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Surgical template impression during stage I surgery for fabrication of a provisional restoration to be placed at stage II surgery
fHmi~**n II swgery
ata i of a pmvisimal
&uring stage I surgery for r43storation to be placed at stage
David A. Hochwald, DDSa University of Southern California, School of Dentistry, Los Angeles, Calif. The fixture impression method presented permits the construction of a master cast after stage I surgery, enabling the dentist and dental technician to make a provisional crown before stage II surgery. At stage II surgery the surgeon can place the provisional crown instead of a classic abutment or healing cylinder. This eliminates the need for the patient to visit the restorative dentist immediately after stage II surgery for the making of a provisional crown, which can be a scheduling and logistic problem. In add&ion, better soft tissue contour is possible at stage II surgery, as the premade provisional crown can be shaped to the desired dimensions in the laboratory for ideal esthetics. The soft tissue will adapt to the predetermined surface dimensions during initial healing. Ideal soft tissue contours are present and stable when the final impression is made, which enables better esthetics to be developed for the permanent fixture-retained single-tooth restoration. (J PROSTHET DENT 1991,$38:796-8.)
I
mplant treatment has improved as surgical and prosthetic expertise have increased in implant diagnosis and treatment. The single anterior tooth implant treatment’-* (Fig. 1) requires significant planning to achieve an ideal functional and esthetic result. Communication between the surgeon, dentist, and dental technician is essent i al5 Proper planning includes the surgical positioning of the implant, using surgical templates6 the choosing of an interim prosthesis for function and esthetics during the implant healing phase as well as after stage II surgery, and
‘(‘hical Instructor. 1 O/1/25662
Pig. 1. Preoperative right central incisor.
photograph
of patient
with missing
determining the design goals of the final prosthesis. To facilitate implant treatment planning, a surgical and laboratory technique is described that allows the dentist to make a registration of a fixture at the time of stage I surgery. This technique is useful in single-tooth treatment and is also adaptable to multiple fixture situations.
TECHNIQUE A surgical template is made with clear acrylic resin and is indexed exactly on the occlusal surfaces of the remaining adjacent teeth? The lingual aspect of the template is cut out to reveal ideal implant position. Standard surgical procedures are used in conjunction with the surgical template to place the fixture into the bone
Fig. 2. Occlusal template at surgery indexed to adjacent teeth with single-tooth fixture carrier still connected to fixture and protruding through template.
STAGE
I PROVISIONAL
CROWN
F ig. 3. Sterile acrylic resin is placed on superior aspect of template to lute fixture carrier to indexed occlusal template.
F ig. 4. Fixture carrier screw is unscrewed from fixture and carrier-template unit is removed from mouth.
F ig. 5. Fixture carrier-occlusal template unit after removal from mouth with fixture analog in position.
F ig. 6. Fixture carrier-template unit with fixture analog attached indexed on cast, modified by grinding away edentulous region of right central incisor. Laboratory
in the ideal position, A single-tooth implant carrier is used to allow placement of the fixture without interference from the adjacent teeth (Fig. 2). Prior to surgery, the implant carrier is beveled with a stone to form one flat side for a reference in the later registration. Following implant placement, the implant carrier is left attached to the fixture. The occlusal surgical template is replaced and indexed to the adjacent teeth with the carrier protruding through the template. Sterile acrylic resin is mixed and placed to attach the carrier to the indexed occlusal template (Fig. 3). The acrylic resin is kept on the superior aspect of the template to facilitate easy removal. After the acrylic resin has set, the fixture carrier screw is unscrewed from the fixture and the carriertemplate unit is removed from the mouth (Fig. 4). The wound is then irrigated with sterile saline, the cover screw is placed routinely on the fixture, and the wound is closed using normal surgical methods. Standard temporary prosthesesare then placed with normal care to avoid loading the healing fixture. Claspless type removable prostheses may be used. THE
JOURNAL
OF PROSTHETIC
DENTISTRY
technique
The original cast used to make the surgical template or another accurate presurgical cast may be used. The edentulous region where the fixture is placed is ground away from the cast to allow the template-carrier unit to be indexed on the adjacent teeth. A fixture analog is then connected to the carrier in the template-carrier unit (Fig. 5), the groove in the inferior portion of the fixture carrier is waxed out, and the template is again indexed to the cast (Fig. 6). W ith the unit in place and carefully held on the adjacent teeth, artificial stone is poured to enclose the fixture analog in the cast. After the stone is allowed to set, the carrier screw is loosened and the carrier-template unit is removed from the cast. This procedure leaves a master cast with the fixture analog and hex head oriented properly for making a provisional crown (Fig. 7). The dental technician has approximately 3 to 6 months to make the provisional crown in the manner desired.
Stage II surgery At the appropriate time, stage II surgery is performed using routine surgical techniques. The laboratory-made 797
HOCHWALD
Fig. 7. Final maeter cast with oriented fixture analog in place for making single-tooth provisional crown prior to stage II surgery.
storative dentist for making a temporary crown. After adequate aoft tissue healing, the patient can return for final and fabrication of the final restoration. Furi ther experience with the technique may show that it is possible to make the final restoration from the master cast. The advantages of the technique are: 1. A master cast with an exactly oriented implant can be made after stage I surgery. 2. The dentist and dental technician will be able to make a provisional crown in the laboratory prior to stage II surgery. 3. The previously made provisional crown instead of a conventional abutment or healing cylinders8 can be inserted at stage II surgery by the surgeon. 4. Logistic and scheduling inconvenience for the patient and dentist will be eliminated in making a provisional crown immediately after stage II surgery. 5. The shape of the provisional crown can be controlled, which will permit more ideal stage II soft tissue contours. 6. There will be greater soft tissue and overall esthetics for the single-tooth restoration. REFRRENCES 1. Branemark system. Clinical procedure for single tooth abutment manual. Goteborg, Sweden: Nobelpharma, 1988. 2. Ohmeil L-O, Hirsch JM, Ericsson T, Branemark P-I. Single-tooth rehabilitation using oamointegration. A modified surgical and prosthodontie approach. Quintemence Int 1988:19:871-86. 3. Jemt T. Modiiled single and short-span restorations supported by osseointegratedfixtures in the partially edentulousjaw. J PR~~THETDENT 1988;65:243-7.
4. Lewis SG, Beumer J III, Perri GR, Homburg WP. Single tooth implant supported restorations. Int J Oral Maxillofac Implants 198&3:25-30. 5. Rieder C. An implant consultation form to improve communication between surgeonand restorative dentist. J Calif Dent Asaoc1990,18(4):2933.
Fig. 8. Final provisional crown in place.
6. Murrell G, Davis WH. Presurgical prosthodontics. J PROSTHET DENT 1988;59:447-52.
provisional crown is placed instead of a conventional abutmentor healing cylinder. The patient is dismissed from the surgical office with a functioning and esthetic temporary restoration (Fig. 8). There are no scheduling or logistic problems brought on by the immediate need to see the re-
7. Pare1S, Sullivan D. Esthetics and osseointegration.Dallas: Osseointegration Seminars Inc. 198922. 8. Branemark P-I, Zarb GA, Albrektason T. Tissue-integrated prostheses. Chicago: QuintessencePublishing Co, 1985:211-32.
Reprintrequests to: DR. D A W D H~CHWALD 14343 BELLFLOWER BLVD. BELLFLOWER, CA 90706
ata i of a pmvisimal
&uring stage I surgery for r43storation to be placed at stage
David A. Hochwald, DDSa University of Southern California, School of Dentistry, Los Angeles, Calif. The fixture impression method presented permits the construction of a master cast after stage I surgery, enabling the dentist and dental technician to make a provisional crown before stage II surgery. At stage II surgery the surgeon can place the provisional crown instead of a classic abutment or healing cylinder. This eliminates the need for the patient to visit the restorative dentist immediately after stage II surgery for the making of a provisional crown, which can be a scheduling and logistic problem. In add&ion, better soft tissue contour is possible at stage II surgery, as the premade provisional crown can be shaped to the desired dimensions in the laboratory for ideal esthetics. The soft tissue will adapt to the predetermined surface dimensions during initial healing. Ideal soft tissue contours are present and stable when the final impression is made, which enables better esthetics to be developed for the permanent fixture-retained single-tooth restoration. (J PROSTHET DENT 1991,$38:796-8.)
I
mplant treatment has improved as surgical and prosthetic expertise have increased in implant diagnosis and treatment. The single anterior tooth implant treatment’-* (Fig. 1) requires significant planning to achieve an ideal functional and esthetic result. Communication between the surgeon, dentist, and dental technician is essent i al5 Proper planning includes the surgical positioning of the implant, using surgical templates6 the choosing of an interim prosthesis for function and esthetics during the implant healing phase as well as after stage II surgery, and
‘(‘hical Instructor. 1 O/1/25662
Pig. 1. Preoperative right central incisor.
photograph
of patient
with missing
determining the design goals of the final prosthesis. To facilitate implant treatment planning, a surgical and laboratory technique is described that allows the dentist to make a registration of a fixture at the time of stage I surgery. This technique is useful in single-tooth treatment and is also adaptable to multiple fixture situations.
TECHNIQUE A surgical template is made with clear acrylic resin and is indexed exactly on the occlusal surfaces of the remaining adjacent teeth? The lingual aspect of the template is cut out to reveal ideal implant position. Standard surgical procedures are used in conjunction with the surgical template to place the fixture into the bone
Fig. 2. Occlusal template at surgery indexed to adjacent teeth with single-tooth fixture carrier still connected to fixture and protruding through template.
STAGE
I PROVISIONAL
CROWN
F ig. 3. Sterile acrylic resin is placed on superior aspect of template to lute fixture carrier to indexed occlusal template.
F ig. 4. Fixture carrier screw is unscrewed from fixture and carrier-template unit is removed from mouth.
F ig. 5. Fixture carrier-occlusal template unit after removal from mouth with fixture analog in position.
F ig. 6. Fixture carrier-template unit with fixture analog attached indexed on cast, modified by grinding away edentulous region of right central incisor. Laboratory
in the ideal position, A single-tooth implant carrier is used to allow placement of the fixture without interference from the adjacent teeth (Fig. 2). Prior to surgery, the implant carrier is beveled with a stone to form one flat side for a reference in the later registration. Following implant placement, the implant carrier is left attached to the fixture. The occlusal surgical template is replaced and indexed to the adjacent teeth with the carrier protruding through the template. Sterile acrylic resin is mixed and placed to attach the carrier to the indexed occlusal template (Fig. 3). The acrylic resin is kept on the superior aspect of the template to facilitate easy removal. After the acrylic resin has set, the fixture carrier screw is unscrewed from the fixture and the carriertemplate unit is removed from the mouth (Fig. 4). The wound is then irrigated with sterile saline, the cover screw is placed routinely on the fixture, and the wound is closed using normal surgical methods. Standard temporary prosthesesare then placed with normal care to avoid loading the healing fixture. Claspless type removable prostheses may be used. THE
JOURNAL
OF PROSTHETIC
DENTISTRY
technique
The original cast used to make the surgical template or another accurate presurgical cast may be used. The edentulous region where the fixture is placed is ground away from the cast to allow the template-carrier unit to be indexed on the adjacent teeth. A fixture analog is then connected to the carrier in the template-carrier unit (Fig. 5), the groove in the inferior portion of the fixture carrier is waxed out, and the template is again indexed to the cast (Fig. 6). W ith the unit in place and carefully held on the adjacent teeth, artificial stone is poured to enclose the fixture analog in the cast. After the stone is allowed to set, the carrier screw is loosened and the carrier-template unit is removed from the cast. This procedure leaves a master cast with the fixture analog and hex head oriented properly for making a provisional crown (Fig. 7). The dental technician has approximately 3 to 6 months to make the provisional crown in the manner desired.
Stage II surgery At the appropriate time, stage II surgery is performed using routine surgical techniques. The laboratory-made 797
HOCHWALD
Fig. 7. Final maeter cast with oriented fixture analog in place for making single-tooth provisional crown prior to stage II surgery.
storative dentist for making a temporary crown. After adequate aoft tissue healing, the patient can return for final and fabrication of the final restoration. Furi ther experience with the technique may show that it is possible to make the final restoration from the master cast. The advantages of the technique are: 1. A master cast with an exactly oriented implant can be made after stage I surgery. 2. The dentist and dental technician will be able to make a provisional crown in the laboratory prior to stage II surgery. 3. The previously made provisional crown instead of a conventional abutment or healing cylinders8 can be inserted at stage II surgery by the surgeon. 4. Logistic and scheduling inconvenience for the patient and dentist will be eliminated in making a provisional crown immediately after stage II surgery. 5. The shape of the provisional crown can be controlled, which will permit more ideal stage II soft tissue contours. 6. There will be greater soft tissue and overall esthetics for the single-tooth restoration. REFRRENCES 1. Branemark system. Clinical procedure for single tooth abutment manual. Goteborg, Sweden: Nobelpharma, 1988. 2. Ohmeil L-O, Hirsch JM, Ericsson T, Branemark P-I. Single-tooth rehabilitation using oamointegration. A modified surgical and prosthodontie approach. Quintemence Int 1988:19:871-86. 3. Jemt T. Modiiled single and short-span restorations supported by osseointegratedfixtures in the partially edentulousjaw. J PR~~THETDENT 1988;65:243-7.
4. Lewis SG, Beumer J III, Perri GR, Homburg WP. Single tooth implant supported restorations. Int J Oral Maxillofac Implants 198&3:25-30. 5. Rieder C. An implant consultation form to improve communication between surgeonand restorative dentist. J Calif Dent Asaoc1990,18(4):2933.
Fig. 8. Final provisional crown in place.
6. Murrell G, Davis WH. Presurgical prosthodontics. J PROSTHET DENT 1988;59:447-52.
provisional crown is placed instead of a conventional abutmentor healing cylinder. The patient is dismissed from the surgical office with a functioning and esthetic temporary restoration (Fig. 8). There are no scheduling or logistic problems brought on by the immediate need to see the re-
7. Pare1S, Sullivan D. Esthetics and osseointegration.Dallas: Osseointegration Seminars Inc. 198922. 8. Branemark P-I, Zarb GA, Albrektason T. Tissue-integrated prostheses. Chicago: QuintessencePublishing Co, 1985:211-32.
Reprintrequests to: DR. D A W D H~CHWALD 14343 BELLFLOWER BLVD. BELLFLOWER, CA 90706