11
IMPLANT DENTISTRYIMPLANT DENTISTRY
PRE-SURGICAL PROSTHESESPRE-SURGICAL PROSTHESES
TEMPLATESTEMPLATES
PRE-MAXILLA IMPLAN...
22
 These are provisional restorations that are madeThese are provisional restorations that are made
and inserted prior t...
33
 The treatment denture satisfyies the estheticThe treatment denture satisfyies the esthetic
considerations that may be...
www.indiandentalacademy.comwww.indiandentalacademy.com 44
55
 The maxillary vermillion border is usually altered by the
loss of the maxillary anterior teeth. Once bone is also los...
66
 Long-term edentulous- patients who have worn
the same denture may require a treatment denture
to restore vertical dim...
77
 As the OVD decreases, the jaw rotates forwardAs the OVD decreases, the jaw rotates forward
and closes in a more progn...
88
 The greater the OVD, the more Class II theThe greater the OVD, the more Class II the
mandible becomes in relationship...
99
 . This denture is fabricated with acrylic teeth so. This denture is fabricated with acrylic teeth so
the teeth may be...
1010
 Improve hard and soft tissuesImprove hard and soft tissues
 Evaluate the bone volume necessary for graftingEvaluat...
1111
 Implant dentistry is a complex treatment modality andImplant dentistry is a complex treatment modality and
involves...
1212
1.1. Diagnostic/Radiographic templateDiagnostic/Radiographic template
2.2. Surgical template.Surgical template.
3.3. ...
1313
 The purpose of diagnostic radiographic templates is toThe purpose of diagnostic radiographic templates is to
incorp...
1414
 The pre-prosthetic imaging procedure enables
evaluation of the proposed implant site at the
ideal position and orie...
1515
The radiographic template is fabricated acrylic resinThe radiographic template is fabricated acrylic resin
which norm...
1616
 To evaluate the relationship between anatomic structuresTo evaluate the relationship between anatomic structures
an...
1717
RequirementsRequirements
1.1. StableStable
2.2. RigidRigid
3.3. Radio-opaque markersRadio-opaque markers
4.4. Enable ...
1818
Use of Barium SulphateUse of Barium Sulphate
 Christoph R J. Baden, John C. Kois, describedChristoph R J. Baden, Joh...
1919
 Plan and adjust the outline of the prostheses asPlan and adjust the outline of the prostheses as
needed.needed.
 W...
2020
 Paint a suitable tinfoil substitute on thePaint a suitable tinfoil substitute on the
pretreatment cast, seal onto t...
2121
 Make a small opening in the shell and fill theMake a small opening in the shell and fill the
shell with the mix of ...
2222
 Position the tooth on the pretreatment cast (made in stepPosition the tooth on the pretreatment cast (made in step
...
2323
 After the resin polymerizes, remove theAfter the resin polymerizes, remove the
assembly from the cast, then finish ...
2424
Template with Barium Sulfate &Template with Barium Sulfate &
Stainless TubesStainless Tubes
Fumitaka Takeshita; Tsuto...
2525
 Procedure:Procedure:
 Form wax sprues at theForm wax sprues at the
distal most teeth bilaterallydistal most teeth ...
2626
 Mix powder that consists of a 4:1 ratio of resin polymerMix powder that consists of a 4:1 ratio of resin polymer
an...
2727
 Cure the finished stent atCure the finished stent at
40° C for 20 minutes in40° C for 20 minutes in
the processor, ...
2828
 Obtain a panoramic tomograph and a CT scan with theObtain a panoramic tomograph and a CT scan with the
stent in pla...
2929
 The barium sulfate in the stent depicts the outline of the predesignedThe barium sulfate in the stent depicts the o...
3030
Template with Lead FoilTemplate with Lead Foil
Javier Urquiola; R. W. Toothaker, described theJavier Urquiola; R. W. ...
3131
 PROCEDUREPROCEDURE
 11 Fabricate a template.Fabricate a template.
 22 Select prosthetically favorable implant sit...
3232
 The major disadvantage of using Lead foil as aThe major disadvantage of using Lead foil as a
marker because its den...
3333
Surgical template.Surgical template.
 The surgical template dictates to the surgeon theThe surgical template dictate...
3434
 The purpose of the surgical template is toThe purpose of the surgical template is to
provide information regarding ...
3535
 Ideally, fixtures are placed parallel to eachIdeally, fixtures are placed parallel to each
other, parallel to the l...
3636
 'With the completely edentulous jaw, after the'With the completely edentulous jaw, after the
transitional complete ...
3737
Mandibular surgical templates, or guides, are
valuable aids in the optimal placement of
endosseal fixtures. They aid ...
3838
Requirements:Requirements:
Several methods of fabrication for the surgical template areSeveral methods of fabrication...
3939
 The ideal angulation for implant insertion should beThe ideal angulation for implant insertion should be
determined...
4040
 Other ideal requirements of the surgical template includeOther ideal requirements of the surgical template include
...
4141
Mandibular Completely EdentulousMandibular Completely Edentulous
TemplatesTemplates
1.1. A complete mandibular surgic...
4242
Mandibular Partially EdentulousMandibular Partially Edentulous
TemplatesTemplates
1.1. A surgical template with a gro...
4343
Maxillary Completely EdentulousMaxillary Completely Edentulous
TemplateTemplate
 A maxillary surgical stentA maxilla...
4444
Dual purpose TemplatesDual purpose Templates
 The use guides for radiographic evaluation andThe use guides for radio...
4545
Michael Gardner & Igor J Pesun’sMichael Gardner & Igor J Pesun’s
Dual TemplateDual Template
 They described the fabr...
4646
 Technique:Technique:
 Make duplicate casts of the arch to be evaluated forMake duplicate casts of the arch to be e...
4747
 If any alteration of the vertical dimension of occlusion isIf any alteration of the vertical dimension of occlusion...
4848
 Duplicate the diagnosticDuplicate the diagnostic
wax-up in dental stone.wax-up in dental stone.
 Block out undercu...
4949
 Make vacuformed templates over the blocked outMake vacuformed templates over the blocked out
diagnostic cast and th...
5050
 Trim the templates to 5 mm below the gingival marginTrim the templates to 5 mm below the gingival margin
of the tee...
5151
 Remove the diagnostic wax template and fill itRemove the diagnostic wax template and fill it
with clear orthodontic...
5252
 Trim and smooth theTrim and smooth the
edges of the guide.edges of the guide.
 Prepare holes in thePrepare holes i...
5353
 Trial fit the template in the patients mouthTrial fit the template in the patients mouth
before the radiographic ap...
5454
 Radiographic analysisRadiographic analysis
 Select the cross-sectionalSelect the cross-sectional
images that conta...
5555
Marcus A. R. Lima Verde, Steven M.Marcus A. R. Lima Verde, Steven M.
Morgano’ s Dual purpose StentMorgano’ s Dual pur...
5656
 A stent was designed that is a modification ofA stent was designed that is a modification of
one originally introdu...
5757
 Fabrication:Fabrication:
 For PartiallyFor Partially
edentulousedentulous
patientpatient
 Make diagnostic casts o...
5858
 Make an irreversible hydrocolloid impression of the castMake an irreversible hydrocolloid impression of the cast
wi...
5959
 Place the cast with the acrylic resin in a pressure potPlace the cast with the acrylic resin in a pressure pot
with...
6060
 Place 2 mm gutta-perchaPlace 2 mm gutta-percha
spheres at the desiredspheres at the desired
location of each implan...
6161
 Adapt weather stripping or beading wax to the facial andAdapt weather stripping or beading wax to the facial and
li...
6262
 Finish and polish theFinish and polish the
stentstent
 Refer the patient toRefer the patient to
the radiologist fo...
6363
 FABRICATION FOR THE TOTALLY EDENTULOUSFABRICATION FOR THE TOTALLY EDENTULOUS
PATIENTPATIENT
 11 Duplicate a satisf...
6464
 ANALYSIS OF THE CT SCANANALYSIS OF THE CT SCAN
 Select the cross-sectional imagesSelect the cross-sectional images...
6565
 Connect the two dots for each location that represents theConnect the two dots for each location that represents th...
6666
 Transfer thisTransfer this
information to the stentinformation to the stent
by preparing guideby preparing guide
ch...
6767
Template for positioning andTemplate for positioning and
angulation of intraosseous implantsangulation of intraosseou...
6868
 David R. Burns, Donald G. Crabtree, and
Dewey H. Bell describe a technique for
fabrication of a surgical guide that...
6969
 In addition, it may be desirable to "sound" the boneIn addition, it may be desirable to "sound" the bone
through th...
7070
 Diagnostic casts areDiagnostic casts are
mounted in an articulatormounted in an articulator
using a centric relatio...
7171
 Artificial teeth of a sizeArtificial teeth of a size
similar to the opposing orsimilar to the opposing or
adjacent ...
7272
 An outline is drawn with a pencil on the cast aroundAn outline is drawn with a pencil on the cast around
each artif...
7373
 ). The cast with the artificial). The cast with the artificial
teeth is removed from theteeth is removed from the
a...
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 ou...
7575
 The open ends of the tub lumen are closed with aThe open ends of the tub lumen are closed with a
temporary plug mat...
7676
 The tubing is then centered overThe tubing is then centered over
the outline of one of artificial teeththe outline ...
7777
 After all of the round tubingAfter all of the round tubing
is positioned on theis positioned on the
edentulous ridg...
7878
 The cast is carefully invested and the template isThe cast is carefully invested and the template is
processed in t...
7979
 Each length of tubing on the template is measured withEach length of tubing on the template is measured with
a Bole...
8080
 The surgeon and prosthodontist study theseThe surgeon and prosthodontist study these
radiographs in conjunction wit...
8181
 When the presurgical evaluation is completed, the portion ofWhen the presurgical evaluation is completed, the porti...
8282
 The surgical template is transferred to the surgeon. AfterThe surgical template is transferred to the surgeon. Afte...
8383
 The hole should beThe hole should be
made approximately 4made approximately 4
mm into the bone.mm into the bone.
 ...
8484
Bilaminar dual-purpose stentBilaminar dual-purpose stent
 Murat C.cehreli, Yavuz Asian, and Sairne Sahin,Murat C.ceh...
8585
 There are 2 issues that should be taken into considerationThere are 2 issues that should be taken into consideratio...
8686
 Make the impressions of both arches using irreversibleMake the impressions of both arches using irreversible
hydroc...
8787
 As an assembly, place both foils on the surveying tableAs an assembly, place both foils on the surveying table
with...
8888
 At this stage, the positioning of the pins should coincideAt this stage, the positioning of the pins should coincid...
8989
 Perform measurements
regarding dimensions of the
available bone and the
angulation of implants on the
CT image.
 I...
9090
 Separate the outer portion-with the pins still in place-Separate the outer portion-with the pins still in place-
fr...
9191
 Make an irreversible hydrocolloid impressionMake an irreversible hydrocolloid impression
over the cast. Pour the ca...
9292
 Fabricate a custom flapFabricate a custom flap
retractor using 1mm,retractor using 1mm,
stainless steelstainless st...
9393
 Remove the palatal portion ofRemove the palatal portion of
the outer lamina with a carbidethe outer lamina with a c...
9494
 To verify the angulation of implants through the shell withTo verify the angulation of implants through the shell w...
9595
 Bilaminar stent is ready for use after sterilizationBilaminar stent is ready for use after sterilization
www.indian...
9696
 The technique has 2 disadvantages. First, the custom flap retractorThe technique has 2 disadvantages. First, the cu...
9797
Accurate three-dimensional models of the patients anatomyAccurate three-dimensional models of the patients anatomy
ca...
9898
 A Stereotactic surgical template is derived fromA Stereotactic surgical template is derived from
the model by align...
9999
PRE-MAXILLA IMPLANTPRE-MAXILLA IMPLANT
CONSIDERATIONSCONSIDERATIONS
www.indiandentalacademy.comwww.indiandentalacadem...
100100
INTRODUCTIONINTRODUCTION
 Several factors affect the condition of the pre maxillaSeveral factors affect the condit...
101101
 In the majority of patients, the bone is lessIn the majority of patients, the bone is less
dense in the anterior ...
102102
 In the premaxilla, esthetics and phonetics dictate that theIn the premaxilla, esthetics and phonetics dictate tha...
103103
Treatment planningTreatment planning
www.indiandentalacademy.comwww.indiandentalacademy.com
104104
 From a biomechanical perspective, the implant-From a biomechanical perspective, the implant-
restored anterior ma...
105105
 (3) Oblique centric contacts (results in potentially(3) Oblique centric contacts (results in potentially
harmful,...
106106
 These compromising characteristics of theThese compromising characteristics of the
premaxilla mandate special con...
107107
 As a result, at least three implants are usuallyAs a result, at least three implants are usually
required to repl...
108108
 An important parameter in treatment planningAn important parameter in treatment planning
is the adequate surface ...
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
Templates and loading of implants/ orthodontics courses
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Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.

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Transcript of "Templates and loading of implants/ orthodontics courses"

  1. 1. 11 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 www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2. 22  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: www.indiandentalacademy.comwww.indiandentalacademy.com
  3. 3. 33  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
  4. 4. www.indiandentalacademy.comwww.indiandentalacademy.com 44
  5. 5. 55  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. www.indiandentalacademy.comwww.indiandentalacademy.com
  6. 6. 66  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. www.indiandentalacademy.comwww.indiandentalacademy.com
  7. 7. 77  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. www.indiandentalacademy.comwww.indiandentalacademy.com
  8. 8. 88  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 www.indiandentalacademy.comwww.indiandentalacademy.com
  9. 9. 99  . 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  10. 10. 1010  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: www.indiandentalacademy.comwww.indiandentalacademy.com
  11. 11. 1111  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: www.indiandentalacademy.comwww.indiandentalacademy.com
  12. 12. 1212 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: www.indiandentalacademy.comwww.indiandentalacademy.com
  13. 13. 1313  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: www.indiandentalacademy.comwww.indiandentalacademy.com
  14. 14. 1414  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. www.indiandentalacademy.comwww.indiandentalacademy.com
  15. 15. 1515 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 www.indiandentalacademy.comwww.indiandentalacademy.com
  16. 16. 1616  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
  17. 17. 1717 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  18. 18. 1818 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.). www.indiandentalacademy.comwww.indiandentalacademy.com
  19. 19. 1919  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. www.indiandentalacademy.comwww.indiandentalacademy.com
  20. 20. 2020  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.) www.indiandentalacademy.comwww.indiandentalacademy.com
  21. 21. 2121  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 www.indiandentalacademy.comwww.indiandentalacademy.com
  22. 22. 2222  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. www.indiandentalacademy.comwww.indiandentalacademy.com
  23. 23. 2323  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
  24. 24. 2424 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
  25. 25. 2525  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. www.indiandentalacademy.comwww.indiandentalacademy.com
  26. 26. 2626  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. www.indiandentalacademy.comwww.indiandentalacademy.com
  27. 27. 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
  28. 28. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  29. 29. 2929  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. www.indiandentalacademy.comwww.indiandentalacademy.com
  30. 30. 3030 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  31. 31. 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
  32. 32. 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 www.indiandentalacademy.comwww.indiandentalacademy.com
  33. 33. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  34. 34. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  35. 35. 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
  36. 36. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  37. 37. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  38. 38. 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
  39. 39. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  40. 40. 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
  41. 41. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  42. 42. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  43. 43. 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
  44. 44. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  45. 45. 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
  46. 46. 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
  47. 47. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  48. 48. 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 www.indiandentalacademy.comwww.indiandentalacademy.com
  49. 49. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  50. 50. 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
  51. 51. 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.) www.indiandentalacademy.comwww.indiandentalacademy.com
  52. 52. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  53. 53. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  54. 54. 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 www.indiandentalacademy.comwww.indiandentalacademy.com
  55. 55. 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
  56. 56. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  57. 57. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  63. 63. 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
  64. 64. 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
  65. 65. 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
  66. 66. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  67. 67. 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
  68. 68. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  69. 69. 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
  70. 70. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  71. 71. 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
  72. 72. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  73. 73. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  74. 74. 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
  75. 75. 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
  76. 76. 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
  77. 77. 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 www.indiandentalacademy.comwww.indiandentalacademy.com
  78. 78. 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
  79. 79. 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
  80. 80. 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
  81. 81. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  82. 82. 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 www.indiandentalacademy.comwww.indiandentalacademy.com
  83. 83. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  84. 84. 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
  85. 85. 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 www.indiandentalacademy.comwww.indiandentalacademy.com
  86. 86. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  87. 87. 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
  88. 88. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  89. 89. 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
  90. 90. 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
  91. 91. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  92. 92. 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 www.indiandentalacademy.comwww.indiandentalacademy.com
  93. 93. 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 www.indiandentalacademy.comwww.indiandentalacademy.com
  94. 94. 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
  95. 95. 9595  Bilaminar stent is ready for use after sterilizationBilaminar stent is ready for use after sterilization www.indiandentalacademy.comwww.indiandentalacademy.com
  96. 96. 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
  97. 97. 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 www.indiandentalacademy.comwww.indiandentalacademy.com
  98. 98. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  99. 99. 9999 PRE-MAXILLA IMPLANTPRE-MAXILLA IMPLANT CONSIDERATIONSCONSIDERATIONS www.indiandentalacademy.comwww.indiandentalacademy.com
  100. 100. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  101. 101. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  102. 102. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  103. 103. 103103 Treatment planningTreatment planning www.indiandentalacademy.comwww.indiandentalacademy.com
  104. 104. 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
  105. 105. 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. www.indiandentalacademy.comwww.indiandentalacademy.com
  106. 106. 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, www.indiandentalacademy.comwww.indiandentalacademy.com
  107. 107. 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
  108. 108. 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."' www.indiandentalacademy.comwww.indiandentalacademy.com
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