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A dual-purpose guide for optimum placement of dental implants

Murat C. Çehreli, DDS, PhD,a A. Can Çaliş, DDS,b and Saime Şahin, DDS, PhDc
Faculty of Dentistry, Hacettepe University, Ankara, Turkey
Correct placement of implants is a requirement for implant treatment. The use of computed tomogra-
phy and precise surgical guides is required when inadequate bone support is anticipated. This article
describes the fabrication and use of an acrylic resin dual-purpose guide for radiographic evaluation of
recipient sites and implant placement, which uses internally stacked stainless steel surgical guide chan-
nels. The drill guides are machined to allow consecutive surgical drills to be used without changing the
implant angulation during surgery. (J Prosthet Dent 2002;88:640-3.)

O sseointegration has provided predictable long-

term success in the rehabilitation of completely and par-
precise surgical guides may be helpful to the surgeon in
placing implants accurately in low-density bone, in
tially edentulous patients.1-4 The ultimate objective of which there is a higher risk of malaligning implants in
implant treatment is a functional, esthetic, and easily comparison to dense bone.27 A dual-purpose guide in-
maintained restoration.5,6 Correct implant placement is corporating a single stainless steel surgical guide has
essential. Accurate radiographic images of the potential been described.7 The need for prefabricated surgical
recipient sites and proper surgical guides are required to guides that could be internally stacked to form an assem-
place implants in their predetermined position.7 bly or individual tubes with dimensions that would
In the last decade, computed tomography (CT) has match the diameter of all surgical drills used during a
frequently been used as an imaging technique for pre- routine dental implant surgery has been mentioned.20
operative evaluation of the maxilla or mandible for im- The purpose of this article is to describe the use of in-
plant treatment.8-12 The evaluation of available bone in ternally stacked prefabricated surgical guides in a dual-
thin multiplanar images offers improved determination purpose guide to place implants in the anterior maxilla.
of the location of anatomic structures and of the bone This approach is an evolution of a guide presented in a
density.13-15 Among all imaging techniques, currently, previous article by the authors.7 The guide includes 3
CT is more accurate in evaluating recipient sites and internally stacked stainless steel drill guides machined to
locating vital structures such as the mandibular ca- allow consecutive surgical drills to be used without
nal.16-18 changing the implant angulation during surgery.
Guides with radiopaque markers assist in determining
the dimension, location, and angulation of implants ac-
cording to the available bone and vital structures and the TECHNIQUE
proposed prosthesis.7,19-25 Surgical guides can be fabri- 1. Make impressions of both arches with an irrevers-
cated with the information obtained from periapical or ible hydrocolloid impression material (CA 37;
panoramic images. The main disadvantage of radio- Cavex, Harleem, Holland), and pour casts in type
graphic techniques is the 2-dimensional image they pro- III dental stone (Moldano; Bayer, Leverrusen, Ger-
vide. The determination of implant position in a guide many). Complete maxillomandibular records, and
partially based on 2-dimensional imaging requires as- mount casts in a semiadjustable articulator (Model
sumptions.12,26 Dual-purpose guides, however, are ac- 8500; Whip Mix Corp, Louisville, Ky.).
tually radiographic guides that are modified for implant 2. Determine the dental implant recipient sites and
surgery.7,20-22 For such guides the location and angula- complete an appropriate arrangement of artificial
tion of implants are determined by the CT image. The teeth. Make a single-mix condensation silicone
data are then transferred to the same guide through a (Coltene/Whaledent, Mahwah, N.J.) impression of
conversion procedure.7,20-22 Therefore dual-purpose the artificial teeth. Upon setting, remove the im-
guides may be more useful than single-use surgical pression and the denture teeth from the cast. Elim-
guides. inate wax with hot water, and coat the cast with a
During guide fabrication, accurate preparation of tin-foil substitute.
surgical guide channels is required. Surgical and dual- 3. Flow a mix of autopolymerized methyl methacry-
purpose guides often have guide channels that allow late resin (Orthocryl 2000; Dentaurum, Ispringen,
only 1 surgical drill to pass through them. The use of Germany) into the impression in the space previ-
ously occupied by the artificial teeth. Reinsert the
Research Assistant, Department of Prosthodontics.
cast into the impression, secure it with an elastic
Research Assistant, Department of Prosthodontics. band, and place the assembly into a pressure pot for
Professor, Department of Prosthodontics. polymerization. Upon polymerization, remove the



Fig. 1. Labial view of polished resin portion of guide on cast.

Fig. 3. Correct angulation of implants determined by angu-

lation of bone (line a is angulation of bone, line b is angu-
lation of pin incorporated into guide, and x represents de-
sired change in angle). The buccopalatal angle of the pin is
used to determine correct implant alignment and to incorpo-
rate internally stacked stainless steel guide channels into the
acrylic resin carrier.

pin in CT evaluation is to view the entire pin in only

1 section of the cross-sectional CT images and to
make changes in implant location when needed.
Measure and record the anteroposterior angulation
of each pin at this stage by placing tripod marks on
the side of the cast. The tripod marks will be useful
Fig. 2. Pins secured to guide on surveyor. Angulation of pins for reorientation of the cast on the surveying table if
determined by assumptions made on possible angulation of required.
bone. 5. Place the guide in the patient’s mouth and obtain
2-dimensional CT images. Measure the dimensions
and angulation of the available bone, and determine
resin guide from the cast. Finish and polish the the appropriate location and angulation of the im-
guide (Fig. 1). plants (Fig. 3). The difference between the angula-
4. Place the cast and the acrylic resin guide as an as- tions of the bone and the pin is the required change
sembly onto a surveying table. Tilt the table to de- in the tilt of the surveying table.7
termine the desired angulation of the proposed 6. If a change in implant angulation is indicated, this
dental implants. For each implant site, prepare a pin can be performed by using the angulation of the
hole, 1 mm in diameter, at the anticipated central radiographic pins as a reference. In this event, re-
axis of the implant in the acrylic resin guide. Secure place the guide onto the surveyor and retilt the
a pin (1 mm in diameter ⫻ 10 mm; S. J. Filhol surveying table in accordance with previous tripod
Dental, West Cork, Ireland) in each hole (Fig. 2). marks placed on the cast. At this stage, the pins
The rationale for use of a 1-mm-thick radiographic incorporated into the guide are also used for chang-

DECEMBER 2002 641


Fig. 4. A, Interplaced stainless steel surgical guides matching drills with diameters of 2 mm, 3 mm, and 3.8 mm (from left to
right). B, Two-millimeter surgical drill inserted into guides on surveyor. Tubes incorporated into guide according to CT data.

Fig. 5. A, Occlusal view of converted guide for surgery. B, Use of dual-purpose guide for surgery during site preparation with
2-mm drill.

ing the buccopalatal angulation of the surveying of the pins is determined according to the angle of
table. For each implant site, the absolute vertical the tooth neighboring the edentulous ridge. This
alignment of a pin presents the original situation, procedure allows determination of the final bucco-
when the pin was initially incorporated into the palatal implant angulation with negligible error. Af-
guide. Hence, to determine the correct implant an- ter reorienting the surveying table, remove the por-
gulation for each site, the surveying table is tilted tion of the guide where the stainless steel surgical
buccopalatally according to the required change in guides will be incorporated. Secure a 2-mm surgical
the buccopalatal angle (x), as determined in the CT twist drill (NobelBiocare, Goteborg, Sweden) to
evaluation (Fig. 3). Because the CT image presents the surveyor as an analyzing rod, and pass the drill
the buccopalatal angulation of the pins, it is not through the assembled prefabricated stainless steel
possible to change the mesiodistal angulation by surgical guides (Fig. 4). The internally stacked
using CT. Nevertheless, the mesiodistal angulation stainless steel guides used in this technique were



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