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TECHNIQUES

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TECHNOLOGIES

A System for the Diagnosis, Placement, and Prosthetic Restoration of Root Form Implants (U.S. Patent #5,769,636)
Francesco Di Sario, DDS
It is difcult to achieve a high degree of reproducibility when using a diagnostic wax-up as the template for fabrication of a denitive implant restoration. Here a method for implant prosthesis treatment planning is described that allows fabrication of the provisional restoration before surgical placement of the implant. The method involves 6 steps: (1) determining the mesiodistal inclination of the implant, (2) determining the buccolingual dimension of the alveolar ridge, (3) determining the proper position of the implant, (4) fabricating the surgical guide, (5) fabricating the provisional restoration, and (6) performing surgical placement of the implant followed by immediate placement of the provisional restoration. J Prosthodont 2003;12:2-7. Copyright 2003 by The American College of Prosthodontists. INDEX WORDS: reproducibility, immediate loading, template, guide pins

ARIOUS PREOPERATIVE planning strategies have been proposed to enable dentists to place implants in a manner that facilitates prosthodontic therapy.1,2 These techniques are used to support decision making during the surgical phase rather than to determine the denitive position of the implant.3 Because the ultimate goal is a properly positioned and properly supported restoration,4 a clinical procedure that produces exact surgical placement of the implant and allows preplacement fabrication of the provisional restoration is desirable. Ideally, this procedure would duplicate the restorations form and position on the master cast, allowing direct transfer to the patients mouth. Such a system, which does not call for advanced radiographic techniques or computer programs, is described in this article.

Technique
The replacement of tooth #13 is described.

Private practice, Canose Sannita, Italy. Accepted September 24, 2002. Originally presented at a poster session of The American College of Prosthodontists meeting, Kona, Hawaii, November 2000. Correspondence to Dr. Francesco Di Sario, Via Garibaldi 29, Canosa Sannita 66010, Italy. E-mail: francesco.disario@tin.it. Copyright 2003 by The American College of Prosthodontists 1059-941X/03/1201-0002$30.00/0 doi:10.1053/jpro.2003.4

Step 1: Determining the mesiodistal inclination. First, a diagnostic wax-up is made (Fig 1). The implant position is simulated by a radiopaque post incorporated into a radiographic stent (Fig 2). The radiographic stent is then transferred to the patients mouth, and a periapical radiograph is obtained to check whether the position of the post is consistent with the position of adjacent roots and the available bone (Fig 3). If the mesiodistal inclination is considered satisfactory, then the stent is returned to the master cast, which is then sectioned buccolingually through the long axis of the post (Fig 4). During cast fabrication, the cast is pinned using the Pindex system (Coletene/Whaledent, Mahwah, NJ), allowing accurate repositioning of sectioned pieces. Step 2: Determining the buccolingual dimension of the alveolar ridge. With the distal section of the cast removed, the outline of the alveolar crest is transferred to the cross-sectioned cast with the aid of a bone-measure stent. The stent is fabricated to hold tubes at multiple buccal and palatal locations along the alveolar ridge (Fig 5). Under local anesthesia, the tubes are used to guide placement of a probe into contact with the underlying bone. Measurements from the top of the tubes to the bone are directly transferred via the stent to the previously crosssectioned cast. The buccolingual outline of the

Journal of Prosthodontics, Vol 12, No 1 (March), 2003: pp 2-7

March 2003, Volume 12, Number 1

Figure 1. A diagnostic wax-up is completed in the rst phase of implant diagnosis.

Figure 4. The radiographic stent guides the sectioning of the cast through the long axis of the post.

Figure 2. The radiographic stent is fabricated, incorporating a radiopaque post and a lm holder.

alveolar ridge is created by marking the transferred measurements (Fig 6). Step 3: Determining the proper position of the implant. Using the diagnostically waxed tooth position and bone-dimension data, a custom implant prototype is mounted in the cross-sectioned cast, simulating the planned implants clinical location. The square-shank end holds the cylindrical body of the custom implant prototype in place within the cast. The custom implant prototype is positioned within the buccolingual outline of the alveolar ridge (Fig 7). Step 4: Fabricating the surgical guide. The surgical guide contains a matched series of 4 circular metal sleeves. The rst sleeve (sleeve A) is seated

Figure 3. The periapical radiograph shows the position of the post with respect to the adjacent roots.

Figure 5. The bone-measure stent is composed of single tubes that guide a probe tted with a stopper.

A Root Form Implant System

Di Sario

Figure 6. The single-probing measurements are marked on the cross-sectioned cast.

Figure 8. A metal sleeve (sleeve A) is attached to the frame during the fabrication of the surgical stent.

onto the custom implant prototype and incorporated into the acrylic resin surgical guide using autopolymerizing resin (Dentaplast KFO; Bredent, Senden, Germany) (Fig 8). The custom implant prototype is then removed from the cross-sectioned cast. When the surgical guide is placed intraorally, sleeve A is correctly positioned in space to assist the clinical transfer of the planned implants location from the cast to the mouth. Sleeves B, C, and D t within each other and within sleeve A and are held together via an internal locking system (Figs 9 and 10). At the
Figure 9. Three additional sleeves are assembled onto sleeve A.

Figure 7. The prototype implant analog is mounted on the cross-sectioned cast within the limitations of the bone.

Figure 10. Additional sleeves (B, C, and D) are attached to sleeve A. The sleeves can be removed 1 at a time.

March 2003, Volume 12, Number 1

Figure 11. The sleeve components used in the fabrication of the surgical guide are shown; sleeve A is marked. The implant xture mount inside of sleeve B is identied by the letter B. A 3-mm-diameter drill within sleeve C is identied by the letter C; a 2-mm-diameter drill within sleeve D, by the letter D.

Figure 13. The analog is connected to the xture mount (Winsix Ltd.), with the red band guiding placement depth.

time of implant placement, the 3 progressively widening sleeves guide the precise delivery of a 2-mm-diameter drill (sleeve D), a 3-mm-diameter drill (sleeve C), and the implant xture mount (sleeve B) (Fig 11). Step 5: Fabricating the provisional restoration. The provisional restoration is fabricated before surgical placement of the implant. With sleeves C and D temporarily removed, the surgical guide is seated on the cast. The distance between the shoulder of sleeve B and the top of the bony crest is mea-

sured and recorded (Fig 12). A laboratory analog (Winsix Ltd., London, UK) is connected to the mount (Fig 13) and positioned through sleeve B to the previously recorded depth. The analog is xed in place in the cast with plaster (Super stone; Techim Italia s.r.l., Arese, Italy) (Fig 14). Thus the analog is positioned in the cast to simulate the clinical placement of the implant when the top of implant is level with the crest of the bone. The xture mount and the surgical stent are then removed. After a provisional abutment is attached to the analog, the provisional restoration is fabricated (Fig 15).

Figure 12. The distance between the bone crest and the sleeve shoulder is recorded.

Figure 14. The analog is afxed with plaster.

A Root Form Implant System

Di Sario

Figure 15. The provisional restoration is completed using a hybrid ceramic (Estenia hybrid ceramic; Kuraray Co. Ltd., Tokyo, Japan).

Figure 17. The provisional restoration is screwed onto the implant for immediate loading.

Step 6: Performing surgical placement of the implant followed by immediate placement of the provisional restoration. At stage 1 surgery, the surgical stent is seated intraorally. The surgical drills are delivered through the surgical guide using sleeves C and D. The implant (Winsix Ltd.) is placed through sleeve B (Fig 16) using the xture mount. Once the implant is properly placed, the

provisional restoration is screwed onto the implant (Fig 17). The provisional restoration provides immediate loading and veries the accuracy of the implant-placement system. The resulting restoration (Fig 18) is positioned consistent with the original wax-up (Fig 1).

Summary
The basic concept behind this technique is that an implant should be planned with the same approach as a conventional xed prosthodontic restoration. The technique, with input into both the surgical and prosthetic phases of treatment, allows the cli-

Figure 16. The implant is placed through sleeve B.

Figure 18. The provisional restoration, positioned as determined by the diagnostic wax-up, is shown 2 weeks after implant placement.

March 2003, Volume 12, Number 1

nician to determine the best positioning options before implant placement. The surgical procedures are safer, allowing possible complications, such as bone fenestration or root-to-implant proximity, to be avoided. Although 3 stents must be fabricated (i.e., radiographic, bone-measure, and surgical), the laboratory procedures are simplied because of the accuracy of the technique. In fact, the control of implant placement as demonstrated in this system makes many implant alignment-correcting and position-correcting techniques unnecessary. The system should not be used when a reduced buccolingual dimension of the bone (as determined from the probing process) necessitates a bone augmentation procedure before implant placement. For accuracy and ease of use, only custom-manufactured components, as described in this article, are recommended.

Acknowledgment
The author thanks Mr. Tonino DAlicandro for practical advice concerning the laboratory process, and Mr. Leo Cinelli and his coworkers for support and assistance in preparing this manuscript.

Reference
1. Edge MJ: Surgical placement guide for use with osseointegrated implants. J Prosthet Dent 1987;57:719-722 2. Verstreken K, Van Cleynenbreugel J, Marchal G, et al: Computer-assisted planning of oral implant surgery: A 3-dimensional approach. Int J Oral Maxillofac Implants 1996;11: 806-810 3. Sicilia A, Noguerol B, Cobo J, et al: Prole surgical template, a systematic approach to precise implant placement: A technical note. J Oral Maxillofac Implant 1998;13:109-114 4. Higginbottom FL, Wilson TG: Three-dimensional templates for placement of root-form dental implants: A technical note. Int J Oral Maxillofac Implant 1996;11:787-793

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