The discussion about freehand versus computer-guided implant placement is frequently conducted as a matter of principle – as though every practitioner had to commit permanently to one camp. In the second episode of the trilogy on computer-guided implantology in the podcast Queens & Sons of Dentistry, an experienced oral surgeon who himself works intensively with navigation systems argues for a pragmatic middle course: what is decisive is not the method as such, but the indication in the specific case.
Three routes lead to the implant
The surgeon sums up his position with a rhetorical question: why should one do only one thing when there are three options? Anyone announcing that they work exclusively navigated or exclusively guided by a template makes, in his view, the same mistake as someone who solves everything freehand. Available are freehand implant placement, statically guided implant placement by means of a surgical guide, and dynamic navigation – prospectively supplemented by robotics, provided a corresponding system is available. The practitioner's task is to choose the procedure appropriate to the situation at hand.
Simple cases: freehand remains the first choice
The guest illustrates what this selection looks like in practice with an example: if a single first molar is being replaced, with the second premolar and the second molar still in place and the implant simply having to be positioned between them, he reaches for no navigation device. Freehand is of course faster in such situations – open the cassette and drill. A prerequisite here too, however, remains sound mental planning, because anyone wishing to operate well freehand must equally know where the implant is to sit, where the later crown will be placed and how deep it is inserted.
When computer-guided: the typical indications
Asked by the host where the boundary lies for him and when a case is no longer simple, the surgeon names concrete constellations in which he reaches for computer-guided support in any event:
- Anterior region: a great deal can go wrong here, and the result has to be aesthetically convincing – which is not always simple.
- Extensive bone augmentation: anyone who has gone to great lengths to build up the bone wants to place the implant exactly in the augmented area.
- Complete restorations: particularly when they are carried out in augmented bone.
- Deliberate angulation: cases in which the implant is to be angulated in order, for example, to reach the correct position past the maxillary sinus.
In such situations it is very valuable to have support, is the guest's summary.
Full-arch: the prime case for navigation
The benefit becomes particularly clear, in his view, with complete restorations. With experience, the right structure and the right people alongside, working navigated is definitely faster here than freehand. The procedure is complicated enough – navigation relieves the practitioner of the question of where to drill and which implant belongs where. One knows the sequence of the drills, works as in the freehand approach, but knows precisely at all times what needs to be done in terms of workflow and position. The surgeon speaks of an enormous relief; put succinctly: the more elaborate the procedure, the greater the benefit of the computer-guided approach.
Gain in safety as an additional argument
Alongside the workflow, the system's feedback also speaks in favour of navigation from the guest's point of view: during the procedure the practitioner continuously receives the information about where he is and where he needs to go. In addition, the planning draws attention to anatomical risks – for instance to a strong vessel in the region of the sinus window, which can be avoided by deliberately placing the window lower. The surgeon also sees navigation ahead in terms of predictability: it is more precise, which pays off in particular with immediate loading, when the restoration planned on the computer together with the dental technician can in the end be screwed in exactly as planned.
Conclusion: indication instead of ideology
The conversation culminates in the host's conclusion: freehand is not wrong – but no longer the best solution in every case. Anyone who masters all the procedures and selects them according to the indication ultimately works, in the guest's view, more precisely, more safely and in the patient's interest.