Dental Science - Review Article

Implant surgical guides: From the past to the

present
Manikandan Ramasamy, Giri1, Ramesh Raja1, Subramonian1, Karthik2,
Rachuri Narendrakumar2

Department of ABSTRACT
Prosthodontia, K.S.R
Advent of osseointegration has rapidly led to use of dental implants over recent years. Implant complications
Dental College,
2
Department of
are often inadvertent sequelae of improper diagnosis, treatment planning, surgical method, and placement.
Prosthodontia, K.S.R This can be overcome by using surgical guides for implant positioning. Although conventionally made surgical
Institute of Dental guide are used, the clinical outcome is often unpredictable, and even if the implants are well placed, the
Science and Research, location and deviation of the implants may not meet the optimal prosthodontic requirements. High accuracy
Thiruchengode, in planning and execution of surgical procedures is important in securing a high success rate without causing
1
Department of iatrogenic damage. This can be achieved by computed tomography, 3D implant planning software, image‑guided
Prosthodontia, Rajas template production techniques, and computer‑aided surgery. This article evaluates about the various systems
Dental College, of conventionally made surgical guide using radiograph and also the newer computer generated surgical guide
Kavalkinaru, Thirunelveli,
in detail.
Tamil Nadu, India

Address for correspondence:

Dr. Manikandan Ramasamy,
E‑mail: drmanikanda@gmail.
com
Received : 02-05-13
Review completed : 04-05-13 KEY WORDS: Computer‑aided design/computer‑assisted manufacture, computed tomography, implant,
Accepted : 04-05-13 surgical guide

D ental implants have become a treatment options widely

used for the replacement of lost teeth. The development of
dental implants has had a major impact on the patients and the
implant supported oral restoration has become an increasingly
used treatment option for partially edentulous and completely
edentulous patients, also even in patients with severe bone
loss and in locations which all previously considered unsuitable
for implant placement has been made possible by means of
bone augmentation, regeneration and soft tissue regeneration
procedures.[1] The success of dental implants in the treatment
of patients is directly related to patient evaluation and good
treatment planning.
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Earlier dentists were intended to place implants where the greatest
amount of bone was present, with less regard to placement of
final definitive restoration. In most of the times, the placement of
implant is not as accurate as intended. Even a minor variation in
comparison to ideal placement causes difficulties in fabrication of
final prostheses.[1,2] Failures arise as a result of lack of consideration
of the super structure during pre‑surgical planning. Accurate
placement is required to achieve best functional and esthetic result.
Since the oral cavity is a relatively restricted space, a high degree of
accuracy in placement of implant is very important for success of
the prostheses. This can be achieved by means of a surgical guide
which provides adequate information regarding implant placement
and at the time of surgery it fits on to the existing dentition or on
to the edentulous span.[2‑5] This article evaluates the conventionally
used radiographic templates with their fabrication, advantages,
disadvantages and a review of computer aided surgical guide.

Surgical Template
DOI:
10.4103/0975-7406.113306 The surgical template enables a predictable and a safe minimally
invasive surgery. Glossary of prosthodontic terms (Gpt) 8,

How to cite this article: Ramasamy M, Giri, Raja R, Subramonian, Karthik, Narendrakumar R. Implant surgical guides: From the past to the present.
J Pharm Bioall Sci 2013;5:98-102.

 S98 Journal of Pharmacy and Bioallied Sciences June 2013 Vol 5 Supplement 1

define surgical template as a guide used to assist in proper
surgical placement and angulation of dental implants.[6] The
main objective of surgical template is to direct the implant
drilling system and provide an accurate placement of the
implant according to the surgical treatment plan. To precisely
transfer the plan to the operative site, customized conventional
radiographic or computer image guided surgical templates have
become a treatment of choice.
A surgical guide is the union of two components: The guiding
cylinders and the contact surface. The contact surface fits
either on an element of a patient’s gums or on the patient’s
jaw (i.e., the bone, the teeth). Cylinders within the drill guides
helps in transferring the plan by guiding the drill in the exact
location and orientation.[7] The implant must be placed such
that firstly the bottom and sides are covered fully by bone or
bone‑replacement material. Second should be the care of not
damaging any neighboring anatomic structures. These are in
particular the mandibular nerve in case of mandible and the
schneiderian membrane of the maxillary sinus in maxilla and also
the roots of adjacent teeth. Thirdly, position of the implant has to
be compatible with the intended final prosthodontic restoration.[8]
There are three types of surgical guide:[7]
1. Bone supported,
2. Mucosa supported, and
3. Tooth supported.
Three techniques commonly used for preparing the guide holes
and fabricating the radiographic and surgical implant guide are
conventional free‑hand, milling, and computer‑aided design/
computer‑assisted manufacture (CAD‑CAM) technology.[9]
Customized Conventional Radiographic Surgical
Template
The radiographic template is the key to the success, since it
allows the transfer of the predetermined prosthetic setup to the
actual implant planning.[7] In surgical template that makes use
of a conventional radiographic method, a thorough radiographic
examination and proper diagnosis of the bony architecture
are fundamental prerequisites.[1] Panoramic radiography is
still the standard for planning of implants. However, precise
measuring of the bone architecture is impossible, because
they have a magnification factor that is not always uniform.
Therefore a better assessment of the bone dimensions in
panoramic radiographs is by determination of the magnification
factor (Mupparapu and Singer 2004).[8]
Conventional dental panoramic radiography and plain film
radiography are usually performed with the patient wearing a
radiographic template with integrated metal spheres or rods,
sleeves, guide posts at the position of the wax up. Based on the
magnification factor and the known dimensions of the metal,
the depth and dimensions of the implants are planned.[1,8,10] The
implant placement planning is guided by quality and quantity
of bone, as well as the position of the teeth for esthetics and
phonetics.[4]
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Ramasamy, et al.: Surgical guide: Present trends
Fabrication Process
Several types of surgical guides have been reported in the
literature. Some are designed for placement of a single implant,
while other reports present designs for implant fixed partial
dentures, multiple single implants, and implant‑retained
overdentures. Some of the most commonly used techniques
are mentioned briefly here.
Diagnostic casts of the dental arches are made from irreversible
hydrocolloid impressions. A diagnostic wax up of the proposed in
case of an implant supported FPD is done. A silicone impression of
the cast with the waxed FPD is made as a mold. A clear, chemically
activated acrylic resin is poured into the mold space and cured.
Access holes are made according to information obtained from the
cast model for initial surgical drill. Stainless steel guide sleeves of
uniform length is cut and placed in access holes and cured.[2,10,11]
Yet another method to prepare a radiographic guide is from
vacuum formed templates. After the diagnostic wax up of the
final restoration is completed, duplication is made and a cast is
poured. The vacuum formed template fabricated is placed over
the cast and the edentulous space is filled with radio opaque
material (Barium sulphate, lead strip, gutta percha).[12‑17]
In another method, it make use of two vacuum formed
templates, one over the blocked out diagnostic cast and other
over the duplicate cast of the diagnostic wax up with a clear
plastic sheet is made.[3] Both the templates are returned to
the unaltered diagnostic cast. The edges of the two templates
are trimmed to make them coincident. The diagnostic wax
template is removed and filled with clear orthodontic resin or
radio opaque material. The filled template is placed over the
template of the unaltered diagnostic cast.[3] Holes are made
according to information obtained from the radiograph for
placement of implants, followed by placement of drill guides.
The radiopaque markers helps in predesigning the direction
of implant placement and in comparing the angulations of
radiopaque markers with the available bone and also in locating
the position of the vital structures to determine the best
angulations for the implant.[12‑17] These radio‑opaque markers
can be placed in the center of the occlusal surfaces of the teeth
that corresponds to the screw access holes of the prosthesis.[12]
The milling technique is an accurate technique in which it employs
parallel holes in the surgical guide. This technique needs the aid
of a conventional dental surveyor.[9,17‑19] All the conventional made
radiographic guides can be converted to an accurate surgical guide
by means of this milling technique. Limitation in this technique is, it
requires special equipment not commonly available in private dental
practices. In addition, the practitioner needs a certain amount of
experience and knowledge to use this machine properly.[9]
Limitations
However, panoramic radiography which is still the standard
and widely used, has diagnostic limitations, such as expansion
 Ramasamy, et al.: Surgical guide: Present trends
and distortion, setting error, positional artifacts and there is no
information regarding the dimension of bone in bucco‑lingual
direction.[9] Further these surgical templates are fabricated on
dental casts, which is a rigid, nonfunctional surface without
the knowledge of underlying soft tissue resiliency and bone
topography.[8,12] Anatomical landmarks are not precisely located,
it does not show the lingual blood vessels, and approach is always
two dimensional.[1,8] So thereby more chances of malpositioning
the implants during placement. Always there is less stability
during surgery. The success of the final outcome always depends
on clinician skill and alertness.[4] It requires more chair time,
leads to stress on the dentist and patient. Although conventional
surgical templates will allow the placement of implant guiding,
they do not provide exact 3D guidance.[1]
Computer generated surgical template
To overcome the limitations associated with conventional
radiographic surgical template, computer generated surgical
template have been evolved.[1] A computer generated surgical
guide provides a link between our treatment plan and the actual
surgery by transferring the simulated plan accurately to surgical
site. This surgical guide is made using stereolithography process
and is custom manufactured for each patient.
Stereolithography, a rapid prototyping technology, a newer
outcome in dentistry allows the fabrication of surgical guides
from 3D computer generated models for precise placement of the
implants.[12] The surgical templates fabricated by this technology
are preprogrammed with Individual depth, angulations,
mesio‑distal and labiolingual positioning of the implant.[12]
Fabrication of stereolithographic templates requires patient’s
computed tomography (CT) image. In CT, multi planar
reformatting allows one to reformat a volumetric dataset in
sagittal, axial, and coronal cuts and also helps in building
multiple cross‑sectional and panoramic views. Shaded
surface display and volume rendering methods generate 3D
reconstructions of the entire dental arch and their relevant
structures, including nerves, which makes dental CT the most
precise and comprehensive radiologic technique for dental
implant planning. Software’s specially planned has been adapted
to allow practitioners to virtually view the implant site and plan
location, angle, depth, and diameter of virtual implants, which
are superimposed on the 3D data. Following backward planning,
the diagnostic wax up has to be visualized through CT scan with
radiographic templates in place.[1,20,21]
Procedures in fabrication of stereolithographic
templates
1. Radiographic template
2. CT scan procedure
3. 3D computer simulation
4. Fabrication of templates
A radiographic template fabricated using radio opaque marker is
kept in patient mouth while performing CT scan procedure.[12,22]
 S100 Journal of Pharmacy and Bioallied Sciences June 2013 Vol 5 Supplement 1
During the scan, this indicates the position of the teeth and
gingival tissues.[9] During fabrication, a diagnostic wax up is
established, representing the outline of the final restoration,
and is then transferred into a radiographic guide.[12]
Diagnostic casts of the dental arches are made from irreversible
hydrocolloid impressions. A diagnostic wax up of the proposed
definitive restoration (in case of an implant supported FPD)
is done. A silicone impression of the cast with the waxed FPD
is made as a mold. After retrieving the silicone impression, the
waxed FPD is removed[2] and in case if the implant site is of
full arch, a duplicate of a denture is made so that a radiographic
stent can be made from it.[23] A clear, chemically activated
acrylic resin is poured into the mold space and cured.[24] As an
alternate, a duplicate cast is made in Type IV dental stone and
a radiographic template is made using vacuum formed matrix
or barium sulfate as the radio‑opaque marker. Access holes are
made according to information obtained from the cast model,
as in case of conventional radiographic guide.
If the patient is a new denture wearer, complete denture wax up
is done to establish the setup of denture teeth with phonetics,
esthetics and proper vertical dimension of occlusion. The
fabrication of an ideal denture is necessary, to avoid varied
dimensions that plays a primary controlling factor in minimizing
deviated angulations.[4,25]
The radiographic template, thus fabricated act as an exact replica
of desired prosthetic end result, and are usually supported with
different radiopaque markers such as gutta percha balls, sleeves,
disks and tubes, radiopaque varnishes or lead strip or foil.[1,12,14‑17]
Some authors prefer metal pins for better accuracy.[24] In order
to stabilize the template, the patient can be instructed to use
denture adhesive during the scanning procedure.[8] In case, if
it is a completely edentulous condition, six to eight radiopaque
markers are placed into the guide.[4] A bite index is created to
ensure a correct positioning of the radiographic guide in the
patient’s mouth during scanning.
The understanding of underlying bony architecture and anatomic
structures are prerequisites for appropriate implant planning.[1] In
general, the quality of CT data depends on the slice thickness and
the influence of possible artifacts. The thinner the slice thickness
and the smaller the voxel size, the higher the resolution and
accuracy of measurements of delineated structures. Movement
and metallic artifacts of some dental restorations may lead to
geometric distortion and invalid acquisition.[1]
Double scan protocol
For artifact free, high resolution digitization of the radiographic
guide, some authors have developed a specific double‑scan
technique. In this technique, the first scan is a scan of the
patient wearing the radiographic guide. The second scan is
a scan of only the radiographic guide. Based on the spherical
markers visible in both scans, the scans are superimposed onto
each other, resulting in a 3D bone model of the patient together
with a 3D model of the radiographic guide.[4,13]

Converting raw data to 3D information is done by various
software’s available or by just sending to master site of the
particular software manufacturers. CT or Cone beam scan
data thus obtained is sent from the radiology site to Master
site nearby. Master site will convert the CT or Conebeam scan
data into a file that contains reformatted images in 2D and an
insightful 3D representation of patient’s anatomy. On finally
the file contains cross‑sectional images, panoramic views, axial
images, and a 3D representation of the patient’s anatomy.[12]
The combination of a 3D bone model and 3D radiological
dataset lets dental professionals to evaluate bone quantity.[13]
Underlying anatomical structures such as nerves and blood
vessels, as well as dental roots, can be identified and marked
with the help of several reslice views. Special tools are available
to highlight dental roots, nerves and other anatomical structures
or restrictions. Software allows to turn 3D images, rotate
these images, and to view the treatment plan from all angles
simplifying diagnostic procedures and placement of implants.
3D distances can easily be measured, and a tool to measure the
grey values is also available. These anatomical annotations are
visible in the 3D setting and in the reslice viewer.[13]
The combination of a 3D bone model, including the 3D
radiological dataset and the 3D radiographic guide model,
enables clinician to place implant locations according to
anatomical, functional and esthetics needs and demands.
In order to achieve this, the clinician virtually positions the
implants, with the optimal length and diameter. Any of the
modifications in 3D location and implant type, size or shape
can be done in the 3D setting or in the reslice viewer. After
finalizing the planning, the corresponding surgical template is
designed. The surgical template thus fabricated contains all the
necessary planning information‑It is customized according to
location, type and size of the planned implants.
Making a computer aided template
CAD‑CAM a rapid prototyping technique in which after the
generation of a 3D treatment plan, software slices from the file
is sent to a machine that fabricates the part slice by slice. Two
main methods of rapid proto typing are[26]
1. Additive – widely used
2. Subtractive – less effective
Stereolithographic apparatus consists of a vat, which contains a
liquid photo polymerized resin. Corresponding to slice intervals,
an laser that is mounted on top of vat moves in sequential
cross sectional of 1 mm increments, to produce template.
Polymerization process of photo polymerized resin occurs in
layers. Once, the surface layer of the resin on laser contact
gets polymerized, a mechanical table immediately below the
surface layer moves down 1 mm, carrying with it the previously
polymerized resin layer. The laser now polymerizes the next
layer over the previously polymerized layer of the model. In
stereolithography Apparatus (SLA) only 80% of the total
polymerization is completed in the vat, whereas the remaining 20%
can be completed in a conventional ultraviolet light curing unit.[12]
Journal of Pharmacy and Bioallied Sciences June 2013 Vol 5 Supplement 1 S101 
Ramasamy, et al.: Surgical guide: Present trends
The so produced surgical template is provided with surgical
grade stainless steel tubes with sleeves that are 5 mm in height,
0.2 mm wider than osteotomy, and also with drill limiting
angulation deviation to 5°. Buccal window is made so that it
enhances retention during surgery. Usually, three 2 mm holes
are placed into the buccal surface of each side of the denture.[4]
Advantages
  1. More precise placement of implants.
  2. Preservation of anatomic structures.
  3. High geometrical accuracy of 0.1 mm.
  4. Shorter treatment times, surgery times.
  5. Less invasive, flapless surgery and therefore less chance of
swelling.
  6. Less post‑operative strain on dentist and patient.
  7. Transparency of material which allows seeing through the
model.
  8. To summarize stereolithography fabrication process.
  9. A CT scan procedure is performed with a radiographic
template fabricated using radio opaque marker in place.
10. Data obtained from CT scan procedure is either sent to
master site of a particular software company or dentist can
view the virtual 3D model from different angles using the
software to customize the treatment plan.
11. The final proposed treatment plan is sent to SLA that
scans the image and fabricates the template.
Conclusion
In order to achieve a successful final treatment outcome, a position
at least equivalent to the maximum deviation of the implant
placement is necessary. This has been best achieved clinically with
the help of a computer aided surgical guide. But compared to the
conventional technique, limitation with computer‑aided implant
surgery requires substantially greater investment and effort. Based
on clinical data, image guidance is not required for cases with
sufficient anatomic orientation and bone height. Computer
aided planning and image guided surgery can be carried out,
when implant positioning is to be precisely executed, and when
safe positioning of implants with optimal use of available bone,
and whenever a CT scan is recommended as a diagnostic means.
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Source of Support: Nil, Conflict of Interest: None declared.
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