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A Simple Way to Plan Implant te ot

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ss e n c e
fo r

Positioning: The S-Technique

Sergio Piano, DDS

EAED Afliate
Private Practice, Genoa, Italy

Correspondence to: Dr Sergio Piano

Viale Brigata Bisagno 4, 16129 Genoa, Italy

tel: +39-010-592578; e-mail: serg.piano@tiscali.it

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Abstract
This study presents a technique for im-
proving implant placements. As is wide-
ly known, a correct positioning is essen-
tial in restoration-driven implants, as well
as in tilted implants in order to obtain
satisfactory nal functional and esthetic
results.
To this end, some authors have em-
phasized the importance of using a di-
agnostic and/or surgical guide to plan
the exact implant position.
In practice, one of the clinical prob-
lems faced is how to check the accur-
n
acy of the template prior to initiating
ss e n c e
fo r
surgical phase. A simple method called
the S-Technique is proposed in order
to evaluate and to change, if necessary,
the projected position of the implants
by way of metal rods as radiopaque
markers. This device is easy to produce
and is cost-saving to the clinician and,
therefore, to the patient. Furthermore, in
specic patients, this method could al-
so decrease the need for computerized
tomography scans and/or radiographs,
thus reducing health risks for the patient.
(Eur J Esthet Dent 2011;6:328341)

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Introduction
Implantology has made great advances
in the last few years, both in regard to
esthetics and reliability. An essential
prerequisite of effective therapy is the
establishment of an accurate diagnosis
and precise planning.1,2 Nevertheless,
it is equally important to apply all the in-
formation collected during the project
phase to the actual treatment in the pa-
tients mouth.
To this end, a diagnostic wax-up is
usually used to make a diagnostic or
surgical template to plan or to check the
exact implant position in line with the ini-
tial treatment plan.3,4
With the correct implant position, sev-
eral goals can be reached. That is, to
simplify the treatment, reduce the trauma
and guarantee the patients comfort
whilst obtaining satisfactory nal func-
tional and esthetic results.5
On a more specic level, a precise
positioning is often required to either ob-
tain a correct nal rehabilitation by way
of an axial position of the implants (resto-
ration-driven implants)6 or to avoid ana-
tomical structures such as the maxillary
sinus, the alveolar nerve, or adjacent
teeth by way of a non-axial positioning
of the implants (tilted implants).7
Both of these above concepts are
well supported in dental literature. As
suggested by recent research, bone
re-absorption seems to have the same
incidence rate around straight or tilted
implants8 and prosthetic complications
do not appear to be increased by the an-
gling of the implant.9 Thus, the clinicians
choice of implant positioning should be
based on the specic situation of the
patient. A well-executed surgical guide
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can successfully improve the way
ss e n c efo r
serting both axial and tilted implants.
A predictable procedure to obtain a
reliable template is to perform a compu-
terized tomography (CT) scan exam with
a diagnostic stent in place. This method
allows the clinician to obtain precise 3-D
information on the correct positioning
of the implants. This approach is also
frequently used in certain patients, but
it must be considered that the level of
x-ray radiation is never negligible and,
therefore, could result in increased
health risks to the patient.
As a consequence, when anatomical
conditions are favorable (i.e. well-repre-
sented horizontal ridge width or regular
arch shape), it could be benecial to
make a surgical stent without submitting
the patient to a high level of radiation.
From a practical point of view, in these
above-mentioned methods, often the
problem is how to verify the accuracy of
the template prior to starting the surgi-
cal intervention,10 when a CT scan is not
performed. For this task, the following
simple method called the S-Technique
can be used in order to evaluate and to
change, if necessary, the projected pos-
ition of the implants in order to obtain a
simplied surgical phase and high qual-
ity results.
Technique
Reproducing the diagnostic wax-up, an
acrylic resin template, with the shape of
the teeth to be replaced, is created. The
purpose is to produce a binding guide
only on the mesiodistal inclination (in
line with conventional two-dimensional
radiographs), allowing the clinician to
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use his expertise to vary the axis in the
ss e n c e
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buccolingual or buccopalatal direction
(not seen in intraoral radiographs). To
this aim, the half-buccal part of the resin
teeth is removed (Fig 1). It is then possi-
ble to evaluate the mesiodistal direction
of the implant preparation by applying
metal rods (Fig 2) as radiopaque mark-
ers, with pieces of soft wax in a groove
chosen by the dental technician if the
implant axis is quite clear, or directly on
the buccal surface of the half-resin tooth Fig 1 The stent is produced by cutting the half-
if the implant direction is difcult to esti- buccal part of resin tooth; a groove is created only

mate (Fig 3). With the simple guidance where the implant axis is reasonably clear.

of an intraoral radiograph, this template

permits us to verify the exactness of the
mesiodistal direction of the preparation
(Fig 4) and allows for an easy evaluation
of the accuracy of the guide in relation
to adjacent structures. If the proposed
axis is not satisfactory, the metal rods
can be simply rotated and xed again,
repeating the intraoral radiograph until
the correct position is obtained (Fig 5).
The fact that these metal rods can be ro-
tated around their axes in an S shape
has given the technique its name. Fig 2 Metal rods used for checking the accuracy
The concluding step is the renement of template as radiopaque markers.
of the guide by the dental lab based on
the clinicians nal instructions (Fig 6).
Using this method, a correct position-
ing can be obtained (Figs 7 and 8) with-
out any contact whatsoever between the
implants and anatomical structures or
adjacent teeth. The stent exactly deter-
mines the position of the implant shoulder
and suggests a guided, but not strictly
limiting, execution of the rst cutting dur-
ing the surgical phase,11,12 as well as
allowing the clinician to possibly modify
the buccolingual or buccopalatal axis.13
Fig 3 By means of pieces of soft wax, the metal
The same approach can be taken rods are xed on the stent, indicating the chosen
into account when, in a fully edentulous orientation.

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Fig 4 Radiograph with the surgical guide in pos- Fig 5 With the rotation of the markers, the correct
ition: the metal rods show that the implant axes are direction on the resulting radiograph is obtained.
not ideal.

Fig 6 The nal axis position is marked by the den- Fig 7 The implants are positioned following the
tal technician on the template. indication of the guide.

Fig 8 The post-surgical radiograph (executed Fig 9 A U-shaped guide can be used for fully-
with the template in position, provided with the metal edentulous patients. Also in this patient, the applica-
rods) conrm the exactness of the guide and the tion of metal rods allows the determining of the right
consequent precision of implant positioning. axis of the implants related to anatomical obstacles.

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patient, the implants must be placed
closely to the maxillary sinuses in a
distally-tilted position. In this situation,
a U-shaped resin mold (Fig 9) is used
as a surgical guide; on the buccal side,
the metal rod is placed in the same way
as in the previous situation and a re-
sulting radiograph is used to check the
exactness of the implant axis in relation
to the maxillary sinus. If the orientation
is not correct, it is possible to move or
rotate the pin until the right position is
found. At this point, with the information
gathered, the technician is able to trans-
form the resin mold into the nal surgical
template.
Clinical applications
considering two patient
studies
The rst patient study is that of a female
subject who had compromised posterior
teeth in the left side of the maxilla (Figs 10
and 11) requiring implant replacements
n
in an area where the presence of
ss e n c e
fo r
maxillary sinus is an anatomical obs-
tacle. In order to avoid a complex surgi-
cal approach involving sinus elevation,
a tilted implant was placed immediately
mesial to the anterior wall of the sinus.
To determine the correct position of the
implants, a stent was made and, using
a metal rod as shown above (Fig 12),
the axis of the distal implant was veri-
ed by means of a radiograph (Fig 13).
With this technique, it is easy to modify
an incorrect direction simply by rotating
the metal rod until the exact position is
obtained (Fig 14).
The resulting data allows the clinician
to dene the appropriate implant axis
on the guide. In line with this device,
the surgical phase is thus performed
(Fig 15) and the implants placed in the
correct position.
The use of an angulated abutment on
the distal implant leads to the re-align-
ment of the prosthetic axis, and contrib-
utes to obtaining a nal satisfactory re-
sult (Figs 16 to 19).

Figs 10 and 11 First patient study: initial situation with radiograph showing the presence of the maxillary
sinus as an anatomical obstacle to the positioning of the distal implant.

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Fig 12 The guide with the applied metal rod as Fig 13 First attempt to nd the correct position-
seen on the model. ing: the projected rod required further angling in
order to avoid the maxillary sinus.

Fig 14 Second attempt resulting in correctly an- Fig 15 Extraction of compromised tooth and in-
gled rod position. sertion of the two implants in line with the selected
axis position.

Figs 16 and 17 Correctly angled abutments provide the right prosthetic position for the nal xed partial
denture.

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Figs 18 and 19 Final clinical and radiographical result.

A similar approach is considered in

the second patient study. In the maxilla
of a male patient (Fig 20) the remain-
ing roots were to be extracted and the
edentulous maxilla treated with xed
rehabilitation. For the nal prosthesis, a
Toronto xed partial denture supported
by a reduced number of implants was
chosen; and, once again, it was neces-
sary to correctly tilt the implants so as
not to have contact with the sinuses, and
to avoid the use of cantilevers. Fig 20 Second patient study: initial situation of
patients mouth, which is severely compromised.

Figs 21 and 22 A U-shaped guide is produced, and a position on which to attach the rod is selected.

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Fig 23 First attempt to determine the correct pos- Fig 24 The pin is rotated: with the second radio-
ition: it is necessary to rotate the pin. graph, the appropriate angle is chosen in order to
avoid the maxillary sinus.

Fig 25 The same procedure is performed on the Fig 26 Based on this information, the nal guide
opposite side until the right axis is obtained. is produced and the technician is able to dene the
groove for guiding implant placement.

A U-shaped resin base was produced
by the lab (Fig 21) and put in the patients
mouth after having positioned the metal
rods for the purpose of determining the
correct direction of cutting (Fig 22). As
seen above, the procedure was per-
formed by checking the ideal position
by means of taking a radiograph. In this
particular patient, the metal rod was
rotated and the correct axis checked
again (Figs 23 and 24). This same ap-
proach was carried out on the other side
(Fig 25) and the resulting data transmit-
ted to the Lab in order to rene the surgi-
cal guide (Fig 26).
Through the us of this guide, the im-
plants were placed correctly (Figs 27 to
29) and could be immediately loaded
with a provisional screwed prosthe-
sis (Figs 30 and 31). The radiographic
images (Fig 32) show that the implants
were precisely tilted in order to avoid
any contact with the maxillary sinuses.

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Discussion ss e n c e
fo r
Precise planning is important for the
desired and correct positioning of im-
plants.14 However, there are many clin-
ical situations where more than the usual
careful planning is required in order to
obtain satisfactory results, and it is in
these situations where the guide be-
comes crucial. For example, Belser et
al15 reported that, for the correct treat-
ment of esthetic situations, a carefully Figs 27 to 29 In line with the guide, the implants
executed surgical guide is mandatory. are placed in the right position.

Likewise, Leblebicioglu et al16 state that,

when a considerable number of implants
are to be inserted, the implant surgeon
should use a template, accurately work-
ing out each precise step involved. Fur-
thermore, Sclar17 and Oh et al18 rec-
ommend a well-tailored surgical guide,
fabricated with the aid of a radiographic
stent, as a key element in the success of
the apless implant surgery technique.
Morand and Irinakis19 also underline the
importance of a well-projected template
for the correct insertion of the implants,
providing a rationale for the use of short Fig 28

implants. Finally, when tilted implants

have to be positioned, Fortin et al20 pro-
pose the fabrication of a surgical tem-
plate to transfer the planned positions
to the bone with high accuracy in order
to avoid any contact with structures that
must remain untouched.
Moreover, the importance of the sur-
gical guide comes into play again in
certain scenarios where, due to the
complexity of the local anatomy, surgi-
cal procedures are rendered even more
demanding. As described by van den
Bergh et al,21 sinus oor elevation is fre-
Fig 29
quently performed to solve the problem
of inadequate bone height in the lateral

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Figs 30 and 31 Immediate loading prosthesis after a few weeks of healing: easy access for oral hygiene
is highlighted.

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Fig 32 The nal radiographs conrming the accuracy of the positioning.
part of the maxilla, and, as critically ana-
lyzed by Chiapasco et al,22 several aug-
mentation procedures for the rehabilita-
tion of decient edentulous ridges with
implants are often utilized.
These techniques are not always well
accepted by the patients due to the re-
sulting discomfort that is often experi-
enced. In addition, surgical complica-
tions following implant placements, such
as neuro-sensory disturbances, injuries
to adjacent teeth, penetration into the
maxillary sinus, or tissue emphysema,
can arise, especially with an increase in
the complexity of the surgery.23
For these reasons, when the anatom-
ical obstacles render the implant pos-
itioning difcult or complicated, one of
the treatment options could be to sim-
plify the surgical approach with a stra-
tegic positioning of the implants in the
remaining bone regions by means of an
extremely accurate surgical template.
In an attempt to alleviate these implant
positioning difculties, numerous types
of radiological, surgical, and combined
templates have been proposed. The
most accurate of these methods is the
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use of an image-based surgical guide
and a 3-D computer-assisted planning
of oral implant surgery.24 However,
since this kind of approach implies a
high radiation dose, the added clinical
value provided by the images need to
outweigh the negative resulting health
risks. In fact, sometimes wrongly, even
less demanding cases are planned with
a CT-guided stent without considering
the importance of the increased radi-
ation exposure. Therefore, the choice of
planning technique should be carefully
evaluated in order to take into account
the pros and cons of each method.24
Concerning this, it is interesting to
underline the conclusion of the recent
systematic review by Jung et al25 on
computer technology applications in
surgical implant dentistry: There is not
yet evidence to suggest that computer-
assisted surgery is superior to conven-
tional procedures in terms of safety,
outcomes, morbidity, or efciency.
Moreover, in a review by BouSerhal et
al,26 regarding the image technique se-
lection for the preoperative planning, it
was stated that many clinical situations
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demand the use of cross-sectional im-
aging techniques, but they are not re-
quired in patients in which the clinical
examination reveals sufcient bone
width and where radiographic exami-
nations show adequate bone height.
Also guidelines introduced by EAO27
to avoid any over-use of radiographic
methods focused on the importance of
cross-sectional imaging while the use of
2-D imaging in minor and/or established
low-risk surgery should be left to the dis-
cretion of the clinician.
In these situations, one of the most
important aspects is to check the ac-
curacy of the stent produced by the
dental lab. Garber28 described the cor-
rect planning for implant placement as
a sequence of evaluations that, in the
last step, nishes with the insertion of
the implant in a predetermined pos-
ition using an appropriate template. It
is obvious that the last step determines
the success of all prior planning steps.
Controlling the accuracy of the device
(ie, with radiographs) becomes the nal
and fundamental phase for achieving
the correct implant positioning.
In fact, a guide can only be appreci-
ated as a valuable tool if it is customized
to the specic anatomy of the patients
mouth and not only to the ideal position
of the teeth.29 A surgical guide that is
not well planned or tested may repre-
sent more of a limitation than an aid to
the implant treatment. When a guide is
chosen, the possibility to check the ac-
curacy of the template prior to surgery
plays an important role in avoiding un-
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foreseen complications or unsuccessful
ss e n c e
fo r
results. Nevertheless, reducing the ra-
diation dose to the patient is an import-
ant aspect to take into account when a
preoperative planning approach is se-
lected.
Conclusions
Concerning esthetic implant dentistry,
in the single-gap treatment as well as in
full-arch cases with multiple implants,
the precise positioning and angling of
implants is fundamental to achieving
the desired prosthetic result. Among
the different types of guide utilized for
this purpose, it is important to choose
a template that is easy to use and pro-
duce and one that allows the evaluation
of its accuracy prior to surgical interven-
tion. A simple, but accurate methodol-
ogy, such as the S-Technique, is key
to achieving these goals, as outlined
above.
It should also be noted that this ap-
proach is also cost-saving to the clin-
ician (and therefore to the patient) by
reducing the amount of the technicians
work involved and the clinicians chair-
time. Moreover, this method could de-
crease the necessity of CT scans and/or
radiographs while reducing health risks
for the patient.30
The S-Technique has been used for
several years in surgery with more than
satisfactory results, enhancing planning
procedures and simplifying surgical
phases.

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