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The use of barium sulfate for implant templates
Christoph H. J. Basten,a DMD, Dr Med Dent, MSD,= and John C.
Kois, DMD, MSDh Diisseldorf, Germany, and Tacoma, Wash.
Fig. 1. Partially edentulous maxillae with ridge defect.
A controlled step-by-step approach for the use of templates for
placement of dental implants is discussed. The provisional
restoration, the blueprint for the final restoration, is duplicated
in a radiopaque radiographic template. This illustrates the outline
of the planned restoration in relation to the hard tissues. (J
Prosthet Dent 1996;76:451-4.)
P lacement of dental implants requires meticu- lous planning and
careful surgical procedures because the position of the implant
cannot be easily changed af- ter implant osseointegration. Some
templates use radiopaque markers to relate the planned implant
posi- tion to the bone structures of the patient.Q Templates must
be dimensionally accurate, rigid, and stable.3-5 Metal bearings are
often used because they are not sen- sitive to distortion by the
radiographic imaging proce- dure. However, they do not relate the
contour of the fi- nal restoration to the patients hard tissue.
This article describes a procedure that uses radiopaque
material, barium sulfate (Hypaque-sodium, Winthorp Pharmaceuticals,
New York, N. Y.), for fabrication of a radiographic template during
the diagnostic phase. The radiographic template, which is a copy of
the provisional restoration, is used as a blueprint of the planned
resto- ration. The full-contour radiopaque template enables the
clinician to visualize the outline of the planned restora- tion in
relation to the bone structures. Treatment plan- ning can be
facilitated at this phase to allow any neces- sary procedures, such
as ridge augmentation, to be com- pleted before implant placement.
The procedure for making such a radiopaque template is described in
this article.
Developing of a provisional restoration according to the
functional and esthetic needs of the patient is illus- trated in
Figure 1. The patient traumatically lost some maxillary teeth, and
the trauma created a ridge defect. The interim removable partial
denture (Fig. 2) serves as a provisional restoration, allowing the
patient the op- portunity to evaluate the prosthesis esthetically
and functionally.
PROCEDURE
Fig. 2. Interim partial denture (provisional restoration).
with (Fig. 4) the provisional restoration in place. (Casts may
be poured in type III or type IV dental stone.)
1. Plan and adjust the outline of the prosthesis as needed.
2. When both patient and dentist are satisfied, make the
impressions and casts both without (Fig. 3) and
Private practice, Diisseldorf, Germany. bPrivate practice,
Tacoma, Wash.
3. Make an Omnivac shell (Buffalo Dental Mfg. Co., Syoset, N.
Y.) over the cast with the provisional res- toration (made in step
2) in place.
4. Paint a suitable tinfoil substitute on the pretreat- ment
cast, seal onto the pretreatment cast made in step 2, and use
sticky wax to seal the Omnivac shell onto the pretreatment
cast.
5. Make a mix of radiopaque resin by mixing one part barium
sulfate with two parts acrylic resin powder
OCTOBER 1996 THE JOURNAL OF PROSTHETIC DENTISTRY 451
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THE JOURNAL OF PROSTHETIC DENTISTRY BASTEN AND KOIS
Fig. 3. Cast of clinical situation without provisional res- Fig.
6. Boxing of cast with duplicated radiopaque teeth toration in
place. in place ready for application of orthodontic resin.
Fig. 4. Cast of clinical situation with provisional resto-
ration in place.
Fig. 7. Occlusal view of radiopaque template.
Fig. 5. Omnivac shell of provisional restoration on cast
radiopaque.
(Jet Acrylic, Lang Dental Mfg. Co., Wheeling, 111.). Mix the
powder thoroughly; then add the acrylic resin monomer to make the
mixture fluid. (Barium sulfate is a nontoxic, white, tasteless,
odorless pow- der used in intestinal radiography.)
6.
7.
8.
9.
10.
11.
Make a small opening in the shell and fill the shell with the
mix of fluid radiopaqued resin. Inject the resin with a 12 cc
Monoject disposable syringe (Monoject Division, Sherwood Medical,
St. Louis, MO.) (Fig. 5). (When the resin polymerizes, it pro-
vides a radiopaque duplicate of the provisional res- toration.)
Separate the radiopaque provisional restoration from the shell and
the cast. Cut and trim the opaqued provisional restoration to
preserve only the block of teeth. Separate the resin teeth, trim
them to open the gin- gival embrasures, and do whatever contouring
is nec- essary to make them look like individual teeth. Position
the teeth on the pretreatment cast (made in step 2), and use a
small amount of sticky wax to hold them in place. (Because the
ridge laps of the opaqued resin teeth were made in direct contact
with the cast, except for a thin coating of separation me- dium, it
is easy to replace them accurately on the cast [Figs. 6 through
81.) Box the opaqued resin teeth positioned on the cast with
beading wax and include several of the stone teeth both anterior
and posterior to the edentulous portion of the ridge (Fig. 6).
452 VOLUME 76 NUMBER 4
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BASTEN AND KOIS THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 10. CT scan detail of panoramic overview. Fig. 8.
Radiopaque template in place before CT scan (in- terim removable
partial denture duplicated).
Fig. 9. CT scan of horizontal overview of maxilla.
12. Paint tinfoil substitute separating medium on the adjacent
stone teeth and cast that will be contacted with the Orthodontic
resin (Caulk-Dentsply, Milford, Del.), which will be applied
next.
13. Apply Orthodontic resin by the salt and pepper method to
create an acrylic resin overlay over the adjacent teeth and to hold
the opaqued resin teeth in position (Fig. 7).
14. After the resin polymerizes, remove the assembly from the
cast; then finish and polish it.
15. Fit the restoration to the patients mouth (Fig. 8) and have
a computerized tomography (CT) scan (Syberview 1200 SX scanner,
Picker Int., Cleveland Ohio) (DentalPlus software, Dimensional
Medicine, Minnetonka, Minn.) made of the patients mouth witb the
template and the radiopaqued teeth in place to show the
relationship of the anatomic topogra- phy to the planned
restoration (Figs. 9 through 11).
DISCUSSION
The number of the CT scan slices allows easy orienta- tion (Fig.
10) because the numbering is the same throngh- out the entire scan.
Because the hard and soft tissue is shown in relation to the
planned restoration, the need
Fig. 11. CT scan detail of vertical slice picture.
for augmentation can be clearly diagnosed before sur- gery. The
CT scan is a useful guide for the surgeon, be- cause it provides a
picture in a 1:l format. It helps plan- ning and performing
augmentation and implantation procedures.
According to individual preferences, the radiographic template
can be modified into any type of surgical tem- plate according to
the individual preferences of the sur- geon.
CLINICAL SIGiNIFICANCE
Implant dentistry is a complex treatment modality and involves
many specialists. Communication between spe- cialists and patients
and careful treatment planning are imperative. The use of
radiopaque radiographic tem- plates that demonstrate the outline of
the planned res- toration in relation to the anatomic situation
enables the clinician to plan and communicate the patients treat-
ment needs to everyone involved in the process. Using
OCTOBER 1996
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THE JOURNAL OF PROSTHETIC DENTISTRY BASTEN AND KOIS
the same template, which is a duplicate of the provisional
restoration, throughout the whole process of the diagno- sis
reduces transfer errors during the augmentation and implant
placement procedures to a minimum and allows a predictable
step-by-step approach to implant dentistry.
REFERENCES
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planning of the surgical phase of treatment of edentulism by
osseointegrated imulants: an in vitro study. J Prosthet Dent
1991:65:541-6.
5. Davarpanah M, Tecuianu JF, Ragot P, Jansen C, Moon J. An
x-ray computed tomography study with radiographic splints in
implant evaluation. Rev Stomatol Chir Maxillofac
1990;91(Suppl1):102-4.
Reprint requests to: DR. CHRISTOPH H. J. BASTEN LUEGPLATZ 3 D -
40545 D~JSSELDORF GERMANY 1. Burns DR, Crabtree DG, Bell DH.
Template for positioning and
angulation of intraosseous implants. J Prosthet Dent
1988;60:479- 83.
2. Cranin AN. Fabrication of an implant stent for the edentulous
man- dible. J Prosthet Dent 1993;69:352.
3. Engelman MJ, Sorensen JA, Moy P. Optimum placement of
osseointegrated implants. J Prosthet Dent 1988;59:467-73.
Copyright 0 1996 by The Editorial Council of The Journal of
Prosthetic Dentistry.
0022-3913/96/$5.00 + 0. 10/l/75580
Plaque-induced peri-implantitis i the presence or absence of
keratinized mucosa: an experiment study in monkeys. Warrer K, Buser
D, Lang P, Karring T. Clin Oral Imp1 Res 1995;6:131-8. Purpose.
Controversy exists about the need for keratinized mucosa adjacent
to teeth to maintain gingival health. Experimental studies have
failed to demonstrate an association between the width of
keratinized tissue and the progression of gingival lesions. Plaque
control appears to be more critical to gingival stability. The
importance of a band of dense connective tissue surrounding the
soft tissue penetration of an endosseous implant has been
described. This study examines the relationship of bacterial plaque
accumulation and attachment loss in areas with and without
keratinizing mucosa surrounding implants in a monkey model.
Material and Methods. Five adult male monkeys were treated in this
study by removal of the second premolar and the first and second
molar teeth. All keratinized tissue was excised for one side of the
jaw and retained for the contralateral side. A 3-month healing
period preceded the placement of three IT1 implants in each
edentulous space. Attempts were made to place half the implants in
contact with retained root tips to allow periodontal ligament
formation around the implants. All eight implants that were placed
in contact with the roots were excluded from study analysis.
Consequently, this study followed up 22 osseointegrated implants.
Plaque control was eliminated for eight implants surrounded by
keratinizing mucosa and eight implants surrounded by nonkeratinized
mucosa. Wool ligatures were placed passively at the entrance of the
periimplant sulcus and held in place by an oversized cover screw to
induce plaque formation for implants in keratinized and
nonkeratinized tissue. Results. Percent of bone to implant contact
demonstrates no statistical correlation with induced plaque
accumulation for either of the implant groups. Ligated implants
without keratinizing mucosa demonstrated increased mucosal
recession in comparison with nonligated implants with or without
keratinzed mucosa or ligated implants with keratinized mueosa.
Ligated sites with either mucosal characteristic demonstrated the
largest loss of attachment. Conclusions. Because of the inductive
capacity of the periodontal ligament, natural teeth universally
possess a minimum width of keratinizing mucosa. This condition is
in contrast to the situation where keratinizing tissue may be
completely absent around dental implants. Without keratinized
tissue, implants in this study demonstrated an increase
susceptibility to bacterial plaque-induced tissue breakdown, loss
of attachment, decrease in probing depth, and mucosal recession. It
is hypothesized that the lack of keratinized mucosa leads to an
increased susceptibility to plaque-induced tissue breakdown. 26
References-SE Eckert
454 VOLUME 76 NUMBER 4