Academy Library

Immediate loading with Guided Surgery

clinical case
Performed by Dr. Francesco Gallo / Dr. Francesco Zingari

Patient: 59 y.o., non-smoker, not suffering from any remarkable systemic disease

The patient referred to us with an upper temporary bridge anchored on 3 roots, the maxillary right lateral central and left canine, and on one dental implant at the left first premolar.

Furthermore, the patient had two other implants at teeth right maxillary premolars with fractured prosthetic connections that were no longer exploitable.

Dental roots exhibited a degree 3 mobility and the implant at maxillary first premolar showed a 4/5 mm horizontal bone resorption with previous abscesses.

Severe bone atrophy in the posterior areas was identified.

Immediate loading with guided surgery 1

Treatment plan

The treatment plan provided for the patient to undergo guided surgery with traditional implants in the anterior areas and 2 free-hand zygomatic implants in the posterior areas, with a total amount of 12 unit immediately-loaded prosthesis.


Data collection

The first step of the treatment plan is the impression-taking of the surgical area, of its antagonist and of the bite block with an intraoral scanner.

Immediate loading with guided surgery 2


Then, facial scans are taken. These latter scans may prove useful as STL files and as a preoperative iconographic documentation.

Immediate loading with guided surgery 3-4


In the next stage the patient goes for a CBCT examination with stent in place. This extraoral geometry is necessary to realign DICOM files of CBCT with STL files of facial and intraoral scans.

Immediate loading with guided surgery


Afterwards, condylar movements are recorded using prosystom software.

This recording collects right and left side condylar movements as well as opening and closing condylar movements that are detected separately and within a full masticatory pattern. Data are subsequently exported into a format readable for the Exocad modelling software.

Immediate loading with guided surgery 6


Intraoral scan files, facial scan files, CBCT files and axiography files are matched inside the software for fabricating a patient-calibrated individual diagnostic wax-up.

Immediate loading with guided surgery 7


The patient-calibrated individual diagnostic wax-up matched with CBCT files (pic. 8) enables us to determine the most suitable implant position by analyzing the quality and quantity of bone in relation to the future teeth position.

This approach is defined as prosthetically-guided surgery, which makes it possible to have a temporary restoration fitting the patient’s masticatory pattern ahead of surgery.

Immediate loading with guided surgery 9-10


The implants of traditional length in the premaxilla area are virtually placed using the software

Immediate loading with guided surgery 11


and then a 3D-printed surgical guide is manufactured to guide drills and implants into the selected site. As for the zygomatic implants that will be placed free-handed, they are digitally studied as well with prosthetic emergence underneath the first molar teeth.


Surgical intervention

After an infiltration using articaine with adrenaline at 1:100.000, the dental maxillary remaining root, the implants with broken collar at the right maxilla and the implant with peri-implantitis at the left maxilla are removed. Accurate socket cleaning is then performed.

The surgical guide is positioned into the mouth through silicone surgical index and fixed to the upper jaw using positioning pins

Immediate loading with guided surgery 12-13


The first drill is a mucotome resecting the portion of mucosa in the area where the following drill sequence will make the new socket.

Immediate loading with guided surgery 14


Then the predetermined drilling length is reached after several drilling steps advancing millimetre by millimetre. The newly-created socket is bored by the drills to define its diameter.

Immediate loading with guided surgery 15


The drill sequence shall be strictly followed to achieve a predictable outcome.

Guided surgery as such requires that every single passage is guided by the sleeves where indexed drills have an unequivocal 3D position and a stopper for the cutting part. Furthermore, the implant shall be inserted through the same sleeves without removing the guide.

Implants are picked from the blister-pack using the carrier that is screwed to the implant and works as a guide inside the sleeve.

Immediate loading with guided surgery 16


Once the implant is placed in the new socket, it is held in place by the carrier, thus stabilizing the surgical guide.

Immediate loading with guided surgery 17


After placing all the implants by means of the related carriers and achieving the minimum requested torque for immediate loading, the guide is removed.

Immediate loading with guided surgery 18



For the insertion of zygomatic implants, a mini-invasive access with a 5 mm palatal to the ridge crest incision and some vestibular releasing incisions in the areas of right premolar to second molar and left maxillary premolars are made. Afterwards, the skeletonization of the upper jaw and the exposition of the lateral wall of the maxillary sinus, of the infraorbital nerve and of the body of the zygoma (until detecting the anterior margin of the tendon of the masseter muscle) are performed. By detecting the position of the first molar on each side of the maxillary crest, it is coherently determined the ideal path of the two zygomatic implants. Along the ideal path of the implant, an osteotomy of the lateral wall of the maxillary sinus is performed using a diamond ball burr that enables a reduced detachment of the Schneider membrane. A further osteotomy of the lateral wall is made using a tapered diamond burr;

Immediate loading with guided surgery 19


this latter defines the natural seat of the drill for the final osteotomy.

Immediate loading with guided surgery 21


After defining the new implant socket, the zygomatic implant is placed in compliance with the prosthetic plan. Following a thorough haemostatic control, the mucosa flaps are sutured.

Immediate loading with guided surgery 21


All the inserted implants achieved an insertion torque allowing for immediate loading.

The temporary restoration is bonded using metal-to-metal cement.

Immediate loading with guided surgery 22

more Clinical cases