UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
CASE REPORT DOI: https://doi.org/10.4322/bds.2024.e4327
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Braz Dent Sci 2024 Apr/June;27 (2): e4327
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
How reverse planning and the use o digital devices revolutionize
implantology? – Case report
Como o planejamento reverso e o uso de ferramentas digitais revolucionam a implantodontia? – Relato de caso
Tatiana Cursino PEREIRA1 , Fernanda GODOY1 , Diana CUNHA1 , Diogo Cabecinha VIEGAS2 ,
Guilherme de Siqueira Ferreira Anzaloni SAAVEDRA1,2
1 - Universidade Estadual Paulista, Departamento de Prótese Dentária e Materiais Odontológicos. São José dos Campos, SP, Brazil.
2 - Faculdade de Medicina Dentária da Universidade de Lisboa. Departamento de Prótese Fixa. Lisboa, Portugal.
How to cite: Pereira TC, Godoy F, Cunha D, Viegas DC, Saavedra GSFA. How reverse planning and the use o digital devices revolutionize
implantology? – Case report. Braz Dent Sci. 2024;27(2):e4327. https://doi.org/10.4322/bds.2024.e4327
ABSTRACT
Objectives: The aim of the study was to demonstrate how digital devices can be applied in the eld of implant
dentistry. By integrating data from computed tomography, panoramic radiography, and intraoral scanning into
software, it is feasible to perform virtual planning of prosthetic rehabilitation and implant placement predictably.
The adoption of reverse planning increases the chances of treatment success. Material and Methods: In this
case report, oral rehabilitation of the area of tooth 36 was conducted through implant placement. The implant
was installed based on the virtual planning done in the software, followed by the production of a rigid static
guide and guided surgery. Results: It was noted that there is a learning curve associated with the use of these
technologies, requiring professionals to have theoretical and practical knowledge of digital devices. By using
software and surgical guides obtained through 3D printing, it was possible to achieve high precision and preserve
vital structures such as blood vessels and nerves, resulting in aesthetic and functional satisfaction for the patient.
Conclusion: The use of digital devices in implant dentistry offers speed and predictability in treatment.
KEYWORDS
CAD/CAM; Dental planning; Dental prosthesis; Guided surgery; Implant.
RESUMO
Objetivos: O objetivo do estudo foi evidenciar como as ferramentas digitais podem ser aplicadas na área da
implantodontia. Ao integrar dados de tomograa computadorizada, radiograa panorâmica e escaneamento
intraoral em um software, é viável realizar o planejamento virtual da reabilitação protética e implante de forma
previsível. A adoção do planejamento reverso aumenta as probabilidades de sucesso do tratamento. Material e
Métodos: Neste relato de caso, a reabilitação oral da área do dente 36 foi conduzida por meio da instalação de
um implante. O implante foi instalado com base no planejamento virtual realizado no software, seguido pela
produção de um guia estático rígido e cirurgia guiada. Resultados: Notou-se que há uma curva de aprendizado
associada ao uso dessas tecnologias, exigindo que os prossionais possuam conhecimento teórico e prático dos
dispositivos digitais. Ao utilizar softwares e guias cirúrgicos personalizados obtidos por impressão 3D, foi possível
alcançar alta precisão e preservar estruturas vitais como vasos sanguíneos e nervos, resultando em satisfação
estética e funcional para o paciente. Conclusão: O emprego de ferramentas digitais na implantodontia oferece
rapidez e previsibilidade no tratamento.
PALAVRAS-CHAVE
CAD-CAM; Planejamento dental; Prótese dentária; Cirurgia guiada; Implante.
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Braz Dent Sci 2024 Apr/June;27 (2): e4327
Pereira TC et al.
How re verse planning and the use o digital devices r evolutionize implantology? – Case report
Pereira TC et al. How reverse planning and the use o digital devices
revolutionize implantology? – Case report
INTRODUCTION
Dental implant surgery stands out as a widely
adopted solution for the replacement of one or
more missing teeth. The correct positioning of
the implant is crucial for the treatment’s success,
ensuring not only aesthetics but also proper
function in the dental arch [1]. Currently, there
are two predominant methods for implant
placement: the conventional approach, where
the dentist makes incisions in the gums to assess
oral anatomy and position the implant, and
the guided technique, which utilizes software
enabling meticulous analysis of oral elements
and virtual surgical planning [2,3].
A guided surgical approach can be
classied into static and dynamic methods [4,5].
In dynamic guided surgery, there is preplanning,
but surgery is performed using real-time optical
tracking via a computer that monitors and
guides the surgeon regarding anatomical
landmarks [6]. This approach is advantageous
for experienced professionals, who possess
greater skill, confidence, and speed, and can
make more autonomous decisions during surgery.
Conversely, less experienced professionals may
face difculties due to the need for prior skills
and the required adaptation time [5,6]. This
increases the potential for errors in dynamic
guided surgery [6,7].
The technique of static guided surgery
employs a rigid guide printed from a specic plan
and is used in conjunction with a guided surgery
kit [3]. This results in a reduced dependence
on the experience and skill of the professional,
thereby increasing the accuracy and predictability
of outcomes [4]. The fabrication of a rigid plate
guides both the initial bone drilling and the
guided implant insertion, providing precision
in angle and depth. Among its advantages, it
eliminates incisions in the gums, preserving blood
supply to the bone tissue and reducing surgical
trauma, thus accelerating the healing process and
providing greater post-surgical comfort [3,4].
The placement of implants without prior
planning that takes into account anatomical
structures and future prosthetic rehabilitation can
lead to functional and aesthetic problems [8,9].
The main reason for prosthesis failure and
subsequent implant loss is attributed to poor
planning [9,10]. Improper implant positioning
is identied in some studies as a key factor for
future loss of hard and/or soft tissues [11,12].
Therefore, this work aims to demonstrate the
advantages offered by digital technologies
through reverse planning and the performance
of static guided surgery for implant installation
and prosthetic rehabilitation.
CLINICAL REPORT
A healthy 60-year-old male patient sought
treatment at the Institute of Science and
Technology of São Paulo State University (ICT
Unesp) in São José dos Campos (Figure 1).
An anamnesis was conducted, and the
patient underwent an intraoral scanning (CS
3600 Carestream).
It was observed that tooth 36 presented
extensive coronal fracture, and after periapical
radiography, it was found that the tooth also
had a fractured root. Prior to performing the
surgery for extraction of the remaining tooth
and installation of the implant, complementary
laboratory tests were requested from the patient
to assess systemic condition, and a computed
tomography scan was requested for evaluation
of the region in question.
The mandibular image was obtained in PLY
format through intraoral scanning. Subsequently,
it was integrated into the DICOM volumetric le,
containing cone beam tomographic image, using
Exoplan Rijeka 3.1 software (exocad, Darmstadt,
Germany). Thus, the planning for implant installation
and prosthetic rehabilitation was initiated. As it
was a rehabilitation of only one element in the
mandible, the case presented high chances of
success, given the region’s high bone density. It was
possible to virtually plan and analyze anatomical
structures in three dimensions using Exoplan
Rijeka 3.1 software (exocad, Darmstadt, Germany).
Figure 1 - Initial intraoral register.
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Braz Dent Sci 2024 Apr/June;27 (2): e4327
Pereira TC et al.
How re verse planning and the use o digital devices r evolutionize implantology? – Case report
Pereira TC et al. How reverse planning and the use o digital devices
revolutionize implantology? – Case report
Through the software, virtual extraction of tooth
36 was performed. Subsequently, simulations were
conducted with different diameters and sizes of
implants, respecting a 2mm distance from the nerve
to avoid damaging it, and also aiming to respect
axial inclination and avoid detrimental horizontal
forces (Figures 2, 3, and 4).
After selecting the implant, a simulation of the
crown for tooth 36 was performed, conceptualizing
the virtual reverse planning (Figures 5 and 6).
Figure 2 - Sagittal section - virtual implant planning respecting 2mm from the nerve, Exoplan Rijeka 3.1 software (Exocad).
Figure 3 - Cross-sectional view - virtual implant planning respecting 2mm from the nerve, Exoplan Rijeka 3.1 software (Exocad).
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Braz Dent Sci 2024 Apr/June;27 (2): e4327
Pereira TC et al.
How re verse planning and the use o digital devices r evolutionize implantology? – Case report
Pereira TC et al. How reverse planning and the use o digital devices
revolutionize implantology? – Case report
Due to the presence of neighboring teeth adjacent
to the prosthetic space, it was possible to establish
appropriate proximal contact points.
After planning the crown, the surgical
guide design was created, generating a new
PLY file covering only the hemiarch of the
prosthetically relevant side, using the same
software. The teeth within the hemiarch itself
contribute to a design that promotes better
stability and adaptation (Figures 7 and 8).
The guide was obtained using the Cara Print
printer (Kulzer) with Dima Print Guide resin
Figure 4 - Selection of the most suitable implant for the case.
Figure 5 - Reverse Virtual Planning.
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Pereira TC et al.
How re verse planning and the use o digital devices r evolutionize implantology? – Case report
Pereira TC et al. How reverse planning and the use o digital devices
revolutionize implantology? – Case report
(Kulzer) after transferring the digital planning
le to Cara Print CAM slicing software (Kulzer).
Subsequently, the guide was sanitized with
isopropyl alcohol and polymerized using the Hi
Lite Power 3D device (Kulzer).
Extraction of tooth 36, which was condemned
due to crown and root fracture, was performed
(Figure 9). Subsequently, the adaptation of
the obtained guide in the mouth was veried
(Figure 10).
Figure 6 - Reverse Virtual Planning
Figure 7 - Lateral view of the digital guide. Conexão Sistemas de Prótese Ltda.
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Braz Dent Sci 2024 Apr/June;27 (2): e4327
Pereira TC et al.
How re verse planning and the use o digital devices r evolutionize implantology? – Case report
Pereira TC et al. How reverse planning and the use o digital devices
revolutionize implantology? – Case report
The surgical phase began with the minimally
traumatic extraction of tooth 36, aiming to
preserve the remaining bone and periodontal
condition. Immediately after the extraction of
tooth 36, a new periapical radiograph of the
region was taken, and the implant installation
was initiated using a specific surgical kit for
guided surgery. The platform used was a Morse
cone, Torq 3.75mm NP x 11.5mm (Conexão
Sistemas de Prótese, Brazil). After implant
installation, the outcome of the extraction and
immediate implant placement was analyzed
through clinical evaluation and a new periapical
radiograph of the region (Figures 11 and 12).
After implant installation, it was possible
to perform immediate loading with a temporary
restoration printed from Dima Print C&B Temp
resin (Kulzer, Germany). A Large Ti base, with
a 1.5mm collar height (Conexão Sistemas de
Prótese Ltda, Brazil) was used and nalized with
occlusal adjustment (Figure 13 and 14).
DISCUSSION
The case report highlights a positive change
brought about by static guided surgery performed.
This technique offers benets for professionals
and, consequently, for patients, due to its
tools that bring greater clarity and accuracy in
communication [3]. This technique demonstrates
effectiveness and agility in diagnosis, detailed
virtual planning, and fabrication of precise surgical
guides, offering predictable outcomes [1,2]. This
approach signicantly reduces procedure time and
provides greater precision in the nal positioning
of the implant and dental prosthesis [3,4].
Despite the evident benets, assimilating
the use of digital tools in this workow may be
perceived as a signicant challenge in terms of
the learning curve. It is crucial to have a deep
understanding of this aspect to evaluate the
effectiveness of various dental approaches [13-16].
However, studies, such as the one conducted by
Figure 8 - Occlusal view of the digital guide. Conexão Sistemas de Prótese Ltda.
Figure 9 - Intraoral photo after extraction of tooth 36.
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Pereira TC et al.
How re verse planning and the use o digital devices r evolutionize implantology? – Case report
Pereira TC et al. How reverse planning and the use o digital devices
revolutionize implantology? – Case report
Clayton T. Rau et al., highlight that the learning
curve when employing digital tools is notably
more favorable compared to analog methods.
Furthermore, the use of digital tools results in
a reduction in the number of clinical steps, thus
minimizing the chances of errors. This body of
evidence reinforces how digital technologies not
only contribute to a smoother learning curve,
enhancing the skills of dental professionals, but
also offer a more efcient approach with lower
error propensity when compared to traditional
analog methodologies [15,16].
The adopted technology not only transforms
clinical practice but also communication between
professionals and patients. Clear visualization of
the treatment plan, planned implant position, and
occlusal adaptation of the prosthetic rehabilitation
through virtual models facilitate patient
understanding, promoting more effective and
transparent communication [17]. Additionally,
the integration of these technological tools
enhances the relationship between the dentist
and the laboratory technician and ensures
assertive communication, resulting in fewer
prosthetic reworks [2,17].
The assertion that static guided surgery is
considered minimally invasive and conservative
is supported in the literature and presents a series
of benefits [1-4,16]. Precise virtual planning
allows for a highly focused surgical approach,
preserving healthy tissues and reducing the
need for extensive incisions. This results in less
trauma for the patient, decreased trans- and post-
operative discomfort, and quicker recovery [2,3].
However, the perceived ease of use of this
technique compared to traditional techniques of
conventional surgery may lead to less caution
on the part of experienced surgeons [11,15,18].
As evidenced by studies evaluating the accuracy
of implants installed with guided or conventional
surgery according to the surgeon’s level of
experience, experienced surgeons may exhibit
greater deviations, raising the possibility of
decreased caution due to long practice of the
technique [4]. On the other hand, inexperienced
surgeons may be more cautious, resulting in fewer
Figure 10 - Surgical guide trial, occlusal view.
Figure 11 - Intraoral post-surgical photograph.
Figure 12 - Periapical radiographs of the region (A) initial; (B) immediately after extraction, and (C) final.
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Braz Dent Sci 2024 Apr/June;27 (2): e4327
Pereira TC et al.
How re verse planning and the use o digital devices r evolutionize implantology? – Case report
Pereira TC et al. How reverse planning and the use o digital devices
revolutionize implantology? – Case report
deviations, making guided surgery a crucial tool
for reducing undesirable angulations [11,12,18].
Thus, it is important to recognize that,
although minimally invasive, static guided
surgery is not without limitations. Dependency
on technology may pose a challenge in cases of
malfunction or technical errors. The essence of
these technological advances lies in the direct
benefits to the patient [18]. Static guided
surgery not only provides faster, more accurate,
and predictable treatments but also results in a
safer and more satisfactory experience for the
patient [2,3,13]. The democratization of access
to high-quality treatments, regardless of the
dentist’s experience, underscores the importance
of technology in promoting inclusive and effective
dentistry.
CONCLUSION
It can be concluded that through the use of
reverse planning, oral rehabilitation by dental
Figure 13 - Installation of the immediate prosthetic crown and
occlusal adjustment.
Figure 14 - Case completed with immediate prosthetic crown.
implants becomes more predictable and precise,
generating satisfactory functional and aesthetic
prosthetic results, which increases the longevity
of the rehabilitation. This method also makes the
intraoperative period more comfortable for the
patient, as well as providing a more favorable
postoperative period. Static guided surgery
represents an evolution in dental practice as it is
a minimally invasive and conservative technique.
The incorporation of these technologies has
improved not only communication between
dentist and technician but also with the patient,
who has the possibility to participate clearly and
actively in their own treatment.
Author’s Contributions
TCP: Conceptualization, Investigation,
Methodology, Writing – Original Draft, Writing –
Review & Editing. FG: Investigation, Methodology,
Writing – Original Draft, Writing – Review & Editing.
DC: Investigation, Methodology, Writing – Original
Draft, Writing – Review & Editing. DCV: Writing –
Original Draft, Writing – Review & Editing. GSFAS:
Conceptualization, Project Administration.
Conict of Interest
The authors declare that they have no
conicts of interest.
Funding
The authors declare that they have no
funding during the development of the clinical
case.
Regulatory Statement
For the development of this study, the
patient signed the free and informed consent
form.
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Tatiana Cursino Pereira
(Corresponding address)
Universidade Estadual Paulista, São José dos Campos, SP, Brazil.
Email: tatiana.pereira@unesp.br
Date submitted: 2024 Apr 02
Accept submission: 2024 May 24
