Fabrication of imaging and surgical guides for dental implants

Dov M. Almog, DMD,a Eduardo Torrado, DDS,b and Sean W. Meitner, DDS, MSc
University of Rochester Eastman Dental Center, Rochester, N.Y.
Research and experience have suggested that the success of dental implants depends on a welldeveloped and careful treatment plan approach. Historically, implant size and angulation were
determined with the use of panoramic radiographs and clinical judgment during surgery. This
occasionally resulted in mechanical and esthetic compromise. This article describes the step-by-step
fabrication process for 4 different imaging and surgical guides. Set-up disks, which enhance the
design and fabrication of guides, also are introduced. These guides are used in conjunction with
cross-sectional tomography during the preimplant assessment of surgical sites. (J Prosthet Dent
2001;85:504-8.)

espite significant development in devices and

techniques, problems still occur during treatment of
the dental implant patient. Examining diagnostic casts,
anesthetizing and probing the depth of the mucosa
over bone, and using panoramic and lateral skull radiographs are frequently used to help determine the
adequacy of bone. However, relying entirely on clinical examinations, diagnostic models, and panoramic
radiographs can produce unintentional results.
For example, 1 postoperative restorative problem
occurs when the angle of the implant placement is
such that an angled abutment is necessary for the
restoration. When the angle between the residual bone
angulation and planned prosthetic angulation is
greater than 20 degrees, restorative difficulties and an
unfavorable bending moment may be introduced. A
second problem occurs when implants are placed too
close to an adjacent tooth or to each other. The
restoration of such implants is difficult or impossible.
Often, implant placement is based on a wax-up of the
missing teeth or the tooth position on a removable
partial or full denture. Loss of space and/or small
teeth may result in some implants being too close
together, making the restorative phase very difficult.
Adequate room should be left between the implants to
allow the dental papilla to exist. It has been suggested
that implant placement should be 1.5 mm from an
adjacent root and that there should be 3.0 mm
between the surface of adjacent implants. Placed too
closely, implants may be nonrestorable and may have
to be put to sleep.
Technology and techniques that can make dental
implant procedures more predictable are now readily
available. It is recommended that conventional treatment planning include the use of plane cross-sectional
tomography, in conjunction with imaging and surgical

aAssociate

Professor, Division of Prosthodontics.

student, Division of Prosthodontics.
cAssistant Professor, Division of Periodontics.
bGraduate

504 THE JOURNAL OF PROSTHETIC DENTISTRY

guides, before the surgical phase. In recent years, a number of authors1-6 have reported that cross-sectional,
3-dimensional radiographic studies can provide critical
anatomic orientation. Some argue that the addition of
cross-sectional tomography to an imaging and surgical
guide provides a more predictable method for assessing bone adequacy and its angulation in relation to the
prosthetic needs.7-14 The information from these studies makes the planning and placement of dental
implants a more factual and dependable procedure:
With additional information, the implant team can
transpose valuable prosthetic planning information,
confirmed with diagnostic imaging, to the surgical
phase.
This article describes the step-by-step fabrication
process for 4 different imaging and surgical guides.
Set-up disks, which enhance the design and fabrication
of guides, also are introduced. The objective of this
article is to offer guidance to implant teams that use
technical aids to help transpose valuable prosthetic
planning information, confirmed with diagnostic
imaging, to the surgical phase.

PROCEDURES
Circumference lead strip guides
1. Pour diagnostic casts in stone.
2. Complete a diagnostic wax-up using hand articulation or a precision articulator. This establishes
the desired prosthetic orientation of each tooth in
the edentulous area.
3. Use wax to block out all undercuts on at least 2
teeth on either side of the edentulous area. Coat
the lingual/palatal, buccal, and occlusal surfaces
of the cast with a lubricant.
4. Make a template using a 0.020-in., vacuum-formed,
thermoplastic material such as Thermoforming
Material (T&S Dental & Plastics Mfg, Myerstown,
Pa.).
5. Separate the vacuum-formed shell template from
the cast, and trim it.
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ALMOG, TORRADO, AND MEITNER

Fig. 1. Demonstration model with circumference guide in

area of maxillary left first molar. Two-millimeter wide lead
strip is attached to buccal, occlusal, and lingual surfaces,
outlining tooth over implant site. Circumference lead strip
only delineates prosthesis over implant site; it does not
serve as surgical guide.

6. Remove the wax-up from the cast. Reline the vacuum-formed template in the edentulous area with
custom tray material (Triad, Dentsply Co, York,
Pa.) or autopolymerizing resin (Jet Acrylic, Lang
Dental Mfg Co, Wheeling, Ill.), and set it back on
the cast. Filling the shell template with resin down
to the edentulous part of the cast will strengthen
the template.
7. For enhanced stability in the mouth, make sure
that the template extends at least 2 teeth on
either side of the edentulous area. When the site
is a distal abutment, extend the template anteriorly and, if necessary, across the arch and past
the canine.
8. Make a prosthetic determination of the most
appropriate placement of the radiopaque indicator
for each surgical site. Create a circumference
radiopaque indicator by gluing a 2-mm wide lead
strip, cut from any intraoral dental film lead sheet,
to the buccal, occlusal, and lingual/palatal surfaces of the template, outlining the tooth over the
implant site (Fig. 1).

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 2. Demonstration model with lead strip guide in area of

mandibular right first and second molars. Vertically placed
lead strips on lingual wall of surgical grooves serve as
radiopaque imaging indicator, denoting planned prosthetic
angulation on radiograph. This type of guide serves as both
imaging indicator and surgical osteotomy guide.

Fig. 3. Demonstration model with gutta-percha guide in

area of mandibular right first molar. Gutta-percha fills
access hole (arrow) and serves as radiopaque imaging
indicator, denoting planned prosthetic angulation on radiograph. This guide serves as both imaging indicator and
surgical osteotomy guide.

Vertical lead strip guides

1. Complete steps 1 through 6 outlined in the circumference guide fabrication section.
2. Separate the vacuum-formed template from the
resin tooth. Connect the resin tooth by using a
layer of resin placed on the occlusal and lingual/palatal surfaces of at least 2 teeth on either
side of the edentulous area. When the site is a distal abutment, extend the template anteriorly and,
if necessary, across the arch and past the canine.
MAY 2001

3. Make a prosthetic determination of the most

appropriate placement of the access hole for
each surgical site. Drill buccal access grooves in
the template over the planned prosthetic
implant sites. Create a vertical radiopaque indicator from a 2-mm wide lead strip cut from any
intraoral dental film lead sheet, and vertically
glue it on the lingual/palatal wall of the groove
(Fig. 2).
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ALMOG, TORRADO, AND MEITNER

surveyor may be used as an aid to determine the

inclination of the access hole. Condense guttapercha (Hygenic, The Hygenic Co, Akron, Ohio)
to fill the access hole (Fig. 3).

Metal sleeve guides

Fig. 4. Demonstration model with metal sleeve guide in

area of maxillary left lateral incisor. Guide is positioned in
desired prosthetic place and trajectory. This type of guide
serves as both imaging indicator and precise surgical
osteotomy guide.

Fig. 5. Demonstration model with set-up disks secured with

rope-wax in area of mandibular left first and second molars
and first and second premolars. Set-up disks are used in
place of diagnostic wax-up to evenly space implants being
placed in edentulous areas. Disks have outside diameters
graduating from 5.5 to 11.5 mm and are 5.0 mm in height.
Each disk has 3.0-mm hole in center to drill through when
template is made with metal sleeve guide technique.

Gutta-percha guides
1. Complete steps 1 through 6 outlined in the circumference guide fabrication section.
2. Follow with step 2 outlined in the vertical lead
strip guide fabrication section.
3. Make a prosthetic determination of the most
appropriate placement of the access hole for each
surgical site. Use a 532-in. drill bit in a laboratory
handpiece to drill an access hole through the template over the planned prosthetic implant site. A
506

1. Complete steps 1 and 2 outlined in the circumference guide fabrication section.

2. Make a prosthetic determination of the most
appropriate angulation and placement of the
access holes for each site. Use a 332-in. drill bit in a
laboratory handpiece to drill through the diagnostic wax-up into the stone cast to a depth of at
least 10 mm. This hole in the cast represents the
osteotomy site in the alveolar ridge.
3. Remove the wax-up from the cast. Insert the
smallest end of an 18-mm Guide Right (De
Plaque Corp, Victor, N.Y.) pin into the 332-in. hole
prepared in the cast, providing the orientation
that needs to be captured and transferred to the
guide sleeve. Place an appropriate Guide Right
stainless steel sleeve over the pin. The sleeves are
precision cut and deburred electrochemically, and
they come in multiple diameters and lengths.
4. Use wax to block out all undercuts on at least 2
teeth on either side of the edentulous area. Coat
the lingual/palatal, buccal, and occlusal surfaces
of the cast with a lubricant.
5. Secure the relationship between the sleeve and
adjacent teeth with custom tray material (Triad,
Dentsply Co) or autopolymerizing resin (Jet
Acrylic, Lang Dental Mfg Co) as the base material. Extend the template with a layer of resin placed
on the occlusal and lingual/palatal surfaces of at
least 2 teeth on either side of the edentulous area
(Fig. 4). When the site is a distal abutment,
extend the template anteriorly and, if necessary,
across the arch and past the canine.

Set-up disks
Set-up disks (De Plaque Corp) recently were
developed to help manage implant position spacing
(Fig. 5). These graduated disks have outside diameters ranging from 5.5 to 11.5 mm and are 5.0 mm
in height. Each disk has a 3.0-mm hole in the center
to drill through when a template is made with the
metal sleeve guide technique. If the edentulous
space is less than 5.5 mm and an implant larger than
3.5 mm in diameter is placed, the recommended
1.5-mm space between the implant surface and adjacent roots will be encroached upon. For placement
of 3.75- or 4.0-mm diameter implants, 6.5- or 7.5mm disk spacing is required. For placement of
5.0-mm implants, 8.5 mm or greater disk space
should be used. For placement of adjacent 6.0-mm
implants, a spacing of 9.5 mm or greater is necessary
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ALMOG, TORRADO, AND MEITNER

to allow for 3.0 mm between the outer surface of the

adjacent implants.
1. Pour diagnostic casts in stone.
2. Use hand articulation or a precision articulator.
3. Select the appropriate disk and position it in the
desired prosthetic position on the edentulous
ridge; use soft wax rope to secure the disk in place.
Then articulate the opposing arch to check the
relationship to opposing teeth.
4. Use a 332-in. drill bit in a laboratory handpiece to
drill through the disk into the stone cast to a
depth of at least 10 mm. This hole in the cast represents the osteotomy site in the alveolar ridge.
5. Remove the disk and rope wax from the cast, and
set the smallest end of an 18-mm Guide Right pin
(De Plaque Corp) into the 332-in. hole prepared in
the cast.
6. Proceed with steps 4 and 5 outlined in the metal
sleeve guide fabrication section.

DISCUSSION
The guides and disks presented in this article are
aids proposed for use in conjunction with crosssectional tomography during the preimplant assessment of surgical sites. They should help the implant
team transpose valuable prosthetic and diagnostic
imaging information to the surgical phase. This
includes recognition of (1) the relationship between
the residual bone angulation and planned prosthetic
angulation, and (2) the relationship between the
planned implant angulation and anatomic structures
and adjacent implants.
The circumference lead strip guide serves only as an
imaging guide, not as a surgical osteotomy guide; it
delineates the prosthesis over the implant site. It is the
least specific of the guides, especially with regard to
the planned prosthetic angulation. The lead strip guide
allows for inconsistent surgical latitude related to
implant angulation when drilling the osteotomy. Thus,
it may result in unacceptable placement of the access
hole and/or unacceptable implant angulation.
The vertical lead strip guide serves as both an imaging and surgical osteotomy guide. Although it is more
confining than the circumference lead strip guide, it
allows for buccal-lingual latitude related to implant
angulation during the osteotomy. The use of the vertical lead strip guide may also result in the unacceptable
placement of the access hole and/or unacceptable
implant angulation, but to a lesser extent than the circumference lead strip guide.
The gutta-percha guide is both an imaging and surgical osteotomy guide. The gutta-percha serves as a
radiopaque imaging indicator, transposing the planned
prosthetic angulation to the cross-sectional tomogram;
the access hole serves as an osteotomy guide. With
regard to implant angulation when surgically preparMAY 2001

THE JOURNAL OF PROSTHETIC DENTISTRY

ing the osteotomy, the gutta-purcha guide is considered more confining than the circumference and
vertical lead strip guides. However, unless the access
hole is altered, the implant surgeon who uses a guttapercha guide is assured maintenance of the desired
prosthetic angulation.
The metal sleeve guide is rigid and provides a high
level of precision. It serves as both an imaging indicator and a precise surgical osteotomy guide. When the
surgical drill is placed in the stainless steel sleeve, the
osteotomy prepared in the bone has the same orientation as the hole in the cast and is consistent with the
planned prosthetic angulation. During the crosssectional imaging, if a discrepancy is found between the
planned prosthetic angulation and the residual bone
angulation or anatomic structures, the guide is altered
and the sleeve reoriented. The imaging phase may have
to be repeated to confirm a safe and suitable trajectory
during the osteotomy. Disregarding the guide may be
the only way to alter placement of the osteotomy.
Set-up disks, which are used to evenly space the
implants being placed in edentulous areas, can be used
instead of conventional diagnostic wax-ups. They
ensure correct horizontal spacing (1.5 mm from the
surface of adjacent roots and/or 3.0 mm from the surface of adjacent implants).

SUMMARY
The fabrication of 4 different imaging and surgical
guides, as well as the use of disks that enhance the
design and fabrication of guides, has been described.
The circumference guide only traces the outline of
the planned prosthesis; it does not provide necessary
transposition of prosthetic and/or bone angulation
information. Because it allows for inconsistent surgical
latitude during the osteotomy, it is considered the least
specific of the indicators. The vertical lead strip and
gutta-percha guides serve primarily as imaging indicators and allow for some surgical latitude in preparation
of the osteotomy sites. The metal sleeve guide used in
conjunction with a set-up disk appears to be the most
accurate imaging and surgical guide. It serves as both
an imaging and a precision surgical osteotomy guide,
ensuring consistency between the planned prosthetic
angulation (confirmed by diagnostic imaging) and the
trajectory of osteotomy during the surgical phase.
However, before clinical guidelines can be developed,
numerical data must be obtained on the success-tofailure ratio after the concomitant use of cross-sectional
tomography and guides.
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dental implant radiography: a comparison of linear tomography, CT
scan, and panoramic and intra-oral techniques. J Oral Implantol
1990;16:156-64.

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2. Petersson A, Lindh C, Carlsson LE. Estimation of the possibility to treat

the edentulous maxilla with osseointegrated implants. Swed Dent J
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6. Weinberg LA. CT scan as a radiologic data base for optimum implant
orientation. J Prosthet Dent 1993;69:381-5.
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8. Kassebaum DK, Nummikoski PV, Triplett RG, Langlais RP. Crosssectional radiography for implant site assessment. J Colo Dent Assoc
1991;70:9-12.
9. Modica F, Fava C, Benech A, Preti G. Radiologic-prosthetic planning of
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Noteworthy Abstracts
of the
Current Literature

ALMOG, TORRADO, AND MEITNER

11. Mecall RA, Rosenfeld AL. The influence of residual ridge resorption patterns on implant fixture placement and tooth position. 2. Presurgical
determination of prosthesis type and design. Int J Periodontics Restorative
Dent 1992;12:32-51.
12. Almog DM, Onufrak JM, Hebel K, Meitner SW. Comparison between
planned prosthetic trajectory and residual bone trajectory using surgical
guides and tomographya pilot study. J Oral Implantol 1995;21:275-80.
13. Almog DM, Sanchez R. Correlation between planned prosthetic and residual bone trajectories in dental implants. J Prosthet Dent 1999;81:562-7.
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Reprint requests to:
DR DOV M. ALMOG
DIVISION OF PROSTHODONTICS
UNIVERSITY OF ROCHESTER EASTMAN DENTAL CENTER
625 ELMWOOD AVE
ROCHESTER, NY 14620
FAX: (716)273-1372
E-MAIL: dov_almog@urmc.rochester.edu
Copyright 2001 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2001/$35.00 + 0. 10/1/115388

doi:10.1067/mpr.2001.115388

Clinical evaluation of polyacid-modified resin composite

posterior restorations: one-year results
Luo Y, Lo EC, Fang DT, Wei SH. Quintessence Int
2000;31:630-6.

Purpose. This study evaluated the clinical performance of Dyract AP used, in combination with
Non-Rinse Conditioner and Prime & Bond NT, for occlusal stress-bearing class I and class II
restorations in permanent teeth.
Material and methods.
The study sample included 41 Class I and 50 Class II restorations at baseline. A split of maxillary
and mandibular posterior teeth was included, with all teeth being in occlusion. All teeth were
treated according to manufacturers instructions. One layer of Non-Rinse Conditioner was
applied with an applicator tip for 20 seconds. The cavity was saturated with Prime & Bond NT
for 30 seconds before placement of Dyract AP. Two trained evaluators accessed the restorations
directly with modified US Public Health Service criteria at baseline. Follow-up evaluations were
performed by 1 examiner at 6 and 12 months after placement.
Results. Eighty-two of the original 91 restorations were available at the 1-year follow-up evaluation. Four class II restorations (4.9%) failed because of partial fracture or recurrent caries. In all
other categories, there was no significant difference between the class I and class II restorations.
Color matching remained acceptable in all restorations, and 95.1% of the restorations showed
excellent color matching over the 12-month period. Only 35.4% of the restorations were rated
Alfa for marginal integrity after 1 year. This result can be explained, in part, by operator error.
Conclusion. Notwithstanding the findings related to marginal integrity, the authors concluded
that the Dyract AP restorative system had a satisfactory clinical performance during the length of
the study. 24 References. ME Razzoog

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