Guided surgery with narrow implant: a case report using CAD/CAM technology

Cirurgia guiada utilizando implante estreito: relato de caso utilizando tecnologia CAD/CAM

ABSTRACT

The increasing need for precise and efficient rehabilitation of reduced edentulous spaces, such as narrow alveolar ridges, limited inter-root or mesiodistal dimensions, and decreased alveolar height, has driven the evolution of surgical techniques and implant systems. Narrow-diameter implants (≤3.5 mm) were developed to address these sites with limited mesiodistal space. Advancements in computed tomography and digital scanning have enabled enhanced visualization of anatomical structures, leading to improved precision and accuracy in implant placement. By integrating Digital Imaging and Communications in Medicine data from computed tomography scans and Standard Tessellation Language files from digital impressions, implant placement can be meticulously planned in relation to the final prosthesis using 3D software. A surgical guide is then prototyped based on this virtual plan. Virtual planning and Computer-aided Design/Computer-aided Manufacturing fabricated surgical guides offer several advantages, including reduced chair time, increased predictability and reduced surgical trauma, optimal implant positioning for prosthetic restorations, and early identification of potential challenges. This study presents a clinical case where the rehabilitation of a reduced edentulous space was performed using minimally invasive techniques, employing a 2.9 mm narrow diameter implant (Straumann, Basel, Switzerland) through flapless guided surgery, utilizing Computer-aided Design/Computer-aided Manufacturing technology.

Indexing terms
Computer-aided design; Cone-beam computed tomography; Dental implants; Prostheses and implants; Stereolithography

RESUMO

A crescente necessidade de reabilitação precisa e eficiente de espaços edêntulos reduzidos, como cristas alveolares estreitas, limitações inter-radiculares ou mesiodistais e diminuição da altura alveolar, impulsionou a evolução das técnicas cirúrgicas e sistemas de implantes. Implantes de diâmetro reduzido (≤ 3,5 mm) foram desenvolvidos para abordar esses locais com espaço mesiodistal limitado. Avanços na tomografia-computadorizada e escaneamento digital possibilitaram uma melhor visualização das estruturas anatômicas, resultando em maior precisão e acurácia na instalação de implantes. Por meio da integração dos dados Digital Imaging and Communications in Medicine provenientes de tomografias computadorizadas e arquivos Standard Tessellation Language de impressões digitais, o posicionamento do implante pode ser meticulosamente planejado em relação à prótese final utilizando software 3D. Uma guia cirúrgica é então prototipada com base nesse planejamento virtual. O planejamento virtual e as guias cirúrgicas fabricadas por Computer-aided Design/Computer-aided Manufacturing oferecem diversas vantagens, incluindo redução do tempo de cadeira, maior previsibilidade e menor trauma cirúrgico, posicionamento ideal do implante para restaurações protéticas e identificação precoce de possíveis desafios. Este estudo apresenta um caso clínico em que a reabilitação de um espaço edêntulo reduzido foi realizada por meio de técnicas minimamente invasivas, empregando um implante de 2,9 mm de diâmetro reduzido (Straumann, Basileia, Suíça), através de cirurgia guiada sem elevação de retalho, utilizando tecnologia Computer-aided Design/Computer-aided Manufacturing.

Termos de indexação
Desenho assistido por computador; Tomografia computadorizada de feixe cônico; Implantes dentários; Próteses e implantes; Estereolitografia

INTRODUÇÃO

Tooth loss is a public health problem affecting millions of people worldwide, with significant consequences for quality of life. Oral rehabilitation with dental implants has proven to be an effective option for replacing missing teeth, providing both aesthetics and function [¹,²].

However, the rehabilitation of small spaces presents a challenge in implantology. Narrow-Diameter Implants – NDIs – (≤3.5 mm) indicated to replace maxillary and mandibular lateral incisors have been widely used, presenting good clinical stability and high implant survival rates, thus being a viable alternative. The availability of interdental space less than 6 mm and/or residual bone width less than 5 mm is also indicative for the use of NDIs. Late loading, especially in single-tooth prostheses, increases its predictability. Studies demonstrate a high survival rate of these implants, regardless of the surgical technique used [³-⁶].

For the successful installation of implants and future prostheses, 3D virtual planning techniques are available, resulting in ideal implant positioning and better clinical outcomes. This software is capable of processing Digital Imaging and Communications in Medicine (DICOM) data provided by Cone-Beam Computed Tomography (CBCT) images, which led to a better visualization and understanding of the anatomy in the areas where implants are being planned for installation and reproduce the anatomy with submillimeter accuracy [⁷-¹¹].

Guided implant surgery involves the fabrication of a surgical guide [virtually designed and produced in-house using a 3D printing device] through Computer-aided Design/Computer-aided Manufacturing (CAD/CAM) procedures. Various modeling systems, such as stereolithography, can be used to manufacture surgical guides, in which the guide sleeves facilitate the precision of drilling during surgery [⁷,⁹].

Guided implant surgery can be especially useful in cases with critical bone volume or anatomy, where a unique and ideal implant site is mandatory to improve aesthetics or in cases where implants are placed with minimal surgical exposure of bone or even with a flapless approach [⁸,¹²]. The advantages of not elevating a mucoperiosteal flap are reduced surgical times, fewer postoperative complications, such as pain and bleeding, and greater patient comfort [¹³]. Additionally, recent studies have found better healing and lower rates of alveolar and peri-implant bone loss when using this technique [¹⁴-¹⁶].

Given the above, the aim of this study is to present a case report in which the rehabilitation of an edentulous space was performed using minimally invasive techniques, using a 2.9 mm narrow-diameter implant (Straumann, Basel, Switzerland), through guided surgery without flap elevation.

CASE REPORT

A 54-year-old female patient, a non-smoker with adequate plaque control, sought dental treatment due to dissatisfaction with the functional and aesthetic limitations of her prosthesis. She presented with the absence of teeth 14, 15, 16, and 24 in the maxilla (figures 1A and 1B). Cone-beam computed tomography scans were requested, and after evaluation of the imaging exams, adequate space was found for the placement of implants in teeth 14, 15, and 16 in a favorable three-dimensional position. However, in the region of tooth 24, limited mesio-distal space was observed (figures 1C and 1D) where guided surgery proved to be an excellent alternative, providing greater safety for the ideal positioning of the implant, preventing injuries to the roots of adjacent teeth, and being a closed-field surgical procedure (flapless) without the need for incision, elevation, and suturing of the maxillary alveolar ridge tissues.

Figure 1
Images and diagnosis. A/B) Initial photographs showing the absence of upper teeth. C/D) CT scan showing a narrow space for the implant in tooth number 24. E) Cone beam computed tomography (CBCT) for surgical planning. F) Tomographic sections of the edentulous site 24.

The implant selected was the Roxolid SLA active 2.9 mm (Straumann, Basel, Switzerland). The patient was referred for a new CBCT and an intraoral scan (3Shape scanner, Copenhagen, Denmark), and new tomographic images were obtained (figures 1E and 1F). The Standard Tessellation Language (STL) files (referring to the intra-oral scan) and DICOM (Digital Imaging and Communications in Medicine) files were processed in the CoDiagnostix software from Dental Wings (Straumann, Basel, Switzerland). In the virtual implant planning process, STL files resulting from an intraoral diagnostic scan can often be imported and merged with DICOM files in the virtual implant planning software. Subsequently, the planning of the ideal three-dimensional position of the implant was determined (figure 2A) and a muco-dentally supported prototype guide was planned (figures 2B and 2C) and fabricated (figures 2D and 2E). The patient was instructed to use pre- and postoperative medication.

Figure 2
A) Digital implant planning with CoDiagnostix software. B/C) Virtual planning of the surgical guide prototype. D/E) Fabricated surgical guide prototype.

On the day of surgery, the stability and passive fit of the guide were verified (figure 3A), and it was disinfected by immersion in an aqueous solution of 0.12% chlorhexidine digluconate (Periogard, Colgate, São Paulo, Brazil) for 20 minutes. With the guide positioned, infiltrative anesthesia was administered in the sulcular area, slowly and in small quantities to avoid interfering with the passive seating of the guide, using a solution based on 2% mepivacaine hydrochloride with 1:100,000 epinephrine (DFL, Rio de Janeiro, Brazil).

Figure 3
Surgical planning and procedure. A) Surgical guide in position. B) Surgical instrumentation process. C/D) Straumann BLT SLActive Roxolid 2.9x10 mm implant. E) Implant being placed in the prepared site. F) Healing abutment placed over the implant.

The Straumann Guided Surgery Kit (Straumann, Basel, Switzerland) was used, and the surgical instrumentation was performed in a progressive sequence of drills, maintaining frequent in-and-out movement. The surgical guide’s orifice allowed specific drills to be used, initiating the preparation of the surgical site for subsequent implant placement. Two drills were used to prepare the surgical site: first, a 1.6 mm diameter sharp drill at 800 rpm to remove soft tissue and perform a superficial initial drilling, marking the region to be implanted. Second, a 2.2 mm diameter twist drill (figure 3B) at 800 rpm, reaching a depth of 10 mm in intermittent movements. After drilling the surgical socket, the prototype guide was removed, and the Straumann BLT SLActive Roxolid 2.9 x 10 mm implant (figures 3C and 3D) was placed by hand (figure 3E), exhibiting excellent primary stability of 50N. A 3.5 mm healing abutment was manually screwed into place (figure 3F), finishing at the gingival level to allow for both initial gingival conditioning of the implant site and the use of a new provisional removable prosthesis, providing greater comfort and aesthetics in the postoperative period. There was no need for suturing.

Following a 3-month implant osseointegration period [¹⁷-¹⁹], a provisional restoration was fabricated on a temporary abutment (figure 4A) to promote optimal gingival conditioning in the surrounding area. Once the emergence profile was established and gingival health and maturity were achieved, a definitive abutment (Variobase) with a 3 mm gingival height was selected. Zirconia was chosen as the material for the prosthetic framework, and the final restoration was a ceramic crown (figures 4B and 4C). The radiographic image confirms the precise placement and healthy status of the implant in the region of tooth 24 (figure 5).

Figure 4
Completion of the prosthodontic rehabilitation. A) Provisional prosthesis in place. B) Frontal view of definitive prosthesis for teeth 24. C) Occlusal views of the definitive prostheses for teeth 14, 15, 16, 24, 26, and 27.

Figure 5
Radiographic view of the implant in the 24 region demonstrating ideal placement.

Ethical Considerations

The risks associated with the procedure primarily involve the potential failure of implant osseointegration. Regarding the risks associated with ethical considerations, the confidentiality of the participant’s data has been assured and will be maintained throughout all phases of the research. Furthermore, anonymity will be guaranteed through the non-identification of the participant or the utilization of codes or a pseudonym. The Informed Consent Form (ICF) clearly outlines the data protection measures in place. This case report was approved by the Research Ethics Committee under the number 7.511.772.

DISCUSSION

The use of osseointegrated implants has proven to be a highly safe and effective alternative for the rehabilitation of both full and partial edentulous spaces, even in cases where bone availability is limited. Narrow-diameter implants have significantly reduced the need for bone grafting in completely edentulous patients. This would avoid complications associated with alveolar bone augmentation, such as edema, pain, discomfort, risk of nerve injury, prolonged healing time, and increased surgical morbidity. Furthermore, the cost of placing standard-diameter implants along with grafting procedures may be prohibitive for some patients [²⁰].

However, NDI has a smaller osseointegration area compared to standard-diameter implants, with the average removal torque being lower for a 3.0 mm diameter implant compared to a 3.75 mm diameter implant. Additionally, NDI is less resistant to loading forces. These disadvantages have encouraged the design and execution of clinical studies to report on the predictability of NDI in oral rehabilitation [¹,⁴,⁶]. The most common prosthetic complications encountered were abutment screw loosening and debonding. Interestingly, screw/implant fracture was less frequent than expected [¹,⁴].

Thomé et al. [⁶] presented a successful case report of using narrow implants in a patient with agenesis of the maxillary lateral incisors and reduced bone volume. After one year, osseointegration, stability, and esthetics were observed to be satisfactory. The placement of a standard-diameter implant in close proximity to adjacent teeth in an edentulous space may result in a loss of proximal bone height, which can negatively influence the final position of the papilla and supracrestal soft tissues. Therefore, when evaluating single-tooth anterior restorations, the esthetic outcome and the stability of peri-implant soft tissues are the primary concerns in addition to implant survival [¹].

Cruz et al. [⁵] conducted a systematic review and meta-analysis to analyze the clinical outcomes in the anterior region of NDIs compared to regular-diameter implants (RDIs), considering implant survival rate, marginal bone loss, and mechanical and biological complications. The results did not indicate differences between SDIs and RDIs regarding implant survival rate, marginal bone loss, or mechanical and biological complications. In the present clinical case, the bone availability in the mesiodistal direction was scarce, necessitating the placement of a narrow implant, 2.9 mm in diameter (Straumann, Basel, Switzerland). Studies support that there is no difference in longevity between narrow-diameter and standard implants when supporting single crowns. Additionally, narrow implants present a lower risk of injury to adjacent structures [²¹].

To obtain a prototype, the following steps are necessary: computed tomography examination of the region of interest; recording of images in DICOM format; sending the file with the images to the company that produces the prototype; conversion of the files to BMP format in the software; and obtaining the final piece. The CAD/CAM system consists of three main components. The first is a digitizing tool (scanner), which converts geometry into digital information that can be processed by the computer. The second component is the software, which processes the information and, depending on the application, provides information and data about the product to be manufactured. The third component is a milling device/production technology that converts the information into the specific product [²²].

The use of prototyped surgical guides fabricated via CAD-CAM systems aids in the ideal positioning of the implant [²³,²⁴]. To achieve a long-term successful clinical outcome, it is essential that the implants be installed in an adequate three-dimensional position. When deviations occur in this position, there will be difficulties in prosthetic execution, resulting in aesthetic and functional defects observed in the short, medium, or long term. D’haese et al. [⁸] reported a study that compared the accuracy of conventional and stereolithographic surgical guides, in which they found a mean deviation at the entry point of 1.5 mm compared to 2.1 mm at the apex of the implants in the conventional group. When the stereolithographic guide was used, these deviations were significantly reduced to 0.9 and 1.0 mm, respectively. A more accurate transfer was obtained with guided implant surgery.

The limited bone availability in this case led to the choice of computer-guided surgery to enable better accuracy in three-dimensional positioning, as well as preservation of the bone tissue volume around the implant. Furthermore, Becker et al. [²⁵] describe that the patient must have a minimum bone thickness of 4 mm to allow for flapless surgery. The patient evaluated in this study presented sufficient bone dimensions in the vestibulo-palatal direction, which facilitated the decision for flapless guided surgery, with the advantages of significantly reducing postoperative pain, analgesic use, edema, and hematoma occurrence [⁹,²⁶].

In implantology, the surgical technique that proposes the placement of implants without a flap has gained interest after some studies related its performance to the reduction of vestibular bone resorption after tooth extraction, since maintaining the periosteum intact, there is no significant reduction in the blood supply to the underlying bone, nor is there significant resorption [¹⁴,²⁷]. The fabrication of stereolithographic guides from computed tomography scans to guide the placement of implants has enabled an increase in its precision, minimizing the possible iatrogenic effects of not directly visualizing the anatomy of the residual bone. This has increased the reliability for performing flap-less surgeries [²⁸].

CONCLUSION

Prosthetic rehabilitation of small spaces using implants requires care and strategies beyond those routinely employed. The use of narrow implants, combined with tomography and digital surgical guide technology, presents a viable and safe alternative.

• How to cite this article
  Maffei SH, Botega DM. Guided surgery with narrow implant: a case report using CAD/CAM technology. RGO, Rev Gaúch Odontol. 2026;74:e20260003. http://dx.doi.org/10.1590/1981-86372026000320240097

Data availability

The research data are available in the body of the document.

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Edited by

• Assistant editor
  Luciana Butini Oliveira

Publication Dates

• Publication in this collection
  20 Mar 2026
• Date of issue
  2026

History

• Received
  04 Apr 2025
• Reviewed
  24 June 2025
• Accepted
  27 Aug 2025