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Harold, a dentist, asks:

I have begun to make surgical stents for my surgeon to guide the placement of dental implants inthe maxillary aesthetic zone. There is some controversy over where to place a dental implant for a maxillary central incisor and what inclination to use.

I am making the stent to place the long axis of the dental implant so that it passes through the cingulum. I am locating the dental implant to the lingualof where the natural tooth was located to preserve the

buccal cortical plate.

Some authorities, though, recommend orienting the implant so that it passesthrough the incisal edge of the natural tooth. What are you all doing? I’d appreciate somethoughts on the proper technique here. Thanks.Advice

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28 Responses to “ Surgical Stents for Implant Placement ”• Robert J. Miller October 23rd, 2006

The only reason you should be placing the long axis through the cingulum is for a screwretained restoration in minimal interocclusal space. We have been placing our long axisthrough the incisal edge or even slightly facial for over a decade. You will find that there

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As for the surgeon who said that GP’s shouldn’t be placing implants “leave surgery to thesurgeons.” The reason for GP’s doing implants as of late is due to the very fact that wehave left it to surgeons. I can’t tell you how many times I have to cover up for thesurgeon cowboys who misplace fixtures. Your colleagues freehand placement withoutsurgical guides and it is us “novices” who are left with the mess. Why not have better control over the case from the get go. We will be going through the same learning curveas you did only the end result will most likely be more esthetic and have greater longevity.

• Terence Lau October 25th, 2006

A well edicated surgeon is a well educated surgeon. The key word being education.Please remember, dental implantology should be prosthetically driven and planning for the long hall. Please review Tarnow’s numbers and remember that bone loss aroundimplants is 3 dimensional, not 2 dimensional!

• Anonymous October 25th, 2006

I was enjoying the posts until I read the uncalled for attack by the so called oral surgeonagain and again reminding us how ignorant & unskilled us poor general dentists are.Youmust really have a chip on your shoulder because the surgeons I know are not intimidated

by the implants I place or the impacted 3′rd molars I remove or the sinus lifts that I perform or the soft tissue grafts I place.Frankly my work is judged by my peers &colleagues that often complement my work as perhaps looking better than the cases theyget back from their surgeons.The top two graduates one being myself in dental schoolchose to be general practicioners not because we could’nt get into surgery but we lovedall aspects of dentistry.So please do not post that only surgeons should do this and that,there are believe it or not dentists out there far more skilled than you and I.As far as the

original question is concerned,you should place the implant where your diagnostic waxup dictates,and if this compromises the facial plate you may consider bone grafting.• Scott D. Ganz, DMD October 25th, 2006

The last post regarding Tarnow’s numbers… is indicative of most of the literature whichrelates the levels of bone, or implant-to-tooth, or implant-implant relationships using twodimensional radiographs. As I have stated many times, “there is a danger when we are

bound by two dimensional concepts in a three dimensional world.”

Understanding the cross-sectional 3-D anatomy using CT images will allow for an newappreciation of the true volume of bone surrounding our natural teeth. The “Triangle of

Bone” is a concept which aids clinicians in determing this available bone - and thus thecorrect placement of an implant, with the desire tooth position always remainingconstant.

You are welcome to download a recently updated article on this concept from mywebsite, which graphically describes this concept. The original concept dates back to1993.

• Terence Lau, DDS October 25th, 2006

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As I stated, a three dimensional situation. Also, anyone out there, when I wrote “surgeon”I meant anyone who performs the actual placement…general dentist ,periodontist or oralsurgeon! Some of the best “surgeons” I know are general (restorative) dentists! I, myself,am a restorative (general) dentist who has been placing implants since 1987…By the

way, Scott, I’ve always thought that was a great article!• robertthompsondds October 27th, 2006

Dr.Ganz what is your opinion on Nobel guide?from what company’s pushing is in fact the lattest trend in implant dentistry.Using the surgical guide,expandable abutments( what are the biomechanics behind of it?)they state That this is Best system in planning.Please let me know what you think?

Thank you in advance

confused practioner • Anonymous October 29th, 2006

The Nobel Guide system has been sued by Materialise, SurgiGuide&SimPlant, for patentinfringement. I can’t say which system is better, but one sure does crow as if nothingcomes out the other end. When best ever promises don’t quite produce best ever results,

Nobel Direct or their Scalloped implant as examples. Nobel followed the idea in themarket place and the lawsuit is still pending. With a large chunk of Materialise nowowned by DentSupply their will likely be no stomping on the little guy.

• dr.ejazkhawer October 31st, 2006

i personally recomend the placement should be lingually and implant margin 2mm behindthe facial edges of the adjacent teeth. This is what ITI also endorse.

• Albert Hall October 31st, 2006

The best (only) system planning came from Materialise years ago Dr.Thompson,but youseemed to be too surprise about this!

Nobel will experience some changes next year and surely the Materialise issue will causesome problems in the “leading,creative, implant company of the world”…what will dothe too many relevant doctors when they will experience that Nobel copied the software?I do want to hear that comments

• Andrej Meniga November 5th, 2006

I advise coleagues who want to compare more than a decade old SurgiGuide to the recent NobelGuide system read some literature before making a statement, to see the differenceand the precision that allow teeth in (let’s be flexible) an hour and half!

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• robertthompson DDS December 10th, 2006

so far in terms of accuracy there is no an article, only the cadaver study by vanstreerenbergh. please correct me if i’m wrong DrMendinga, if there is so please writereferences to look up, thank you

• Richard D. Cottrell, DDS May 1st, 2007

I agree with Scott Ganz. You want to favor the osseous triangle if possible. When placedimmediately the fixture should be held to the lingual side of the extraction socket but theapical end should penetrate thru the apical lingual side of the socket. This can result inthe implant pointing thru the incisal edge, but because the implant is pointed into theosseous triangle to avoid the buccal cortical plate not because the coronal aspect of thefixture is brought to the facial. Since there is little difference between delayed or immediate placement with respect to the fixture position the same holds for delayed

placement positioning. This is now being better understood, but just consider that placing

a ficture into an extraction socket doesn’t change the healing process dramatically. After a few months it’s going to look much the same either way as long as the fixture placeddelayed is done in a timely manner. However, with delayed placement 3D imaging helpsyou visualize the external bony topography and internal bone volume since the extractionsocket is no longer available for reference.

In the future the sloped top fixtures from Astra will allow you to align the lingual side of the implant with the lingual bone level. This simplifies depth of placement and allowsyou to focus on the ideal fixture positioning as placement depth becomes for the most

part automatic.• S.HarveyKarpinos DDS May 2nd, 2007

I agree with the other general dentists concerning the oral surgeon’s inappropriateremarks. I began to do my own surgery when I could not find an oral surgeon whounderstood the prosthetic requirements of implant restorations. I had too many problemsdealing with their poor placement of implants, and ultimately it was my responsibility todeaql with ther patient and the poor result. Now that I place my own implants my resultsare 100% better. The requirements of the surgical protocall are not as demanding as therequirements of proper occlusion, and esthetics. I mustr add that some of the

periodontists that are doing surgery, are very good far better then the oral surgeons as agroup.

• Dr. Bill Woods May 3rd, 2007

To the oral surgeon who posted the inappropriate remark, you comment about generaldentists placing implants is unfounded and certainly unprofessional. We as generaldentists have had to deal with restorative complications from poor placement byspecialists for years. I had one tell me personally in front of 10 other people (who by theway isnt a specialist anymore) that“general dentists were f—— up the honeyhole for all the specialists!” come-on…take thehigh road. All specialists dont place implants poorly and I have had MANY in function

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for over 20 years because they were placed well, BUT…I have had some restorativenightmares from extremely poor placements returned to me “ready to go.” Now, unless a

patient has a specific request, I control my own placement. and when there is a problem, Ilook only in the mirror. The restorative component guides the surgery, not the other wayaround. Thank god for the specialists AND general dentists who trained me throughAAID and ICOI programs. They know the true meaning of being a “colleague” and“teacher”. I just emailed Dr Craig Cooper, past president of the AAID, to thank him for one of his hands-on pearls at the recent AAID bone grafting course. He is truly the typeof colleague and teacher we need as implantologists. Maybe you could take an AAIDcourse along with your other specialist and general colleagues and THEN weigh your comments…along with your name. To the other specialists like Maurice Salama, CarlMisch, Mike Pikos, Lee Silverstein, Dennis Smiler and Don Callan (and many others)who effortlessly continue to contribute to the advancement of implantology by layingaside their own personal specialists egos …I am truly grateful. Many thanks. Bill

• Don Callan May 9th, 2007

I have been teaching how to do bone graft procedures and placement of implants for 17years, and I have seen MANY general dentist to do a better job than some OS andPeriodontist. I feel as long as anybody gets the proper training there is plenty for everyone. The more we all know, the better all of us will be for our patients.

• F Lugo, D.M.D. May 9th, 2007

For the anterior sextant we rather have a CT available to plan for the surgical needs prior to the surgery and discuss the options with the restorative dentist and patient, with Panex,many times the implant position ends up modified during the surgery. Another thing thatI try to do is to plan the surgical procedure when the restorative dentist can be present, so

that if modifacations are necessary he agrees on them.Another thing I find easy to do, to reduce the possibilities of poorly positioning theimplants, is to request the residents and students to make a Surgical Stent using theStraumann’s Drill Sleeve ( with collar and 2.3 mm diam. inside ) and the pins( Straumann’s ) which can be done in the study model using a Dremmel mounted in aDrill Press ( that comes for it )utilizing the Struamann’s drill ( Thermoplastic DrillTemplate Set). It works as long as the bone width is adequate and the pins are alingned

properly in the vertical direction. This avoids the pilot drill to move elsewhere or changethe intended direction, again as long as the Surgical Stent is correctly aligned.

• Anonymous September 18th, 2007

My wife will be having an implant done on #19. The dentist says that he doesn’t need astent since it is a molar. Is this correct? I was under the impression that a stent should beused for all areas.

• emilverban October 23rd, 2007

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a surgical guide which is restrictive is of great benefit in the anterior region. You must prevent movement or walking of the drill and a guide will do this—-the use of a drillstopfor vertical control and a guide will help in the 3-dimensional placement. I know

promotion of a product is frowned upon–but my drillstop is designed by me a dentist— for dentists to improve placement and increase safety for which we are all striving.

•

Pros Boss February 27th, 2008

I support 3 oral surgeons and a periodontist. I would recommend a surgical stent in allinstances. Yes, with the use of custom abutments you can overcome placement errors(within reason). But I find it no excuse to have placement errors when a stent is provided.Even when the implant is placed in about the right position I often see that the implant isangled in the wrong direction.

• Hank April 27th, 2009

After reading all the posts I believe a Stint and drill guide is a must for ANY implantcase. I can’t tell you how many times I have to compromise a case due to poor placementof the implant.

• Richard Hughes DDS, FAAID, FAAIP, Dipl.ABOI/ID April 28th, 2009

Hank,Yes you are correct.• Bill Schaeffer April 28th, 2009

Just for clarity, I am going to post what the correct terminology for this stuff is.

By all means consider me OCD, pedantic etc. but I see incorrect terminology being usedtoo often in implants;

In implants, a “surgical guide” or “drilling guide” is a device to help you correctly position the osteotomy when creating it.

A “stent” however is “a man-made ‘tube’ inserted into a natural passage/conduit in the body to prevent, or counteract, a disease-induced, localized flow constriction. The termmay also refer to a tube used to temporarily hold such a natural conduit open to allowaccess for surgery.” This definition is from Wikipedia but no definition that I can findtalks about a stent being used for drilling holes for implants. Unfortunately, this incorrectuse of the term appears to be popular.

There is no such thing as a “stint” in medical or dental terminology. In common language

it is “a stretch: an unbroken period of time during which you do something” i.e. nothingto do with implants or osteotomies.

So, perhaps we should stop calling these things “Stints”?

Right, I’m off to take my OCD meds now!!

Bill Schaeffe