Surgical Template Research Articles

Predictable Full Digital Workflow Using Stackable Surgical Templates for Complete Dental Arch Rehabilitation with Implant-Supported Fixed Restorations—Case Series and Proof of Concept

Background: In recent years, advancements in digital dentistry have provided new opportunities for more predictable and efficient treatment options, particularly in patients with failing dentition. This study aimed to evaluate the effectiveness and accuracy of a fully digital workflow using stackable surgical templates for complete dental arch rehabilitation with implant-supported fixed restorations. Methods: Four patients, comprising two males and two females with a mean age of 66 years, were included in this case series. Each patient underwent meticulous digital planning, including CBCT and intraoral scanning, to create a virtual patient for preoperative assessment and virtual treatment planning. The assessment of the trueness of implant positioning was conducted in Geomagic Control X software (version 2017.0.3) by referencing anatomical landmarks from both the preoperative and one-year postoperative CBCT scans. Results: A total of 25 dental implants were placed in the maxilla, followed by the installation of long-term provisional restorations. The results showed minimal deviation between the planned and actual implant positions, with mean 3D coronal, apical, and angular discrepancies of 0.87 mm, 2.04 mm, and 2.67°, respectively. All implants achieved successful osseointegration, and no failures were recorded, resulting in a 100% survival rate at the one-year follow-up. Patients reported high satisfaction with both the esthetic and functional outcomes based on their subjective feedback. Conclusions: The findings suggest that the use of a fully digital workflow with stackable surgical templates is a reliable and effective approach for immediate implant placement and prosthetic rehabilitation, enhancing treatment precision and patient comfort.

A modified protocol merging two published techniques for computer guided zygomatic implants surgery: a technical note

ObjectivesZygomatic implant surgery can be difficult due to the limited intraoperative visibility of the surgical field and the complex anatomy of the zygomatic bone, which could lead to serious complications. This study aims to assess the accuracy of zygomatic implants placement using computer-guided surgical templates.Materials and methodsA total of 13 zygomatic implants were placed in four participants. Double-sleeve drill guides were used with the help of computer-guided surgical templates designed with a lateral window. The accuracy was evaluated by measuring the linear deviations regarding the implants’ platforms and apices’ positions in addition to the angular deviations. Moreover, deviations of both implants from three fixed planes of space were measured.ResultsThe mean linear deviation at platforms was 2.44 mm ± 1.57 and at the apices 2.32 mm ± 1 while the mean angular deviation was 3.6˚ ± 1.92. Differences at the entry points were 0.43 ± 1.79 mm, 0.39 ± 1.12 mm, and − 0.54 ± 2.00 mm from the mid-sagittal, horizontal, and coronal planes respectively. Differences at the exit points were − 0.75 ± 1.25 mm, -0.06 ± 1.09 mm, and 0.63 ± 1.24 mm from the same planes respectively. Within all planes, there was no statistically significant difference.ConclusionGiven the limitations of this study, the use of the computer-guided surgical templates augmented by the double sleeve drill guides allowed favorable control over the tip of the long surgical drill away from vital structures during the zygomatic implant osteotomy. It also allowed control over alveolar crest osteotomy and its placement in a favorable prosthetic position. Overall, this protocol should be considered for further research and improvement to allow more predictable surgical outcomes while preventing the occurrence of complications. Before conducting this study, the protocol was reviewed and approved by the Research Ethical Committee of Faculty of Dentistry, Ain Shams University in meeting no. (105), on 15th of July 2020 with the application no.: (FDASU-RecD072029).

Influence of Material, Sterilization, and Disinfection on the Accuracy of Three-Dimensional Printed Surgical Templates: An InVitro Study.

To evaluate the influence of the three-dimensional (3D) printing technology, material, sterilization, and disinfection on the accuracy of guided surgical templates. Fifty printed resin surgical templates were designed and fabricated using a digital light processing 3D printer with a photopolymerizing resin, and 50 printed metal surgical templates were designed and fabricated using a selective laser melting 3D printer with a titanium alloy. Templates from both groups were randomly divided into five subgroups involving different sterilization and disinfection procedures. The group without any sterilization or disinfection procedure served as the control group, whereas the other groups were used as the study groups (hydrogen peroxide gas plasma sterilization, 5% povidone-iodine disinfection, 75% ethyl alcohol disinfection, and steam autoclave sterilization). Implant simulations were performed on the 3D-printed resin models, and postoperative impressions were acquired with scan bodies attached to the implants. All surgical templates were digitally scanned. The root mean square was used to determine and quantify fabrication accuracy and reproducibility, and the definitive and planned implant positions were compared. The printed resin templates exhibited lower fabrication accuracy and reproducibility, as well as higher 3D deviations, after steam autoclave sterilization (p < 0.001); however, the printed metal templates were not affected by the different sterilization or disinfection procedures (p > 0.05). Printed metal surgical templates are viable alternatives for guided implant surgery. Preoperative steam or gas plasma sterilization is recommended, especially for metal templates, as resin templates show deformation and decreased accuracy after steam sterilization. chictr.org.cn number: ChiCTR2400081334.

Achieving automated and high-precision in situ analysis of the dimensional accuracy and dynamic deformation of 3D-printed surgical templates: an in vitro study

PurposeTo demonstrate the viability of a coordinate-measuring machine (CMM) for the geometric analysis of 3D printed surgical templates.MethodsThe template was designed and modified by adding 18 cylindrical landmarks for CMM test and then classified into five groups according to the slicing software and resins (opaque and transparent): Streamflow-O, Streamflow-T, Shapeware-T, Rayware-T and Polydevs-T (N = 3). Three standing times (0 w, 1 w, and 2 w) were included to observe possible deformation. All the measurements were performed automatically by the CMM through a preset program. The Euclidian distance (dxyz) was regarded as the representation of global dimension accuracy, and displacements in the x-, y-, and z-axes were also calculated.ResultsThe average dxyz values of Streamflow-O, Streamflow-T, Shapeware-T, Rayware-T and Polydev-T are 32.6 μm, 31.3 μm, 56.4 μm, 96.4 μm, and 55.3 μm, respectively. Deviations were mainly induced by the upward bending of the free end region (positive direction of the z-axis). Different resins did not have a significant influence on the dimensional accuracy. Moreover, deformation appeared to be negligible after 2 weeks of storage, and the z-axis displacements were only approximately 30 μm at week 1 and 10 μm at week 2.ConclusionsThe deviations of the DLP-printed template are induced mainly by z-axis displacements and are determined by the processing accuracy. After 2 weeks, the dimensional stabilities of these templates are reliable, which is encouraging for clinicians. Moreover, the CMM is preliminarily demonstrated to be a feasible tool for achieving automated geometric analysis of surgical templates.

Seating Accuracy of Prefabricated Interim Crowns on Immediate and Delayed Implants: A Laboratory Study.

Evaluation of seating accuracy of interim crowns for the immediate restoration of immediate implants (I-Imp) and delayed implants (D-Imp) placed via static computer-assisted implant surgery (sCAIS). A maxillary training model was modified by removing the central incisors and simulating fresh extraction socket in one site and healed ridge on the other site. An I-Imp was planned in the extraction socket and D-Imp was planned in the healed site. The planned implants were used to design sCAIS surgical template and interim crowns for immediate restoration of the implants. Fourteen surgical models received sCAIS implants after which the interim crowns were inserted. Subsequently, the models with the seated crowns were scanned by a laboratory scanner. The planning virtual model was superimposed against every surgical model to measure vertical, horizontal and proximal contact errors of each crown. All the crowns were positioned more incisally than the planned crowns. This was significantly more noticeable for the D-Imp crowns (0.81 mm) than the I-Imp crowns (0.55 mm). The 2 crown groups had similar horizontal errors (I-Imp &#61;0.35 mm, D-Imp &#61; 0.36 mm). The D-Imp crowns had minimal proximal contact error (0.14 mm), but the I-Imp crowns had significantly greater proximal contact error (0.74 mm) in the form of open distal contacts. This pattern of error appears related to the relationship between the socket morphology and the planned implant position. Prefabricated interim I-Imp crowns suffered from greater errors that affected the proximal contact quality than DImp crowns. The observed deviation of the I-Imp crowns can be attributed to the socket morphology and its relation to the planned implant position. The deviations of the I-Imp crowns are clinically significant and will require clinical adjustments. Thus, caution is needed before routine use of prefabricated interim crowns on I-Imp.

An in-vitro study on accuracy of modular templates used to fully guide implants in combination with bone reduction for complete arch restorations: experts versus students

ObjectivesThis in-vitro study evaluates the accuracy of modular surgical templates used to fully guide implants in combination with bone reduction, performed by expert and students, for complete arch restorations. MethodsAll the procedures were performed by dental students of the final year and an expert clinician, on twelve edentulous mandible models. A virtual implant planning, simulating a complete arch restoration on six implants were performed. Three different surgical guides were designed and printed to allow conventional fully guided implant placement (group 1); fully guided implant placement with modular guides (group 2); and fully guided implant placement after bone reduction, with similar, modular guides (group 3). After implant placement, optical scans of the study models were taken. Surface deviation and accuracy were evaluated and compared between groups and subgroups. ResultsA total of 12 surgical templates were used. Of these, Two templates in each group were used by two different students, while, the other six templates were used by an expert clinician as follows: one template with screwed anchor pins and one with pushed anchor pins in each group. A total of 72 implants were placed. Statistically significant difference was found between different template designs, when the implants were placed by an expert clinician. No statistically significant difference was found between expert and students, except the deviation in an angle value (students 2.13±1.46° versus expert 0.90±0.91°; P Value=0.0447) in the group 3. A statistically significant difference was found in favor of screwed anchor pins, in the group 1, in horizontal deviation (screwed pins 0.18±0.13 mm versus pushed pins 0.56±0.28 mm; P Value=0.0124; Table 5). No statistically significant difference was found between different template designs when the fully guided implants were placed by students, in both angle and horizontally (P=0.2787 and P=0.6601, respectively). A statistically significant difference was found between groups when the implants were placed by an expert clinician, with better value using screwed anchor pins, in the horizontal plane (P= 0.0293) but not in angle (P= 0.3380). ConclusionsModular templates provide a similar level of accuracy to conventional, one-piece guides. Screwed pins should be used to fix the base portion of the modular guides. Further clinical studies are needed to confirm these preliminary results. Clinical SignificanceModular surgical guides provide comparable accuracy to conventional, single-piece guides, however they offer more possibilities, helping in bone reduction and immediate loading procedures. Screwed anchor pins used to fix the base portion of the modular guides provide better final results than pushed pins.

Template based segmental mandibulectomy with nerve preservation and patient-specific PEEK plate reconstruction in a dog.

A 7-year-old French Bulldog presented with an acanthomatous ameloblastoma affecting approximately 30% of the right mandibular body. We utilized a patient-specific 3D-printed surgical template to perform lateral fenestration of the mandible and elevation of the inferior alveolar nerve (IAN), facilitating nerve preservation during subsequent segmental mandibulectomy. The resulting critical-sized bone defect was anatomically stabilized using a patient-specific polyetheretherketone (PEEK) bridging plate. The recovery process was uneventful, with maintained occlusion and orofacial sensitivity.Similar to cases in humans with ameloblastoma, preserving orofacial sensitivity through the preservation of the inferior alveolar nerve seems feasible in dogs. Consequently, potential negative consequences of permanent regional denervation, which are unavoidable in traditional mandibulectomy, can be avoided. Bridging the ostectomy with a PEEK plate, offering advantages such as radiolucency, absence of imaging artifacts, and a modulus of elasticity similar to bone, proved to be functional in this canine patient, with no signs of complications observed up to the latest follow-up at 6 months.

Effect of Storage Conditions and Time on the Dimensional Stability of 3D Printed Surgical Guides: An InVitro Study.

To evaluate the dimensional stability over time of additively manufactured surgical templates, fabricated by different resins, and stored by different methods. Using a 3D printer with DLS technology and two different resins (Surgical Guide (SG)-WhipMix and Key Guide (KG)-KeystoneIndustries), 96 surgical guides were additively manufactured. The guides were stored in three different environments: directly exposed to sunlight (S1), in normal interior room conditions (S2), and in darkness (S3). The guides were digitally scanned immediately after fabrication and post-processing, and after 1, 3, and 6 months of storage. For each group, the mean deviation of the root mean square (RMS) between guide's intaglio surface, as well as the axial deviation between sleeves' housings were calculated. The mean axial variations of angular axis deviation of sleeves' housings ranged between 0.09° and 3.99°. The mean deviation of the RMS discrepancy in guide's intaglio ranged from 0.1 to 0.18 mm. Variations were significant (p < 0.001) only for the S1 group and only for SG material. After 3 months, an additional storage time of 3 months did not have any further effect on dimensional stability. Within the limitations of the present study, storage time of a surgical guide for up to 3 months after manufacturing, as well as printing material can significantly affect surgical guide's dimensional stability, when they are exposed to direct or indirect sunlight conditions. Storage of guides in a dark environment is recommended in order to avoid an additional source of error in computer-guided surgery workflows.

Heat Generation during Dental Implant Bed Preparation Using Surgical Guides with and without Internal Irrigation Channels Evaluated on Standardized Models of the Alveolar Bone

Dental implant bed preparation involves surgical drilling. Heat generated in this process can cause a temperature elevation beyond the bone damage limit (10 °C), affecting the osseointegration of the implant. Surgical templates ensure accurate implant placement, but they limit the access of the irrigation fluid. This study evaluated the hypothesis that surgical guides with internal cooling prevent bone heating more effectively than classical guides. To eliminate biological variability, this study was conducted on artificial bone pieces that mimic the bone density of the human mandible. We created a surgical template that incorporated four pairs of guides—one classical (CLA) and one with internal cooling (INT) in each pair. For each specimen, we randomly selected the type of surgical guide to start with and performed four osteotomies with a 2.7 mm-diameter drill; then, we widened each hole with a 3.3 mm drill and finalized it with a 3.7 mm drill. The temperature was recorded by thermocouples placed at 0.8 mm from the prospective edge of the final osteotomy. In 168 measurements (12 osteotomies on 14 specimens) conducted for each type of surgical guide, the mean temperature rise was 7.2 ± 4.9 °C (mean ± standard deviation) for CLA and 5.0 ± 3.8 °C for INT. The mean differences between temperature elevations were 1.5 °C, 2.1 °C, and 3.0 °C for the first, second, and third drill, and they were statistically significant: the p-values of Student’s t-test were 0.004, 0.01, and 0.001, respectively. Although the mean temperatures remained safe, temperature rises exceeded 10 °C in 23.8% (9.5%) of the osteotomies performed in the presence of CLA (INT). Taken together, our results suggest that surgical guides with internal cooling ensure a significant drop in the temperature rise caused by implant site drilling.

The Applications of 3D-Printing Technology in Prosthodontics: A Review of the Current Literature.

Prosthodontics has become increasingly popular because of its cosmetic attractiveness. 3D printing has revolutionized prosthodontics, enabling the creation of high-quality dental prostheses. It creates detailed restorations, such as crowns, bridges, implant-supported frameworks, surgical templates, dentures, and orthodontic models. In addition, it saves production time but faces challenges such as elevated expenses and the requirement for innovative materials and technologies. Thisreview gives insights into the uses of 3D printing in prosthodontics, presenting how it has significantly changed clinical practices. This article discusses different materials and techniques. Additionally, it showcases the capacity of 3D printing to improve prosthodontic practice and proposes prospects for future investigation.

Computer guided versus freehand dental implant surgery: Randomized controlled clinical trial

ObjectiveThis study compares, in terms of rehabilitation and recovery, freehand implant placement using flapless or mini-flap procedures with the use of 3D implant design software and specialized surgical templates among patients who are partially or completely edentulous. A secondary aim is to propose an algorithm for predicting the accuracy of implant placement. Method.Patients with an alveolar height of at least 7 mm and an alveolar width of at least 4 mm were randomly assigned to two groups. Group I comprised ten patients who received computer-guided dental implant placement, while Group II comprised ten patients who received manual placements. A temporary prosthodontic was immediately inserted onto the implants, which was replaced by a permanent one after 4–6 months. ResultsThe study enrolled twenty patients. A blinded, independent assessor evaluated the outcome variables, which included implant failure, marginal bone loss, treatment duration, post-surgical pain and swelling, use of painkillers, surgical time, and patient satisfaction. Pain scores in Group II were significantly higher than those in Group I, but there were no other significant differences. All patients experienced pain after 2 days, but by 7 days, only two patients in Group I and four patients in Group II were still suffering, although this difference was not statistically significant. After 14 days, all patients were asymptomatic. ConclusionAlthough the freehand technique is straightforward for experienced surgeons, surgical guides enhance the accuracy of implant placement, particularly in a deficient alveolar ridge.

Use of collapsible surgical templates in full dentures with immediate loading

Use of collapsible surgical templates in full dentures with immediate loading

Vertical Mouth Opening Requirements for CAD/CAM Fully Guided Implant Surgery: An Analysis of Different Implant Systems.

To determine the vertical space required for implant osteotomy preparation when utilizing a CAD/CAM fully guided surgical template. A total of 14 surgical osteotomy drills (individual and sequential drills) were collected and measured individually using a digital caliper, as well as the total length when the drills were positioned in a surgical handpiece. The height of the surgical guide sleeves and the offset of 14 implant systems in the market were also collected. The vertical dimension of the drills included in this study ranged from 28.2 to 46.3 mm. When these drills were inserted into the handpiece, the total length ranged from 30.0 to 49.5 mm. The height of the surgical guide sleeve and the offset required for the guide had a range of 3.2 to 7.0 mm and 5.0 to 13.5 mm, respectively. This dimension resulted in the total vertical space required for CAD/CAM fully guided surgical templates for each implant system, which ranged from 30.0 to 58.5 mm. Limited mouth opening can pose challenges and limitations in both guided and nonguided dental implant surgery. It can affect the accessibility of surgical implant placement and may result in increased patient discomfort, surgical implant positioning errors, and postoperative complications. Clinicians should determine the patient's mouth opening capabilities during the treatment planning phase prior to deciding on the appropriate implant system to be used and the implant placement technique.

Computer-assisted open exposure of palatally impacted canines for orthodontic eruption: A randomized clinical trial

ObjectiveThis randomized clinical trial aimed to assess the feasibility of computer-assisted open exposure of palatally impacted canines. Materials and methodsPatients aged 11–30 years who required orthodontic eruption for the full palatal impaction of their canines were included in this study. Exclusion criteria were psychosocial and dental contraindications of orthodontic treatment, congenital craniofacial disorders, and trauma in the patient's history in the vicinity of the surgical site. Virtual planning software was used to register the intraoral scans and cone-beam computed tomography data and to design a surgical template. In the test group, exposure of the canines was guided by a surgical template, whereas in the control group, the surgeon relied on the surgical plan to localize the impacted canine. The success of the intervention, duration of surgery, and complications, including excessive hemorrhage, damage to the canine or neighboring anatomical landmarks, and postoperative inflammation of the surgical site were assessed. Postoperative pain was reported by the patients using the visual analog pain scale (VAS). ResultsSurgery was deemed successful in all patients in both groups. During healing, no complications were observed. The duration of surgery decreased significantly in the test group (4 min 45.1 s ± 1 min 8.4 s) compared to that in the control group (7 min 22.3 s ± 56.02 s). No statistically significant differences were observed between the VAS scores of the two study groups. ConclusionsThe application of virtual planning and static navigation is a viable approach for the open exposure of palatally impacted canines. Clinical trial registration numberNCT05909254. Clinical significanceComputer-assisted surgery is a feasible method for open exposure of palatally impacted canines, which decreases the duration of surgery compared to the freehand method.

ИСПОЛЬЗОВАНИЕ ЦИФРОВЫХ ТЕХНОЛОГИЙ ПРИ РЕАБИЛИТАЦИИ ПАЦИЕНТОВ С ПЕРВИЧНОЙ АДЕНТИЕЙ

Abstract. Introduction. Number of patients with hypodontia has increased at orthodontic appointments. According to different authors, the frequency of tooth rudiments absence ranges from 2 % to 16.5 %. The highest rank is held by maxillary lateral incisors hypodontia. Due the increased patients’ aesthetic requirements, it is a difficult task, especially with the alveolar ridge bone deficiency. Treatment of such patients requires a multidisciplinary approach and the use of digital technology. The aim of the study is to improve the treatment effectiveness for patients with hypodontia, using digital planning, surgical templates, intraoral scanning, and the CAD/CAM modelling of metal-free screw-retained crowns on dental implants. Materials and Methods. The clinical study was performed in the dental office PreziDent (Cheboksary) in 2018-2023. The total number of patients was 24 people (female), aged 16 to 34 years. There were two groups (n=12). The first group patients had their missing teeth replaced using dental implantation without using any digital technology. In the second group, those with the use of digital technologies. Gingival condition of the dentition defect area was assessed: Severity of stippling phenomenon degree, density gingival margin adherence to the structural materials, vacuum capillary resistance by Kulazhenko, and Mülleman-Cowell bleeding index. SPSS 13.0 software package was used for the statistical processing of the results obtained. Results and Discussion. The first stage of treatment included orthodontic treatment, bracket placement and canine distalization. Some patients were fitted with orthodontic miniscrews in the subclavicular region. After creating gaps for the future lateral incisors, a surgical template was fabricated and dental implants were placed. Four months after implantation, the bracket system was removed and the implant temporary crowns were placed; six months later, CAD/CAM digital metal-free prosthetics were placed. Not a single case of implant loss was detected. An algorithm framework was developed for managing patients with maxillary lateral incisor hypodontia. Conclusions. Using computer programs for planning dental implantation and in navigation surgery allows installing dental implants most accurately and making digital metal-free prosthetic constructions by computer-aided modelling and manufacturing. Thus, the risk of complications is reduced and an effective functional and aesthetic state of dentoalveolar system is achieved in patients with primary anodontia.

Cone-wedge anchored surgical templates for stackable metal guide: a novel technique

ObjectiveTo address the instability in implant surgical guides, this technique proposes an alternative anchoring mechanism in the stackable metal surgical guides utilizing cone-wedge anchors for improved stability.MethodsPostoperative implant position superimposed onto the preoperatively planned design using Mimics Medical 21.0 and Materialise Magics 24.0 to assess 3D coronal implant deviation, 3D apical implant deviation, and implant angular deviation.ResultsPostoperative cone-beam computed tomography (CBCT) revealed a high level of precision in the implant placement, with an average 0.97 mm deviation at implant coronal region, 1.56 mm at implant apexes, and 2.95° angular deviation.ConclusionThis technique introduces a novel cone-wedge anchoring mechanism to enhance the stability of stackable metal surgical guide templates, addressing inherent instability issues. The utilization of this approach significantly improves the accuracy of implant placement procedures.

Merging Mandibular Virtual Data Sets in Partially Edentulous Patients with a High-level of Scattering on Cone-beam CT Scans: A Technical Report.

Digital implant planning, utilizing the convergence of digital surface scanners, cone beam computer tomography (CBCT) scans, and advanced planning software, has transformed dental implantology. The merging of these data sets through triangulation of landmarks provides a detailed digital model of the jaws, facilitating precise implant positioning in edentulous areas. A critical step in this digital workflow is the accurate merging of DICOM files with STL/PLY/OBJ files, which underpins the design and fabrication of surgical templates for accurate implant placement. Errors in this phase can lead to implant mispositioning or damage to adjacent structures. Particularly in partial edentulism, the merging is based on the occlusal topography of the remaining teeth but scattering in the CBCT data-caused by interactions of radiation with radiodense materials-can complicate this process or even render it impossible. The manuscript presents a technique utilizing radiopaque markers to overcome scattering effects, ensuring accurate dataset superimposition in the mandible.

ГОТОВНОСТЬ ВРАЧЕЙ-СТОМАТОЛОГОВ К ИСПОЛЬЗОВАНИЮ НАВИГАЦИОННЫХ ХИРУРГИЧЕСКИХ ШАБЛОНОВ ПРИ ПЛАНИРОВАНИИ ДЕНТАЛЬНОЙ ИМПЛАНТАЦИИ

Dental implantation surgery is becoming an increasingly demanded dental procedure. Along with the growing number of installed dental implants, the number of complications inevitably increases, including those associated with planning errors in both the surgical intervention itself and subsequent orthopedic treatment. Despite the wide awareness among practicing dentists about the possibilities of navigational surgery, its prevalence remains insufficient. This paper analyzes the frequency of use and reasons for refusal to use navigational surgical templates among dental surgeons and orthopedists from different regions of Russia working in both public and private healthcare systems.

Guided and Prosthetically Driven Bone Augmentation Using the Shell Technique and Allogeneic Cortical Plate: A Prospective Case Series.

To describe the use of digital technology to surgically guide the shell technique using allogenic cortical plates for a fully guided bone augmentation procedure. A total of 10 patients who required bone augmentation for implant placement were included in this study. Allogenic cortical plates were planned using CAD/CAM to have identical thickness to the original cortical plates, then were digitally positioned and shaped to outline the bone defect according to the existing anatomical details. A cutting pattern and a surgical template were manufactured according to the digitally preplanned bone graft and the intraoral setting. A total of 12 horizontal bone grafting procedures were performed using the shell technique with allogenic cortical plates. All grafting procedures were deemed successful and allowed for ideal 3D implant positioning. Of the 12 bone grafting procedures, which used a surgical template to position the cortical plate, 3 required an adjustment to reposition the plate to a more ideal position. Digital technology was used to create a surgical template to guide the shell bone grafting technique with allogenic cortical plates. All surgical templates offered a fixed support to hold the cortical allogenic plate in the preplanned position, offering a predictable, simplified, and accurate guided bone grafting procedure. Further studies on a larger population of patients are necessary to assess those results and to verify the treatment approach described in this study.

Individualized digitally designed surgical template for guided soft tissue surgery in cases with severe gingival enlargement: A clinical application in hereditary gingival fibromatosis.

The purpose of this study was to present the use of computer-assisted periodontal surgery utilizing a novel surgical guide for cases with severe gingival enlargement through a clinical application in a patient with hereditary gingival fibromatosis. The treatment plan included nonsurgical periodontal therapy, surgical periodontal treatment, and regular periodontal maintenance before the initiation of orthodontic treatment. Due to the increased soft tissue thickness, a surgical guide with a novel design was fabricated to facilitate the periodontal surgery since most of the patient's teeth were malpositioned and underexposed due to fibromatosis. For this purpose, the patient's intraoral scan was merged with a CBCT image in order to plan surgical excisions based on the anatomy of the teeth and the bone contour. The customized surgical guide facilitated the gingivectomy by controlling not only the shape of the initial incisions but also their orientation toward the level of the cementoenamel junction, improving the efficiency of the clinical time compared with freehand surgery and assisting in the verification of the final soft tissue shape, based on the treatment plan. Digital technology through the superimposition of multiple data sets can assist in the diagnosis and multidisciplinary management of cases with gingival fibromatosis. The proposed design of the surgical guide can facilitate soft tissue surgery based on the digital treatment plan, leading to more predictable management of the soft tissue, especially in patients with severe gingival enlargement, as in cases with hereditary gingival fibromatosis or drug-induced gingival overgrowth.