, or radiotherapy.
Examination
Extraoral. Upon inspection of the maxilla and mandible, there is no evidence of lumps or swelling. The maximum incisal opening is 58 mm.
The intraoral examination reveals bleeding on probing and deep pockets in multiple sites. The patient’s oral hygiene is good. No other soft or hard tissue abnormalities are seen.
Imaging
A panoramic radiograph revealed missing teeth in the upper and lower jaws with horizontal and vertical bone loss ( Fig. 37.1 ).
A cone-beam computed tomography (CBCT) scan was obtained on a well-calibrated machine.
Investigations
Basic laboratory investigations were made, and the patient did not give any specific medical history, complete blood count, prothrombin time with international normalized ratio, or blood sugar levels.
Assessment
Stage III, grade B periodontitis.
Treatment
Phase I: Cause-related therapy
Initial treatment included oral hygiene, scaling, root planing, extraction of the hopeless teeth, and repairing caries. Follow-up and maintenance treatment were carried out after 3 weeks.
Phase II: Surgical phase
Periodontal surgery was performed for the upper and lower jaws with follow-up after 3 weeks. The patient was scheduled for implant placement surgery for teeth #47, #37, and #17.
The risks, benefits, alternative treatment plans, cost, and treatment time were thoroughly discussed with the patient. He chose treatment with implants. CBCT DICOM (Digital Imaging and Communications in Medicine) files were imported to dynamic navigation software (Navident, Claronav Inc.) ( eFig. 37.2 ).
The treatment plan involved placing a 4.5-mm × 8.5-mm implant (AnyRidge implant, MegaGen Co.) as a single-stage flapless approach for tooth #47. To control the drilling depth and use live navigation, a digital implant was placed in the ideal location, biologically and prosthetically, with respect to the planned digital crown ( Fig. 37.3 ).
The restorative dentist approved the virtual prosthetic design and positioning of the implant.
Local anesthesia was performed with infiltration technique on the buccal and lingual of the lower right second molar area.
To accurately guide the drilling process, the navigation system must map the drill tip to a computed tomography (CT) scan image of the jaw, which consists of three steps: registration, calibration, and tracking ( eFig. 37.4 ). Registration is the process of mapping the CBCT image to the patient’s physical jaw structures. First, the Jaw Tracker, a tag used for real-time tracking of the patient’s jaw, was fitted onto the incisal surfaces of the mandibular incisors; then it was fixed in position with impression material ( Fig. 37.5 ). The system’s tracking camera (Micron Tracker, ClaroNav Inc.) tracked the Jaw Tracker in the physical three-dimensional (3D) space, allowing continuous tracking of the patient’s mandibular anatomic structures. Next the trace registration procedure was performed ( eFig. 37.6 ).
Trace registration was performed by marking four landmarks on teeth using a panoramic 3D presentation of the jaw and then tracing these landmark regions with the tracer tool while the camera and software collected 100 points on each tooth ( Fig. 37.7 and eFig. 37.8 ). The software automatically registered the Jaw Tracker with the patient’s mandibular CBCT scan based on the collected points. Therefore, the computer can map the patient’s anatomic structures to the CBCT scan images, accurately maintaining this mapping during the surgery regardless of the patient’s possible movement.
