The Keyless Partially Guided Implant

Placement Protocol: Success Rate

and Complications

Elkhadem et al

Amr Hosny Elkhadem, DDS, MSc1

Abstract

Background:
to
describe
the
concept and use of a simplied keyless
guided
implant
placement
system
in
partially and completely edentulous patients.

Results: All implants demonstrated insertion

torque values greater than 30 Ncm. Only few
post- operative complications were reported.
98.9% of the placed implants integrated.

Methods: 89 implants were placed in 23

patients (7 complete, and 16 partial cases)
using the universal simple guide kit. After
CBCT and virtual implant planning, surgical guides with c-shaped sleeves were constructed. The implants were placed using ap
or apless approach according to the need
for soft or hard tissue augmentation. The intraoperative complications, post-operative complains and implant survival rate were reported.

Conclusions: The keyless partial guidance using the simple guide kit and c-shaped
sleeves is a promising economic alternative to conventional guided approach. Further investigations are required to evaluate
its accuracy and long term success rates.

KEY WORDS: Computer-aided Implantology, surgical guide, open sleeve, tolerance

1. Lecturer, Prosthodontics, Faculty of Oral & Dental medicine, Cairo University

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Elkhadem et al

Figure 1: The simple guide kit. (a) cortical drill, (b) 2.3 mm
starter drill, (c,d,e) 2.2 mm pilot drill with variable lengths,
(f) 2.8 mm intermediate drill.

INTRODUCTION
The use of CT scans combined with computer
software to plan implant cases has been proposed since the 1990s.1 The technique aims
to provide correlation between the bone anatomy and the desired tooth position allowing
for predictable aesthetic and functional outcomes. Many authors refer to guided implant
placement as a protocol that enhances the
accuracy and safety of implant placement.2-4
Moreover, it allows for the minimally invasive
apless technique in many situations, which
minimizes the intra-operative time, postoperative pain and postoperative complications.4,5
Despite of the aforementioned advantages the techniques is not popular among
implant practitioners. This might be attributed
to the higher cost and time required to plan
the cases and fabricate the guides. Expensive
guided implant kits with complex assortment
are also mandatory.6 Additionally, the control
over implant direction is usually achieved with
a closed circular conguration with small drill
tolerance. Using the relatively longer drills for
guided systems through such closed conguration was always associated with accessibil-

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Figure 2: Surgical guide with c-shaped sleeve establishing

3 mm facial openings for side approach of the drills.

ity problems in the posterior region for dentate

patients. Such a small tolerance is mandatory to provide accuracy, yet it is thought to
block the passage of the irrigation and might
cause increased incidence of implant failure in dense bone and deep osteotomies7
Moreover, there is an uprising question
related to the accuracy imposed by the mechanical tolerance of the machined components. To
provide adequate precision of the guided systems, a small gap of approximately 20 microns
is provided between the main sleeve xed in
the guide and the removable, diameter specic, keys. A similar tolerance gap is designed
between the removable keys and the drills. The
friction during repeated use of the keys and
the drills increases the gap obviously which
might contribute to increases linear and angular deviation with these guided systems.8,9
When weighing the merits and demer-

Elkhadem et al

Figure 3: Virtual implant planning for an edentulous case. Implants were placed in relation to the required prosthetic
position guided by the radio-opaque scan appliance.

its of conventional guided systems one can

understand why such protocol is not so popular. Hence, there is a great need to provide modication in the concept and design
of guided surgical approach to overcome
the drawbacks and maximize the benets.

MATERIALS AND METHODS

The technique utilizes a simplied universal kit
design (Simple guide kit, Dentis Co.-Ltd, Daegu,
South Korea) and a modied C-shaped main
sleeve. The kit design eliminates the removable
keys used in conventional guided kits, and adopt
the concept of guidance for the pilot and intermediate drills only. For all cases, the nal drilling is done after removing the surgical guide
using the conventional non-guided nal drills.
The design and sequence of the simplied

kit is different from the regular guided implant

drills (Fig 1). All drills are composed of cutting
utes and a smooth guiding shaft that is compatible in size with the main sleeve of the surgical guide with no removable key in between. The
drilling sequences starts with a pointed drill for
penetration of the cortical bone. A starter drill
(2.3x8mm) is used to create an initial osteotomy
inside the bone. This is followed by the use of
pilot drills (2.2mm in diameter). The pilot drills
have variable lengths according to the desired
implant to be placed. As the pilot drill diameter is
smaller than the initial osteotomy created by the
starter drill, it will snap into the osteotomy engaging 8 mm of vertical bone height and part of its
guiding shaft will engage the main sleeve of the
guide. In all scenarios, a 2.8x8mm intermediate
drill is used afterwards to prepare the coronal

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Elkhadem et al

Figure 4: Point registration of the scan appliance over the patient scan. Several points are selected to minimize the
superimposition errors.

8 mm of the osteotomy. As the osteotomy path

is shaped the surgical guide is removed and the
nal drill of the conventional kit is used to create the nal osteotomy shape. This is followed
by inserting the implant in the conventional non
guided fashion. Additionally, the surgical guide
is designed with a c-shaped metal sleeve with a
facial opening (Fig 2). The opening allows for side
approach of the drills and unrestricted access of
the coolant. In this report, 23 cases were operated. 89 implants were installed in 7 completely
edentulous and 16 partially edentulous cases.

COMPLETELY
EDENTULOUS CASES
37 implants were installed in 7 completely
edentulous cases (two mandibular and 5 maxillary) using this technique. Preparation started
by duplicating the patient denture into radio-

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opaque scan appliance (Barium sulphate to

acrylic resin 1:4). Holes were prepared in the
tooth centre of the proposed site to facilitate its
identication on the CT scan. Double scan technique was performed. The rst scan was done
with the patient wearing the scan appliance
and biting on cotton rolls allowing for teeth
separation. The second scan was made for
the scan appliance alone. Virtual planning was
performed using Blue sky Plan (Bluesky Bio,
LLD USA). The virtual implants were placed
in the required anatomical sites after correlating them to the desired tooth positions (Fig 3).
3D superimposition of the scan appliance was
done over the patient CT scan using a point
registration technique (Fig 4). After dening
the diameter, height and offset of the guiding
tubes the software generated the virtual guide
by binding the scan appliance to the guiding

Elkhadem et al

Figure 5: A bilateral flapless maxillary case. Plan was made to avoid enlarged sinus on the left side (a). The guide design
allowed implant placement at the tuberosity region (b).

tubes. The STL le of the guide was fabricated

using additive manufacturing. C-shaped sleeves
were xed in the surgical guide and the guiding tubes were opened facially opposite to the
sleeve openings (Fig 2). The guide was xed
in the patient mouth with 3 xation screws and
the suggested drilling sequence was applied.

PARTIALLY
EDENTULOUS CASES
52 implants in 16 partially edentulous cases
(7 mandibular and 9 maxillary) were placed.
Patient scanning protocol differed according to
the number of missing teeth and the presence
of metallic restorations. In cases with few missing teeth and few or no metallic restoration, the
patient received a CBCT with no scan appliance. The patient model was scanned using a
laser scanner. When the patient had multiple
missing teeth and /or numerous metallic restorations a scan appliance with radiopaque markers was rst prepared. The patient had a CBCT
wearing the scan appliance. Afterwards, a
CBCT for the patient model with the scan appli-

ance was made for superimposition purposes.

Virtual planning was done after correlating the
prosthetic position to the underlying bone anatomy. When no scan appliance existed virtual
tooth setting was utilized. When designing the
guide, extension over the adjacent teeth as well
as part of the palatal and lingual mucosa was
required to assure proper stability. All cases not
requiring grafting were done in a apless manner (Fig 5). In cases requiring bone grafting a
ap was rst raised and the guide was then
used for implant placement (Fig 6). When extra
security was required to x the guide in place
light-cured owable composite was used to temporarily bond the guide to the supporting teeth.

RESULTS
No major intra-operative complications or
problems were reported in either ap or apless cases. In few cases the c-shaped sleeves
were detached off the guide when contacting the drills. The sleeves were replaced and
the procedure completed. All implants demonstrated acceptable implant stability at inser-

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Elkhadem et al

Figure 6: An anterior maxillary case with labial bone deficiency. The guide was placed after flap elevation to guide ideal
implant drilling (a), which was followed by GBR procedures (b).

tion (more than 30 Ncm). There was no reports

of postoperative infections among all participants. Only 4 patients reported postoperative
pain that lasted more than one week after the
surgery. The rest of the patients reported no
postoperative pain or mild pain for few days.
Only two case (one ap and one apless)
reported transient post-operative oedema. At
the second stage, only one maxillary implant
failed with overall success rate of 98.9%.

DISCUSSION
The keyless partially guided technique seems
to offer numerous advantages. First, the elimination of the removable keys together with the
open shaped sleeves allowed for better accessibility during surgery especially in the posterior region up to the maxillary tuberosity. The
open guiding sleeves allowed also for unrestricted access of the irrigation during drilling.
The proposed simplied approach did not
compromise the control over osteotomy preparation at all stages of drilling. The use of a

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short starter (2.3x8mm) drill created an initial osteotomy channel that accommodated
the smaller pilot drill. This assured dual guidance of the pilot drill by engaging the initial
osteotomy apically and the guiding sleeve coronally. The path created by the pilot and intermediate drill is so denite that it guides further
drilling with minor possibilities of introduce
a change in the osteotomy direction or depth.
Final drills with blunt non cutting tip are usually preferred because they seem to be safer.
By eliminating the removable keys only
one mechanical tolerance is present instead
of the two gaps in the conventional guided
approaches. Theoretically, this will reduce the
mechanical tolerance error to the half. Minimizing the error introduced by the bur sleeve gap
is thought to be a crucial factor in reducing the
intrinsic errors imposed by guided surgery 8-9
As the majority of cases were apless, the
incidence of post-operative pain and complications were less.10-11 As the guide are based
on 3D implant planning on CBCT, direct expo-

Elkhadem et al

sure of bone was not utilized unless soft

and / or hard tissue augmentation was required.
Moreover, conservative transmucosal drilling was used. Tissue punch was not used
as there is no proven clinical advantage or
impact on the implant success rate when compared to transmucosal drilling. On the contrary, the increase in the size of the punched
tissue is thought to increase the probing
depth and crestal bone loss around implants.12
A debate exist about the accuracy of partial
guidance in comparison to classical fully guided
systems. While some practitioners might believe
that guided nal drilling and insertion signicantly affect the accuracy others believe that
guidance of the initial osteotomy provides sufcient guidance to the rest of the procedures.
The clinical data regarding the survival rate
and accuracy of partial versus full guidance is
still sparse.13 Kuhl et al.14 evaluated the accuracy of half versus fully guided techniques on
cadaver model. They found no statistical signicant difference between the two protocols.
Yet, there is a need to conduct more clinical trials to evaluate the accuracy of both systems.

CONCLUSION
The use of the simplied partially guided keyless approach seems to be a promising alternative to conventional guided surgery. The
technique allowed easy access to the posterior region with efcient delivery of the irrigation during drilling. The use of a small economic
universal kit might encourage many practitioners to utilize guided surgery. Further studies are required to compare the accuracy
and success rate versus the conventional
guided techniques and manual techniques.

Correspondence:
Dr. Amr Hosny Elkhadem
e-mail: amrelkhadem@gmail.com
Address: 5 jasmine buildings zahraa elmaadiCairo Egypt
Postal code: 11435

Disclosure
The author reports no conicts of interest with anything mentioned in this article.
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