l?. J. R. O’Neilly, BDS, LDSRCS, MS,a and E, A.

McGlumphy, DDS, MSb

Eastman Dental Hospital, London, England, and The Ohio State University College of Dentistry,
Columbus, Ohio

This article describes the process of making and using a surgical guide stent. It is
intended to enable the surgeon to maintain the same horizontal and vertical axes of
cylindrical endosseous implants during the surgical phase of implant placement as
those determined at the treatment planning stage. Furthermore, the stent can be
used with the entire series of surgical drills, thereby minimizing the chance of
inadvertently enlarging the implant site as a result of freehand use of the hand-
piece. (J FROSTHET DENT 1993;70:506-10.)

c
ylindrical endosseous implants that are correctly
located on the edentulous ridge may have an incorrect an-
face of the restoration
tion can be obtained.‘,*
so that superior esthetics and func-
It is possible for the x (anterior-
gdation. If an edentulous region is to be restored with a posterior) and y (medio-lateral) coordinates of the implant
screw-retained prosthesis, it is desirable that the retaining to be satisfactory with respect to the proposed restoration
screw emerges through the occlusal or palatalflingual sur- (Fig. 1). However, if the z (inferior-superior) coordinate is
incorrect, prosthetic reconstruction with screw-retained
prostheses is difficult if not impossible. It has been stated
Presented at the Carl 0. Boucher Prosthodontics Conference, Co- that when implants are placed in the anterior region of the
lumbus, Ohio
maxilla, an error in angulation (2 coordinate) of the implant
aLecturer, Conservative Dentistry, Eastman Dental Hospital.
“Assistant Professor, Department of Restorative and Prosthetic
by as little as 10 degrees can render the implant unrestor-
Dentistry, The Ohio State University. able.3
Copyright 1993 by The Editorial Council of THE JOURNAL OF Several surgical guide stents have been described in the
PROSTHE'VICDENTISTRY. literature.1,4-7 Balshi and Garver4 described a stent where
0022-3913/93/$1.00 + .lO. 10/l/50412 2 mm holes are made in an acrylic resin template to act as
a guide for the 2 mm pilot drill. Because of its thickness and

Fig. 1. Relationship of x (anterior-posterior), y (medio-

lateral) and z axes (superior-inferior) of implant to eden- Fig. 2. Stainless steel template mounted in arm of sur-
tulous ridge and proposed restoration. veyor.

VOLUME70 NUMBER6
O’NEILLY AND McGLUMPHY THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 3. A, Stainless steel template used to determine correct X, y, and z coordinates for
proposed implants in relation to vacuum-formed matrix of diagnostic wax-up. B, Matrix
is removed and coordinates are related to edentulous ridge. Difficulties in obtaining ade-
quate accesswith head of handpiece can be anticipated at this stage.

Fig. 5. Additional acrylic resin has been added to stent

for rigidity.

similar to that of Pare1 and Sullivan‘j; however, they sug-

Fig. 4. Vacuum-formed matrices are repositioned on cast
and surveyor. The open side of stent is placed so that
handpiece can be inserted when stent is placed.
spacing to allow irrigation, the stent cannot always guide
the drill to the full depth of the hole. Once the 2 mm hole
has been made, the stent is of little value and the remain-
ing site preparation is done freehand. Furthermore, if an
alternative implant location is preferred, the stent cannot
be used. The stent described by Edge5 has drawbacks sim-
ilar to those of Balshi and Garver.4
Pare1 and Sullivan6 and Hobo et a1.7 described a stent
whereby the buccal contours of the proposed implant-sup-
ported restoration are created in the stent. The stent does
not serve as a direct mechanical guide, and site preparation
is done freehand. Engleman et a1.l also described a stent
gest that the angulation of the implant site be verified by
placing guide pins into the pilot holes with the stent in po-
sition. With this technique, the implant angulation (z axis)
with respect to the proposed restorations can only be de-
termined after the pilot hole has been prepared.
This article describes a new method to make a surgical
guide stent that would enable the operator to maintain the
same r, y, and z coordinates of the implant throughout the
course of the surgical phase.
DIAGNOSTIC AND LABORATORY PHASE
This technique includes the use of a stainless steel tem-
plate that is of the same diameter as the head of the con-
tra-angle handpiece used in the surgical stage (Fig. 2). One
end is machined to a point and the opposite end is
machined to fit in a surveyor.
The diagnostic and preoperative evaluation procedures

DECEMBER 1993 507

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 6. Open side of stent is trimmed to receive head of
handpiece.
Fig. 7. Guide stent used while pilot hole is drilled in bone.
described in other studies should be followed.‘, 3-i This
evaluation would include appropriate radiologic examina-
tions, (periapical, lateral cephalometric, tomographic, pan-
oramic, and computerized tomography [CT]). A diagnostic
wax-up or setup of the proposed prosthesis is also essential.
When the intended artificial tooth position has been con-
firmed estheticahy and functionally, a stone cast is made of
the wax-up and a vacuum-formed matrix is made over it for
later use.
A diagnostic cast is mounted on a surveyor. The cast is
tilted to establish the most favorable coordinates (x, y, and
z) for the implants by relating the position of the retaining
screw(s) for the proposed prosthesis (formed by the matrix
of the diagnostic wax-up) with the underlying edentulous
.50x
O’NEILLY AND McGLUMPHY
Fig. 8. Bottom of guide channel has been removed and
stent is used in later stages of implant site preparation.
ridge (Fig. 3). The intended coordinates may be modified
to accommodate radiographic or clinical findings. With this
procedure, the proposed implant locations can be aligned
with the intended prostheses and, most important, the un-
derlying bone topography and relevant anatomic struc-
tures (Fig. l).l
The template can also indicate possible difficulties in
gaining correct access with the handpiece (Fig. 3, B).
When the desired coordinates (x, y, and z) have been es-
tablished, the diagnostic cast is carefully removed from the
surveyor and the matrix of the diagnostic wax-up is set
aside. A vacuum-formed matrix is made of the original di-
agnostic cast. The matrix is trimmed so that only the incisal
edges, the occlusal surfaces of the supporting teeth, and the
edentulous ridge are covered. A sufficient number of teeth
should be present in the arch to adequately support and
stabilize the stent. A matrix is then formed around the
stainless steel template to provide a smooth internal sur-
face of the stent against which the head of the handpiece
can slide.
The diagnostic cast is returned to the surveyor in its
original position. The template is repositioned in the arm
of the surveyor and placed so that the tip of the template
is exactly over the proposed implant site on the edentulous
ridge (Fig. 4). The x, y, and z axes can be verified if desired.
The “open” side of the template is positioned to permit
easy accessof the handpiece when the stent is placed clin-
ically.
Autopolymerizing acrylic resin is added incrementally to
join the matrix on the diagnostic cast to the matrix around
the template. Additional acrylic resin is added to give suf-
VOLUME 70 NUMBER 6
O’NEILLY AND McGLUMPHY
Fig. 9. Implant angulation for first molar determined by
described stent. Different stent was used for second molar.
Differences in evaluation of occlusal access can be noted.
ficient strength and rigidity (Fig. 5). If required, the tem-
plate can be disconnected from the arm of the surveyor and
the cast placed in a pressure pot.
When the resin has polymerized, the template can be re-
moved. The open side of the matrix is modified to enable
the head of the handpiece to be fully inserted, thus form-
ing the guide channel of the stent (Fig. 6). The bottom of
the guide channel is in the form of an inverted cone where
a hole for the pilot drill can be made through the stent at
the apex of the inverted cone.
SURGICAL STAGE
When the pilot hole is made in the alveolar bone, the
stent supports and guides the drill and the handpiece along
the predetermined axes (x, y, and z) to the desired depth
(Fig. 7). Once the pilot hole has been made, the inverted
cone portion of the stent is removed with a bur. The oper-
ator can now continue to use the stent throughout site
preparation and minimize the risk of accidentally enlarg-
ing the implant site because of the use of the handpiece
freehand (Fig. 8).
The use of this stent will establish reasonable x, y, and
z axes of the implants, which result in ideal access for
screw-retained prostheses (Figs. 9 and 10).
DISCUSSION
When the stent described in this article is used, the sur-
geon can maintain the predetermined x (anterior-posteri-
or), y (medio-lateral) and z (superior-inferior) coordinates
for the intended implants while the surgical site is actually
being prepared. Use of this guide ensures that the implants
are correctly oriented with respect to the proposed resto-
rations, thus reducing the risk of difficult or complex pros-
thetic reconstruction1z3 In addition, the operator can use
the entire series of surgical drills with the stent, thereby
DECEMBER 1993
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 10. Distal implant placed with described stent. Dif-
ferent stent used for mesial implant. Angulation of mesial
implant is shown. (Photograph courtesy of Dr. S. Porter,
with permission.)
reducing the risk of inadvertent eccentric enlargement of
the implant site as a result of freehand use of the handpiece.
The stent is particularly indicated in situations where, be-
cause of prosthetic requirements, there is minimal latitude
for alternative implant location and where radiographic
examination indicates no adverse bone topography in the
ideal sites. Fabrication is simple when it involves materials
that are inexpensive and readily available.
This stent can only be used along one specific path.
Changing the angulation at the time of surgery is difficult.
If the surgeon is unable to use the stent as described
because of unfavorable bone topography, the stent can be
modified. The guide channel of the stent should be reduced
to the level of the occlusal surface or incisal edge of the in-
tended restoration until it measures only 1 to 2 mm in
height. Alternative coordinates (x, y, and z) for the implant
can then be indicated, If the alternative z (superior-inferi-
or) axis of the intended implant can be aligned so that it
emerges through the approximate center of the modified
guide channel, acceptable implant angulation can be an-
ticipated. The coordinates of the new implant location can
be verified by a paralleling pin placed in the pilot hole with
the stent in position in a manner described Engleman et a1.l
SUMMARY
This article describes an implant surgical guide stent
that is intended to minimize adverse implant position and
angulation caused by operator error at the time of place-
ment.
REFERENCES
1. Engleman MJ, Sorensen JA, Moy P. Optimum placement of osseointe-
grated implants. J PROSTHET DENT 1988;59:467-73.
2. Sullivan R. Avoiding screw access problems. Nobelpharma News
1992;6(4):6.
509
THE JOURNAL OF PROlSTHLTIC DENTISTRY O’NEILLY AND McGLUMPAY

3. Wqtson RM, D&a DM, foreman GH, Coward T. Considerations in Reprint requests to:
deeig~-,& h&&t&n of m&lIary implant supported prostheses. Int DR. P. J. R. O’NEILLY
~4 t2&&. I9&1;4:232-9. DEPARTMENT OF CONSERVATIVE DENTISTRY
4. Bale& Td, G&ver Do. Smgical guidestents for placement of implants. EASTMAN DENTAL HOSPITAL
d&al %ixiiofac-Surg 198~45~463-5. 256 GRAY’S INN ROAD
5. Edge J. Suqical placement guide for use with osseointegrated implants. LONDON
J PFWIBE$ D&m 196~57:719-22. WC1 8LD
6. Pare1 SM, Sullivan DY. Esthetics and osseointegration. OS1 publication UNITED KINGDOM
1989;24741.
7. Hobo S, Ichida E, Garcia LT. Osseointegration and occlusal rehabilita-
tion. Tokyo: Quintessence Pub1 Co Ltd, 1989;120-1.

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