Surgical guide for dental implant placement

Curtis M. Becker, DDS, M S D , a and David A. Kaiser, DDS, M S D b

University of Colorado Health Science Center, Denver, Colo., and University of Texas Health Science
Center at San Antonio, San Antonio, Texas

Restorative problems with less than desirable implant placement can be challenging. A procedure is
presented for the fabrication of a surgical guide stent that dictates placement of dental implants.
This surgical guide can enhance implant placement in an efficient and acceptable manner so that final
restorations can be properly contoured and esthetic. (J Prosthet Dent 2000;83:248-51.)

S i n c e the introduction of dental implants, the need

for appropriate placement of the implant has always
been essential. Restorative problems with less than
desirable placement o f implants can be challenging
(Fig. 1). With the advent of improved surgical tech-
niques, new and improved grafting biomaterials, multi-
ple dental implant options, and increased knowledge
about bone and wound healing, dentistry can offer the
patient a natural-appearing final result.
Patients expect a level of esthetic and functional
excellence that was the exception 10 to 15 years ago.
This new standard for dental implants requires precise
placement of each implant so that a restorative dentist
can address the esthetic demands of a patient. Although
many dentists readily acknowledge the need tbr precise
placement of implants, there is little published infor- Fig. 1. Placement of implant with facial angulation that
mation regarding surgical guide stints that assist the make esthetics difficult.
surgeon achieve precise placement. 1 4
The purpose of this article is to describe a procedure
to construct a precise surgical guide. When used appro-
priately at the time of surgery, demands of the patient
can be achieved.
TREATMENT PLANNING
The precise placement of implants is directly depen-
dent on the amount of quality of bone in a desirable
implant site and on the "dcsired end placement" of the
restoration. ] To avoid placement of implants in sites
that are unsuitable restoratively or when there is inade-
quate bone, communication between the surgeon and
the restorative dentist is essential. To enhance this com-
munication, a diagnostic wax-up of the ideal placement
of each tooth should be completed before surgical dis-
cussions. In some instances, this can be as simple as Fig. 2. Diagnostic wax-up is essential for determination of
placement of denture teeth on provisional tooth-form position of implant placement.
crowns on a hand-articulated diagnostic cast. Con-
versely, a complete diagnostic wax-up with use of a pre-
cision articulator and appropriate maxillomandibular
registrations may be indicated (Fig. 2). With the diag-
aAssociate Clinical Professor, Department of Fixed Prosthodontics,
University of Colorado Health Science Center. nostic wax-up and appropriate radiographs, the sur-
bAssociate Professor, Department of Prosthodontics, Dental School, geon can dctcrmine placement of implants in the
University of Texas Health Science Center at San Antonio. desired positions. The restorative dcntist can augment

248 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 83 NUMBER 2

BECKER A N D KAISER THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 3. Pour 2 casts from irreversible hydrocolloid copy of Fig. 5. Cut holes in vacuum-formed template where implants
diagnostic wax-up. Teeth (and pontics) where implants will are placed.
be placed are cut from a duplicate cast.

Fig. 6. Surveyor determines optimal path of insertion for

implants.

responsibility of a restorative dentist to construct a sur-

gical guide template that dictates to the surgeon exact
placement of each implant. This ensures that implant
placement will not compromise the restoration.
PROCEDURE
1. Complete diagnostic wax-up and duplicate the
diagnostic wax-up with irreversible hydrocolloid,
then pour 2 casts in stone (Fig. 3).
2. Make a vacuum-formed, clear template (0.020-in.
Fig. 4. Make vacuum-formed clear template, with O.020-in. thickness) on one of the duplicate casts (Fig. 4).
thick material. 3. Cut teeth (and pontics) off second cast (step 1)
where implants will be placed (Fig. 3).
4. Place the vacuum-formed clear template from step
the desired treatment plan to accommodate optimal 2 on the cast with teeth and pontics removed from
implant placement if needed. After the surgeon and step 3.
restorative dentist have agreed on a desired treatment 5. Cut holes through occlusal surface of the vacuum-
plan to accommodate implant placement, it is the formed template over the site of each implant (Fig. 5).

FEBRUARY 2000 249

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 7. Surveyor to ensure parallelism, drill holes in working
cast where each implant is placed.
Fig. 8. Place brass tubes (size 3/16in.) on parallel pins that are
placed in holes drilled in working cast. Brass tubes extend 1
to 2 mm past vacuum-formed template.
6. Place the cast with the vacuum-formed template
on the surveyor and determine the path o f inser-
tion for optimal placement (Fig. 6). (This will
ensure parallelism o f implants and subsequent
implant abutments. It should also direct the sur-
geon not to place implants in interproximal areas.)
7. Use a slow-speed handpiece attached to the sur-
veyor and a %>in. diameter drill and place holes in
cast where each implant is to be placed (Fig. 7).
8. Use 2 brass tubes (K&S Engineering, Chicago,
I11.) to ensure appropriate surgical placement o f
the implants. The sizes o f the tubes are %2 and
3A6 in. in diameter. (The %2-in. tube corresponds
to a 3.3-mm surgical drill; the ¾6-in. tube corre-
sponds to a 4 . 1 - m m surgical drill. These brass
tubes can be purchased inexpensively at most
hobby shops and come in lengths o f approximate-
250
BECKER A N D KAISER
Fig. 9. Attach brass tube to vacuum-formed template with
orthodontic resin.
Fig. 10. Strengthen guide stent by adding more orthodontic
resin around brass tubes from internal side and on lingual of
vacuum-formed template.
ly 12 to 14 in. The ¾6-in. tube is sectioned in
lengths o f 4 to 8 mm with a separating disk.) Slide
a ¾6-in., sectioned brass tube over a paralleling pin
and place a pin with a brass tube in each o f the
holes drilled in the cast in step 7. The brass tube
must extend past the vacuum-formed template
approximately 1 to 2 mm (Fig. 8).
. Use a clear orthodontic resin (Dentsply, Caulk,
Milford, Del.) and attach brass tubes to the vacu-
um-formed template (Fig. 9). Once the resin has
set, remove the template, with the brass tubes
attached, from the cast and place additional clear
orthodontic resin to the underside to ensure firm
attachment o f the v a c u u m - f o r m e d template.
(Because the 0.020-in., clear vacuum-formed
material is not rigid, additional resin may be added
to the lingual surface to strengthen the guide
stent. This is particularly important when implants
are placed in a distal extension area [Fig. 10].)
VOLUME 83 NUMBER 2
BECKER AND KAISER THE JOURNAL OF PROSTHETIC DENTISTRY

l 1. Sterilize the completed guide stent fbr the appro-

priate time before surgery.
SUMMARY
This article describes a procedure tbr constructing a
precise surgical guide that ensures appropriate place-
mcnt o f dental implants. If implants are placed proper-
ly, the position o f abutments will bc suitable. This will
result in a functional and esthetically pleasing restora-
tion. Although the procedure is time-consuming dur-
ing the diagnostic phasc o f treatment, it is worth the
effort to ensure a long-term esthetic and functional
result.

Fig. 11. Smaller brass tube (size 5k2 in.), cut to fit inside larg- REFERENCES
er brass tube, allows surgeon to precisely drill pilot hole and
first twist drill (2.2 mm) hole for implant placement. 1. Graver D, Belser U. Restoration driven implant placement with restoration
generated site development. Compend Contin Educ Dent 1995;16:796.
2. Tanaka M, Sawaki Y, Niimi A, Kaneda T. Effects of bone tapping on
osseointegration of screw dental implants. [nt J Oral Maxillofac Implants
1994;9:541-7.
10. Use a %>in. brass tube and cut a section so it is 2 3. Kennedy BD, Collins TA Jr, Kline PC. Simplified guide for precise implant
to 3 m m more than any attached brass tube in the placement: a technical note. IntJ Oral Maxillofac Implants 1998:13:684-
8.
completed guide stent. Slip this tube inside one of 4. Jensen OT. The sinus bone graft. Chicago: Quintessence Publishing Co;
the larger brass tubes connected to a completed 1999. p. 49-50.
guide stent. (This smaller tube will be used by sur-
Reprint requests to:
geon to make a pilot hole at surgical placement o f DR DAVIDA. KAISER
implants and is also the same size as the osseous UTHSCSA DENTALSCHOOL
drill [2.2 mm] [Fig. 11]. The larger tube is the 7703 FLOYDCURLDR
SAN ANTONIO.TX 78284-7912
same size as the surgeon's second osseous drill FAX: (210)567-6376
[3.5 mini. I f a surgeon has selected an implant that E-MAIL: kaiser@uthscsa.edu
is wider than 3.5 ram, then the guide stent is
Copyright © 2000 by The Editorial Council of The Journal of Prosthetic
removed and holes are enlarged to the desired size Dentistry.
without a guide stent.) 0022-3913/2000/$12.00 + 0.10/1/104280

FEBRUARY 2000 251