Surgical Guide Techniques - Triad & Vacuuform

I was fortunate enough to have an implant case this semester. At UBSDM, we're involved in every aspect of the implant treatment, from it's placement to it's final restoration. As we were taught in pre-clinic, implant treatment involves a team of practitioners and careful planning and communication is essential.

The Surgical Guide is a tool made by the restorative dentist and [hopefully] used by the implant surgeon to place the implant in the location dictated by the restorative dentist. Once placed properly, the restorative dentist can then select an abutment and crown to finish the restoration. The surgical guide is used in treatment planning as well. Once completed, the patient is brought back, the guide tried in and a radiograph (CBCT or PA) is taken to assess the angulation and planned placement of the implant.

At the initial evaluation, we take a medical and dental history, and address any chief complaints. The implant treatment planning starts here, where we take the necessary radiographs to assess bone, alginate impressions, a facebow and bite registration so that we can mount the diagnostic casts.

So this implant is being planned for position #29. 

[Left]So here's the cast of the lower arch. 

[Middle]We first do a diagnostic wax up of the tooth, with proper embrasures and [Right]occlusal contacts. Next, an alginate impression is taken of the cast with the wax up so that we have a template from which to make the vaccuformed surgical guide. 

[Left]Here's the duplicated cast, trimmed and after the vaccumform was made. The hole in the tongue space helps the template better adapt. The template is then removed from the cast somewhat carefully. The cast won't be needed anymore so it shouldn't be concerning if it breaks, but the template should be handled carefully.

[Middle] Here's the trimmed guide after removal from the cast. The area around #29 is trimmed to the gingival margin, however around all other teeth the guide is trimmed to half the occluso-gingival height of the tooth. The guide should seat on the original cast without rocking. 

[Right] Next we need to fill position #29 with a radiopaque material so that when the guide is tried in the patient's mouth, we can assess the angulation of the implant. Barium sulfate is combined with PMMA and the tooth to be restored is filled in.

A hole is then made to accomodate the metal cylinder. The vacuuformed template with PMMA and barium Sulfate is slide onto the cast, and the cylinder is secured into place with super glue. I'll need to get a photo up of the finished thing. But here is a finished TRIAD guide:

 

So with these guides the surgeon can make a pilot hole at an angulation that has been previously evaluated radigraphically. After the implant is placed we'll be going through the impressioning techniques to restore!