JOMI on CD-ROM, 1986 Jan (47-49 ): Use of Splint Material in the Placement of Implants Ri

Copyrights 1997 Quintess

Use of Splint Material in the Placement of Implants

Richard Blustein, D.D.S., M.S./Richard Jackson, D.D.S./Kenneth Rotskoff, D.D.S., M.D./ Richard E. Coy, D.M.D., M.S./Dennis Godar, D.M.D.

With the use of a clear splint fabricated from a diagnostic wax-up, implant placement becomes predictable. With this technique the end result of the implant prosthesis is not left to chance, but is preoperatively planned. A key ingredient for successful restorative dentistry is using implants in proper position. Improper tooth or implant position that results in poor form and contour, tilted teeth, occlusal interferences, and closed embrasures is a problem in restorative dentistry. 1 If the restorative dentist places an implant in an improper position, the subsequent restoration will be incorrect even if parallelism of the abutments and imbutments are correct.2 The restorative dentist, utilizing implants, can improve the final esthetic results of fixed prostheses by using a modification of Preston's clear splint in the diagnosis of tooth contours, tooth position, and clearance. This method has withstood the test of clinical usage and is used extensively in fixed prosthodontics. 3 The purpose of this article is to present Preston's clear acrylic resin splint concept in order to give guidance for implant placement.

Methods
The initial step in patient management is the collection of detailed medical and dental histories, periodontal charting, and diagnostic casts. On the diagnostic cast in the selected edentulous area, a diagnostic wax-up is completed to determine tooth size, position, and occlusion. After the diagnostic wax-up, a full arch alginate impression is made and poured. On the resultant diagnostic cast, an Omnivac shell is pressed and then trimmed with a scissors to fit over the gingival line of the buccal and lingual alveolar plate (Fig. 1). This splint can now be used to determine the parameters within which the oral surgeon will have to work. In addition, a panoramic radiograph is taken preoperatively to determine the proper length of an imbutment within the chosen placement sites. The implant can be drawn on the radiograph to relate to the maxillary sinus or inferior alveolar nerve to implant (Figs. 2a and 2b).

Surgical technique
Prior to surgery, Preston's clear acrylic resin splint is prepared for the patient by placing it in a cold sterilizing solution. The initial incision should be made over the crest of the ridge and the sulcular areas should be avoided, if possible. Releasing incisions should allow for adequate reflection of flaps buccally and lingually to expose the edentulous ridge. If the ridge is thin and spiked, it must be flattened to allow for a broad base of alveolar bone, thereby providing a satisfactory reception site.4 When these preliminary diagnostic measures are accomplished, the surgeon may proceed with the insertion of the splint form. When the splint form is inserted, a marking pencil is used on the center of the tooth where the implant is to be placed. With the splint form still in place, a twist bur is used to drill

JOMI on CD-ROM, 1986 Jan (47-49 ): Use of Splint Material in the Placement of Implants Ri

Copyrights 1997 Quintess

through the splint along the axis of the tooth. In this manner, parallelism, proper position placement, and angulation needed for the implant can be achieved. Once the guide pin hole is made through the splint, the guide pin inserted, and the splint over the guide pin replaced, the surgeon can observe the parallelism and path of insertion and position. The guide pin should fit the exact center of the selected tooth. Without the splint, the implant will often be positioned lingually and may interfere with the opposing occlusion. 5 With the splint and guide pin in place, the surgeon can easily observe lingual clearance and move the implant buccally when needed. The proper position assures that the coronal restoration will be uniformly shaped, and that cleansable embrasure form can be established (Fig. 3). Recovery of the submerged implant may be a problem. If a surgeon has trouble locating a submerged implant, it may be necessary to increase exposure and use radiographs to assist with recovery. By utilizing the same preoperative splint to pinpoint the location, it can easily be recovered regardless of the amount of bone and soft tissue that has covered the implant (Fig. 4).

Discussion
To achieve a desirable result, it is necessary for the restorative dentist to know the objective. Though present at the surgeon's office during placement of the implant, the restorative dentist can only estimate a placement position. A diagnostic wax-up and splint fabrication will eliminate most of the guess work involved. Delineating parameters of implant size, type, place, position, parallelism, angulation, and occlusion, the splint also demonstrates the anticipated tooth form, tooth size, and tooth position for the surgeon. With the guide pin in the implant and the splint material over the implant, it is quite obvious that the finished restoration will be acceptable. When accompanying the patient and used as a preoperative management tool, the splint obviates the need for the restorative dentist to be a direct participant in the surgery.

Conclusion
The assurance of success in properly placing the implant support for fixed restorations can be determined preoperatively. The surgical placement of an implant may be technically easy to accomplish. However, to eliminate fabrication problems, the restorative dentist must know the answers to questions involving placement, size, type, angulation, position, occlusion, parallelism, and esthetics. The use of a clear splint fabricated from a diagnostic wax-up can provide such information. With this technique the end result is not left to chance, but is preoperatively planned.

JOMI on CD-ROM, 1986 Jan (47-49 ): Use of Splint Material in the Placement of Implants Ri

Copyrights 1997 Quintess

1. Beyron, H. Occlusion: Point of significance in planning restorative procedures. J Prosthet Dent 30:641, 1973. 2. Adell, R., Rockler, R., and Brnemark, P-I. A 15 year study of osseointegrated implants in the treatment of edentulous jaw. Int J Oral Surg 6:387, 1981. 3. Preston, J.D. A systematic approach to the control of esthetic form. J Prosthet Dent 35:393-402, 1976. 4. Watt, O.M. Morphological changes in the denture-bearing area following extraction of teeth. Thesis. Seatlane: University of Edinburgh, 1961. 5. Zarb, C.A. The edentulous milieu. J Prosthet Dent 49:825, 1983.

JOMI on CD-ROM, 1986 Jan (47-49 ): Use of Splint Material in the Placement of Implants Ri

Copyrights 1997 Quintess

Figs. 1a to 1d Study cast showing edentulous area (top) and with diagnostic wax-up (top center), Preston's clear splint (bottom center). Splint shown in patient's mouth indicating where implant should be (bottom).

JOMI on CD-ROM, 1986 Jan (47-49 ): Use of Splint Material in the Placement of Implants Ri

Copyrights 1997 Quintess

Figs. 2a and 2b Template used to access vertical bone height and implant length (top). Reversed image with implants in predetermined position (bottom).

JOMI on CD-ROM, 1986 Jan (47-49 ): Use of Splint Material in the Placement of Implants Ri

Copyrights 1997 Quintess

Fig. 3 Splint form used to guide implant placement at surgery.

Fig. 4 Preoperative splint used to locate submerged implants.