SCIENCE & TECH
Ask Q+A
Dr. Christensen
Guided versus freehand dental implant
placement
AS A GENERAL DENTIST, I am considering becoming more involved with placing dental implants. I have
attended several implant surgery courses and placed a few root-form implants, but I have a question that
Q continues to bother me. Should I orient my practice toward only placing implants using surgical guides,
only placing them freehand, or doing both methods?
More dentistsspecialists and generalistsare placing
A implants. In many countries, implant placement by general
dentists is as common as placing composite resin resto-
rations. At this time, using a surgical guide as a routine
procedure is controversial.
Consider the placement of implants from a historical
perspective. When the original developers of the root-form
implant placement concept introduced this technique to
GORDON J.
CHRISTENSEN,
the profession, there were no cone beam devices and little
DDS, MSD, PhD, or no adaptation of conventional CT radiography to dental
is a practicing implants. Dentists who became involved in placing implants
prosthodontist in
did so with the help of diagnostic casts, panoramic and
Provo, Utah. He is
the founder and
periapical radiographs, and occasionally tomographic im-
director of Practical ages (individual facial-lingual radiographic slices). This
Clinical Courses, an orientation was present until the introduction of cone
international beam imaging about 15 years ago.
continuing-education
Therefore, more than 15 years of implant placement
organization founded
in 1981 for dental
passed without using cone beam or todays sophisticated
professionals. Dr. guided-placement techniques. Undoubtedly, there were
Christensen is a many mistakes made, and some implants could have been
cofounder (with his placed in better locations. However, the long-term service
wife, Rella
characteristics of root-form implants and their approxi-
Christensen, RDH,
PhD) and CEO of
mately 95% success rate is proof of the historical techniques
Clinicians Report viability. Directly related to the introduction of cone beam
(formerly Clinical imaging, guided placement of implants has been available
Research for several years and is becoming more used in the
Associates).
profession.
Is guided placement better than freehand placement? Is
guided placement mandatory or elective? Should you be
considering guided placement for all of your implant place-
ments, none of your patients, or only selected ones? Does it
take more time and cost more money for your practice to use
guided placement routinely? I will answer these questions
for you in the following narrative.
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IN THIS MONTHLY FEATURE,
Dr. Gordon Christensen addresses the most frequently
asked questions from Dental Economics readers. If you
would like to submit a question to Dr. Christensen,
please send an e-mail to info@pccdental.com.
CURRENT TYPICAL TECHNIQUE FOR GUIDED
IMPLANT PLACEMENT
Access to cone beam is necessary for guided implant place-
ment. You may choose to purchase one individually or with
other dentists, find a practitioner in your area who will
provide acceptable images for you, or send the patient to
a local cone beam radiographic laboratory that can make
proper images.
You need to obtain enough continuing education to
learn how to interpret the cone beam images, or have an
oral and maxillofacial radiologist interpret them for you.
In my opinion, its best to learn how to read them yourself
and then use a radiologist when you need help.
Send cone beam information to a laboratory of your
choice. There are hundreds of labs that will be pleased to
make a surgical guide for you. Costs vary among labs.
The following steps are usually involved in making a
surgical guide:
1. Make a diagnostic appointment with the patient and obtain
his or her agreement on placing the implant(s).
2. Make an impression, either a conventional one or a scan
for a virtual model.
3. If you made a conventional impression, pour and trim
the cast.
4. If the impression was a scan, transmit the virtual im-
pression to a laboratory of your choice.
5. Sign up at the laboratory of your choice.
6. When you sign up at the lab, you specify a) the implant
manufacturer you plan to use, b) the brand or type of
implant within that company, c) the surgical kit you will
be using, and d) which archmaxillary or mandibular
7. You may or may not request a wax-up by the lab.
8. The lab will send you an electronic potential plan or
plans for your implant placement.
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 GUIDED VERSUS FREEHAND DENTAL IMPLANT PLACEMENT
9. Communicate with the lab to discuss the potential plans, and ap-
prove the plan of your choice.
10. The lab will send you a further detailed plan for the placement.
11. Communicate with the lab for final approval of the plan.
12. The lab will make the guide and send it to you ( figures 1 and 2).
13. If every step has been done correctly, you have a very accurate guide
for placing the implant(s).
14. Place the implant(s).
Figures 1 and 2:
The lab has made a printed
surgical guide for a specific
case. The designated drill is
easily related to the guide
and provides near-perfect
placement of the implant.
ADVANTAGES OF GUIDED IMPLANT PLACEMENT
If all the steps in the described procedure above are correct, the
implant placement is almost foolproof, accurate, fast, nonthreatening
to the clinician, and predictable.
Guided placement produces confidence for the clinician that the
best technique has been accomplished, and the implant is in the
most appropriate location.
LIMITATIONS OF GUIDED IMPLANT PLACEMENT
An absolutely accurate impression (conventional or virtual) is
mandatory.
An absolutely accurate stone cast or virtual model is mandatory.
Guides are no more accurate than the impressions and casts/models
sent to the lab.
Significant time involvement is required to plan the guide, including
communicating with the lab that makes the guide.
There is a cost for making the guide, although some third-party
payers will provide some financial benefit.
When using most labs, there is a delay while the guide is being made.
CURRENT TYPICAL TECHNIQUE FOR FREEHAND IMPLANT
PLACEMENT
1. Make a diagnostic appointment with the patient and obtain his or
her agreement for placing the implant(s).
2. Make an impression, either a conventional one or a scan for a virtual
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model. Most dentists make a typical conventional diagnostic
impression.
3. If you made a conventional impression, pour and trim the cast.
4. Analyze the casts and the radiographspanoramic, periapical, and
preferably cone beam.
5. Determine the implant type, brand, diameter, length, and apparent
bone density for the sites involved.
6. Place the implant using the freehand technique described later in
this article.
ADVANTAGES OF FREEHAND IMPLANT PLACEMENT
Communication time with laboratory about the guide is
eliminated.
The dentist saves significant time by not having to make the guide.
Depending on your clinical schedule, there is no major wait before
implant placement.
Cost of making the guide is eliminated.
LIMITATIONS OF FREEHAND IMPLANT PLACEMENT
You are required to make clinical judgments on implant placement
based on visualizing the clinical situation from the information
provided by the casts and radiographs.
Placement of the implants usually requires significantly more time
than with the guided technique, since you must think and plan while
placing the implants.
Paralleling numerous implants is more difficult using the freehand
technique.
The technique is not as predictable as adequately accomplished
guided placement.
Most clinicians do not have as much confidence using the freehand
technique as when placing implants with a guide.
Where are we when comparing the two implant-placement
procedures? I have placed implants for more than 30 years, and I have
communicated with many who have had similar experiences. With
that experience, I have the following current opinions relative to the
two procedures. My opinion may change as guided placement becomes
simpler and less expensive, and as cone beam becomes more dominant
in the profession.
PLACING SINGLE IMPLANTS IN HEALTHY PATIENTS WHO
HAVE ADEQUATE BONE:
This situation accounts for the vast majority of implants placed
currently.
The freehand technique is the most used and probably the most
appropriate at this time.
The following freehand technique is simple:
1. From a facial orientation, place the implant osteotomies in the
center of the edentulous space from a mesial and distal orientation,
using periapical radiographs to verify the parallelism and appro-
priate distance from the adjacent teeth ( figure 3).
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 GUIDED VERSUS FREEHAND DENTAL IMPLANT PLACEMENT

2. In the facial-lingual orientation, locate the osteotomies in the 3. Use several periapical radiographs while cutting bone and placing
center of the ridge and parallel with the adjacent teeth. Use finger the implant(s) to verify proper angulation.
contact on the facial and lingual of the ridge while making the
drill cuts. If you feel extra vibration on one or the other side of the PLACING MULTIPLE IMPLANTS IN HEALTHY PATIENTS
ridge, reorient the drill appropriately ( figures 47). WHO HAVE ADEQUATE BONE.
It has been approximated that placing multiple implants in the same
Figure 3: patient constitutes only a small percentage of the total implants
It is easy to center placed. The same concepts as expressed in the previous section are
the implant used if using the freehand technique. However, paralleling the im-
osteotomy between plants can be difficult if not using a guide.
the two adjacent Guided placement can offer significant advantages when placing
teeth using your own multiple implants ( figure 8).
clinical judgment
and periapical
radiographs. Figure 8: Multiple
implant placement
is often difficult,
and surgical guides
Figures 47: can help place the
This series of images implants in the best
shows a clinical locations and parallel
situation, the cone to one another.
beam images, and
the freehand implant
placement.
Additional resources from Practical Clinical Courses

Some of our educational products relate directly to this subject:

One-hour videos
Simple, Inexpensive Implant PlacementGuide or No Guide
Item V2373

Placing Mini Implants, Simple, Safe, and Effective

Item V2360

Two-day hands-on courses

Implant Surgery Level 1 (Single implants in healthy patients
with acceptable bone)

Implant Surgery Level 2 (Multiple implant placement, grafting,

sinus lift, etc.)

For more information on these educational resources, visit our

website at pccdental.com or contact us at (800) 223-6569.

SUMMARY
Placement of single implants in healthy patients who have adequate
bone is a simple procedure and should be a part of most general prac-
tices. Single implants can be very adequately placed by the freehand
technique, or also easily and more predictably placed with the more
complicated and expensive guided-placement technique. Use of a guide
is often indicated for placement of multiple implants or for patients
lacking optimum bone quality or quantity.

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