A dual-purpose guide for optimum placement of dental implants

Murat C. Çehreli, DDS, PhD,a A. Can Çaliş, DDS,b and Saime Şahin, DDS, PhDc
Faculty of Dentistry, Hacettepe University, Ankara, Turkey
Correct placement of implants is a requirement for implant treatment. The use of computed tomogra-
phy and precise surgical guides is required when inadequate bone support is anticipated. This article
describes the fabrication and use of an acrylic resin dual-purpose guide for radiographic evaluation of
recipient sites and implant placement, which uses internally stacked stainless steel surgical guide chan-
nels. The drill guides are machined to allow consecutive surgical drills to be used without changing the
implant angulation during surgery. (J Prosthet Dent 2002;88:640-3.)

O sseointegration has provided predictable long-

term success in the rehabilitation of completely and par-
tially edentulous patients.1-4 The ultimate objective of
implant treatment is a functional, esthetic, and easily
maintained restoration.5,6 Correct implant placement is
essential. Accurate radiographic images of the potential
recipient sites and proper surgical guides are required to
place implants in their predetermined position.7
In the last decade, computed tomography (CT) has
frequently been used as an imaging technique for pre-
operative evaluation of the maxilla or mandible for im-
plant treatment.8-12 The evaluation of available bone in
thin multiplanar images offers improved determination
of the location of anatomic structures and of the bone
density.13-15 Among all imaging techniques, currently,
CT is more accurate in evaluating recipient sites and
locating vital structures such as the mandibular ca-
nal.16-18
Guides with radiopaque markers assist in determining
the dimension, location, and angulation of implants ac-
cording to the available bone and vital structures and the
proposed prosthesis.7,19-25 Surgical guides can be fabri-
cated with the information obtained from periapical or
panoramic images. The main disadvantage of radio-
graphic techniques is the 2-dimensional image they pro-
vide. The determination of implant position in a guide
partially based on 2-dimensional imaging requires as-
sumptions.12,26 Dual-purpose guides, however, are ac-
tually radiographic guides that are modified for implant
surgery.7,20-22 For such guides the location and angula-
tion of implants are determined by the CT image. The
data are then transferred to the same guide through a
conversion procedure.7,20-22 Therefore dual-purpose
guides may be more useful than single-use surgical
guides.
During guide fabrication, accurate preparation of
surgical guide channels is required. Surgical and dual-
purpose guides often have guide channels that allow
only 1 surgical drill to pass through them. The use of
a
Research Assistant, Department of Prosthodontics.
b
Research Assistant, Department of Prosthodontics.
c
Professor, Department of Prosthodontics.
precise surgical guides may be helpful to the surgeon in
placing implants accurately in low-density bone, in
which there is a higher risk of malaligning implants in
comparison to dense bone.27 A dual-purpose guide in-
corporating a single stainless steel surgical guide has
been described.7 The need for prefabricated surgical
guides that could be internally stacked to form an assem-
bly or individual tubes with dimensions that would
match the diameter of all surgical drills used during a
routine dental implant surgery has been mentioned.20
The purpose of this article is to describe the use of in-
ternally stacked prefabricated surgical guides in a dual-
purpose guide to place implants in the anterior maxilla.
This approach is an evolution of a guide presented in a
previous article by the authors.7 The guide includes 3
internally stacked stainless steel drill guides machined to
allow consecutive surgical drills to be used without
changing the implant angulation during surgery.
TECHNIQUE
1. Make impressions of both arches with an irrevers-
ible hydrocolloid impression material (CA 37;
Cavex, Harleem, Holland), and pour casts in type
III dental stone (Moldano; Bayer, Leverrusen, Ger-
many). Complete maxillomandibular records, and
mount casts in a semiadjustable articulator (Model
8500; Whip Mix Corp, Louisville, Ky.).
2. Determine the dental implant recipient sites and
complete an appropriate arrangement of artificial
teeth. Make a single-mix condensation silicone
(Coltene/Whaledent, Mahwah, N.J.) impression of
the artificial teeth. Upon setting, remove the im-
pression and the denture teeth from the cast. Elim-
inate wax with hot water, and coat the cast with a
tin-foil substitute.
3. Flow a mix of autopolymerized methyl methacry-
late resin (Orthocryl 2000; Dentaurum, Ispringen,
Germany) into the impression in the space previ-
ously occupied by the artificial teeth. Reinsert the
cast into the impression, secure it with an elastic
band, and place the assembly into a pressure pot for
polymerization. Upon polymerization, remove the

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ÇEHRELI, ÇALIŞ, AND ŞAHIN THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. Labial view of polished resin portion of guide on cast.

Fig. 3. Correct angulation of implants determined by angu-

lation of bone (line a is angulation of bone, line b is angu-
lation of pin incorporated into guide, and x represents de-
sired change in angle). The buccopalatal angle of the pin is
used to determine correct implant alignment and to incorpo-
rate internally stacked stainless steel guide channels into the
acrylic resin carrier.

pin in CT evaluation is to view the entire pin in only

Fig. 2. Pins secured to guide on surveyor. Angulation of pins
determined by assumptions made on possible angulation of
bone.
resin guide from the cast. Finish and polish the
guide (Fig. 1).
4. Place the cast and the acrylic resin guide as an as-
sembly onto a surveying table. Tilt the table to de-
termine the desired angulation of the proposed
dental implants. For each implant site, prepare a pin
hole, 1 mm in diameter, at the anticipated central
axis of the implant in the acrylic resin guide. Secure
a pin (1 mm in diameter ⫻ 10 mm; S. J. Filhol
Dental, West Cork, Ireland) in each hole (Fig. 2).
The rationale for use of a 1-mm-thick radiographic
1 section of the cross-sectional CT images and to
make changes in implant location when needed.
Measure and record the anteroposterior angulation
of each pin at this stage by placing tripod marks on
the side of the cast. The tripod marks will be useful
for reorientation of the cast on the surveying table if
required.
5. Place the guide in the patient’s mouth and obtain
2-dimensional CT images. Measure the dimensions
and angulation of the available bone, and determine
the appropriate location and angulation of the im-
plants (Fig. 3). The difference between the angula-
tions of the bone and the pin is the required change
in the tilt of the surveying table.7
6. If a change in implant angulation is indicated, this
can be performed by using the angulation of the
radiographic pins as a reference. In this event, re-
place the guide onto the surveyor and retilt the
surveying table in accordance with previous tripod
marks placed on the cast. At this stage, the pins
incorporated into the guide are also used for chang-

DECEMBER 2002 641

THE JOURNAL OF PROSTHETIC DENTISTRY ÇEHRELI, ÇALIŞ, AND ŞAHIN

Fig. 4. A, Interplaced stainless steel surgical guides matching drills with diameters of 2 mm, 3 mm, and 3.8 mm (from left to
right). B, Two-millimeter surgical drill inserted into guides on surveyor. Tubes incorporated into guide according to CT data.

Fig. 5. A, Occlusal view of converted guide for surgery. B, Use of dual-purpose guide for surgery during site preparation with
2-mm drill.

ing the buccopalatal angulation of the surveying
table. For each implant site, the absolute vertical
alignment of a pin presents the original situation,
when the pin was initially incorporated into the
guide. Hence, to determine the correct implant an-
gulation for each site, the surveying table is tilted
buccopalatally according to the required change in
the buccopalatal angle (x), as determined in the CT
evaluation (Fig. 3). Because the CT image presents
the buccopalatal angulation of the pins, it is not
possible to change the mesiodistal angulation by
using CT. Nevertheless, the mesiodistal angulation
of the pins is determined according to the angle of
the tooth neighboring the edentulous ridge. This
procedure allows determination of the final bucco-
palatal implant angulation with negligible error. Af-
ter reorienting the surveying table, remove the por-
tion of the guide where the stainless steel surgical
guides will be incorporated. Secure a 2-mm surgical
twist drill (NobelBiocare, Goteborg, Sweden) to
the surveyor as an analyzing rod, and pass the drill
through the assembled prefabricated stainless steel
surgical guides (Fig. 4). The internally stacked
stainless steel guides used in this technique were

642 VOLUME 88 NUMBER 6

ÇEHRELI, ÇALIŞ, AND ŞAHIN
custom-made to allow the use of 2-mm-, 3-mm-,
and 3.8-mm-diameter surgical drills of the Nobel-
Biocare Brånemark System. The height of the tubes
is 4 mm, and the inner diameter of each tube has
0.1-mm machining tolerance to allow surgical drills
to pass through easily. The guides for 2-mm and
3-mm drills also have collars that extend horizon-
tally and rest on the consecutive guide. Hence, the
first guide (used for the 2-mm drill) rests on the
second guide used for the 3-mm-diameter drill, and
finally this guide rests on the third guide retained in
the acrylic resin. This design provides excellent po-
sitioning and stability of the guides during surgery.
When assembled, the tubes are also frictionally re-
tained to one another and do not dislodge during
surgery.
7. Secure the internally stacked guides to the surgi-
cal guide with acrylic resin (Orthocryl 2000; Den-
taurum). Repeat the procedure for each implant
site. The guide is ready to be used for surgery
after sterilization (Fig. 5, A and B). During sur-
gery, the 2- and 3-mm twist drills (NobelBiocare)
were used with the corresponding surgical drill
guides for this patient. The 3.8-mm drill guide
served as a carrier for other drill guides in this
patient.
SUMMARY
A technique for fabricating a dual-purpose guide with
interplaced stainless steel surgical guides has been pre-
sented. The use of such guide channels assists the sur-
geon during site preparation.
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Reprint requests to:
DR MURAT C. ÇEHRELI
GAZI MUSTAFA KEMAL BULVARI
61/11 06570 MALTEPE
ANKARA
TURKEY
FAX: 90-312-311-3741
E-MAIL: mcehreli@hotmail.com
Copyright © 2002 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2002/$35.00 ⫹ 0 10/1/130145
doi:10.1067/mpr.2002.130145
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