cast based guided implant placement/ general dentistry


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Dentistry, Periodontics and General Dentistry.

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  • One of the challenges of implantplacement is planning the correct positioning of the implant in the bone to achieve a prosthetic solution that fulfills biologic, esthetic, and biomechanic requirements.
    At the same time, it is important to prevent encroachment
    on vital structures, adjacent teeth, and body cavities
  • . The x-axis is clinically the mesiodistal plane, the y-axis represents the buccolingual plane, and the position on the z-axis determines the length at the apex of the implant and the depth of the prosthetic table at the top of the implant.
  • cast based guided implant placement/ general dentistry

    1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
    2. 2. To aid the surgeon in this endeavor,many types of surgical guides have been proposed Design concepts vary from 1. nonlimiting, 2. partially limiting 3. completely limiting surgical guides
    3. 3. Information acquired in the preoperative planning phase is transferred to the surgical guide. Since with guides that are completely restrictive, the exact position of the implant is not known before surgery, the prefabrication of a provisional restoration might be less precise compared to a provisional restoration developed following the fabrication of the nonlimiting guide
    4. 4. Bone sounding has been used in clinical dentistry to acquire an understanding of the thickness of the soft tissue overlying the bone. Perez et al have shown that this technique provides a depiction of available bone volume that is slightly less than is actually available. Clinically,this provides the clinician reliable information with a small margin of safety. By subtracting the measured tissue thickness of the corresponding sites on a dental cast, a 3-dimensional (3-D) representation of the bone volume will be created. Within this volume of bone, the correct position of the dental implant can be established.
    5. 5. When determining the position of a dental implant, 3 axes must considered separately When considering the position of the implant in the mesiodistal plane, the proximity to the adjacent teeth is the greatest limiting determinant, followed by the requirements of the prosthetic reconstruction. In the buccolingual direction, the available bone volume, again in combination with the prosthesis, will guide the desired implant location.
    6. 6. This article demonstrates a combination of analog techniques to produce a surgical guide, allowing placement of a dental implant in a precise predetermined position. The surgery is a flapless procedure, improving patient comfort. Since the implant position relative to the surrounding dentition is known, a provisional restoration and, if desired, the definitive abutment, can be prefabricated, so that it can be inserted at the time of surgery if an immediate provisional restoration is desired.
    7. 7. Data acquisition Select a stock impression tray Palpate the area of the proposed implant site and determine if there are areas susceptible for soft tissue deformation. Apply a utility wax strip Use irreversible hydrocolloid
    8. 8. Use a pinless tray and die system Create a cast by casting the impression.. Remove the impression from the cast once the material has polymerized. Make a partial overimpression over the soft tissue area and adjacentteeth of the proposed implant site with a stiff VPS material.
    9. 9. Fit a sterile 0.4 x 8-mm (27 G) dental needle with an endodontic rubber stop Anesthetize the patient as needed. Make the first measurement
    10. 10. Remove the needle from the measured site and record the distance Make the second measurement on the buccal surface Make the third measurement in a similar position on the lingual surface, while measurements 4 and 5 are made in between the crest and the most apical portion.
    11. 11. Make a periapical radiograph of the proposed site in such a way that foreshortening or elongation is prevented and the image is dimensionally true, while capturing the apices of the adjacent teeth as much as possible. Adjust the digital image using an image manipulation program (Photoshop CS3; Adobe Systems, Inc, San Jose, Calif ) to create a true 1:1 image From the IMAGE menu, select SIZE, set the image size to the size of the digital radiograph sensor in millimeters, SAVE, then PRINT. The printed image is now 1:1. Use conventional analog film as is.
    12. 12. On the modified radiograph, use scissors to cut out the bone between the root structures and the occlusal surface of the teeth. Place the modified radiograph on the cast, to coincide with the occlusal and interproximal surfaces on the cast .
    13. 13. Outline the position of the root structures on the cast with a pen. Mark the area available for implant placement in the mesiodistal direction. Mark the best position for the midline of the proposed implant. Remove the cast from the Accu-Trac (Coltene/Whaledent, Inc). Cut the cast exactly in the selected plane with a large 45-mm diamond- coated disk
    14. 14. Select 1 portion of the sectioned cast to transfer the clinical tissue depth measurements. Mark the depths on the cast in positions similar to those from which they were acquired clinically. Connect the marking points, Select the implant diameter based on the availability of bone in both the mesiodistal and buccolingual planes.
    15. 15. Determine the axis for the buccolingual plane, guided by the availability of bone and the prosthetic reconstruction. Mark the axis on the cast. Mark the depth of the implant platform with a horizontal line perpendicular to the implant axis. Place the marked cast piece back into the Accu-Trac tray
    16. 16. Place a drill bit, the size of the selected implant diameter, in the chuck of a drill press Unlock the table, and place the sectioned part of the cast against the drill to transfer the mesiodistal plane
    17. 17. Rotate the table to coincide with the marking of the buccolingual axis, while taking care to not change the previously established mesiodistal plane
    18. 18. Lock the surveyor table, and confirm both planes to be parallel with the drill bit Remove the Accu-Trac tray from the surveyor table, and reposition the remaining section of the cast in the tray. Place the Accu-Trac tray back onto the surveyor table, then move the cast under the drill bit Make the cast osteotomy at a depth slightly deeper than the length of the implant laboratory analog
    19. 19. Remove the Accu-Trac tray from the surveyor table, open and remove 1 section of the cast. Visually inspect Position a laboratory implant analog in the section of the cast osteotomy, with the platform at the previously selected depth. Secure with cyanoacrylate glue
    20. 20. Coat the contralateral part of the cast osteotomy with cyanoacrylate glue Remove the area above the analog and between the adjacent teeth with a scalpel to start the creation of simulated gingival tissue. Place a 2-mm healing cap onto the analog. Perforate the previously made, preoperative, stiff VPS impression at opposing sites and reposition the preoperative impression on the cast.
    21. 21. Inject a heavy-body polyether impression material .Once the material has polymerized, cut the soft tissue mask to simulate the desired emergence profile
    22. 22. Select a guide sleeve consistent with the selected implant width Weld 2 sections, 10 cm by 0.5 mm, of metal wire to the lateral sides of the sleeve
    23. 23. Assemble a laboratory guide pin (Nobel Biocare USA) onto the laboratory analog in the cast. Bend the wires to create a framework around the teeth
    24. 24. Place a 2-cm section of polyethylene tubing over the top of the laboratory guided cylinder pin Isolate the cast with a spray of separator , as both materials are VPS and otherwise will bind together. Perforate a small disposable plastic impression tray so that it will fit over the tubing.
    25. 25. Inject a stiff VPS occlusal record registration material surrounding the teeth and the guided cylinder. Place the plastic impression tray over the tubing and VPS
    26. 26. Upon the completion of polymerization, unscrew and disassemble the guided laboratory pin. Remove the buccal and lingual walls next to the guide sleeve to create access for the clinical surgical instrumentation .
    27. 27. Place the completed surgical guide intraorally and make a periapical radiograph parallel to the occlusal portion of the sleeve Extend the lateral borders of the sleeve on the radiograph and confirm the correctness of the mesiodistal trajectory . Disinfect the approved guide for 12 minutes in a disinfectant
    28. 28. Fabricate the provisional restoration or definitive abutment- provisional restoration combination, since the exact position of the implant is known before the surgery.
    29. 29. Prepare and anesthetize the patient as needed. Place the surgical guide and introduce the tissue punching drill with water irrigation through the sleeve. Puncture the soft tissue and create a starting point for the osteotomy
    30. 30. Place a 2-mm drill guide in the sleeve, to allow precise guidance of the 2-mm drill. Place a drill stop on the 2-mm and subsequent drills at the implant length plus 10 mm, per the system requirements
    31. 31. Gradually enlarge the osteotomy, depending on the diameter and the resistance of the bone, to the appropriate size Place the implant on the guided implant mount , and introduce it through the guide into the osteotomy. Make the lobe marking on the implant mount to correspond with the lobe mounting on the surgical guide. Ensure that the implant mating surface is in the same orientation intraorally as on the cast
    32. 32. Remove the implant mount and use a tissue punch to clean soft tissue tags that might interfere with the seating of the prosthetic components. Place the screw-retained provisional restoration or abutment/provisional restoration combination if sufficient initial stability (35 N/cm) is obtained
    33. 33. Ensure that the provisional restoration does not have interproximal and occlusal contact, as to limit excess motion during the osseointegration healing period
    34. 34. Fabrication and use of a simple implant placement guide: Richard J. Windhorn, (J Prosthet Dent 2004;92:196-9.) This article describes an acrylic resin implant placement guide which is simple to fabricate and easy to use. This device guides the surgeon in the precise position and angulation planned for the implant, yet allows for some flexibility in the event slight adjustments are necessary during surgery
    35. 35. Diagnostic cast with wooden stick in place. Handpiece head in place on wooden stick as reference for molding acrylic resin. Trimmed acrylic guide placed back on cast with reference line drawn on vertical
    36. 36.
    37. 37. Implant surgical guide fabrication for partially edentulous patients :Jeffrey L. Shotwell, et al J Prosthet Dent 2005;93:294-7. This article presents an innovative method for the fabrication of implant drill guides for partially edentulous patients. Using a light-polymerized composite material and drill blanks placed in the prosthodontically driven implant position, surgical guides for each implant drill are constructed on the diagnostic cast.
    38. 38. Light-polymerizing material adapted and contoured at buccal aspect to provide reference to proposed gingival margin of restoration. Orientation of cast with aid of dental surveyor to establish proper angulation of implant Implant site with reference lines drawn to determine bucco-lingual as well as mesio-distal placement of implant.
    39. 39. Drill blank placed in opening showing orientation of proposed implant and light-polymerized material adapted to cast and drill blank from lingual aspect. View of implant drill guide used during implant site osteotomy. View of presurgical radiographic guide, and drill guides for each implant drill (from bottom to top).
    40. 40. A surgical guide for dental implant placement in edentulous posterior regions :Saadet Saglam Atsu, J Prosthet Dent 2006;96:129-33. This article describes a simple technique for fabricating a vacuum-formed surgical guide to assist in dental implant placement in edentulous posterior regions
    41. 41. Implant sites prepared through occlusal surfaces of artificial teeth with dental surveyor.( vacuum-formed, rigid clear template) Stainless steel tubes placed in channels drilled through artificial teeth. Smaller metal tubes inserted into larger metal tubes to facilitate drilling pilot holes for implant placement Surgical
    42. 42. Since the volume of the cast is used to subtract the measured thickness of the overlying intraoral tissue, it is imperative that the relationship of the soft tissue to the bone is determined correctly. Areas that might be susceptible for errors are the tissue overlying the lingual concavity of the posterior mandible and the buccal mucosal fold Conventional impressions are cast in a dental stone. While this is a viable technique, this article proposes the use of a stiff VPS. The material allows for the creation of a cast with acceptable accuracy,
    43. 43. Soft tissue measurements are made to determine the bone volume in a buccolingual direction (y-axis); the radiograph is used to determine the mesiodistal plane (x-axis). The thickness of the soft tissue overlying the bone is measured at the middle of the estimated implant site from a mesiodistal perspective. This position is selected as it is, in most situations, due to resorption, the narrowest part of the residual ridge, and the interest is in acquiring knowledge of the smallest dimension available.
    44. 44. Traditionally, restrictive surgical guides are fabricated with an autopolymerizing acrylic resin or composite resin. If in a hard guide, a small area is not correct, it will prevent the guide from seating completely. In contrast to a hard guide, a slightly flexible guide will seat completely even when small discrepancies are encountered. In addition, this type of guide will snap over the height of contour of the covered teeth and, thus, be retentive The fabrication process of the VPS guide is rapid, comparatively inexpensive,
    45. 45. The surgical implant placement appointment is different compared to conventional surgery. All decisions regarding implant positioning have been previously made. It is a matter of executing the plan according to the restrictive surgical guide In the author’s experience, implant and provisional restoration placement require 5 minutes or less. Although preplanning is more time consuming
    46. 46. Cast-based guided implant surgery allows for the precise placement of dental implants with the possibility to continue with an immediate load protocol. The fast flapless procedure allows for minimal patient discomfort, while attaining a high level of precision. This article describes the unique use of VPS material for the fabrication of the cast and the surgical guide.
    47. 47. Fabrication and use of a simple implant placement guide :Richard J. Windhorn, :J Prosthet Dent 2004;92:196-9. Implant surgical guide fabrication for partially edentulous patients: Jeffrey L. Shotwell :J Prosthet Dent 2005;93:294-7. A surgical guide for dental implant placement in edentulous posterior regions :Saadet Saglam Atsu,: J Prosthet Dent 2006;96:129-33. Atsu SS. A surgical guide for dental implant placement in edentulous posterior regions. J Prosthet Dent 2006;96:129-33.
    48. 48. Thank you For more details please visit