MAXILLOFACIAL

PROSTHODONTICS
SURGICAL STENTS

SUPERVISED BY :
PROF. MOATAZ KHAMIS
PROF. AHMED ELSHIMY
Presented by MSc :
Yusra Muftah Elfaidy

OUTLINE :
Introduction.
Surgical stents :
Definition.
Types.
Objectives.
Techniques of fabrication.
Surgical guide for implant positioning :
Definition.
Objectives.
Requirements.
Advantages.
Conventional free hand design.
CAD/CAM based design.

INTRODUCTION :

MAXILLOFACIAL PROSTHETICS :
The branch of Prosthodontics
concerned with the restoration and/or
replacement of the stomatognathic
(jaws) and craniofacial (facial)
structures with prostheses that may or
may not be removed on a regular or
elective basis-GPT 8.

Maxillofacial prosthodontics treat

patients with defects of the head and
neck region due to cancer, surgery,
trauma and/or birth defects.
Our topic today is about one of the
miscellaneous intraoral prosthesis
called STENTS.

STENTS :

Are appliances constructed to cover

the tissues and/or the teeth. They
are used for protection, to keep skin
graft in place, to carry medicaments,
radium for radiation or to control
bleeding.

OBJECTIVES :

1. To control bleeding, especially in haemophilic patients.

2. To promote healing and prevent wound contamination.

3. To carry medicaments and surgical packs to required areas

in the oral cavity.

4. To hold skin & mucosal grafts in position.
5. As a vehicle carry radium materials for radiation therapy in

case of malignancy.
6. Preserve the depth of the vestibules after sulcus

deepening and ridge augmentation.

7. Protect teeth and associated structures in contact sports.

MATERIALS USED
FOR CONSTRUCTION

Acrylic resin:

Soft materials:

heat cured resin.

Self cured resin.

soft rubber.
soft resins.
silicone.

Modeling
plastic:
black gutta percha.

(In emergency cases where there is

no time to construct a stent, these
materials may be used directly in the
oral cavity on the bleeding area ).

T YPES OF STENTS :

SURGICAL STENTS :

DEFINITION :

Any ancillary prosthesis prepared for insertion

during a surgical procedure and intended for
short-term use-GPT 8.

T YPES OF SURGICAL STENTS :

SURGICAL STENT
AFTER
VESTIBULOPLASTY
Vestibuloplasty is a

surgical procedure
designed to restore
alveolar ridge height by
lowering muscles attaching
to the buccal, labial and
lingual aspects of the jaws.
Vestibuloplasty operations

can be done either with or

without skin or mucosal
graft.

A prefabricated surgical
stent is used in conjunction
with vestibuloplasty
operations to:

1- Carry and secure the graft

in the desired position.
2-Prevent reattachment of
the vestibule borders during
the healing period, till
granulation tissue is formed.

TECHNIQUE :
Impressions are made, stone casts are poured and

duplicated.
The sulcus is modified on the cast by deepening it to the

required depth.
The surgical stent is made from a clear acrylic resin to fit

the modified cast.

The stent is fitted in the operating room immediately

after surgery and wired if it is advisable.

It is kept for few weeks till complete healing.
The patient should use it till the final denture is finished.

The stent can be lined

with a soft liner at the
time of surgery to
cover and extend to
the wound site with
minimum irritation.

A MODIFIED APPROACH FOR

VESTIBULOPLASTY IN SEVERELY
RESORBED MANDIBLE USING AN
IMPLANT-RETAINED
POSTOPERATIVE STENT:

A case report :

A modified approach for vestibuloplasty in severely

resorbed mandible using an implant-retained
postoperative stent, oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2008 Oct;106(4):e7-14. doi:
10.1016/j.tripleo.2008.05.029. Epub 2008 Jul 26.

Severe resorption of the mandibular ridge, presence of

alveolar mucosa over implants, and a shallow vestibule.

Six months after surgery

In combination with
Vestibuloplasty and
mucosal graft, the use of
a postoperative stent,
decreased the pull of
mentalis muscle and
provided a periimplantally stable soft
tissue around implants.

Incision in the mucogingival line

Exposure of the implants. The lingual flap was

not elevated, except around each implant.

Cover screws removed and healing

caps installed (3.75 6 mm).
Standard abutments (3.75 7 mm)
were placed in the distal implants.

Grafts stabilized in the receptor area

with horizontal mattress sutures

Postoperative acrylic stent

Postoperative stent fixed to distal

standard abutments.

Six months after surgery

Linear measurement of vestibular depth

before the vestibuloplasty procedure.

Linear measurement of vestibular depth 6

months after the vestibuloplasty procedure.

SURGICAL STENT
AFTER RIDGE
AUGMENTATION
Ridge augmentation is a

surgical procedure
performed to increase the
size of the ridge using
autogenous bone grafts or
alloplastic grafts ( ex:
hydroxyapatite material)
Surgical stent is used over
the augmented ridge to
reestablish ridge height
and contour prior to
denture construction or
implant placement.

SURGICAL STENT
AFTER TORI
REDUCTION
This stent is a simple

acrylic plate that covers

the palate after palatal
surgery such as surgical
removal of palatal tori or
palatal mucosal grafting.
It is used to:

1- facilitate hemostasis.
2- protect the raw surface of
the palate during healing.

TECHNIQUE
Alginate impression is made

before surgery and cast is

poured.
Palatal tori are scrapped on

the cast.
Palatal plate with wrought

wire clasps is constructed to

cover the palate before the
surgery.
The plate is lined with tissue

conditioning material and

inserted just after the
surgery and left for 2 to 7
days.

ANTIHEMORRHAGIC
STENT

This stent is constructed

for patients having a
history of severe
bleeding or hemophilic
patients to be used after
extraction to control
bleeding.

REQUIREMENTS :
It should be:
1-Constructed in clear acrylic resin for easy inspection and
detection of pressure spots.
2-Done with suitable relief to accommodate the
hemostatic agent.

TECHNIQUE

Impression is made before surgery.

Casts are mounted to the articulator.
The tooth to be extracted is removed from the stone cast.

A layer of wax is adapted on the cast to cover the ridge in

the future site of extraction and extend buccally and

lingually around the adjacent teeth.
The articulator is closed to allow the opposing

teeth to touch the top of the wax.

The wax is processed in clear acrylic resin, heat cured or

cold cured.
The stent is lined with tissue conditioning material and

gently inserted immediately after extraction.

Bleeding is controlled by the gentle pressure applied by

the patient over the extraction site.

It should be kept in position for 5-7 days.

For a hemophilic patient:

The stent is designed not only to protect the socket and

the blood clot from the tongue, but also to hold a

hemostatic dressing in place to help to arrest bleeding.
In this case,
No pressure should be applied and the stent can be left

for a week or even more.

It should be lined with a soft liner.

CYST PLUGS
It is an acrylic plug which
fits the neck of the cavity
that is resulted after
marsupialization of a
cyst.
The cyst is plugged with
gauze or wet cotton wool
leaving the neck part of
the cavity free.

AIM OF CONSTRUCTION :
It is constructed to prevent closing of the

opening of the cyst before complete healing of its

cavity after marsupialization.

TECHNIQUE :
Impressions are made & a cast is produced with

asmall depression representing the cyst neck.

The plug should have a labial & buccal flange

with an acrylic projection in the cyst cavity but

not to the full depth.
Gradual reduction from the depth of the acrylic

plug until it`s almost removed entirely, as the cyst

cavity will be decreasing in size.

EFFECTIVE MANAGEMENT OF LARGE

RADICULAR CYSTS USING SURGICAL
ENUCLEATION VS.
MARSUPIALIZATION
Case report in oral surgical study

Sakkas N, Shoeen R. Obturator after marsupialization of

a recurrence of a radicular cyst of the mandible. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2007 ;
103: 16-18.

CASE REPORT
A 10 year-old male patient

complain of painless swelling

in the lower right back region
of the jaw.

Based on history, clinical and

radiographic examination, a
provisional diagnosis was
radicular cyst associated with
the lower right D&E and a
follicular cyst related to the
4.4 and 4.5 was made.

The case was posted for

surgical marsupialization of
the lesion under local
analgesia, the superficial
lesional lining was enucleated
and the teeth D and E
removed, followed by an
obturator incorporated into a
partial denture treatment to
guide the eruption of the
premolars and bone healing,
also to prevent food
accumulation and maintain a
patent surgical opening.

LOCAL BASE
INDICATOR
It`s an appliance made of

wax o acrylic with metal

inserted in it.
Used to locate the

position of foreign bodies

as amalgam fragments,
bullet fragments or
fractured needle inside the
bone by measuring the
relationship of it to this
foreign body. So, helps in
locating and removing it.

PERIODONTAL
STENT FOR
LASER CROWN
LENGTHENING
PROCEDURE
Assist in determining the
apical extent of the
gingival margin

SURGICAL GUIDE
FOR IMPLANT
POSITIONING :

DEFINITION :
A guide used to assist in proper surgical
placement and angulation of dental
implants-GPT 8.
It is an appliance used for radiographic

evaluation during treatment planning for

implant placement and during surgical
procedures to locate optimal implant
placement site.

OBJECTIVES :

REQUIREMENTS :
It should dictates to the surgeon implant placement that

offers the best :

Esthetics

Support
for the
Hygiene
repetitive
requirements force of
occlusion

ADVANTAGES :
1. Minimizing unnecessary osteotomy.
2. Reduced surgical trauma.
3. Reduced surgical time.
4. Favourable design of prosthesis and hence

increased patient comfort.

DIFFERENT TYPES OF SURGICAL GUIDES :

Types of stent

Advantages

Disadvantages

1. Clear vaccuform stent

Simple and quick to fabricate

Too much flexibility in positioning

of implant and less accurate

2. Self cure acrylic stent with lead

strips

Simple to fabricate

Only an imaging stent (diagnostic)

and not a surgical stent

3. Self cure acrylic with metal

sleeves and disks

Most accurate

Expensive, metal tubes and disks

do not provide any flexibility
during placement
procedures(allows only single size
of drill to pass through)

4. Self cure acrylic with channel

filled with gutta percha

Acceptable accuracy, easy to

fabricate and inexpensive

Not as accurate as metal sleeves

and disks

BASED ON THE AMOUNT OF SURGICAL RESTRICTION

OFFERED BY THE SURGICAL GUIDE TEMPLATES :

Non-limiting
design

DESIGN
CONCEPTS FOR
SURGICAL GUIDE
FABRICATION :

Partiallylimiting design
P

Completelylimiting design

NON-LIMITING DESIGN :
Indicates the ideal location of the implants without any emphasis on

the angulation of the drill. So, too much flexibility of the final
positioning of the implant could be occur.

Disadvantages :
1. Unacceptable placement of the access hole.
2. Unacceptable implant angulation.
3. Act only as imaging indicator (diagnostic) and not surgical.

PARTIALLY-LIMITING DESIGN

Indicates the direction of the first drill during osteotomy and the

remainder of the osteotomy and implant placement is then finished

free hand by the surgeon.
This concept involve the fabrication of a radiographic template which

is then converted into a surgical guide template following

radiographic evaluation.

COMPLETELY-LIMITING DESIGN

This design restricts all of the instruments used for the osteotomy in

a BL & MD planes.
This include two popular designs

CONVENTIONAL
FREE HAND
METHOD

Talwar N, Singh BP, Chand P, Pal US. Use of Diagnostic

and Surgical Stent: A Simplified Approach for Implant
Placement. Journal of Indian Prosthodontic Society.
2010;10(4):234-239. doi:10.1007/s13191-010-0036-7.

USE OF DIAGNOSTIC
AND SURGICAL
STENT: A SIMPLIFIED
APPROACH FOR
IMPLANT PLACEMENT
Case report
A 30 year old male patient
was referred to the
department of
Prosthodontics for the
management of missing 46
and 47
.

Treatment Planning
Prosthetic rehabilitation
with implant supported
crowns to replace missing
teeth.

Diagnostic articulated casts &

preoperative panoramic view.

The occlusal 2/3 of the

prosthesis was trimmed on the
duplicate cast.

Cast with wax-up then duplicate cast.

Location of the access holes both MD

& BL and the desired angulation
delineated along the buccal side of the
cast by use of dental surveyor.

Achannel was made through the predetermined MD

& BL center of the stent and then filled with guttapercha marker.

Stent fabricated using transparent

self-cured acrylic resin over the
trimmed teeth & implant position was
transferred on it.

The stent placed in the patient mouth and dental CT

scan images of the implant site were obtained.

The angulation of the gutta percha represent

the ideal angulation of the implant.

The information was transferred to the patient

mouth by removing gutta percha from the channels
& thus diagnostic stent converted to a surgical stent
that used for implant placement.

Analysis of CT scan was done using dental scan

software in cross-sectional, axial & panoramic view
where gutta percha rods were visible for determining
3-Dimensional position of the implant.

Cost
effective

Advantages of
conventional
method :

Easy to
fabricate
Adequate accuracy in
implant position &
angulation
Helps to determine
relative parallelism
between adjacent
abutments

CAD/CAM BASED
SURGICAL GUIDE :

CAD/CAM TECHNOLOGY
Uses data from CT scan to plan implant rehabilitation.
The CT images are converted into data by a dental software.

This software then transfers this presurgical plan to the surgery

site using STEREOLITHOGRAPHIC drill guides.

STEREOLITHOGRAPHY is a computer-guided, laser-dependent,

rapid prototyping polymerization process that can duplicate the

exact shape of the anatomic landmarks to produce a special 3D
transparent resin model which fits intimately with the hard and/or
soft tissue surface.

ADVANTAGES :
1. 3D views of the bony morphology allow the surgeon to

visualize the surgical bone site prior to implant placement.

2. Risks such as inadequate osseous support or compromising

important anatomic structures are avoided.

3. Using a scanographic template allows the treatment to be

optimized from a prosthodontics & biomechanical points of

view.
4. Promotes flapless surgeries.
5. Allows presurgical construction of master cast and provisional

restorations and facilitates immediate loading.

DISADVANTAGES :
1. Lack of visibility and tactile control during the surgical

procedure.
2. Insufficient mouth opening jeopardizes surgical procedure.
3. A risk of damage to vital anatomical structures.

DRAWBACKS :
1. Special training for familiarity with the entire system.
2. Special equipment necessary.
3. Technique-related complications :

Inaccurate
Intrinsic errors Software
Radiographic
planning
stent error during scanning planning

Information
Rapid
prototyping transfer for
a prosthesis

DOUBLE SCANNING FOLLOWED :

1st scan with patient wearing radiographic template &

radiographic index.
2nd scan for the non-radiopaque radiographic guide, to
visualize the bony anatomy of the site of interest.
Those are 2D imaging which then converted into a file format
compatible with the 3D printing program resulting in scanning
in 3D space.
The plan saved as sim file & sent to the processing center for
fabrication of the surgical guide slice by rapid prototyping
which is of 2 types :
Additive
Widely used.
Subtractive
Less effective.
Various implant planning software products are available
commercially named, Simplast, Surgicase, Proceraetc.

AN IMMEDIATELY
LOADED

CAD/CAMGUIDED DEFINITIVE
PROSTHESIS: A
CLINICAL REPORT
Case report
60yrs old women with
maxillary complete
denture & mandibular
fixed implant complete
denture, pt. never
comfortable with the
maxillary prosthesis.
Treatment plan
Implant therapy with
immediate loading of
the dental implants

3D view for implant planning

THE JOURNAL OF PROSTHETIC DENTISTRY, VOLUME 93

NUMBER 1, AN IMMEDIATELY LOADED CAD/CAM-GUIDED DEFINITIVE
PROSTHESIS: A CLINICAL REPORT

Stereolithography cast mounted on

articulator to determine tooth position
for esthetics & phonetics, and to
determine occlusal vertical dimension

Surgical template positioned

and held into position with
horizontal stabilization pins

Surgical template fabricated and

interocclusal record made between surgical
template and opposing arch for reproducible
placement of the scan template intraorally.

First implant placed and template abutment

inserted to stabilize position of surgical template

Initial closure of patient after implant

surgery and insertion of prosthesis

Postoperative periapical radiographs

made 3 months after implant surgery

COMPUTER GUIDED SURGERY

FOR IMPLANT PLACEMENT AND
DENTAL REHABILITATION IN A
PATIENT UNDERGOING SUBTOTAL MANDIBULECTOMY AND
MICROVASCULAR FREE FLAP
RECONSTRUCTION
Case report

JOURNAL OF ORAL IMPLANTOLOGY, AAID-JOI-D-11-00142, VOL.

XXXIX /NO. FOUR /2013

CASE REPORT
A 58-year-old woman
presented with an
extensive, destructive,
and expansive cyst-like
lesion of the mandibular
body

3D CT scan of the mandible

Stereolithographic model of
the mandible

Ant. Max. teeth extracted & the cyst enucleated

The resected specimen

Fibula flap

Acrylic mandibular radiographic stent marked with gutta

percha markers

3D virtual environment showing

resected mandible, radiographic
stent & planned implant positions

Stereolithographic drill
guide

Computer-guided surgery in progress

CONCLUSION :
3D imaging and modelling, and CAD technologies are

hugely impacting on all aspects of dentistry.

Nowadays, nearly everything we make for our patients

can be made by a 3D printer, but no single technology is

sufficient for all our patients needs.
In maxillofacial and implant surgery, it is becoming

commonplace and prerequisite to use anatomical

models made by any number of different 3D printing
techniques to assist with the planning of complex
treatments.

REFERENCES :
A modified approach for vestibuloplasty in severely resorbed mandible using an

implant-retained postoperative stent, oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2008 Oct;106(4):e7-14. doi: 10.1016/j.tripleo.2008.05.029. Epub 2008 Jul
26.

Sakkas N, Shoeen R. Obturator after marsupialization of a recurrence of a

radicular cyst of the mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2007 ; 103: 16-18.

Patras M, Martin W, Sykaras N. A Novel Surgical Template Design in Staged Dental

Implant Rehabilitations. Journal of Oral & Maxillofacial Research. 2012;3(2):e5.

doi:10.5037/jomr.2012.3205.

Kola MZ, Shah AH, Khalil HS, et al. Surgical Templates for Dental Implant

Positioning; Current Knowledge and Clinical Perspectives. Nigerian Journal of

Surgery : Official Publication of the Nigerian Surgical Research Society.
2015;21(1):1-5. doi:10.4103/1117-6806.152720.

Types of Implant Surgical Guides in Dentistry: A Review Kathleen Manuela

D'Souza, Meena Ajay Aras, Journal of Oral Implantology 2012 38:5, 643-652.

 British Dental Journal 219, 521 - 529 (2015), 3D printing in dentistry .

Ramasamy M, Giri, Raja R, Subramonian, Karthik, Narendrakumar R. Implant

surgical guides: From the past to the present. Journal of Pharmacy & Bioallied
Sciences. 2013;5(Suppl 1):S98-S102. doi:10.4103/0975-7406.113306.

Pal US, Chand P, Dhiman NK, Singh RK, Kumar V. Role of surgical stents in

determining the position of implants. National Journal of Maxillofacial Surgery.

2010;1(1):20-23. doi:10.4103/0975-5950.69153.

Talwar N, Singh BP, Chand P, Pal US. Use of Diagnostic and Surgical Stent: A

Simplified Approach for Implant Placement. Journal of Indian Prosthodontic

Society. 2010;10(4):234-239. doi:10.1007/s13191-010-0036-7.

Journal of prosthetic dentistry, volume 93 number 1, An immediately loaded

CAD/CAM-guided definitive prosthesis: A clinical report

Journal of Oral Implantology, AAID-JOI-D-11-00142, Vol. XXXIX /No. Four /2013

Prosthetic rehabilitation of maxillofacial defects, prof.Mohamed A. EL-Dakkak,

Part I, 2015.