Implant Dentistry Treatment Prostheses and Templates

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IMPLANT DENTISTRYIMPLANT DENTISTRY
PRE-SURGICAL PROSTHESESPRE-SURGICAL PROSTHESES
TEMPLATESTEMPLATES
PRE-MAXILLA IMPLANT CONSIDERATIONSPRE-MAXILLA IMPLANT CONSIDERATIONS
LOADING OF IMPLANTSLOADING OF IMPLANTS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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 These are provisional restorations that are madeThese are provisional restorations that are made
and inserted prior to first surgical procedure.and inserted prior to first surgical procedure.
These are also called as treatment prostheses.These are also called as treatment prostheses.
 These may be used to improve the soft tissueThese may be used to improve the soft tissue
used for support and stability before restorativeused for support and stability before restorative
procedures. A tissue conditioning treatment isprocedures. A tissue conditioning treatment is
often indicated.often indicated.
 The existing denture can also be used as aThe existing denture can also be used as a
treatment prostheses.treatment prostheses.
Pre-Surgical Prostheses:Pre-Surgical Prostheses:

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 The treatment denture satisfyies the estheticThe treatment denture satisfyies the esthetic
considerations that may be indicated beforeconsiderations that may be indicated before
surgery, tooth shape, size, position, color,surgery, tooth shape, size, position, color,
gingival color and contour.gingival color and contour.
 A fixed restoration design must allow accessA fixed restoration design must allow access
for proper hygiene procedures around thefor proper hygiene procedures around the
teeth and implants. a high or low lip lineteeth and implants. a high or low lip line
position may influence the gingival contour ofposition may influence the gingival contour of
the restoration. A treatment prosthesis maythe restoration. A treatment prosthesis may
determine if an implant-supported removabledetermine if an implant-supported removable
prosthesis rather than a fixed restoration isprosthesis rather than a fixed restoration is
required to satisfy patient's goals and desires.required to satisfy patient's goals and desires.www.indiandentalacademy.comwww.indiandentalacademy.com

www.indiandentalacademy.comwww.indiandentalacademy.com 44

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 The maxillary vermillion border is usually altered by the
loss of the maxillary anterior teeth. Once bone is also lost
the natural support of the entire lip is often deficient and
depends on the labial flange of the prosthesis. A fixed
partial denture may require an anterior cantilever away
from the soft tissue in a horizontal and vertical dimension
to provide this support. A treatment prosthesis can
provide the information required to determine if a fixed
prosthesis will compromise esthetics, support, or hygiene
in this region.

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 Long-term edentulous- patients who have worn
the same denture may require a treatment denture
to restore vertical dimension and ridge
relationship before implant surgery. The OVD
may gradually collapse, especially in the
completely edentulous patient, as a result of
continued bone loss and prosthesis occlusal wear.
Temporomandibular joint and myofacial
dysfunction may be the further sequence of this
condition. A treatment prosthesis to reestablish
proper OVD and/or an asymptomatic joint helps
determine the patient's specific needs regarding
the dysfunction.

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 As the OVD decreases, the jaw rotates forwardAs the OVD decreases, the jaw rotates forward
and closes in a more prognathic pseudo-Classand closes in a more prognathic pseudo-Class
III relationship. Subperiosteal implants,III relationship. Subperiosteal implants,
require the design of the prostheticrequire the design of the prosthetic
superstructure concomitant with the implantsuperstructure concomitant with the implant
substructure. Hence a treatment prosthesis issubstructure. Hence a treatment prosthesis is
indicated to establish the proper OVD andindicated to establish the proper OVD and
tooth position before the fabrication andtooth position before the fabrication and
placement of the implant and attachedplacement of the implant and attached
superstructure bar.superstructure bar.

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 The greater the OVD, the more Class II theThe greater the OVD, the more Class II the
mandible becomes in relationship to themandible becomes in relationship to the
maxilla. This influences the position ormaxilla. This influences the position or
angulations of the implant. In addition, theangulations of the implant. In addition, the
location of an over denture bar may be equallylocation of an over denture bar may be equally
influenced by variations of the verticalinfluenced by variations of the vertical
dimension of occlusion. the treatmentdimension of occlusion. the treatment
prosthesis may be used to establish prostheticprosthesis may be used to establish prosthetic
position of teeth.position of teeth.
 A treatment prostheses for a completelyA treatment prostheses for a completely
edentulous patient before a fixed or aedentulous patient before a fixed or a
removable implant prosthesis is most often aremovable implant prosthesis is most often a
complete denturecomplete denture

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 . This denture is fabricated with acrylic teeth so. This denture is fabricated with acrylic teeth so
the teeth may be reshaped easily, or acrylic isthe teeth may be reshaped easily, or acrylic is
added to change the OVD or lip support. Aadded to change the OVD or lip support. A
partially edentulous patient most often has apartially edentulous patient most often has a
fixed treatment prosthesis. an additional benefitfixed treatment prosthesis. an additional benefit
i of treatment prostheses is that patienti of treatment prostheses is that patient
management may be established, includingmanagement may be established, including
financial and compliance considerations.financial and compliance considerations.
 A treatment prosthesis most always is used onA treatment prosthesis most always is used on
the implants before the fabrication of the finalthe implants before the fabrication of the final
restoration. Acrylic restorations that graduallyrestoration. Acrylic restorations that gradually
load bone for progressive loading may beload bone for progressive loading may be
considered treatment prostheses.considered treatment prostheses.

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 Improve hard and soft tissuesImprove hard and soft tissues
 Evaluate the bone volume necessary for graftingEvaluate the bone volume necessary for grafting
proceduresprocedures
 Evaluate esthetics and hygiene considerationsEvaluate esthetics and hygiene considerations
 Reestablish proper OVDReestablish proper OVD
 Establishment of Co at the CR positionEstablishment of Co at the CR position
 Determine placement of the superstructure barDetermine placement of the superstructure bar
 Evaluate the patient's psychological health andEvaluate the patient's psychological health and
attitudeattitude
 Determine conditions for patient managementDetermine conditions for patient management
Treatment prosthesis and its Goals:Treatment prosthesis and its Goals:

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 Implant dentistry is a complex treatment modality andImplant dentistry is a complex treatment modality and
involves many specialists. And careful treatment planning.involves many specialists. And careful treatment planning.
The use of templates outlines the planned restoration inThe use of templates outlines the planned restoration in
relation to the anatomic situation enables the clinician torelation to the anatomic situation enables the clinician to
plan and communicate the patient's treatment needs toplan and communicate the patient's treatment needs to
everyone involved in the process. Using the sameeveryone involved in the process. Using the same
template, which is a duplicate of the provisionaltemplate, which is a duplicate of the provisional
restoration, throughout the whole process of the diagnosisrestoration, throughout the whole process of the diagnosis
reduces transfer errors during the augmentation andreduces transfer errors during the augmentation and
implant placement procedures to a minimum and allows aimplant placement procedures to a minimum and allows a
predictable step-by-step approach to implant dentistry.predictable step-by-step approach to implant dentistry.
Templates:Templates:

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1.1. Diagnostic/Radiographic templateDiagnostic/Radiographic template
2.2. Surgical template.Surgical template.
3.3. CombinationCombination
4.4. CADCAM Stereotactic surgical templateCADCAM Stereotactic surgical template
Types:Types:

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 The purpose of diagnostic radiographic templates is toThe purpose of diagnostic radiographic templates is to
incorporate the patient's proposed treatment plan into theincorporate the patient's proposed treatment plan into the
radiographic examination. This requires a treatment planradiographic examination. This requires a treatment plan
developed prior to the imaging procedure. ideally,developed prior to the imaging procedure. ideally,
mounted diagnostic casts, a diagnostic wax-up,mounted diagnostic casts, a diagnostic wax-up,
agreement between the clinicians on the number andagreement between the clinicians on the number and
location of proposed dental implants, and priorlocation of proposed dental implants, and prior
authorization of the proposed treatment by the patientauthorization of the proposed treatment by the patient
makes the diagnostic template a very useful tool andmakes the diagnostic template a very useful tool and
many times the determining factor in the final treatmentmany times the determining factor in the final treatment
plan of the patient.plan of the patient.
Diagnostic Templates:Diagnostic Templates:

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 The pre-prosthetic imaging procedure enables
evaluation of the proposed implant site at the
ideal position and orientation identified by
radiographic markers incorporated into the
template.
 An accurate preview of the supporting bone
related to the proposed implant sites avoids
complications that occurs due to the lack of
available bone leading to errors in positioning
as minimal as 2mm or in angulations of merely
10` degrees can render implant fixture
unusable.

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The radiographic template is fabricated acrylic resinThe radiographic template is fabricated acrylic resin
which normally is radiolucent, therefore thiswhich normally is radiolucent, therefore this
template requires a radio-opaque marker on them,template requires a radio-opaque marker on them,
making the template or a part of the template visiblemaking the template or a part of the template visible
during radiographic imaging.during radiographic imaging.
 These radio-opaque markers are:These radio-opaque markers are:
1.1. Gutta-perchaGutta-percha
2.2. Metal spheresMetal spheres
3.3. Barium sulphateBarium sulphate
4.4. Stainless steel tubesStainless steel tubes
5.5. Color chalk powderColor chalk powder
6.6. Lead foilLead foil
7.7. Composite materialComposite material
8.8. Radio opaque teethRadio opaque teeth

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 To evaluate the relationship between anatomic structuresTo evaluate the relationship between anatomic structures
and the stent, investigators have reported radiographicand the stent, investigators have reported radiographic
pre-surgical evaluations with gutta-percha, metalpre-surgical evaluations with gutta-percha, metal
spheres, the baseline with color chalk powder, andspheres, the baseline with color chalk powder, and
barium sulfate as radiopaque materials. Gutta-percha hasbarium sulfate as radiopaque materials. Gutta-percha has
an advantage because of its thermoplasticity. Thean advantage because of its thermoplasticity. The
advantages of metal spheres are its round shape, easyadvantages of metal spheres are its round shape, easy
fabrication procedure, and ease of measurement of imagefabrication procedure, and ease of measurement of image
magnification. Color chalk powder and barium sulfatemagnification. Color chalk powder and barium sulfate
materials are useful for observing the outline of the pre-materials are useful for observing the outline of the pre-
designed superstructure because of their radiopacity.designed superstructure because of their radiopacity.
Three-dimensional imaging with computed tomographyThree-dimensional imaging with computed tomography
(CT) or tomography is extremely helpful to evaluate the(CT) or tomography is extremely helpful to evaluate the
pre-designed surgical plan. Several types of radiopaquepre-designed surgical plan. Several types of radiopaque
materials have been used to examine their difference inmaterials have been used to examine their difference in
appearance on radiographic images.appearance on radiographic images.www.indiandentalacademy.comwww.indiandentalacademy.com

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RequirementsRequirements
1.1. StableStable
2.2. RigidRigid
3.3. Radio-opaque markersRadio-opaque markers
4.4. Enable optimum visualizationEnable optimum visualization
5.5. Ease of fabricationEase of fabrication
6.6. Should allow conversion to a surgicalShould allow conversion to a surgical
templatetemplate
7.7. Transparent.Transparent.

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Use of Barium SulphateUse of Barium Sulphate
 Christoph R J. Baden, John C. Kois, describedChristoph R J. Baden, John C. Kois, described
A controlled step-by-step approach for the useA controlled step-by-step approach for the use
of templates for placement of dental implants.of templates for placement of dental implants.
The provisional restoration, the blueprint forThe provisional restoration, the blueprint for
the final restoration, is duplicated, and athe final restoration, is duplicated, and a
radiographic template is fabricated. Thisradiographic template is fabricated. This
illustrates the outline of the planned restorationillustrates the outline of the planned restoration
in relation to the hard tissues (J Prosthet Dentin relation to the hard tissues (J Prosthet Dent
1996;76-451-4.).1996;76-451-4.).

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 Plan and adjust the outline of the prostheses asPlan and adjust the outline of the prostheses as
needed.needed.
 When both patient and dentist are satisfied,When both patient and dentist are satisfied,
make the impressions and casts both withoutmake the impressions and casts both without
and with the provisional restoration in place.and with the provisional restoration in place.
 Make an Omnivac shell over the cast with theMake an Omnivac shell over the cast with the
provisional restoration (made in step 2) inprovisional restoration (made in step 2) in
place.place.

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 Paint a suitable tinfoil substitute on thePaint a suitable tinfoil substitute on the
pretreatment cast, seal onto the pretreatment castpretreatment cast, seal onto the pretreatment cast
made in step 2 and use sticky wax to seal themade in step 2 and use sticky wax to seal the
Omnivac shell onto the pretreatment cast.Omnivac shell onto the pretreatment cast.
 Make a mix of radiopaque resin by mixing oneMake a mix of radiopaque resin by mixing one
part barium sulfite with two parts acrylic resinpart barium sulfite with two parts acrylic resin
powder . Mix the powder thoroughly then addpowder . Mix the powder thoroughly then add
the acrylic resin monomer to make the mixturethe acrylic resin monomer to make the mixture
fluid (Barium sulfate is a nontoxic, white,fluid (Barium sulfate is a nontoxic, white,
tasteless, odorless powder used in intestinaltasteless, odorless powder used in intestinal
radiography.)radiography.)

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 Make a small opening in the shell and fill theMake a small opening in the shell and fill the
shell with the mix of fluid radiopaque resin.shell with the mix of fluid radiopaque resin.
Inject the resin with a 12 cc Monoject disposableInject the resin with a 12 cc Monoject disposable
syringe. (When the resin polymerizes, it providessyringe. (When the resin polymerizes, it provides
a radiopaque duplicate of the provisionala radiopaque duplicate of the provisional
restoration.)restoration.)
 Separate the radiopaque provisional restorationSeparate the radiopaque provisional restoration
from the shell and the cast.from the shell and the cast.
 Cut and trim the opaqued provisional restorationCut and trim the opaqued provisional restoration
to preserve only the block of teeth.to preserve only the block of teeth.
 Separate the resin teeth, trim them to open theSeparate the resin teeth, trim them to open the
gingival embrasures, and do contouring necessarygingival embrasures, and do contouring necessary
to make them look like individual teethto make them look like individual teeth

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 Position the tooth on the pretreatment cast (made in stepPosition the tooth on the pretreatment cast (made in step
2), and use a small amount of sticky wax to hold them in2), and use a small amount of sticky wax to hold them in
place. (Because the ridge laps of the opaqued resin toothplace. (Because the ridge laps of the opaqued resin tooth
were made in direct contact with the cast, except for a thinwere made in direct contact with the cast, except for a thin
coating of separation medium, it is easy to replace themcoating of separation medium, it is easy to replace them
accurately on the cast.accurately on the cast.
 Box the opaqued resin teeth positioned on the cast withBox the opaqued resin teeth positioned on the cast with
beading wax and include several of the stone teeth bothbeading wax and include several of the stone teeth both
anterior and posterior to the edentulous portion of theanterior and posterior to the edentulous portion of the
ridge.ridge.
 Paint tinfoil substitute separating medium on the adjacentPaint tinfoil substitute separating medium on the adjacent
stone teeth and the cast that will be contacted with thestone teeth and the cast that will be contacted with the
Orthodontic resin which will be applied next.Orthodontic resin which will be applied next.
 Apply Orthodontic resin by the salt and pepper method toApply Orthodontic resin by the salt and pepper method to
create an acrylic resin overlay over the adjacent teeth andcreate an acrylic resin overlay over the adjacent teeth and
to hold the opaqued resin teeth in position.to hold the opaqued resin teeth in position.

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 After the resin polymerizes, remove theAfter the resin polymerizes, remove the
assembly from the cast, then finish and polish it.assembly from the cast, then finish and polish it.
 Fit the restoration to the patients mouth andFit the restoration to the patients mouth and
have a CT scan to show the relationship of thehave a CT scan to show the relationship of the
anatomic topography to the planned restoration.anatomic topography to the planned restoration.
 Using the same template, which is a duplicate ofUsing the same template, which is a duplicate of
the provisional restoration, thought the wholethe provisional restoration, thought the whole
process of the diagnosis reduces transfer errorsprocess of the diagnosis reduces transfer errors
during the augmentation and implant placementduring the augmentation and implant placement
procedures to a minimum and allows aprocedures to a minimum and allows a
predictable step-by-step approach to implantpredictable step-by-step approach to implant
dentistry.dentistry. www.indiandentalacademy.comwww.indiandentalacademy.com

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Template with Barium Sulfate &Template with Barium Sulfate &
Stainless TubesStainless Tubes
Fumitaka Takeshita; Tsutomu Tokoshima; Tsuneo Suetsugu,Fumitaka Takeshita; Tsutomu Tokoshima; Tsuneo Suetsugu,
described a stent for pre-surgical evaluation of implantdescribed a stent for pre-surgical evaluation of implant
placement using with barium sulfate and stainless steelplacement using with barium sulfate and stainless steel
tubes for the accurate radiographic evaluation of thetubes for the accurate radiographic evaluation of the
relationships of the pre-designed superstructure, therelationships of the pre-designed superstructure, the
scheduled implant placement, and the anatomic structure.scheduled implant placement, and the anatomic structure.
The barium sulfate in the stent depicts the outline of theThe barium sulfate in the stent depicts the outline of the
pre-designed superstructure, and the stainless steel tubespre-designed superstructure, and the stainless steel tubes
indicate the intended location and inclination of theindicate the intended location and inclination of the
implants on the computed tomographic scans. In addition,implants on the computed tomographic scans. In addition,
this stent can be used as a surgical stent to guide the pilotthis stent can be used as a surgical stent to guide the pilot
drill to the desired site. (J Prosthet Dent 1997;77:36–8.)drill to the desired site. (J Prosthet Dent 1997;77:36–8.)www.indiandentalacademy.comwww.indiandentalacademy.com

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 Procedure:Procedure:
 Form wax sprues at theForm wax sprues at the
distal most teeth bilaterallydistal most teeth bilaterally
of the approved trial waxof the approved trial wax
denture and make a siliconedenture and make a silicone
impression. The stent isimpression. The stent is
made of clearmade of clear
autopolymerized methylautopolymerized methyl
methacrylate resin pourmethacrylate resin pour
material.material.
 After the clear stent isAfter the clear stent is
recovered from therecovered from the
impression, remove all theimpression, remove all the
teeth. Reposition the clearteeth. Reposition the clear
stent base in the impression.stent base in the impression.

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 Mix powder that consists of a 4:1 ratio of resin polymerMix powder that consists of a 4:1 ratio of resin polymer
and barium sulfate with monomer. Pour the mixture intoand barium sulfate with monomer. Pour the mixture into
the tooth forms of the impression. (The degree ofthe tooth forms of the impression. (The degree of
radiopacity of various mixture ratios.radiopacity of various mixture ratios.

2727
 Cure the finished stent atCure the finished stent at
40° C for 20 minutes in40° C for 20 minutes in
the processor, thenthe processor, then
recover and polish.recover and polish.
 Make the access holes toMake the access holes to
guide the first surgicalguide the first surgical
drill according todrill according to
information obtainedinformation obtained
from the final cast and thefrom the final cast and the
provisional restoration.provisional restoration.
 stainless steel tube spruesstainless steel tube sprues
to a uniform height, placeto a uniform height, place
into the access hole, andinto the access hole, and
retain with waxretain with wax www.indiandentalacademy.comwww.indiandentalacademy.com

2828
 Obtain a panoramic tomograph and a CT scan with theObtain a panoramic tomograph and a CT scan with the
stent in place.stent in place.
 After the radiographs are obtained, remove the tubeAfter the radiographs are obtained, remove the tube
sprues.sprues.
 Sterilize the stent so it (the access holes) can be used toSterilize the stent so it (the access holes) can be used to
guide the surgical drill to the desired site for implantguide the surgical drill to the desired site for implant
placement.placement.

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 The barium sulfate in the stent depicts the outline of the predesignedThe barium sulfate in the stent depicts the outline of the predesigned
superstructures, and the stainless tubes represent the location andsuperstructures, and the stainless tubes represent the location and
inclination of the intended implant placement. The powder bariuminclination of the intended implant placement. The powder barium
sulfate and resin polymer mixture exhibit good radiopacity withoutsulfate and resin polymer mixture exhibit good radiopacity without
radiologic artifact and the panoramic radiographs revealed theradiologic artifact and the panoramic radiographs revealed the
markers and the inclination.markers and the inclination.
 The most important advantage is found in its use with a CT scan. TheThe most important advantage is found in its use with a CT scan. The
radiopaque markers located on the reconstructed image of the CT scanradiopaque markers located on the reconstructed image of the CT scan
can be clearly observed. The clear image of the stainless steel tubecan be clearly observed. The clear image of the stainless steel tube
demonstrates the predesigned inclination of implant placement,demonstrates the predesigned inclination of implant placement,
whereas the image of the barium sulfate shows the position of thewhereas the image of the barium sulfate shows the position of the
anterior teeth on CT scans. The location and inclination ofanterior teeth on CT scans. The location and inclination of
predesigned implant placement in the stent can then be corrected aspredesigned implant placement in the stent can then be corrected as
necessary before surgery according to the radiographic information.necessary before surgery according to the radiographic information.
Other advantages of using this procedure with barium sulfate andOther advantages of using this procedure with barium sulfate and
stainless steel tubes are its ease of use, economy (inexpensive), andstainless steel tubes are its ease of use, economy (inexpensive), and
simple design of the materials.simple design of the materials.

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Template with Lead FoilTemplate with Lead Foil
Javier Urquiola; R. W. Toothaker, described theJavier Urquiola; R. W. Toothaker, described the
fabrication of a radiographic template usingfabrication of a radiographic template using
lead foils.lead foils.
There are several advantages to using lead foil;There are several advantages to using lead foil;
the material is readily available, inexpensive,the material is readily available, inexpensive,
and easy to manipulate. Because the lead foiland easy to manipulate. Because the lead foil
is found in standard periapical radiograph filmis found in standard periapical radiograph film
packets, the cost is less than otherpackets, the cost is less than other
commercially available materials.commercially available materials.

3131
 PROCEDUREPROCEDURE
 11 Fabricate a template.Fabricate a template.
 22 Select prosthetically favorable implant sites.Select prosthetically favorable implant sites.
 33 Cut the lead foil into strips.Cut the lead foil into strips.
 44 Adhere the foil to the template with cyanoacrylate.Adhere the foil to the template with cyanoacrylate.
 55 Cover the lead strips with a thin layer of clear,Cover the lead strips with a thin layer of clear,
autopolymerizing acrylic resinautopolymerizing acrylic resinwww.indiandentalacademy.comwww.indiandentalacademy.com

3232
 The major disadvantage of using Lead foil as aThe major disadvantage of using Lead foil as a
marker because its density produces beammarker because its density produces beam
hardening artifact and distorts the diagnostichardening artifact and distorts the diagnostic
value of the CT films. The authors found that ifvalue of the CT films. The authors found that if
lead foil strips are placed on the buccal aspect oflead foil strips are placed on the buccal aspect of
the template and at a significant distance from thethe template and at a significant distance from the
area being analyzed, the center of the ridge, thearea being analyzed, the center of the ridge, the
beam hardening artifact produced by the lead foilbeam hardening artifact produced by the lead foil
at the buccal periphery of the template fails toat the buccal periphery of the template fails to
reach the ridge and cause distortion in this areareach the ridge and cause distortion in this area

3333
Surgical template.Surgical template.
 The surgical template dictates to the surgeon theThe surgical template dictates to the surgeon the
implant body placement that offers the bestimplant body placement that offers the best
combination ofcombination of
 (1) support for the repetitive forces of Occlusion,(1) support for the repetitive forces of Occlusion,
 (2) Esthetics, and(2) Esthetics, and
 (3) Hygiene requirements.(3) Hygiene requirements.

3434
 The purpose of the surgical template is toThe purpose of the surgical template is to
provide information regarding implant fixtureprovide information regarding implant fixture
sites and desired angulations. The surgeon cansites and desired angulations. The surgeon can
assess the information in relation to anatomicassess the information in relation to anatomic
limitations, along with the radiological datalimitations, along with the radiological data
especially that of the reformatted multiplaner CTespecially that of the reformatted multiplaner CT
scans. This provides optimal implant placement.scans. This provides optimal implant placement.
The surgeon and the prosthodontist must planThe surgeon and the prosthodontist must plan
the type of surgical template that will be used tothe type of surgical template that will be used to
aid in placement of the fixture.aid in placement of the fixture.

3535
 Ideally, fixtures are placed parallel to eachIdeally, fixtures are placed parallel to each
other, parallel to the labial face of the anteriorother, parallel to the labial face of the anterior
teeth, and in an area slightly lingual to theteeth, and in an area slightly lingual to the
cingulum of the anterior teeth in thecingulum of the anterior teeth in the
parasymphyaseal region. They are placedparasymphyaseal region. They are placed
parallel to the long axis of the posterior teethparallel to the long axis of the posterior teeth
and in the central fossae region of theand in the central fossae region of the
mandibular posterior teeth and the palatal cuspmandibular posterior teeth and the palatal cusp
region of the maxillary posterior teeth. Theregion of the maxillary posterior teeth. The
maxillary anterior fixtures are placed parallel tomaxillary anterior fixtures are placed parallel to
each other as much as possible, in the cingulumeach other as much as possible, in the cingulum
area of the artificial teeth and should notarea of the artificial teeth and should not
interfere with the occlusion.interfere with the occlusion.www.indiandentalacademy.comwww.indiandentalacademy.com

3636
 'With the completely edentulous jaw, after the'With the completely edentulous jaw, after the
transitional complete denture has beentransitional complete denture has been
constructed, whether maxillary or mandibular, itconstructed, whether maxillary or mandibular, it
is beneficial to duplicate this denture for use as ais beneficial to duplicate this denture for use as a
surgical template so the surgeon can observesurgical template so the surgeon can observe
where the anticipated tooth placement andwhere the anticipated tooth placement and
angulation would be during placement of theangulation would be during placement of the
fixtures during first-stage surgery. The template.fixtures during first-stage surgery. The template.
as well as the mounted set of diagnostic casts, areas well as the mounted set of diagnostic casts, are
then sent to the surgeon prior to implant fixturethen sent to the surgeon prior to implant fixture
placement so the topography of the mouth can beplacement so the topography of the mouth can be
envisioned.envisioned.

3737
Mandibular surgical templates, or guides, are
valuable aids in the optimal placement of
endosseal fixtures. They aid the surgeon to avoid
restorative complications, such as lingual tipping
of posterior fixtures, that will interfere with
tongue movement after the prosthesis is inserted,
avoid labial angulation of anterior fixtures that
will compromise esthetics, and limit severely
lingually inclined anterior fixtures that will
interfere with tongue movements.

3838
Requirements:Requirements:
Several methods of fabrication for the surgical template areSeveral methods of fabrication for the surgical template are
available. The requirements are more relevant than theavailable. The requirements are more relevant than the
options of fabrication.options of fabrication.
 The template should be stable and rigid when in correctThe template should be stable and rigid when in correct
position. If the arch treated has remaining teeth, theposition. If the arch treated has remaining teeth, the
template should fit over and/or around enough teeth totemplate should fit over and/or around enough teeth to
stabilize it in position.stabilize it in position.
 When no remaining teeth are present, the template shouldWhen no remaining teeth are present, the template should
extend onto unreflected soft tissue regions (i.e., the palateextend onto unreflected soft tissue regions (i.e., the palate
and tuberosities in the maxilla or the retromolar pads in theand tuberosities in the maxilla or the retromolar pads in the
mandible). In this way, the template may be used after themandible). In this way, the template may be used after the
soft tissues have been reflected from the implant site.soft tissues have been reflected from the implant site.www.indiandentalacademy.comwww.indiandentalacademy.com

3939
 The ideal angulation for implant insertion should beThe ideal angulation for implant insertion should be
determined on the diagnostic wax-up, and the templatedetermined on the diagnostic wax-up, and the template
should relate this position during surgery. This requiresshould relate this position during surgery. This requires
at least two reference points for each implant. For thatat least two reference points for each implant. For that
purpose, the surgical guide must be elevated above thepurpose, the surgical guide must be elevated above the
edentulous bone. The distance between two pointsedentulous bone. The distance between two points
located respectively on the occlusal surface (central fossalocated respectively on the occlusal surface (central fossa
or incisal edge) of the planned abutment crown and theor incisal edge) of the planned abutment crown and the
crest of the ridge represents about 8 mm. As a result,crest of the ridge represents about 8 mm. As a result,
these two points of reference can be joined by a line thatthese two points of reference can be joined by a line that
represents the path of ideal implant insertion. The idealrepresents the path of ideal implant insertion. The ideal
angulation is perpendicular to the occlusal plane andangulation is perpendicular to the occlusal plane and
parallel to the most anterior abutment (natural orparallel to the most anterior abutment (natural or
implant) joined to the implant.implant) joined to the implant.

4040
 Other ideal requirements of the surgical template includeOther ideal requirements of the surgical template include
size, surgical asepsis, transparency, and the ability tosize, surgical asepsis, transparency, and the ability to
revise the template as indicated, The template should notrevise the template as indicated, The template should not
be bulky and difficult to insert or obscure surroundingbe bulky and difficult to insert or obscure surrounding
surgical landmarks. The surgical template must notsurgical landmarks. The surgical template must not
contaminate a surgical field during bone grafts orcontaminate a surgical field during bone grafts or
implant placement. It should be transparent. In this way,implant placement. It should be transparent. In this way,
the bony ridge and drills can be observed more easilythe bony ridge and drills can be observed more easily
when the template is in place. The surgical templatewhen the template is in place. The surgical template
should relate the ideal facial contour.should relate the ideal facial contour.
 Many edentulous ridges have lost facial bone, and theMany edentulous ridges have lost facial bone, and the
template can determine the amount of augmentationtemplate can determine the amount of augmentation
required for implant placement or support of the lips andrequired for implant placement or support of the lips and
face. The surgical template may be used in conjunctionface. The surgical template may be used in conjunction
with a bone graft, and later the same template may bewith a bone graft, and later the same template may be
used for insertion of implants and again for implantused for insertion of implants and again for implant
uncovery. A sturdy template permits resterilization. anduncovery. A sturdy template permits resterilization. and
use for several procedures.use for several procedures.www.indiandentalacademy.comwww.indiandentalacademy.com

4141
Mandibular Completely EdentulousMandibular Completely Edentulous
TemplatesTemplates
1.1. A complete mandibular surgical templateA complete mandibular surgical template
that has a cutout in the parasymphyasealthat has a cutout in the parasymphyaseal
region corresponding to the cingulum areasregion corresponding to the cingulum areas
2.2. A complete mandibular surgical template inA complete mandibular surgical template in
which the facial aspects have been removedwhich the facial aspects have been removed
in the parasymphyaseal region. This templatein the parasymphyaseal region. This template
provides improved visibility.provides improved visibility.

4242
Mandibular Partially EdentulousMandibular Partially Edentulous
TemplatesTemplates
1.1. A surgical template with a groove cutout in theA surgical template with a groove cutout in the
region of the central fossae of the posterior teeth.region of the central fossae of the posterior teeth.
2.2. A surgical template with a buccal or facial cut-outA surgical template with a buccal or facial cut-out
with maintenance of the lingual aspect of thewith maintenance of the lingual aspect of the
posterior or anterior teeth to prevent lingualposterior or anterior teeth to prevent lingual
inclination of the fixtures. This type of template isinclination of the fixtures. This type of template is
preferred since it provides better access for thepreferred since it provides better access for the
surgeon and better visibility during surgery.surgeon and better visibility during surgery.

4343
Maxillary Completely EdentulousMaxillary Completely Edentulous
TemplateTemplate
 A maxillary surgical stentA maxillary surgical stent
should have sufficientshould have sufficient
tuberosity extension to avoidtuberosity extension to avoid
anterior displacement duringanterior displacement during
surgery.surgery.
 The maxillary surgicalThe maxillary surgical
template is prepared with atemplate is prepared with a
large palatal vent tolarge palatal vent to
accommodate the palatalyaccommodate the palataly
raised flap.raised flap.
 It possesses sufficientIt possesses sufficient
tuberosity extension fortuberosity extension for
stability and preventstability and prevent
displacement.displacement. www.indiandentalacademy.comwww.indiandentalacademy.com

4444
Dual purpose TemplatesDual purpose Templates
 The use guides for radiographic evaluation andThe use guides for radiographic evaluation and
surgical placement of dental implants cansurgical placement of dental implants can
improve the final outcome of treatment forimprove the final outcome of treatment for
patients receiving implants. if a template ispatients receiving implants. if a template is
fabricated for radiographic evaluation offabricated for radiographic evaluation of
implant placement and also serves as aimplant placement and also serves as a
surgical guide for placement of the implantsurgical guide for placement of the implant
they are known as dual purpose template.they are known as dual purpose template.

4545
Michael Gardner & Igor J Pesun’sMichael Gardner & Igor J Pesun’s
Dual TemplateDual Template
 They described the fabrication of a template forThey described the fabrication of a template for
radiographic evaluation and surgical placement ofradiographic evaluation and surgical placement of
implants, to aid in the determination of the idealimplants, to aid in the determination of the ideal
site for the implant, guides with markers were used.site for the implant, guides with markers were used.
they used a template during a CT scan, thatthey used a template during a CT scan, that
contains no metal therefore useful to eliminate thecontains no metal therefore useful to eliminate the
possibility of scatter. Gutta-percha was the malarialpossibility of scatter. Gutta-percha was the malarial
of choice, because it is radiopaque and can beof choice, because it is radiopaque and can be
formed to a desired shape. the goal of any implantformed to a desired shape. the goal of any implant
location and trajectory template is to guide thelocation and trajectory template is to guide the
surgeon in the ideal placement of the implantssurgeon in the ideal placement of the implantswww.indiandentalacademy.comwww.indiandentalacademy.com

4646
 Technique:Technique:
 Make duplicate casts of the arch to be evaluated forMake duplicate casts of the arch to be evaluated for
implant restoration and mount one set of casts on animplant restoration and mount one set of casts on an
articulator in the centric relation position.articulator in the centric relation position.www.indiandentalacademy.comwww.indiandentalacademy.com

4747
 If any alteration of the vertical dimension of occlusion isIf any alteration of the vertical dimension of occlusion is
planned, determine the altered vertical dimension ofplanned, determine the altered vertical dimension of
occlusion and set the articulator, Complete a diagnosticocclusion and set the articulator, Complete a diagnostic
wax-up of the final restoration.wax-up of the final restoration.

4848
 Duplicate the diagnosticDuplicate the diagnostic
wax-up in dental stone.wax-up in dental stone.
 Block out undercuts onBlock out undercuts on
the unaltered diagnosticthe unaltered diagnostic
and with a material dudand with a material dud
is not heat-sensitiveis not heat-sensitive

4949
 Make vacuformed templates over the blocked outMake vacuformed templates over the blocked out
diagnostic cast and the duplicate cast of the diagnosticdiagnostic cast and the duplicate cast of the diagnostic
wax-up with a clear plastic sheet.wax-up with a clear plastic sheet.

5050
 Trim the templates to 5 mm below the gingival marginTrim the templates to 5 mm below the gingival margin
of the teeth or to the height of contour of the soft tissue,of the teeth or to the height of contour of the soft tissue,
whichever is less.whichever is less.
 Return the template to the unaltered diagnostic Cast andReturn the template to the unaltered diagnostic Cast and
place the template of the diagnostic wax-up over theplace the template of the diagnostic wax-up over the
cast. Trim the edges of the two templates to make themcast. Trim the edges of the two templates to make them
coincident.coincident. www.indiandentalacademy.comwww.indiandentalacademy.com

5151
 Remove the diagnostic wax template and fill itRemove the diagnostic wax template and fill it
with clear orthodontic resin, Place the filledwith clear orthodontic resin, Place the filled
template over the template of the unalteredtemplate over the template of the unaltered
diagnostic cast and hold in place with fingerdiagnostic cast and hold in place with finger
pressure until the initial set of the resinpressure until the initial set of the resin
 Trim off excess material that may have flowedTrim off excess material that may have flowed
between the templates.between the templates.
 Place an elastic band around the cast andPlace an elastic band around the cast and
templates to aid in holding the templates intemplates to aid in holding the templates in
place. (Completion of the polymerizationplace. (Completion of the polymerization
process may be done with pressure.)process may be done with pressure.)

5252
 Trim and smooth theTrim and smooth the
edges of the guide.edges of the guide.
 Prepare holes in thePrepare holes in the
guide at the desiredguide at the desired
implant locations.implant locations.
Use a No- a roundUse a No- a round
bur to prepare a pilotbur to prepare a pilot
hole, and enlarge thehole, and enlarge the
width to 3 mm inwidth to 3 mm in
diameter, Fill thediameter, Fill the
prepared holes withprepared holes with
gutta-percha.gutta-percha.

5353
 Trial fit the template in the patients mouthTrial fit the template in the patients mouth
before the radiographic appointment to ensurebefore the radiographic appointment to ensure
that it is comfortable and stable. Adjust thethat it is comfortable and stable. Adjust the
flange or the tissue surface as necessary toflange or the tissue surface as necessary to
allow the guide to sent with ease.allow the guide to sent with ease.

5454
 Radiographic analysisRadiographic analysis
 Select the cross-sectionalSelect the cross-sectional
images that contain the guttaimages that contain the gutta
percha cylinders, thereforepercha cylinders, therefore
correspond to the most desirablecorrespond to the most desirable
locations for the implants.locations for the implants.
 Compare angulation of theCompare angulation of the
gutta-percha cylinder with thegutta-percha cylinder with the
available bone and the positionavailable bone and the position
of the vital structures toof the vital structures to
determine the best angulationdetermine the best angulation
for the implant. (The need forfor the implant. (The need for
angled abutments or pre implantangled abutments or pre implant
augmentation surgery can beaugmentation surgery can be
determined.)determined.)
 33 Transfer this information toTransfer this information to
the surgeon by modifying thethe surgeon by modifying the
guide for surgery. (The verticalguide for surgery. (The vertical
height of the guide in reduced,height of the guide in reduced,
and the gutta percha is removedand the gutta percha is removed
The guide can now be used toThe guide can now be used to
place the implant in the desiredplace the implant in the desired

5555
Marcus A. R. Lima Verde, Steven M.Marcus A. R. Lima Verde, Steven M.
Morgano’ s Dual purpose StentMorgano’ s Dual purpose Stent
 A stent is any device used with a surgicalA stent is any device used with a surgical
procedure and is commonly fabricated toprocedure and is commonly fabricated to
direct the positioning of implants. In addition,direct the positioning of implants. In addition,
a perceptively designed stent can serve as ana perceptively designed stent can serve as an
adjunct during radiological diagnosticadjunct during radiological diagnostic
procedures. The dual-purpose stent combinedprocedures. The dual-purpose stent combined
with computed tomography (CT) can revealwith computed tomography (CT) can reveal
the available bone and the location of vitalthe available bone and the location of vital
structures at an implant site. This same stentstructures at an implant site. This same stent
functions as a guide to the surgeon placing thefunctions as a guide to the surgeon placing the
implants.implants. www.indiandentalacademy.comwww.indiandentalacademy.com

5656
 A stent was designed that is a modification ofA stent was designed that is a modification of
one originally introduced by Stella andone originally introduced by Stella and
Tharanon7 to locate the inferior alveolar canalTharanon7 to locate the inferior alveolar canal
in the posterior edentulous mandible. Thisin the posterior edentulous mandible. This
stent precisely relates the CT cross-sectionalstent precisely relates the CT cross-sectional
images in the maxillae or mandible to theimages in the maxillae or mandible to the
anticipated location and angulation of theanticipated location and angulation of the
implants. The stent then acts as a surgicalimplants. The stent then acts as a surgical
template to ensure accurate placement andtemplate to ensure accurate placement and
favorable angulation of the fixtures.favorable angulation of the fixtures.

5757
 Fabrication:Fabrication:
 For PartiallyFor Partially
edentulousedentulous
patientpatient
 Make diagnostic casts of the dental arches fromMake diagnostic casts of the dental arches from
irreversible hydrocolloid impressions. Complete airreversible hydrocolloid impressions. Complete a
diagnostic waxing of the proposed implant-supporteddiagnostic waxing of the proposed implant-supported
FPD or set acrylic resin artificial teeth as an alternativeFPD or set acrylic resin artificial teeth as an alternative
to replace the missing teeth.to replace the missing teeth.

5858
 Make an irreversible hydrocolloid impression of the castMake an irreversible hydrocolloid impression of the cast
with the waxed FPD, and duplicate the cast in dentalwith the waxed FPD, and duplicate the cast in dental
stone.stone.
 Make a vacuum-formed plastic template of the duplicateMake a vacuum-formed plastic template of the duplicate
cast.cast.
 Seat the plastic template on the original diagnostic castSeat the plastic template on the original diagnostic cast
(wax removed), and pour clear, chemically activated(wax removed), and pour clear, chemically activated
acrylic resin in the template.acrylic resin in the template.www.indiandentalacademy.comwww.indiandentalacademy.com

5959
 Place the cast with the acrylic resin in a pressure potPlace the cast with the acrylic resin in a pressure pot
with 110° F water at 25 psi for 20 minutes.with 110° F water at 25 psi for 20 minutes.
 77 Remove gross excess and place gutta-percha rodsRemove gross excess and place gutta-percha rods
on the stent along the central occlusal line of posterioron the stent along the central occlusal line of posterior
teeth or on the crest of the cingula of anterior teeth.teeth or on the crest of the cingula of anterior teeth.www.indiandentalacademy.comwww.indiandentalacademy.com

6060
 Place 2 mm gutta-perchaPlace 2 mm gutta-percha
spheres at the desiredspheres at the desired
location of each implantlocation of each implant
fixture.fixture.
 Add acrylic resin with aAdd acrylic resin with a
brush to cover the gutta-brush to cover the gutta-
percha spheres and the rodspercha spheres and the rods
at the central occlusal lineat the central occlusal line
 Place a gutta-percha rod onPlace a gutta-percha rod on
the ridge crest Applythe ridge crest Apply
autopolymerizing clearautopolymerizing clear
acrylic resin with a brush toacrylic resin with a brush to
the tissue surface of thethe tissue surface of the
stent and gutta-percha tostent and gutta-percha to
attach the rod to the stent,attach the rod to the stent,
and reposition it on the cast.and reposition it on the cast.www.indiandentalacademy.comwww.indiandentalacademy.com

6161
 Adapt weather stripping or beading wax to the facial andAdapt weather stripping or beading wax to the facial and
lingual surfaces of the stent and several contiguouslingual surfaces of the stent and several contiguous
teeth.teeth.
 1313 Add additional clear acrylic resin to form anAdd additional clear acrylic resin to form an
occlusal index and ensure positive seating of the stentocclusal index and ensure positive seating of the stent
intraorally.intraorally. www.indiandentalacademy.comwww.indiandentalacademy.com

6262
 Finish and polish theFinish and polish the
stentstent
 Refer the patient toRefer the patient to
the radiologist forthe radiologist for
the DentaScan CTthe DentaScan CT
scan with thescan with the
diagnostic stent anddiagnostic stent and
a comprehensivea comprehensive
prescription thatprescription that
includes drawings ofincludes drawings of
the areas that mustthe areas that must
be included in thebe included in the
CT scan.CT scan.

6363
 FABRICATION FOR THE TOTALLY EDENTULOUSFABRICATION FOR THE TOTALLY EDENTULOUS
PATIENTPATIENT
 11 Duplicate a satisfactory complete denture in clearDuplicate a satisfactory complete denture in clear
acrylic resin by using any standard technique. Theacrylic resin by using any standard technique. The
duplicated denture must have a physiologic verticalduplicated denture must have a physiologic vertical
dimension of occlusion, stable centric occlusiondimension of occlusion, stable centric occlusion
coincidental with centric relation, and favorable toothcoincidental with centric relation, and favorable tooth
position. The patient's existing denture often has one orposition. The patient's existing denture often has one or
more major deficiencies and should be remade tomore major deficiencies and should be remade to
fabricate a reliable stent. Duplicating an unsuitablefabricate a reliable stent. Duplicating an unsuitable
complete denture provides unreliable diagnosticcomplete denture provides unreliable diagnostic
information with the DentaScan CT scan procedure.information with the DentaScan CT scan procedure.
 22 Attach the gutta percha rods and spheres similar toAttach the gutta percha rods and spheres similar to
the description for the partially edentulous patient.the description for the partially edentulous patient.www.indiandentalacademy.comwww.indiandentalacademy.com

6464
 ANALYSIS OF THE CT SCANANALYSIS OF THE CT SCAN
 Select the cross-sectional imagesSelect the cross-sectional images
that correspond to the mostthat correspond to the most
desirable locations of thedesirable locations of the
implants, namely the images thatimplants, namely the images that
include the gutta-percha spheres.include the gutta-percha spheres.
Because the cuts with theBecause the cuts with the
DentaScan CT scan are either 1DentaScan CT scan are either 1
or 1.5 mm apart, each 2 mmor 1.5 mm apart, each 2 mm
sphere is always visible in atsphere is always visible in at
least one of the cross-sectionalleast one of the cross-sectional
images.images.
 a – Gutta-percha spherea – Gutta-percha sphere
 b – Gutta-percha rods at the ridgeb – Gutta-percha rods at the ridge
 c – Gutta-percha rod at the central occlusalc – Gutta-percha rod at the central occlusal
line.line. www.indiandentalacademy.comwww.indiandentalacademy.com

6565
 Connect the two dots for each location that represents theConnect the two dots for each location that represents the
gutta-percha rods at the central occlusal line and the ridgegutta-percha rods at the central occlusal line and the ridge
crest. This line represents the most favorable angulationcrest. This line represents the most favorable angulation
of the implant fixture for prosthodontics.of the implant fixture for prosthodontics.
 Compare this angulation with the available bone andCompare this angulation with the available bone and
position of vital structures and determine the bestposition of vital structures and determine the best
angulation for the surgical positioning of the implantangulation for the surgical positioning of the implant
fixtures.fixtures. www.indiandentalacademy.comwww.indiandentalacademy.com

6666
 Transfer thisTransfer this
information to the stentinformation to the stent
by preparing guideby preparing guide
channels to orient thechannels to orient the
surgeon's pilot drill,surgeon's pilot drill,
converting theconverting the
diagnostic stent to adiagnostic stent to a
surgical stent.surgical stent.
 A – occlusal surfaceA – occlusal surface
 B – guide channelsB – guide channels
prepared from facialprepared from facial
surface guide surgeonssurface guide surgeons
pilot drill.pilot drill.

6767
Template for positioning andTemplate for positioning and
angulation of intraosseous implantsangulation of intraosseous implants
 The position angulation of the submerged implant need toThe position angulation of the submerged implant need to
be planned before the time of surgical implant placementbe planned before the time of surgical implant placement
for proper occlusal alignment with the opposing dentitionfor proper occlusal alignment with the opposing dentition
prosthesis.prosthesis.
 The surgeon uses different criteria for implant placementThe surgeon uses different criteria for implant placement
than that used by the prosthodontist. The surgeon mustthan that used by the prosthodontist. The surgeon must
place the implant in a region where the quantityplace the implant in a region where the quantity quality ofquality of
bone is adequate to provide functional support.2 Thebone is adequate to provide functional support.2 The
prosthodontist should not rely on the surgeon's skills aloneprosthodontist should not rely on the surgeon's skills alone
to provide appropriate implant placement, but shouldto provide appropriate implant placement, but should
provide the surgeon with a templateprovide the surgeon with a template for the correctfor the correct
placement of the intraosseous implant.placement of the intraosseous implant.www.indiandentalacademy.comwww.indiandentalacademy.com

6868
 David R. Burns, Donald G. Crabtree, and
Dewey H. Bell describe a technique for
fabrication of a surgical guide that gives the
surgeon the appropriate location and angulation
of the submerged implant.
 In conjunction with the surgeon, the
prosthodontist initially should evaluate the
patient for potential implant treatment including
an adequate history, oral examination,
radiographic examination, and mounted
diagnostic casts, and should carefully palpate
the regions of potential implant placement for
bone undercuts and thickness and morphology.

6969
 In addition, it may be desirable to "sound" the boneIn addition, it may be desirable to "sound" the bone
through the soft tissue from the buccal and lingualthrough the soft tissue from the buccal and lingual
aspect of the alveolar ridge. This can be done by locallyaspect of the alveolar ridge. This can be done by locally
anesthetizing the region and then inserting,anesthetizing the region and then inserting,
perpendicular to the tissue surface, a 25 gauge needleperpendicular to the tissue surface, a 25 gauge needle
(reamer with stopper) through the soft tissue until it hits(reamer with stopper) through the soft tissue until it hits
the underlying bone. The distance of insertion into thethe underlying bone. The distance of insertion into the
soft tissue is measured on the buccal and lingual aspectsoft tissue is measured on the buccal and lingual aspect
of the alveolar ridge at varying vestibular depths. Fromof the alveolar ridge at varying vestibular depths. From
this information, regions of potentially adequate bone,this information, regions of potentially adequate bone,
implant size, number, and location can be tentativelyimplant size, number, and location can be tentatively
determined. The surgeon and prosthodontist shoulddetermined. The surgeon and prosthodontist should
carefully review and discuss their findings and developcarefully review and discuss their findings and develop
a understanding regarding implant location anda understanding regarding implant location and
angulation.angulation. www.indiandentalacademy.comwww.indiandentalacademy.com

7070
 Diagnostic casts areDiagnostic casts are
mounted in an articulatormounted in an articulator
using a centric relationusing a centric relation
record (Fig. 1). Therecord (Fig. 1). The
distance from thedistance from the
edentulous ridge to theedentulous ridge to the
opposing occlusal surfaceopposing occlusal surface
measured to make certainmeasured to make certain
that adequate space isthat adequate space is
available for fabrication ofavailable for fabrication of
the prosthesis above thethe prosthesis above the
implant the verticalimplant the vertical
dimension of occlusion.dimension of occlusion.

7171
 Artificial teeth of a sizeArtificial teeth of a size
similar to the opposing orsimilar to the opposing or
adjacent dentition selected.adjacent dentition selected.
They are arranged in theThey are arranged in the
edentulous space the castedentulous space the cast
over the ridge, asover the ridge, as
determined by the clinicaldetermined by the clinical
examination, to provide anexamination, to provide an
appropriate occlusalappropriate occlusal
relationship with therelationship with the
opposing arch. The artificialopposing arch. The artificial
teeth, held in position withteeth, held in position with
a small amount of utilitya small amount of utility
wax directly under eachwax directly under each
toothtooth www.indiandentalacademy.comwww.indiandentalacademy.com

7272
 An outline is drawn with a pencil on the cast aroundAn outline is drawn with a pencil on the cast around
each artificial teeth.each artificial teeth.

7373
 ). The cast with the artificial). The cast with the artificial
teeth is removed from theteeth is removed from the
articulator and placed on aarticulator and placed on a
surveyor. The analyzing rod issurveyor. The analyzing rod is
aligned with the long axis ofaligned with the long axis of
the artificial teeth.the artificial teeth.
 After the surveyor is properlyAfter the surveyor is properly
aligned, the artificial teeth arealigned, the artificial teeth are
removed from the cast. Theremoved from the cast. The
center of the outline around thecenter of the outline around the
artificial teeth that willartificial teeth that will
represent location for implantrepresent location for implant
placement is then marked, andplacement is then marked, and
the analyzing rod is removedthe analyzing rod is removed
from the surveyor mandrel.from the surveyor mandrel.

7474
 A 10 mm length of 0.045 inch round tubing is prepared.A 10 mm length of 0.045 inch round tubing is prepared.
The outer surface of the tubing is serrated with aThe outer surface of the tubing is serrated with a
separating disk to providing multiple serrations along theseparating disk to providing multiple serrations along the
entire tube length. This procedure provides mechanicalentire tube length. This procedure provides mechanical
retention for tube within acrylic resin on processing ofretention for tube within acrylic resin on processing of
the template and holds the tube in place duringthe template and holds the tube in place during
investment and processing. Care must be taken not to cutinvestment and processing. Care must be taken not to cut
through inner surface of the tube.through inner surface of the tube.www.indiandentalacademy.comwww.indiandentalacademy.com

7575
 The open ends of the tub lumen are closed with aThe open ends of the tub lumen are closed with a
temporary plug material as much material as possibletemporary plug material as much material as possible
should be forced into lumen. All excess material isshould be forced into lumen. All excess material is
removed from around lumen. The tubing is placed andremoved from around lumen. The tubing is placed and
tightened into surveyor mandrel. The tube should betightened into surveyor mandrel. The tube should be
supported wit the mandrel with the metal sheathsupported wit the mandrel with the metal sheath
provided with surveyor to support the carbon markerprovided with surveyor to support the carbon markerwww.indiandentalacademy.comwww.indiandentalacademy.com

7676
 The tubing is then centered overThe tubing is then centered over
the outline of one of artificial teeththe outline of one of artificial teeth
representing the location forrepresenting the location for
implant placement. At thisimplant placement. At this
angulation, the round tubing is mangulation, the round tubing is m
to lightly contact the cast and isto lightly contact the cast and is
luted into place wit small amountluted into place wit small amount
of sticky wax.of sticky wax.
 It is then carefully released fromIt is then carefully released from
the surveyor. Additionalthe surveyor. Additional
identically Paired pieces of tubingidentically Paired pieces of tubing
are luted into position in the sameare luted into position in the same
fashion as determined by thefashion as determined by the
number of submerged Jamsnumber of submerged Jams
planned in the treatment. Oneplanned in the treatment. One
length of tubing for eachlength of tubing for each
anticipated locationanticipated location www.indiandentalacademy.comwww.indiandentalacademy.com

7777
 After all of the round tubingAfter all of the round tubing
is positioned on theis positioned on the
edentulous ridge, the acrylicedentulous ridge, the acrylic
resin portion of the surgicalresin portion of the surgical
template is outlined on thetemplate is outlined on the
cast, incorporating the tubescast, incorporating the tubes
and covering all denture-and covering all denture-
bearing surfaces, similar to abearing surfaces, similar to a
record base .record base .
 This template is built upThis template is built up
with three thickness ofwith three thickness of
baseplate waxbaseplate wax

7878
 The cast is carefully invested and the template isThe cast is carefully invested and the template is
processed in the conventional mannerprocessed in the conventional manner with clearwith clear
heat-processed acrylic resinheat-processed acrylic resin. The surgical template. The surgical template
is carefully recovered from the cast after processingis carefully recovered from the cast after processing
to avoid damage or alteration to the tubes. Acrylicto avoid damage or alteration to the tubes. Acrylic
resin flash around the tubes is removed with anresin flash around the tubes is removed with an
acrylic resin bur and the temporary plug within theacrylic resin bur and the temporary plug within the
tube lumen is pushed out with an anesthetic needle.tube lumen is pushed out with an anesthetic needle.
Acrylic resin surgical template is smoothed andAcrylic resin surgical template is smoothed and
polished ultrasonically cleaned, and sterilized bypolished ultrasonically cleaned, and sterilized by
using cold sterilizationusing cold sterilizationwww.indiandentalacademy.comwww.indiandentalacademy.com

7979
 Each length of tubing on the template is measured withEach length of tubing on the template is measured with
a Boley gauge on shortened to an accurate 5 mma Boley gauge on shortened to an accurate 5 mm
length. For the panoramic and other non occlusallength. For the panoramic and other non occlusal
views, the 5 mm length of tubing is used as a standardviews, the 5 mm length of tubing is used as a standard
reference length to dimensionally correct anyreference length to dimensionally correct any
measurements taken from the radiograph inmeasurements taken from the radiograph in
determining the availabilitydetermining the availability of bone.of bone.www.indiandentalacademy.comwww.indiandentalacademy.com

8080
 The surgeon and prosthodontist study theseThe surgeon and prosthodontist study these
radiographs in conjunction with the mountedradiographs in conjunction with the mounted
diagnostic casts and findings from the clinicaldiagnostic casts and findings from the clinical
evaluation to deter-mine implant size, position,evaluation to deter-mine implant size, position,
and potential complications that may arise fromand potential complications that may arise from
the selected site. The tubing, as seen in thethe selected site. The tubing, as seen in the
radiograph, can help identify the location andradiograph, can help identify the location and
angulation of the implant within the underlyingangulation of the implant within the underlying
bone and aid in providing a more predictablebone and aid in providing a more predictable
outcome for the entire treatment. If problemsoutcome for the entire treatment. If problems
are anticipated with the surgical site,are anticipated with the surgical site,
reevaluation of the implant location on thereevaluation of the implant location on the
diagnostic cast and redesign and fabrication of adiagnostic cast and redesign and fabrication of a
new-template must be done before surgery.new-template must be done before surgery.www.indiandentalacademy.comwww.indiandentalacademy.com

8181
 When the presurgical evaluation is completed, the portion ofWhen the presurgical evaluation is completed, the portion of
tubing extending out of the polished surface of the template istubing extending out of the polished surface of the template is
removed with a separating disk. The remaining tubing,removed with a separating disk. The remaining tubing,
embedded into the acrylic resin. should be approximately 3 mmembedded into the acrylic resin. should be approximately 3 mm
in length as measuredin length as measured withwith a Boley gauge around the template.a Boley gauge around the template.
Metal Hash around the tubing lumen should be removed withMetal Hash around the tubing lumen should be removed with
an explorer and smoothed with a rubber wheel. The entirean explorer and smoothed with a rubber wheel. The entire
surgical template is then smoothed and polished and againsurgical template is then smoothed and polished and again
ultrasonically cleaned and sterilized by using cold sterilization.ultrasonically cleaned and sterilized by using cold sterilization.

8282
 The surgical template is transferred to the surgeon. AfterThe surgical template is transferred to the surgeon. After
anesthesia, the template is positioned iniraorally and heldanesthesia, the template is positioned iniraorally and held
firmly onto the tissue. The lubes are used as a guide forfirmly onto the tissue. The lubes are used as a guide for
drilling a channel hole through the mucosa and into thedrilling a channel hole through the mucosa and into the
bone. The round-tube lumen diameter is select-ed tobone. The round-tube lumen diameter is select-ed to
provide a close tolerance fitprovide a close tolerance fit

8383
 The hole should beThe hole should be
made approximately 4made approximately 4
mm into the bone.mm into the bone.
 On drilling, the bur isOn drilling, the bur is
lowered into the tube,lowered into the tube,
which guides it intowhich guides it into
the bone while thethe bone while the
surgical template issurgical template is
held in place over theheld in place over the
tissue. The hole istissue. The hole is
then used as a guidethen used as a guide
for the location andfor the location and
angulation of theangulation of the
guide pins.guide pins.

8484
Bilaminar dual-purpose stentBilaminar dual-purpose stent
 Murat C.cehreli, Yavuz Asian, and Sairne Sahin,Murat C.cehreli, Yavuz Asian, and Sairne Sahin,
describe a procedure for fabricating a bilaminardescribe a procedure for fabricating a bilaminar
dual-purpose stent. This stent is specificallydual-purpose stent. This stent is specifically
designed for the use of surgical drills in bone withdesigned for the use of surgical drills in bone with
low density. The outer lamina, which is preparedlow density. The outer lamina, which is prepared
as a shell, is used for radiographic purposes and foras a shell, is used for radiographic purposes and for
verifying the alignment of implants with the guideverifying the alignment of implants with the guide
pins in accordance with the predeterminedpins in accordance with the predetermined
superstructure. The inner lamina is designed tosuperstructure. The inner lamina is designed to
accept 2 removable surgical stents bilaterally withaccept 2 removable surgical stents bilaterally with
2 guide channels in diameter.2 guide channels in diameter.www.indiandentalacademy.comwww.indiandentalacademy.com

8585
 There are 2 issues that should be taken into considerationThere are 2 issues that should be taken into consideration
while converting the stent,while converting the stent,
 First, because errors in converting the stent may lead toFirst, because errors in converting the stent may lead to
misalignment of the implants, the angle of themisalignment of the implants, the angle of the
radiopaque markers should provide ease in reorientingradiopaque markers should provide ease in reorienting
the surveying table if guide channel preparation has to bethe surveying table if guide channel preparation has to be
performed in a different angle. In addition, theperformed in a different angle. In addition, the
radiopaque marker should provide accurate transfer ofradiopaque marker should provide accurate transfer of
the 2-dimensional information to the 3-dimensional sentthe 2-dimensional information to the 3-dimensional sent
throughout the entire procedure.throughout the entire procedure.
 Second, there are no prefabricated guide channelsSecond, there are no prefabricated guide channels
offered by dental implant systems that would either beoffered by dental implant systems that would either be
"intcrplaced" to form an assembly or as single tubes"intcrplaced" to form an assembly or as single tubes
whose dimensions would match the diameter of usedwhose dimensions would match the diameter of used
surgical drills. The lack of this feature usually results insurgical drills. The lack of this feature usually results in
a prepared single guide channel that allows only Ia prepared single guide channel that allows only I
surgical drill to pass throughsurgical drill to pass through

8686
 Make the impressions of both arches using irreversibleMake the impressions of both arches using irreversible
hydrocolloid impression material and pour the casts in ty e IIIhydrocolloid impression material and pour the casts in ty e III
dental stone. Using a face-bow transfer , and a centric relationdental stone. Using a face-bow transfer , and a centric relation
record, mount the casts on a semiadjustable articulator.record, mount the casts on a semiadjustable articulator.
 To fabricate the inner lamina, vacuum form a 2.0 x 125-mm clearTo fabricate the inner lamina, vacuum form a 2.0 x 125-mm clear
transparent foil on the upper cast. Gcntlv dislodge the foil, trimtransparent foil on the upper cast. Gcntlv dislodge the foil, trim
the borders to cover the edentulous ridges and the palate and athe borders to cover the edentulous ridges and the palate and a
third of the incisal portions of the remaining anterior teeth,third of the incisal portions of the remaining anterior teeth,
 To fabricate the outer lamina, prepare a diagnostic setup usingTo fabricate the outer lamina, prepare a diagnostic setup using
denture teeth and modeling wax. Make an irrcvcrs1bIedenture teeth and modeling wax. Make an irrcvcrs1bIe
hydrocolloid impression over the clear vacuum -formed foil andhydrocolloid impression over the clear vacuum -formed foil and
the setup. Then, pour the cast in type III dental stone and vacuumthe setup. Then, pour the cast in type III dental stone and vacuum
form another foil over the obtained cast.form another foil over the obtained cast.
 After removing the new foil, trim the borders of the shell portionAfter removing the new foil, trim the borders of the shell portion
according to the cervical margins of the setup and shape otheraccording to the cervical margins of the setup and shape other
borders to approximately fit the inner lamina.borders to approximately fit the inner lamina.

8787
 As an assembly, place both foils on the surveying tableAs an assembly, place both foils on the surveying table
with the cast. Determine the ideal location and possiblewith the cast. Determine the ideal location and possible
angle of implant axis. Drill pin holes through bothangle of implant axis. Drill pin holes through both
plates and secure pins (I mm in diameter) forplates and secure pins (I mm in diameter) for
radiographic evaluation with a small amount of clearradiographic evaluation with a small amount of clear
autopolymcrlzcd acrylic resin .autopolymcrlzcd acrylic resin .www.indiandentalacademy.comwww.indiandentalacademy.com

8888
 At this stage, the positioning of the pins should coincideAt this stage, the positioning of the pins should coincide
the anticipated central axis of the implants. Then, adjustthe anticipated central axis of the implants. Then, adjust
the stern in the mouth and make a bite registration usingthe stern in the mouth and make a bite registration using
additional cure bite registration paste to immobilize theadditional cure bite registration paste to immobilize the
stent while obtaining the CT scan.stent while obtaining the CT scan.

8989
 Perform measurements
regarding dimensions of the
available bone and the
angulation of implants on the
CT image.
 Image of radiopaque marker
that can only be viewed in I
section of scan images
provides accurate evaluation
of predetermined axis of
implant placement and area
representing bone structure at
central section of implant.
Surveying table can simply be
reoriented by using angle of
pins if any change in angle of
implant insertion is indicated.www.indiandentalacademy.comwww.indiandentalacademy.com

9090
 Separate the outer portion-with the pins still in place-Separate the outer portion-with the pins still in place-
from the inner lamina. Remove the plate covering thefrom the inner lamina. Remove the plate covering the
edentulous ridges from the lamina with a carbide buredentulous ridges from the lamina with a carbide bur
and cut 4 stainless burs, leaving approximately I cm ofand cut 4 stainless burs, leaving approximately I cm of
their ends. Then, secure the bur ends (that are plannedtheir ends. Then, secure the bur ends (that are planned
for use in guiding the insertion of the removablefor use in guiding the insertion of the removable
surgical acrylic resin stents to the palatal sides of thesurgical acrylic resin stents to the palatal sides of the
inner lamina) bilaterally using clear autopolymerizinginner lamina) bilaterally using clear autopolymerizing
acrylic resin on the surveying table.acrylic resin on the surveying table.www.indiandentalacademy.comwww.indiandentalacademy.com

9191
 Make an irreversible hydrocolloid impressionMake an irreversible hydrocolloid impression
over the cast. Pour the cast and bilaterallyover the cast. Pour the cast and bilaterally
fabricate 2 acrylic stents covering only thefabricate 2 acrylic stents covering only the
residual ridges. Trim the excess material andresidual ridges. Trim the excess material and
adjust the stents so as to pass through theadjust the stents so as to pass through the
guiding probes.guiding probes.

9292
 Fabricate a custom flapFabricate a custom flap
retractor using 1mm,retractor using 1mm,
stainless steelstainless steel
orthodontic wire. Theorthodontic wire. The
retractor should passretractor should pass
over the posteriorover the posterior
border of the stent,border of the stent,
while extending to thewhile extending to the
anterior (and parallel)anterior (and parallel)
and the buccal sulcusand the buccal sulcus
on both sides.on both sides.
 Secure the custom flapSecure the custom flap
retractor in place withretractor in place with
clear autopolymerizedclear autopolymerized
acrylic resinacrylic resin

9393
 Remove the palatal portion ofRemove the palatal portion of
the outer lamina with a carbidethe outer lamina with a carbide
bur and mount the assemblybur and mount the assembly
on the surveying table. Afteron the surveying table. After
determining the necessary tiltdetermining the necessary tilt
of the surveying table throughof the surveying table through
radiopaque markers, separateradiopaque markers, separate
the outer lamina and insert thethe outer lamina and insert the
fabricated removable acrylicfabricated removable acrylic
resin stents. By using the firstresin stents. By using the first
2 surgical drills, perform guide2 surgical drills, perform guide
channel preparation for 2channel preparation for 2
stents in each segmentstents in each segment

9494
 To verify the angulation of implants through the shell withTo verify the angulation of implants through the shell with
surgical guide pins, remove the radiopaque markers fromsurgical guide pins, remove the radiopaque markers from
the outer lamina and drill holes on the occlusal aspect ofthe outer lamina and drill holes on the occlusal aspect of
the shell approximately 4 mm in diameterthe shell approximately 4 mm in diameterwww.indiandentalacademy.comwww.indiandentalacademy.com

9595
 Bilaminar stent is ready for use after sterilizationBilaminar stent is ready for use after sterilization

9696
 The technique has 2 disadvantages. First, the custom flap retractorThe technique has 2 disadvantages. First, the custom flap retractor
was designed initially to improve the visualization by activating itwas designed initially to improve the visualization by activating it
buccally. However, a design with loops would probably be morebuccally. However, a design with loops would probably be more
efficient.efficient.
 Second, the laboratory procedures to fabricate such stents arcSecond, the laboratory procedures to fabricate such stents arc
rather complicated and time-consuming.rather complicated and time-consuming.
 Unfortunately, precise mechanisms for accurate placement ofUnfortunately, precise mechanisms for accurate placement of
implants are not provided by implant systems, which has led to theimplants are not provided by implant systems, which has led to the
compromised placement of a large number of implants, whereascompromised placement of a large number of implants, whereas
conventional surgical stents include no safety measures toconventional surgical stents include no safety measures to
eliminate the potential risk of contaminating the implant socket byeliminate the potential risk of contaminating the implant socket by
misusing the surgical drills through acrylic resin guide channels.misusing the surgical drills through acrylic resin guide channels.
However, the complex procedure described herein emphasizes theHowever, the complex procedure described herein emphasizes the
significance of the existence of a prefabricated guide channel thatsignificance of the existence of a prefabricated guide channel that
would surely simplify the whole procedure. In that case, an acrylicwould surely simplify the whole procedure. In that case, an acrylic
resin stcnt that includes the form of the prosthesis andresin stcnt that includes the form of the prosthesis and
prefabricated metal guide channels only as such be sufficient forprefabricated metal guide channels only as such be sufficient for
CT evaluation.CT evaluation. www.indiandentalacademy.comwww.indiandentalacademy.com

9797
Accurate three-dimensional models of the patients anatomyAccurate three-dimensional models of the patients anatomy
can be produced by a number of CADCAM andcan be produced by a number of CADCAM and
prototyping procedures.' CADCAM surgical steriotacticprototyping procedures.' CADCAM surgical steriotactic
templates can be produced from CT examinations havetemplates can be produced from CT examinations have
used interactive CT that to devolop a three dimensionalused interactive CT that to devolop a three dimensional
treatment plan for the patient of the position andtreatment plan for the patient of the position and
orientation of dental implants. To incorporate the threeorientation of dental implants. To incorporate the three
dimensional treatment plan of implantdimensional treatment plan of implant
position and orientations into the model, the internalposition and orientations into the model, the internal
archetecture of the patient's anatomy must also be produced.archetecture of the patient's anatomy must also be produced.
a model of the patient's alveolar anatomy incorporateda model of the patient's alveolar anatomy incorporated
with the osteotomy positions and orientations can then bewith the osteotomy positions and orientations can then be
prodeced.prodeced.
CADCAM Stereotactic surgicalCADCAM Stereotactic surgical
templatetemplate

9898
 A Stereotactic surgical template is derived fromA Stereotactic surgical template is derived from
the model by aligning guide cylinders at the implant sites,the model by aligning guide cylinders at the implant sites,
which must accommodate a pilot drill, and producing awhich must accommodate a pilot drill, and producing a
vaccuform using surgical template material of the modelvaccuform using surgical template material of the model
and guide cylinders. This results in a plastic surgicaland guide cylinders. This results in a plastic surgical
template that fits and confirms to patient's bony anatomytemplate that fits and confirms to patient's bony anatomy
and supports the position and orientation of the guideand supports the position and orientation of the guide
cylinders, which precisely reproduces the position andcylinders, which precisely reproduces the position and
orientation of the proposed implants. The surgical guideorientation of the proposed implants. The surgical guide
is stabilized by confirmation of the vacuform. to theis stabilized by confirmation of the vacuform. to the
patient's bony anatomy. the Stereotactic surgical templatepatient's bony anatomy. the Stereotactic surgical template
is used to establish pilot holes / osteotomies to a depth ofis used to establish pilot holes / osteotomies to a depth of
approximately 10 mm for the position and orientation ofapproximately 10 mm for the position and orientation of
the implants.the implants.

9999
PRE-MAXILLA IMPLANTPRE-MAXILLA IMPLANT
CONSIDERATIONSCONSIDERATIONS

100100
INTRODUCTIONINTRODUCTION
 Several factors affect the condition of the pre maxillaSeveral factors affect the condition of the pre maxilla
and may result in a decrease in implant survival and/orand may result in a decrease in implant survival and/or
an increase in prosthetic complications.an increase in prosthetic complications.
 The maxillary anteriorridge is often inadequate inThe maxillary anteriorridge is often inadequate in
available bone for endosteal implants. The facialavailable bone for endosteal implants. The facial
cortical plate may be resorbed from periodontal diseasecortical plate may be resorbed from periodontal disease
or is often fractured during the extraction of teeth. Inor is often fractured during the extraction of teeth. In
addition, it resorbs during initial bone remodeling afteraddition, it resorbs during initial bone remodeling after
tooth loss, and the anterior ridge loses 25% of itstooth loss, and the anterior ridge loses 25% of its
Width within the first year after tooth loss and 40% toWidth within the first year after tooth loss and 40% to
60% over 3 years, mostly at the expense of the labial60% over 3 years, mostly at the expense of the labial
plate. As a result, it migrates to a more palatal position.plate. As a result, it migrates to a more palatal position.

101101
 In the majority of patients, the bone is lessIn the majority of patients, the bone is less
dense in the anterior maxilla than in thedense in the anterior maxilla than in the
anterior mandible. In the mandible, a denseanterior mandible. In the mandible, a dense
cortical layer increases trabecular bonecortical layer increases trabecular bone
strength and permits implants to engage astrength and permits implants to engage a
denser bone quality. The maxilla presents thindenser bone quality. The maxilla presents thin
porous bone on the labial aspect, very thinporous bone on the labial aspect, very thin
porous to-dense compacta in the nasal region,porous to-dense compacta in the nasal region,
and a thick cortical bone on the palatal aspect.and a thick cortical bone on the palatal aspect.
The trabecular bone may be coarse or fine andThe trabecular bone may be coarse or fine and
is often less dense in nature than the anterioris often less dense in nature than the anterior
regions of the mandible.regions of the mandible.

102102
 In the premaxilla, esthetics and phonetics dictate that theIn the premaxilla, esthetics and phonetics dictate that the
replacement teeth be placed at or near their originalreplacement teeth be placed at or near their original
position, which is often cantilevered off the residualposition, which is often cantilevered off the residual
ridge,which is more palatal superior.ridge,which is more palatal superior.
 The crown height is a force magnifier and is anThe crown height is a force magnifier and is an
important consideration in the anterior maxilla, whereimportant consideration in the anterior maxilla, where
the natural crown height is already greater than any otherthe natural crown height is already greater than any other
region even under ideal conditions. arc of closure isregion even under ideal conditions. arc of closure is
anterior to residual ridge; as a consequence, the momentanterior to residual ridge; as a consequence, the moment
force is greatest against the maxillary anterior crownsforce is greatest against the maxillary anterior crowns
supported by implants and directed against the thinnersupported by implants and directed against the thinner
facial bone. All mandibular excursions place lateralfacial bone. All mandibular excursions place lateral
forces on the maxillary anterior teeth, with resultingforces on the maxillary anterior teeth, with resulting
increased stress on the crestal bone, especially on theincreased stress on the crestal bone, especially on the
labial of the implant.labial of the implant.

103103
Treatment planningTreatment planning

104104
 From a biomechanical perspective, the implant-From a biomechanical perspective, the implant-
restored anterior maxilla is often the weakestrestored anterior maxilla is often the weakest
section compared with other regions of thesection compared with other regions of the
mouth.mouth.
 Compromising conditions in this anatomicCompromising conditions in this anatomic
region and their resultant consequences includeregion and their resultant consequences include
 (1) The need for narrower implants (results in(1) The need for narrower implants (results in
increased stress concentrations in both theincreased stress concentrations in both the
implant and contiguous interfacial tissues,implant and contiguous interfacial tissues,
particularly at the crestal region);particularly at the crestal region);
 (2) The use of facial cantilevers (results in(2) The use of facial cantilevers (results in
increased moment loads at the implant crest,increased moment loads at the implant crest,
often leading to localized crestal remodeling andoften leading to localized crestal remodeling and
implant and/or abutment fracture);implant and/or abutment fracture);www.indiandentalacademy.comwww.indiandentalacademy.com

105105
 (3) Oblique centric contacts (results in potentially(3) Oblique centric contacts (results in potentially
harmful, off-axis load components);harmful, off-axis load components);
 4) Lateral forces in excursion (i.e., results in4) Lateral forces in excursion (i.e., results in
dangerous moment loads applied to the implant);dangerous moment loads applied to the implant);
 (5) Reduced bone density (results in compromised(5) Reduced bone density (results in compromised
bone strength and loss of implant support);bone strength and loss of implant support);
 (6) Absence of thick cortical plate at the crest or(6) Absence of thick cortical plate at the crest or
apex (results in loss of high strength implantapex (results in loss of high strength implant
support); andsupport); and
 (7) The inability to place central and/or lateral(7) The inability to place central and/or lateral
incisor irnplants.incisor irnplants.

106106
 These compromising characteristics of theThese compromising characteristics of the
premaxilla mandate special consideration whenpremaxilla mandate special consideration when
establishing the occlusal scheme. An implantestablishing the occlusal scheme. An implant
protective -occlusion suggests the negativeprotective -occlusion suggests the negative
factors be reduced by eliminating posteriorfactors be reduced by eliminating posterior
contacts in excursions, increasing the number ofcontacts in excursions, increasing the number of
maxillary anterior implants, , increasing themaxillary anterior implants, , increasing the
diameter of implants (often requires bonediameter of implants (often requires bone
augmentation), and increasing the number ofaugmentation), and increasing the number of
implants that disocclude the posterior teeth inimplants that disocclude the posterior teeth in
each lateral excursion,each lateral excursion,

107107
 As a result, at least three implants are usuallyAs a result, at least three implants are usually
required to replace the six anterior teeth, and tworequired to replace the six anterior teeth, and two
of these should be in the canine positions .of these should be in the canine positions .
 Posterior cantilevers should not be placed on thesePosterior cantilevers should not be placed on these
three implants, especially when increased factorsthree implants, especially when increased factors
of force are present. The three implants should beof force are present. The three implants should be
splinted together and share any lateral forcessplinted together and share any lateral forces
during excursions. If posterior teeth are also beingduring excursions. If posterior teeth are also being
replaced in the prostheses, additional implants arereplaced in the prostheses, additional implants are
required.required.
 Eight to ten implants are often required to restore aEight to ten implants are often required to restore a
maxilla with a fixed prostheses, especially whenmaxilla with a fixed prostheses, especially when
opposing a natural dentition/ fixed restoration.opposing a natural dentition/ fixed restoration.www.indiandentalacademy.comwww.indiandentalacademy.com

108108
 An important parameter in treatment planningAn important parameter in treatment planning
is the adequate surface area of support for theis the adequate surface area of support for the
load transmitted to the prosthesis. Previousload transmitted to the prosthesis. Previous
studies have shown that the force distributedstudies have shown that the force distributed
over three abutments results in less localizedover three abutments results in less localized
stress to the crestal bone than two abutments.stress to the crestal bone than two abutments.
 In oder to resist mandibular excursions,In oder to resist mandibular excursions,
implants should be splinted and as a result,implants should be splinted and as a result,
premaxillary implants should be placed in bothpremaxillary implants should be placed in both
canine and a lateral or both canine and acanine and a lateral or both canine and a
central for each anterior section of the arch."'central for each anterior section of the arch."'

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