Template for positioning
intraosseous implants
David R. Bums, D.M.D.,* Donald G. Crabtree,
Virginia Commonwealth University, School of Dentistry, Richmond, Va.
S ubmerged implants opposing an existing or planned
occlusion require accurate intraosseousimplant place-
ment to satisfy prosthodontic considerations.The posi-
tion and angulation of the submergedimplant needto be
planned before the time of surgical implant placement
for proper occlusal alignment with the opposing denti-
tion or prosthesis.
The surgeon usesdifferent criteria for implant place-
ment than that usedby the prosthodontist.’ The surgeon
must place the implant in a region where the quantity
and quality of bone is adequate to provide functional
support2 The prosthodontist should not rely on the
surgeon’s skills alone to provide appropriate implant
placement, but should provide the surgeon with a
template for the correct placement of the intraosseous
implant.
This article describesa technique for fabrication of a
surgical guide that gives the surgeon the appropriate
location and angulation of the submergedimplant rela-
tive to the opposing dentition.
In conjunction with the surgeon, the prosthodontist
initially should evaluate the patient for potential implant
treatment including an adequate history, oral examina-
tion, radiographic examination, and mounted diagnostic
casts.3The surgeon should carefully palpate the regions
of potential implant placement for bone undercuts and
bone thickness and morphology. In addition, it may be
desirable to ‘%ound” the bone through the soft tissue
from the buccal and lingual aspect of the alveolar ridge.
This can be done by locally anesthetizing the region and
then inserting, perpendicular to the tissue surface, a
25-gauge needle through the soft tissue until it hits the
underlying bone. The distanceof insertion into the soft
tissueis measuredon the buccal and lingual aspectof the
alveolar ridge at varying vestibular depths. From this
information, regions of potentially adequate bone,
implant size, number, and location can be tentatively
determined. The surgeon and prosthodontist should
carefully review and discusstheir findings and develop a
mutual understanding regarding implant location and
angulation.
TECHNICAL PROCEDURES
Diagnostic castsare mounted in an articulator using a
centric jaw relation record (Fig. 1). The distance from
*Assistant Professor, Department of Removable Prosthodontics.
**Professor Emeritus, Department of Removable Prosthodontics.
THE JOURNAL OF PRO!STHETIC DENTISTRY
and angulation of
D.D.S.,* and Dewey H. Bell, D.D.S.**
the edentulousridge to the opposing occlusal surface is
measuredto make certain that adequate spaceis avail-
able for fabrication of the prosthesisabove the implant at
the vertical dimension of occlusion. Artificial teeth of a
size similar to the opposing or adjacent dentition are
selected.They are arranged in the edentulous spaceon
the cast over the ridge, as determined by the clinical
examination, to provide an appropriate occlusal rela-
tionship with the opposing arch. The artificial teeth are
held in position with a small amount of utility wax
directly under each tooth (Fig. 2). An outline is drawn
with a pencil on the cast around each artificial tooth
(Fig. 3). The cast with the artificial teeth is removed
from the articulator and placedon a surveyor (J.M. Ney
Co., Hartford, Conn.). The analyzing rod is aligned
with the long axis of the artificial teeth (Fig. 4). If a
natural tooth is to be prepared for useasan abutment for
the planned prosthesisin combination with an implant,
the surveyor alignment can be made parallel to the long
axis of the natural tooth.’
After the surveyor is properly aligned, the artificial
teeth are removedfrom the cast.The center of the outline
around the artificial teeth that will represent locations
for implant placementis then marked, and the analyzing
rod is removed from the surveyor mandrel.
A 10 mm length of 0.045 inch round tubing (Unitek
Corp., Monrovia, Calif.) is prepared. The outer surface
of the tubing is serrated with a separatingdisk to provide
multiple serrationsalong the entire tube length (Fig. 5).
This procedure provides mechanical retention for the
tube within acrylic resin on processingof the template
and holds the tube in place during investment and
processing.Care must be taken not to cut through the
inner surface of the tube. The open ends of the tubing
lumen are closedwith a temporary plug material such as
Dentkote (Dentsply International, Inc., York, Pa.). As
much material as possible should be forced into the
lumen. All excessmaterial is removed from around the
lumen. The tubing is placed and tightened into the
surveyor mandrel. The tube should be supported within
the mandrel with the metal sheath provided with the
surveyor to support the carbon marker (Fig. 6). The
tubing is then centered over the outline of one of the
artificial teeth representing the location for implant
placement.At this angulation, the round tubing is made
to lightly contact the cast and is luted into place with a
small amount of sticky wax (Fig. 7). It is then carefully
releasedfrom the surveyor. Additional identically pre-
479
 BURNS, CRABTREE, AND BELL

See opposite page for legends.

480 OCTOBER 1988 VOLUME 60 NUMBER 4

TEMPLATE FOR POSITIONING AND ANGULATION

pared pieces of tubing are luted into position in the same
fashion, as determined by the number of submerged
implants planned in the treatment. One length of tubing
is placed for each anticipated location (Fig. 8).
After all of the round tubing is positioned on the
edentulousridge, the acrylic resin portion of the surgical
template is outlined on the cast, incorporating the tubes
and covering all denture-bearing surfaces, similar to a
record base(Fig. 9). This template is built up with three
thicknessesof baseplate wax (Fig. 10). The cast is
carefully invested and the template is processedin the
conventional manner with clear heat-processedacrylic
resin. The surgical template is carefully recovered from
the cast after processingto avoid damageor alteration to
the tubes. Acrylic resin flash around the tubesis removed
with an acrylic resin bur and the temporary plug within
the tube lumen is pushed out with an anesthetic needle.
The acrylic resin surgical template is smoothed and
polished, ultrasonically cleaned, and sterilized
cold sterilization (Fig. 11).
CLINICAL PROCEDURE
Before surgery, the potential implant placementsite is
again studied if the desired implant location
questionablefrom a surgical point of view. Each length
of tubing on the template is measured with a Boley
gauge and shortened to an accurate 5 mm length. The
template is fitted to the tissue by using a pressure-
indicating pasteon the tissuesurface sideof the template
and adjustments are made as required with an acrylic
resin finishing bur. The template is then positioned
firmly over the tissues.The patient may need to hold the
template in position by closing the mouth against cotton
rolls positioned between the template and the opposing
residual ridge or dentition. While the template is in
position, a radiograph is madeof the region showing the
potential implant site and tubing. This can be accom-
plished by using a panoramic, pcriapical, lateral cepha-
lometric, or occlusal view radiograph or a combination of
views. For the panoramic and other nonocclusal views,
the 5 mm length of tubing is used as a standard reference
length to dimensionally correct any measurements taken
from the radiograph in determining the availability of
bone. The surgeon and prosthodontist study these
radiographs in conjunction with the mounted diagnostic
castsand findings from the clinical evaluation to deter-
mine implant size, position, and potential complications
that may arise from the selectedsite. The tubing, as seen
in the radiograph, can help identify the location and
angulation of the implant within the underlying bone
and aid in providing a more predictable outcome for the
entire treatment. If problems are anticipated with the
surgical site, reevaluation of the implant location on the
diagnostic cast and redesign and fabrication of a new
template must be done before surgery.
When the presurgical evaluation is completed, the
portion of tubing extending out of the polished surface of
the template is removed with a separatingdisk (Fig. 12).
The remaining tubing, embeddedinto the acrylic resin,
should be approximately 3 mm in length as measured
with a Boley gauge around the template. Metal flash
by using around the tubing lumen should be removed with an
explorer and smoothedwith a rubber wheel. The entire
surgical template is then smoothed and polished and
again ultrasonically cleanedand sterilized by using cold
sterilization.
is still The surgical template is transferred to the surgeon.
After anesthesia,the template is positioned intraorally
and held firmly onto the tissue. The tubes are usedas a
guide for drilling a channel hole through the mucosaand
into the bone. The round-tube lumen diameter is select-
ed to provide a closetolerance fit around the model No.
203-102 latch-type spiral twist drill (Brassler USA, Inc.,
Savannah, Ga.) or any other bur with a 1.2 mm
diameter in the slow-speedhandpiece (Fig. 13). The
pilot bur allows fitting of instrumentation for placement
orientation of the Core-Vent implant system(Core-Vent
Corp., Encino, Calif.) and the Integral implant system
(Calcitek, Inc., San Diego, Calif.). It can also be
successfullyused in the placement orientation of other
implant systems.The hole shouldbe madeapproximate-
ly 4 mm into the bone.
On drilling, the bur is lowered into the tube, which
guidesit into the bone while the surgical template is held
in placeover the tissue(Fig. 14). The hole is then usedas
a guide for the location and angulation of the guide pins,

Fig. 1. Diagnostic casts are mounted in articulator.

Fig. 2. Prosthetic denture teeth are set in edentulous space and held in position with
small amount of utility wax.
Fig. 3. Pencil outline is drawn on cast around each of prosthetic denture teeth.
Fig. 4. Appropriate cast is placed on surveyor and analyzing rod is aligned with long
axis of prosthetic denture teeth. Teeth are then removed.
Fig. 5. Round tubing is prepared and cut in 10 mm lengths.
Fig. 6. Prepared tubing is tightened into surveyor mandrel.
Fig. 7. Tubing is aligned with center of outline on cast of prosthetic denture tooth. It is
luted to cast with sticky wax. Surveyor positions tubing at same angulation as long axis
of prosthetic denture teeth.
Fig. 8. One length of tubing is placed for each anticipated implant location.

THE JOURNAL OF PROSTHETIC DENTISTRY 481

 Bums, ~R.~~REE,AND BELL

Fig. 9. Acrylic resin portion of surgical template is outlined on cast.

Fig. 10. Acrylic resin outline is built up with three thicknesses of baseplate wax.
Fig. 11. Surgical template is processed in clear acrylic resin.
Fig. 12. Tubing length is reduced to 3 mm and enclosed within thickness of acrylic
resin.
Fig. 13. Round tube lumen diameter provides close tolerance fit around twist-drill pilot
bur used for implant orientation.
Fig. 14. When surgical template is in place intraorally it is used to guide location and
angulation of implant placement as pilot bur is lowered into tube and drilled into bone
below.

instruments, and burs supplied with the desired implant determined by hone morphology and character. When
system in preparing the hone for reception of the this occurs, the prosthodontist and surgeon should have
implant.. an understanding that the altered implant location will
Occasionally the surgeon will reflect the soft tissue he as closely parallel to the presurgical site as is
and find that the use of the template is inappropriate as possible.

482 OCTOBER1988 VOLUME60 NUMBER4

TEMPLATE FOR POSCMONING AND ANGULATION

The template can be used to determine the location of REFERENCES

the implants when the time comes to uncover and expose 1. Burns DR, Crabtree DG, Bell DH. Transfer impression for
them for restorative purposes. The template is again accurate adjustment of a metal coping insert for the submerged
positioned intraorally, similar to the position at the time implant. J PROSTHET DENT 1987;57:484-7.
2. Lekholm V. Clinical procedures for treatment with osseointe-
of surgery. After anesthesia, a bur or needle is placed
grated dental implants. J PR~SIXET DENT 1983;50:116-20.
through the tubes and into the soft tissue. This mark is 3. Laney WR. Selecting edentulous patients for tissue-integrated
then used as a guide for uncovering the implant located prostheses. Int J Oral Maxillofac Implants 1986;1:129-38.
beneath the soft tissue in the underlying bone.
Reprint requests to:
DR. DAVID R. BURNS
SUMMARY
VIRGINL4COMMONWWLTHUNM3RSITY
Presurgical planning for submerged implant location SCHOOL OF DENTISTRY
and angulation within bone relative to the opposing P.O. Box 566
RICHMOND, VA 23298
occlusion is important for the prosthodontist. This
information is accurately communicated to the surgeon
by using a surgical template. A technique for fabrication
of the template is described.

Inverted anatomic tracing: A guide to establishing

orbital tissue contours for the oculofacial prosthesis
Norman S. Nusinov, M.A.,” John W. McCartney, D.D.S.,** and
Donald L. Mitchell, D.D.S., M.S.***
Walter Reed Army Medical Center, Washington, D.C., and Naval Dental School, Naval Dental Clinic, Naval
Medical Command National Capital Region; Bethesda, Md.

A stonecast duplicate of facial contours is usedin the

fabrication of an oculofacial prosthesis. The cast is
obtained from a facial moulage in which the remaining
eye is closed and often distorted by the weight of the
impression. In addition, the patient must be present
when the ocular prosthesisis tentatively located.‘4 When
orbital anatomy is sculpted, another appointment is
needed to verify the contours of the lids, brow, and
adjacent tissueswhen the eye is open and oriented in its
“conversational gaze.”
This article describesthe technique for making an
inverted anatomic tracing that enablesthe maxillofacial
prosthetic technician to closely approximate individual-
ized contours of the orbital tissues in the laboratory
without requiring the presenceof the patient.

The opinions or assertions contained herein are those of the authors

and are not to be construed as official or as reflecting the views of the
Department of the Navy or the Department of the Army.
*Maxillofacial Prosthetist, Hospital Dental Clinic, Walter Reed Army
Medical Center.
**Lieutenant Colonel, U.S. Army, DC; Resident, Maxillofacial Pros-
thetics Division, Prosthodontia Department, Naval Dental
School.
***Captain U.S. Navy, DC; Chief, Maxillofacial Prosthetics Divi- Fig. 1. Orientation lines are placed with indelil ble
sion, Pdthodonticv Department, Naval Dental School. marker with aid of rigid ruler.

THE JOURNAL OF PROSTI-IEl-IC DENTISTRY 183