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B-Guide System: Improving the Predictability of Complete-Arch Implant and

Prosthetic Placement Using Fixed Prosthesis Guides

Article in Journal of Esthetic and Restorative Dentistry · November 2024

DOI: 10.1111/jerd.13369

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Journal of Esthetic and Restorative Dentistry

CLINICAL ARTICLE

B-­Guide System: Improving the Predictability of

Complete-­Arch Implant and Prosthetic Placement Using
Fixed Prosthesis Guides
Luís Bessa1 | João Fonseca2 | Jorge André Cardoso3 | Maurice Salama4,5 | Irena Sailer6 | Luís Azevedo6

1Department of Periodontology, University Institute of Health Sciences (IUCS), Gandra, Portugal | 2University Institute of Health Sciences (IUCS),
Gandra, Portugal | 3Kings College London, London, UK | 4Department of Periodontics, University of Pennsylvania, Philadelphia, Pennsylvania,
USA | 5Department of Periodontics, Augusta University, Augusta, Georgia, USA | 6Division of Fixed Prosthodontics and Biomaterials, University Clinics
for Dental Medicine, University of Geneva, Geneva, Switzerland

Correspondence: Luís Azevedo ([email protected])

Received: 9 October 2024 | Revised: 21 October 2024 | Accepted: 5 November 2024

Keywords: computer-­aided implant placement | dental implants | dental prosthesis | digital dentistry | immediate dental implant loading | implant-­
supported prosthesis

ABSTRACT
Objective: Computer-­aided implant placement (CAIP) offers improved accuracy and reduced invasiveness. However, traditional
static CAIP (sCAIP) protocols for complete-­arch restorations often involve multiple guides and clinical steps, increasing the risk
of soft tissue trauma and procedural complexity. This article introduces the B-­guide technique, which integrates implant place-
ment and interim prosthesis delivery into a single device to simplify the procedure and minimize tissue damage.
Clinical Considerations: The B-­guide combines the implant osteotomy and placement guide with an abutment placement
and prosthesis pick-­up mechanism. The guide remains in place post-­implantation, allowing immediate prosthesis conversion.
A 55-­year-­old female patient underwent complete-­arch rehabilitation using the B-­guide, enabling immediate implant placement
and loading. The B-­guide minimized soft tissue trauma and eliminated the need for multiple guides, significantly reducing treat-
ment complexity and time.
Conclusions: The B-­guide simplifies procedures and improves predictability compared with traditional systems by integrating
prosthetic adaptation and implant placement, reducing cumulative errors. However, its success is heavily reliant on the operator's
expertise, especially in preoperative planning and design.
Clinical Significance: By integrating implant and prosthesis placement into a single guide, the B-­guide reduces surgical com-
plexity, minimizes trauma, and enhances prosthetic outcomes, improving clinical efficiency.

1   |   Introduction during surgery to adjust the handpiece position, whereas sCAIP

relies on a preoperative digital plan and a restrictive surgical
Computer-­aided implant placement (CAIP) has been extensively guide that prevents intraoperative adjustments [4, 5].
described in dental implantology, offering significant advan-
tages such as increased accuracy, reduced invasiveness, and sCAIP guides are further categorized based on their support
shorter surgical times [1–3]. type—mucosa-­supported, tooth-­supported, bone-­supported, or
mixed-­support—and their stabilization strategy, such as stack-
CAIP can be classified into two categories: dynamic (dCAIP) able or non-­stackable/sequential guides [6]. These systems often
and static (sCAIP). dCAIP uses real-­time software feedback involve multiple guides in the same surgery for tasks such as

© 2024 Wiley Periodicals LLC.

Journal of Esthetic and Restorative Dentistry, 2024; 0:1–13 1 of 13

https://doi.org/10.1111/jerd.13369
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spatial indexing, bone reduction, implant placement, and in- access to an in-­house or nearby laboratory with sufficient finan-
terim prosthesis pick-­
up, each requiring a dedicated guide cial and human resources, which many practices lack.
(Table 1).
This article presents a protocol that integrates the implant place-
Correct 3D implant placement in terms of depth [7–11], bucco-­ ment guide with the interim prosthesis into a single device—the
lingual positioning [12, 13], and mesio-­ distal positioning B-­guide (Bridge guide)—to reduce clinical complexity and min-
[14–16] is important for achieving adequate prosthetic out- imize tissue trauma.
come. Proper placement enables the development of a favorable
supracrestal tissue profile, favoring access for screw-­retained
restorations, and optimizing the long-­term stability of both
2   |   Technique Description
hard and soft tissues, as well as esthetics. Therefore, any effort
that can significantly improve correct dental implant place-
2.1   |   B-­Guide System Parts
ment is important.
The B-­guide system comprises two primary components:
While traditional sCAIP protocols are successful, they present
clinical challenges. The multi-­step nature of the process intro-
a. the B-­ guide—this is the core element of the system
duces the potential for errors due to its sequential complexity,
(Figure 1). It features several cylindrical, sleeveless holes
especially in complete-­arch cases [17]. Additionally, the pros-
surrounded by a flat, round plate. The cylindrical holes
thetically driven implant placement is controlled only during
allow for bone drilling, implant placement, and abutment
the design phase, and implant placement requires a separate
pick-­up, converting the guide into a long-­term provisional
guide from that used for prosthesis design. This requires an
restoration. The flat plate in the occlusal area acts as a verti-
additional clinical step to position the interim prosthesis sep-
cal stop for the drills. The system supports only “T-­shaped”
arate from the implant placement guide. A common but often
drills, which include an active area, a frictionless section,
overlooked issue with traditional guides used solely for implant
and a physical stop (Figure 2).
bed preparation and placement is soft tissue trauma. Soft tissue
contours are frequently unprotected during drilling, resulting in b. the carrier system—the carrier system ensures the proper
injury from the guide's internal design or the sleeves [18]. This alignment of the B-­guide with the patient's anatomy, accu-
delay in provisional pick-­up to a point where the tissues are al- rately replicating the three-­dimensional (3D) prosthodontic
ready injured, swollen, or altered from preoperative conditions and implant planning while maintaining stability through-
may create further complications. out all clinical steps. There are two types of carrier systems:
sequential (Figure 3) and stackable (Figure 4). Table 1 sum-
In multiguide systems, difficulties also arise during the pro- marizes the components and assembly methods of different
visional pick-­
up stage, particularly with divergent implants traditional multisystem guides. The B-­guide follows a similar
and abutments placed initially. To address these issues, intra-­ approach for its carrier system. In traditional systems, an in-
surgical scanning and digital acquisition of implant positions, terim prosthesis guide holds the interim prosthesis. In the B-­
followed by same-­day milling of the interim prosthesis, have guide system, this component is called the “Transport Guide”
been proposed [19]. While this approach may offer benefits in for both types of carriers, as the B-­guide functions as more
terms of physical properties and surface conditions, it requires than just an interim prosthesis—it is a multifunctional guide.

TABLE 1    |    Different types of traditional multiguide systems.

Type of multiguide
Stackable guide system Sequential guide system
Assembly method Guides are placed and removed using Guides are placed and removed
stackable parts. The base plate stays sequentially using single piece parts.
in place the whole procedure.
Index guide Used to index the base plate/can be used Used to drill/place skeletal pins/can be used
to place one or more reference implants. to place one or more reference implants.
Base plate Positioned by the index guide Not used.
to drill/place skeletal pins.
Bone reduction/osteotomy guide Stacked to the base plate. Anchored on pin holes created by the
Used for bone reduction. base plate. Used for bone reduction.
Implant placement guide Stacked to the base plate. Used Uses same skeletal pins locations as
for implant placement. index. Used for implant placement.
Interim prosthesis guide Stacked to the base plate. Uses same skeletal pins locations as index.
Used to keep a correct position of the Used to keep a correct position of the
provisional prosthesis during conversion. provisional prosthesis during conversion.

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FIGURE 2    |    Cylindrical pathways with flat physical stop—B-­g uide drilling function using T-­shaped guided drills.
FIGURE 1    |    3D rendering of the multifunctional device named B-­g uide.

FIGURE 3    |    Sequential carrier system for B-­g uide.

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FIGURE 4    |    Stackable carrier system for B-­g uide.

2.2   |   B-­Guide System Versus Traditional 2.3.2   |   Data Acquisition

Multiguide Systems
The initial steps follow a similar workflow to digital implant
Table 2 summarizes some of the differences between conven- planning for complex cases using a fully guided system: facial
tional multiguide systems and the B-­guide, categorized into photos/scans, intraoral scans, and digital imaging and commu-
three principal areas with clinical implications: technical, sur- nications in medicine (DICOM) files. After merging and regis-
gical, and prosthetic considerations. tering these datasets, the planning and design stage begins.

2.3   |   Clinical Protocol 2.3.3   |   Planning and Design

2.3.1   |   Case Selection—Indications This phase consists of several steps, as outlined in Figure 5.

and Contraindications First, an aesthetic and preliminary prosthodontic design is cre-
ated, followed by a soft tissue simulation to define tissue goals,
Similar to other CAIP techniques, proper case selection including critical and subcritical profiles and pontic designs
based on specific indications is crucial for achieving satisfac- (exocad DentalCAD, exocad GmbH, Germany) [21]. Once these
tory results, from both biological, functional, and aesthetic are established, dental implants (copaSKY, bredent medical
perspectives. GmbH, Germany) are positioned within the arch according to
prosthodontic planning, ensuring their ideal 3D placement.
Clinical indications for the B-­g uide include partial or complete-­
arch cases requiring dental implants, prosthetic concept with- Next, the relationship between the preliminary design and the
out artificial gingiva (such as FP1 or FP2, according to Misch's anatomical situation is evaluated. To accurately capture the
[20] classification), and a pre-­operative situation with a mini- initial anatomical shape of the alveoli and soft tissue after ex-
mum of three stable teeth distributed bilaterally, as stable ref- tractions, an AI-­assisted segmentation process is used to gener-
erence points are essential for precise skeletal fixation before ate standard tessellation language (STL) files from DICOM data
placing the B-­g uide. Two or even one tooth could be viable (BlueSkyPlan, BlueSkyBio, USA). These serve as a reference to
options, provided other fixed elements, such as temporary im- integrate the initial soft tissue profile (from intraoral scans), the
plants, ensure tripod stability; however, these alternatives have alveolar bone model (from segmented cone-­beam computed to-
not been tested by the authors. Additionally, bone regulariza- mography [CBCT]), and the prosthodontic design defining ideal
tion, if needed, should not exceed 2 mm vertically, and imme- gingival margins.
diate loading must be possible. Clinical contraindications for
the B-­g uide include severe bone atrophy in the lower or upper These references help fine-­tune the implant positions and final-
jaw, the need for a dentogingival prosthesis (FP3, according to ize the prosthodontic design in critical and subcritical areas, as
Misch's classification [20], as the B-­g uide may not be suitable well as pontic regions. As a key principle, areas of tissue resec-
for cases that involve significant tissue manipulation and po- tion or addition are identified. For instance, some parts of the
tential anatomical changes), anatomical features that prevent preliminary design might overlap with existing hard or soft tis-
the axial distribution of implants up to the second premolar sue, requiring clearance to prevent fitting issues during surgery
bilaterally, the necessity for surgical bone reduction exceeding and reduce soft tissue trauma. Conversely, areas lacking tissue
2 mm vertically, inability to achieve immediate loading, and the might require augmentation based on the clinician's preferences
requirement for angled multi-­units due to the placement of an- and the predictability of the surgical technique that was defined
gled implants. using the digital data from the CBCT and the initial STL file.

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The biological contact area also demands special attention. clearance. In healed sites, excessive tissue may require bone
Typically, the B-­guide design extends apically beyond the soft reduction or displacement. The prosthetic design must ac-
tissue gingival margin (critical contour) [21], with a subcriti- count for these changes and simulate viable soft tissue out-
cal, intra-­alveolar section at the implant sites. The deeper the comes, as well as bone resection modifications, as shown in
design, the fewer adjustments are required during surgery, but Figure 6.
excessive apical extension may interfere with existing anatomy
or the choice of abutments. Based on clinical experience, the In a traditional system, the guide design would be completed at
recommended extension into the intra-­alveolar area is 1–2 mm, this stage. However, with the B-­guide, the prosthetic design, im-
depending on implant depth and abutment height, to avoid tis- plant tube extensions, and drill offset data are exported to open
sue trauma. software (e.g., Autodesk Meshmixer, Autodesk Inc. USA), where
they are combined to create the bridge-­shaped B-­guide. The last
In edentulous sites, an ovate or stepped pontic design is used step is designing the carrier system—either sequential or stack-
for soft tissue accommodation [22], maintaining a 2 mm bone able—within the same software.

TABLE 2    |    Different types of traditional multiguide systems versus B-­g uide system.

Conventional multiguide system B—Guide (one single device

(separate devices for implant for implant placement and
placement and provisional pick up) provisional pick up)
Technical Complexity of Several steps and devices insertion Less steps and devices insertion
considerations clinical steps and removal result in a potentially and removal result in a
more complex procedure. potentially simpler procedure.
Cumulative errors More guides and steps can result in Less guides and steps can
potentially more cumulative errors result in potentially less
throughout clinical steps. overall cumulative errors.

Visualization of Only in the last clinical step when Early surgical step after removing
prosthetic outcome placing the provisional prosthesis with the index guide and before drilling
the provisional prosthesis guide. and placing dental implants.

Surgical Surgical time Several steps and devices insertion Potentially shorter surgical time
considerations and removal result in potentially since implant placement, abutment
longer surgical time. placement and provisional pick-­up
is done with only one device.
Soft tissue Soft tissue trauma is common because soft The B-­guide is placed immediately
(management) tissues are not protected from drilling/ after extractions. With a correct
trauma placement. The guide design usually anatomical driven design, it
does not consider an anatomical design protects soft tissues during
to assure soft tissue protection. drilling and implant placement.
Soft tissue Allow for soft tissue management or Allow for soft tissue management or
management/ augmentation if guide and provisional augmentation if carrier system and
augmentation design take it into account. B-­guide design take it into account.
Prosthetically Only controlled during the planning design Directly controlled through the
driven implant stage and not possible to assure during B-­guide that serves as the implant
placement surgery without removing the implant placement guide and as a prosthetic
placement guide. Directly controlled during guide blended into one device.
the design phase. Indirectly controlled
during surgery because implant guide and
prosthetic guide are separate devices.
Pre-­op tissue Soft tissues are kept unsupported from Since B-­guide has an anatomical
contour the moment of extraction until the basal shape, it keeps the alveolar
maintenance screwing of the immediate prosthesis. soft tissue contours better supported
during clinical procedures.

(Continues)

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TABLE 2    |    (Continued)

Conventional multiguide system B—Guide (one single device

(separate devices for implant for implant placement and
placement and provisional pick up) provisional pick up)
Prosthetic Implant and Conversion of provisional after Since the abutments are placed
considerations abutment abutment installation is made using through the B-­guide, this
divergency causing a separate guide. This can be difficult difficulty is minimized.
problems during and create time consuming try-­ins and
provisional pick up adjustments procedures due to possible
cylinder angulation divergence.
Design of Usually made of pick-­up material. The subgingival design is largely pre-­
subgingival made in the provisional minimizing
contour on the the volume of the pick-­up material.
provisional
Provisional Usually longer since adjustments Potentially shorter since
pick-­up time. are more common, and material the provisional is picked-­up
pick-­up volume is higher. with less material and fewer
adjustments need to be made.
Finishing steps The design of the guides and the provisional The indications and design of the
can be adjusted to align with a chairside B-­Guide system are always aimed
protocol, although it is unclear which at a chairside finishing protocol.
cases qualify for this approach.

2.3.4   |   Fabrication Additional soft tissue grafts can be performed at this stage, and
the B-­guide is then secured. The flaps in edentulous areas are
The B-­guide is milled from high-­density PMMA material (Prime kept buccally positioned and sutured.
Multistratum, Zirkonzahn GmbH, Italy), while the carrier sys-
tem is 3D-­printed in resin (SG Resin, Formlabs, USA). A special-
ized computer-­aided manufacturing (CAM) software strategy 2.3.6   |   Advantages of the Technique
ensures precise milling (Zirkonzahn Nesting, Zirkonzahn
GmbH, Italy). Before delivery, both components should be thor- The present technique allows clinicians to: (1) use the B-­guide
oughly inspected for accuracy and quality. If desired, a palatal for both implant osteotomy and placement, (2) retain the B-­guide
substructure can be added to increase the provisional's durabil- in position for abutment placement and pick-­up, converting it
ity and strength (Figure 7). chairside into an interim bridge in a streamlined procedure, (3)
ensure effective and predictable prosthetically driven implant
placement, (4) reduce soft tissue trauma, (5) pre-­form a signif-
2.3.5   |   Surgical Sequence icant portion of the biological peri-­implant and pontic shapes
during the computer-­assisted design (CAD) stage, and (6) de-
Index guides are placed either on the teeth or mucosa, depend- crease overall clinical complexity, steps, and potentially surgi-
ing on clinical conditions. For instance, a minimum of three sta- cal time.
ble roots is used for indexing, following the STAR concept [23].
The transport guide and B-­guide are then positioned based on
the chosen system (stackable or sequential). 3   |   Clinical Report

A flapless approach is typically preferred in extraction sockets A 55-­year-­old female patient presented for a consultation re-
to minimize tissue trauma, promote faster healing, and reduce garding complete-­mouth rehabilitation. A thorough review of
volumetric changes caused by flap elevation [24–26]. In edentu- her medical history revealed no systemic contraindications for
lous regions, a palatal incision is made, and the flap is reflected, implant surgery. A series of intraoral and extraoral photographs
displaced buccally, and temporarily sutured to minimize in- were taken, followed by a CBCT scan (CS 9600, Carestream
terference during the procedure. Implants are placed directly Dental LLC USA) and an IOS scan (Medit i500, Medit Corp.,
through the B-­guide, with guided drivers left in place for addi- South Korea). In the upper arch, four incisors (teeth 11, 12, 21,
tional stability. 22) and two molars (teeth 17 and 18) remained, although both
molars exhibited extrusion, encroaching upon the prosthetic
Intermediate abutments (e.g., multi-­units' abutments) and pro- space in the lower arch (Figure 8A).
visional cylinders are inserted through the B-­guide, facilitating
a quick chairside pick-­up procedure with self-­cured acrylic resin Initially, an orthodontic intrusion of the posterior teeth using
(Qu-­resin, bredent medical GmbH & Co.KG, Germany). Once skeletal anchorage was proposed, combined with dental im-
the pick-­up is complete, the B-­guide is finished and polished. plant placement in the edentulous areas. However, the patient

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FIGURE 5    |    Planning and design sequence.

FIGURE 6    |    Example of an area where the pontic design of B-­g uide collides with existing bone anatomy and the need for reduction. (A) Graphic
representation, (B) clinical example.

declined this option due to her dental phobia and concerns patient had provided written informed consent for the treatment
about the extended treatment duration [27]. Instead, she opted and for the use of their case details in this report.
for a complete upper arch rehabilitation with immediate im-
plant placement and immediate loading under sedation, as it The CBCT and IOS scans were superimposed, and a facially driven
better suited her preference for a shorter treatment timeline. The digital wax-­up for both arches was made. Implant positions were

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FIGURE 7    |    Optional bondable reinforcement sub-­structure designed (left) and milled (right).

FIGURE 8    |    Preoperative and B-­g uide fabrication. (A) Baseline photographs, (B) 3D-­printed index guide, (C) B-­g uide milled, (D) B-­g uide system.

planned in 3D based on the wax-­up to ensure a prosthetically-­ through the fixation holes, one at a time, to avoid mucosal distor-
driven outcome. To reduce the risk of zirconia fractures—asso- tion and maintain the accuracy of the guide. Complete maxillary
ciated with full-­arch bridges depending on their extension and anesthesia was subsequently achieved. Atraumatic extractions
cross-­section—eight implants were strategically placed in the re- of the premaxillary teeth were performed (Figure 9D), while
gions of the central incisors, canines, second premolars, and first the molars were left intact to provide support for the tooth-­
molars [28]. This allowed the prosthetic design to be divided into supported guide during implant placement. Full-­thickness pal-
three bridges. Importantly, implant placement in the lateral inci- atally displaced incisions were made at the edentulous sites to
sor region was avoided due to the disproportionate size of multi-­ mobilize crestal and palatal tissue toward the buccal aspect, en-
unit abutments relative to the anatomy of lateral incisors. hancing arch width and future papilla height.

A surgical guide (B-­guide) (Figure 8B–D) was carefully posi- The B-­guide was positioned using a transport guide (Figure 9E,F),
tioned (Figure 9A–C), and local anesthesia was administered and sCAIP were completed (Figure 9G–I). This confirmed the

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FIGURE 9    |    Surgical sequence. (A) Index guide try-­in, (B) fixation pins drilling, (C) index guide with fixation pins in place, (D) teeth extractions,
(E) B-­g uide system, (F) frontal view of B-­g uide system, (G) dental implants placement, (H) B-­g uide in position, (I) bone distance measurement.

final 3D implant positions. Unicone abutments (bredent medical polishing was completed using abrasive discs (Sof-­ Lex, 3M,
GmbH & Co.KG, Germany) and temporary prosthetic cylinders USA) and interproximal sandpaper strips (Epitex, GC Corp.,
(bredent medical GmbH & Co.KG, Germany) were then installed Japan). Occlusion was assessed with 100 μm carbon paper
through the B-­guide (Figure 10A). To convert the B-­guide into the (Bausch occlusion paper, Cologne, Germany) in maximal in-
final implant-­supported interim prosthesis, resin (Qu-­resin, bre- tercuspal position (MIP), as well as in excursive movements,
dent medical GmbH & Co.KG, Germany) was used to connect it to with and without the simulation of bruxing activity. The final
the temporary prosthetic cylinders (Figure 10B,C). Prosthetically-­ polishing was done using finishing rubbers (Astropol Gray,
driven bone reduction was assessed with the converted B-­guide Ivoclar Vivadent, Liechtenstein), followed by polishing rubbers
in place, reference points were recorded for further adjustments. (Astropol Green and Pink, Ivoclar Vivadent, Liechtenstein). The
polished converted B-­guide was then screwed back into place,
After removing the B-­guide and transport guide, bone reduction and the flaps were sutured around it. The postoperative phase
was performed. The extraction sockets were grafted using the was uneventful (Figure 11A,B).
dual-­zone technique with collagen xenograft (Purgo Collagen,
Purgo) at both the bone and soft tissue levels to preserve vol- Four months later, the postoperative evaluation was favor-
ume and minimize the need for additional connective tissue able (Figure 11C–F). The B-­guide was removed, and a digital
grafts. PRF membranes (PRF System France) were applied to impression was taken (Medit i700, Medit Corp., South Korea)
protect the grafts in the extraction sites and to cover the exposed (Figure 12A). Due to the implant distribution, a segmented
bone in the posterior region where flaps had been elevated design for the final prosthetics had been planned from the
(Figure 10D–F). outset. To verify passivity, three aluminum bars were milled
(Figure 12B,C). Reverse analog ISBs (ScanAnalog, Zirkonzahn
The unfilled gaps around the temporary cylinders were relined GmbH, Italy) were used to capture the final implant positions.
with flowable composite resin (Tetris Flow, Ivoclar Vivadent,
Liechtenstein) at the basal aspect of the B-­guide. Finishing, A try-­
in of the teeth was conducted, with esthetics as-
polishing, and occlusal adjustments were performed. Initial sessed through photographs and videos (Figure 12D,E).

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FIGURE 10    |    Prosthetic sequence. (A) Intermediate abutments and temporary cylinders placement through the B-­g uide, (B) B-­g uide after
conversion in interim prosthesis, (C) B-­g uide after polishment, (D) soft-­tissues management, (E) frontal view after suturing, (F) occlusal view of
B-­g uide in place.

FIGURE 11    |    Healing stage. (A) Frontal view after 1 month, (B) frontal view after 2 months, (C) frontal view after 4 months, (D) soft tissues
emergence profile on the right side, (E), frontal view of the soft tissues emergence profile, (F) soft tissues emergence profile on the left side.

Occlusion and force distribution were evaluated using the T-­ 4   |   Discussion
Scan system (Tekscan, USA). The final outcome, with a six-­
month follow-­up, can be seen in the accompanying images Based on the authors' experience, integrating the implant oste-
(Figure 12F). otomy and placement guide with the interim restoration into a

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FIGURE 12    |    Final stage. (A) Upper scanbodies in place for the intraoral digital impression, (B) passive fit evaluation with a passive fit bar, (C)
passive fit bar splinted in mouth, (D) occlusal view of soft tissue emergence profile, (E) milled try-­in prototype for aesthetic evaluation, (F) final
prosthesis after 6 months.

single device appears to offer several clinical advantages, such benefit lies in combining the implant drilling and placement
as shorter surgical time and a potential reduction in position- guide with the interim prosthesis, which reduces both the
ing errors. However, these benefits need to be assessed in future number of devices needed and the overall surgical time. More
studies to confirm their clinical significance. importantly, this integration ensures prosthetically driven
implant placement, potentially minimizing errors that can
Several systematic reviews and meta-­analyses have highlighted arise when using separate guides for implants and prosthetics
the clinical benefits of CAIP, including improved accuracy and placement.
more prosthetically driven implant positioning [2, 3]. This may
also contribute to lower implant failure rates [29]. While CAIP The B-­guide system allows for some divergence in implant place-
is relatively new, various techniques, guide types, and work- ment, provided this does not interfere with fitting the prosthesis
flows have been proposed by different authors [6, 23]. These over straight multi-­unit abutments. However, cases that require
approaches are particularly emphasized in complex complete-­ angled multi-­units due to the placement of angled implants are
arch cases, where positioning errors are more likely to occur not suitable for this method. The B-­guide is most appropriate
[1]. The success of these workflows depends heavily on careful for Misch FP1/FP2 cases [20], given their biological, aesthetic,
planning, design, and surgical expertise, underscoring the im- and functional requirements, as well as the surgical capabili-
portance for adequate clinician training. Although research in ties required. While the B-­guide could potentially be used for
CAIP is growing, much of the progress continues to be driven FP3 cases, specific limitations need to be addressed in future
by clinical experience and innovation of individual practitioners studies. The significantly greater tissue manipulation in FP3
using CAD software. surgeries may lead to more pronounced anatomical changes.
Consequently, an adapted B-­guide protocol would be required
Multiguide systems, however, are prone to errors in 3D posi- to account for these differences.
tioning during the treatment process [30]. To address this, var-
ious redundancy strategies, such as, retaining certain teeth for One potential limitation of the B-­guide system is the need to
support [23] and using sequential implant placement guides for modify the occlusal surfaces of the interim prosthesis to ac-
tooth or skeletal fixation during surgery, have been introduced commodate the drilling stop platform. Although, this may re-
[6]. The B-­guide, as a multiguide system, is not immune to these quire additional occlusal adjustments, the author's experience
indexing errors. Therefore, it could benefit from similar redun- suggests that this has not posed a significant clinical challenge
dancy strategies. Reducing the number of guides in the B-­guide compared with traditional systems.
system could also help minimize cumulative errors, a hypothe-
sis that requires validation through clinical studies. Soft tissue management is especially critical in FP1/FP2
cases [20], and the B-­guide offers particular advantages in this
Compared with traditional multiguide systems, the B-­g uide regard. First, the subcritical shape of the implant areas is largely
offers distinct advantages in complete-­a rch cases. Its main established during the planning stage, reducing the need for

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 17088240, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.13369 by Bibliotheque de l'Universite de Geneve, Division de l'information, Wiley Online Library on [19/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
chairside adjustments. Furthermore, the design helps protect Edentulous Patients and Possible Influencing Factors: A Systematic Re-
the soft tissues during implant drilling and placement, a fea- view and Meta-­A nalysis,” Journal of Prosthodontic Research 66, no. 1
ture not typically included in traditional systems. In traditional (2022): 29–39.
approaches, separate guides are often used to pick up the pros- 2. A. Khaohoen, W. Powcharoen, T. Sornsuwan, P. Chaijareenont, C.
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justments that compromise the peri-­implant area and increase With Computer-­A ided Static, Dynamic, and Robot-­A ssisted Surgery:
A Systematic Review and Meta-­A nalysis of Clinical Trials,” BMC Oral
surgical time and complexity. The B-­guide avoids these issues,
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3. A. Takács, E. Hardi, B. G. N. Cavalcante, et al., “Advancing Accuracy
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Methods,” Journal of Dentistry 139 (2023): 104748.
an interim prosthesis can be performed [19]. While this approach
results in a strong, biocompatible prosthesis, it can delay the pro- 4. X. Yu, B. Tao, F. Wang, and Y. Wu, “Accuracy Assessment of Dynamic
Navigation During Implant Placement: A Systematic Review and Meta-­
cedure, potentially leading to complications such as tissue swell-
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method requires access to advanced laboratory facilities, which
may not be available in all clinical settings. 5. A. Jorba-­García, A. González-­Barnadas, O. Camps-­Font, R. Figue-
iredo, and E. Valmaseda-­Castellón, “Accuracy Assessment of Dynamic
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In summary, from the authors' experience, the B-­guide system Analysis,” Clinical Oral Investigations 25, no. 5 (2021): 2479–2494.
could reduce surgical time and complexity, while improving
predictability and simplifying clinical procedures compared to 6. J. D'haese, J. Ackhurst, D. Wismeijer, H. De Bruyn, and A. Tahmaseb,
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sions of Peri-­Implant Mucosa: An Evaluation of Maxillary Anterior
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on key parameters such as surgical time, clinical outcomes, and
long-­term success rates, comparing the B-­guide with currently 8. H. Gluckman, C. C. Pontes, J. Du Toit, C. Coachman, and M. Salama,
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published methods to provide a comprehensive evaluation of its
CBCT Descriptive Cross-­Sectional Study. Int,” Journal of Esthetic Den-
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CAIP is a dynamic and evolving field, with innovative designs and
10. T. Linkevicius, A. Puisys, M. Steigmann, E. Vindasiute, and L.
strategies continually emerging. The B-­guide technique offers a
Linkeviciene, “Influence of Vertical Soft Tissue Thickness on Crestal
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preoperative planning and design. Future clinical studies are es- G. O. Gallucci, “Implant Prosthodontic Design as a Predisposing or Pre-
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73–80.
The authors thank Digital4All Team for all material and intellectual
support throughout the development and testing stage of this project. 13. A. Monje, A. Roccuzzo, D. Buser, and H. L. Wang, “Influence of
Buccal Bone Wall Thickness on the Peri-­Implant Hard and Soft Tissue
Dimensional Changes: A Systematic Review,” Clinical Oral Implants
Conflicts of Interest Research 34, no. 3 (2023): 157–176.
The authors declare no conflicts of interest. 14. A. Ramanauskaite, A. Roccuzzo, and F. Schwarz, “A Systematic
Review on the Influence of the Horizontal Distance Between Two Ad-
Data Availability Statement jacent Implants Inserted in the Anterior Maxilla on the Inter-­Implant
Mucosa Fill,” Clinical Oral Implants Research 29, no. Suppl 15 (2018):
The data that support the findings of this study are available on request 62–70.
from the corresponding author. The data are not publicly available due
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